THE  UNIVERSITY 


OF  ILLINOIS 
LIBRARY 

61703 

C7&cL 

182.2. 

v.2 


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# 


COMPREHENDING 


all  the  most  interesting  improvements,  from  the  earliest 

TIMES  DOWN  TO  THE  PRESENT  PERIOD ; 

AN  ACCOUNT  OF  THE  INSTRUMENTS,  REMEDIES,  AND  APPLICATIONS 
EMPLOYED  IN  SURGERY ; 

THE  ETYMOLOGY  AND  SIGNIFICATION  OF  THF.  PRINCIPAL  TERMS: 

AND 

Numerous  References  to  Ancient  and  Modern  Works,  forming  together  a “ Catalogue 
Raisonnee”  of  Surgical  Literature 

WITH 


formerly  surgeon  to  the  forces;  member  of  the  royal  college  of  surgeons; 

OF  THE  MEDICAL  AND  CHIHURGICAL  SOCIETY  OF  LONDON  : AND 

, Op  THE  MEDICAL  SOCIETY  OF  MARSEILLES. 


OF  THE  COLLEGE  OF  SURGEONS  OF  EDINBURGH;  PROFESSOR  OF  ANATOMY  AM' 
PHYSIOLOGY  TO  THE  VERMONT  ACADEMY  OF  MEDICINE;  AND 
LECTURER  ON  SURGICAL  ANATOMY  IN  NEW-YORK. 


\ variety  of  original  facts  and  observations 


BY  SAMUEL  COOPER, 


WITH 


NOTES  AND  AN  APPENDIX. 


BY  WILLIAM  ANDERSON, 


N two  volumes 


YOL.  II. 


FROM  THE  FOURTH  LONDON  EDITION 


NEW-YORK  ; 


PUBLISHED  BY  COLLINS  &■  HANNAY,  230  PEARL-STREET 


7.  k J.  Harper,  Printers. 


% 


r 


Southern  District  of  New-York,  ss. 

BE  IT  REMEMBERED,  That  on  the  second  day  oi  December,  m iue  tony  -seventh, 
year  of  the  Independence  of  the  United  States  of  America,  Collins  h Hannay,  of  the 
said  District,  have  deposited  in  this  office  the  title  of  a book,  the  right  whereof  they 
claim  as  proprietors,  in  the  words  following,  to  wit : 

A Dictionary  of  Practical  Surgery  : comprehending  all  the  most  Interesting  Improve 
il  ments,  from  the  earliest  times  down  to  the  present  period  ; an  Account  of  the  Instru- 
ments,  Remedies,  and  Applications  employed  in  Surgery ; the  Etymology  and  Signi 
fication  of  the  Principal  Terms  ; and  Numerous  References  to  Ancient  and  Modern 
1 Works,  forming  together  a “ Catalogue  Raisonnee”  of  Surgical  Literature  ; with  a 
- Variety  of  Original  Facts  and  Observations,  by  Samuel  Cooper,  formerly  Surgeon  to 
ci  the  Forces  ; Member  of  the  Royal  College  of  Surgeons  ; of  the  Medical  and  Chirur- 
*•'  gical  Society  of  London  ; and  of  the  Medical  Society  of  Marseilles.  With  Notes  and 
: an  Appendix,  by  William  Anderson,  of  the  College  of  Surgeons  of  Edinburgh 
“ Professor  of  Anatomy  and  Physiology  to  the  Vermont  Academy  of  Medicine 
rcand  Lecturer  on  Surgical  Anatomy  in  New-York.” 

In  conformity  to  the  Act  of  the  Congress  of  the  United  States,  entitled  u An  Act  for 
the  encouragement  of  Learning,  by  securing  the  copies  of  Maps,  Charts,  and  Books,  to 
the  authors  and  proprietors  of  such  copies,  during  the  times  therein  mentioned.”  And 
also  to  an  Act,  entitled  “ An  Act  supplementary  to  an  Act,  entitled  An  Act  for  the  en 
couragement  of  Learning,  by  securing  the  copies  of  Maps,  Charts,  and  Books,  to  the 
authors  and  proprietors  of  such  copies  during  the  times  therein  mentioned,  and  extending 
the  benefits  thereof  to  the  arts  of  designing,  engraving,  and  etching  historical  and  other 
prints.” 

JAMES  DILL, 

Clerk  of  the.  Southern  District  o f New-  York 


A. 


I c" 


03 


THE  HORARY  OF  THE 

DICTIONARY  ^ A ° 1933 

■ , F ILLINOIS; 

OP 


PRACTICAL  SURGERY. 

P This  murk  (*)  will  signify , that  the  Word  which  it  precedes  is  further  spoken  of  in  the  Apptndix. 


if 

I O ^ 


HER 


Ue'RNTA.  (From  sgvoc,  a branch,  from 
its  protruding  forward.)  Burgeons  under- 
stahd  by  the  term  hernia,  a tumour,  formed 
by  the  protrusion  of  some  of  the  viscera  of 
the  abdomen,  out  of  that  cavity,  into  a kind 
of  sac,  composed  of  the  portion  of  perito- 
neum, which  is  pushed  before  them.  How- 
ever, there  are  certainly  cases  which  will 
not  be  comprehended  in  this  definition  ; 
either  because  the  parts  are  not  protruded 
at  all,  or  have  no  hernial  sac,  as  the  reader 
will  learn  in  the  course  of  this  article. 

“ The  brilliant  progress  which  surgery 
has  made  in  modern  times  (says  Scarpa)  is, 
properly  speaking,  only  the  result  of  patho- 
logical anatomy,  that  is  to  say,  of  exact 
comparisons  of  the  natural  slate  of  our  or- 
gans with  their  different  diseases,  which  may 
depend  upon  an  alteration  of  texture,  a de- 
rangement of  functions,  a solution  of  con- 
tinuity, or  a change  of  situation.  It  is  from 
morbid  anatomy,  that  the  most  rational 
curative  methods,  with  which  modern  sur- 
gery is  enriched,  are  deduced  as  so  many 
corollaries  ; methods,  to  which  we  are  also 
indebted  for  the  perfection  of  operations. 

“ There  are  indeed  a certain  number  of 
surgical  operations,  for  the  prompt  and  sufe 
execution  of  which,  mere  anatomical  know- 
ledge will  suffice;  but  in  many  others,  the 
surgeon  cannot  promise  himselfsuccess, even 
though  he  be  well  acquainted  with  ana- 
tomy, unless  he  has  particularly  studied  the 
numerous  changes  of  position,  and  altera- 
tions of  texture,  of  w’hich  the  parts,  upon 
which  he  is  about  to  operate,  are  susceptible. 
If  he  has  not  the  requisite  information  upon 
all  these  points,  false  appearances  may  de- 
ceive his  judgment,  and  make  him  commit 
mistakes,  sometimes  of  a very  serious  and 
irreparable  kind. 


“ In  order  to  have  a convincing  proof  of 
this  truth,  it  will  be  sufficient  to  take  a view 
of  the  different  species  of  hernia;,  and  their 
numerous  complications.  Assuredly,  no 
anatomist  would  believe,  that  the  intestine 
ccecum,  naturally  fixed  in  the  right  ileum, 
and  the  urinary  bladder,  situated  at  the  bot- 
tom of  the  pelvis,  could  undergo,  without 
being  torn,  so  considerable  a displacement 
as  to  protrude  through  the  abdominal  ring, 


HER 

and  descend  even  into  the  scrotum  ; that  the 
same  intestine,  the  ccecuin,  could  pass  front 
the  right  iliac  region  to  the  umbilicus,  pro- 
trude at  this  opening,  and  form  an  umbili- 
cal hernia  ; that  the  right  colon  could  have 
been  found  protruded  from  the  abdomen  at 
the  left  abdominal  ring,  and  the  left  colon 
through  the  right  one  ; that  the  liver,  spleen, 
and  ovary  could  sometimes  form  the  con- 
tents of  umbilical,  inguinal,  and  femoral 
herniae  ; that  the  caecum  could  engage  itself 
within  the  colon,  and  even  protrude  at  the 
anus ; that  the  stomach  could  be  forced 
through  the  diaphragm,  and  form  a hernia 
within  the  chest  ; that  the  omentum,  or  in- 
testine, or  both  these  parts  together,  could 
sometimes  escape  from  the  belly  through  the 
foramen  ovale,  or  sacro-ischiatic  notch  of* 
the  pelvis;  that  a noose  of  small  intestine, 
after  being  engaged  in  the  abdominal  ring* 
or  under  the  femoral  arch,  could  suffer  the 
most  violent  strangulation,  without  the 
course  of  Ihe  intestinal  matter  being  inter- 
cepted ; lastly,  that  in  certain  circum- 
stances, the  intestine  and  omentum  could 
be  in  immediate  contact  with  the  testicle, 
within  the  tunica  vaginalis,  without  the 
least  laceration  of  this  latter  membrane. 
These  and  several  other  analogous  facts, 
says  Scarpa,  are  so  surprising,  that  they 
would  yet  he  regarded  as  incredible,  had 
they  not  been  proved  by  numerous  obser- 
vations on  individuals  affected  with  hernia  : 
their  possibility  (repeats  this  experienced 
professor)  would  not  even  have  been  sus- 
pected, either  by  the  anatomist  or  physiolo- 
gist.” (see  Scarpa,  Traitc  dcs  Hernits,  Pref.) 

The  parts  of  the  body,  where  hernia;  most 
frequently  make  their  appearance,  are  tlm 
groin,  the  navel,  the  labia  pudendi,  and  the 
upper  and  forepart  of  the  thigh  ; they  do 
also  occur  at  every  point  of  the  anterior  part 
of  the  abdomen  ; and  there  aro  several  les<r 
common  instances,  in  which  hernial  tu- 
mours present  themselves  at  the  foramen 
ovale  ; in  the  perinaeum  ; in  the  vagina ; at 
the  ischiatic  notch,  &,c. 

The  parts,  which,  by  being  thrust  forth 
from  the  cavity,  in  which  they  ought  natu- 
rally to  remain,  mostly  produce  hernia?,  are 
either  a portion  of  (ho  amentum,  or  rv  jwwY 


95 


O iLSJC* 


HERNIA. 


of  the  intestinal  canal,  ©r  both  together. 
But  the  stomach,  the  liver,  spleen,  uterus, 
ovaries,  bladder,  kc.  have  been  known  to 
form  the  contents  of  some  hernial  tumours. 

From  these  two  circumstances  of  situation 
and  contents,  are  derived  all  the  ditlerent 
appellations,  by  which  herniae  are  distin- 
guished. If  a portion  of  intestine  alone 
forms  the  contents  of  the  tumour,  the  case 
is  called  enterocele  ; if  a piece  of  omentum 
only,  epiptocele ; and  if  both  intestine  and 
omentum  contribute  to  the  formation  of  the 
tumour,  it  is  called  an  entero-epiplocele. 
When  the  contents  of  a hernia  protrude  at 
the  abdominal  ring,  but  only  pass  as  low  as 
the  groin,  or  labium  pudendi,  the  case  re- 
ceives the  name  of  bubonocele,  or  inguinal 
hernia ; but  if  the  parts  descend  into  the 
scrotum,  it  is  called  an  oscheocele,  or  scrotal 
hernia.  The  crural,  or  femoral  hernia,  is 
the  name  given  to  that  w’hich  takes  place 
below  Poupart’s  ligament.  W hen  the  bowels 
protrude  at  the  navel,  the  case  is  named  an 
exomphalos,  or  umbilical  hernia  ; and  renlral 
is  the  epithet  given  to  the  swelling,  when 
it  occurs  at  any  other  promiscuous  part  of 
the  front  of  the  abdomen.  The  congenital 
rupture  is  a very  particular  case,  in  which 
the  protruded  viscera  are  not  covered  with 
a common  hernial  sac  of  peritoneum,  hut 
are  lodged  in  the  cavity  of  the  tunica  vagi- 
nalis, in  contact  with  the  testicle,  and,  as 
must  be  obvious,  it  is  not  named  like  herniae 
in  general,  from  its  situation,  or  contents, 
but  from  the  circumstance  of  its  existing 
From  the  time  of  birth. 

When  the  protruded  bowels  lie  quietly  in 
the  sac,  and  admit  of  being  readily  put  back 
into  the  abdomen,  the  case  is  termed  a re- 
ducible hernia;  and  when  they  sutler  no 
constriction,  yet  cannot  be  put  back,  owing 
to  adhesions, *or  their  large  size  in  relation 
to  the  aperture,  through  which  they  have 
to  pass,  the  hernia  is  termed  irreducible. 
An  incarcerated,  or  strangulated  hernia,  sig- 
nifies one,  which  not  only  cannot  be  re- 
duced, but  suffers  constriction  ; so  that  if  a 
piece  of  intestine  be  protruded,  the  pressure 
to  which  it  is  subjected,  stops  the  passage  of 
its  contents  towards  the  anus,  excites  inflam- 
mation of  the  bowel,  and  brings  on  a train 
of  alarming,  and  often  fatal  consequences. 

The  eauses  of  hernia;  are  either  predispo- 
sing, or  exciting.  Among  the  former,  wri- 
ters mention  a preternaturally  large  size  of 
the  openings,  at  which  the  bowels  are  liable 
to  protrude  ; a weakness  and  relaxation  of 
the  margins  of  these  apertures  ; a preterna- 
tural laxity  of  the  peritoneum;  an  unusually 
long  mesentery,  or  omentum,  kc.  With 
regard  to  the  abdominal  ring,  the  transverse 
tendinous  fibres,  which  naturally  cross  and 
strengthen  its  upper  and  outer  part,  are 
much  weaker  in  some  subjects  than  others. 
No  idea  seems  more  prevalent  in  books, 
than  that  taking  a good  deal  of  oil  with  our 
food,  is  conducive  to  the  formation  ol  her- 
nial diseases.  Some  of  the  alleged  predis- 
posing causes,  may  justly  excite  scepticism  ; 
but  several  circumstances  tend  to  prove, 
that  a natural  deficiency  of  resistance,  fn  any 


part  of  the  parietes  of  the  abdomen,  pro- 
motes the  occurrence  of  hernia.  Hence, 
persons  who  have  had  the  peritoneum 
wounded,  are  very  liable  to  the  present  dis- 
ease ; ( llicherand  JVosogr.  t hir.  T.  3 ,p.  317  ; 
Schmucker,  Vermischte  Chir.  Schriften,  B.  1, 
p.  197,)  and  men  are  much  more  liable  than 
women,  to  inguinal  hernia,  owing  evidently 
to  the  larger  size  of  the  abdominal  ring; 
while  in  women,  as  there  is  a larger  space 
for  the  protrusion  of  the  viscera,  below  Fou- 
part’s  ligament,  they  are  more  exposed  than 
men  to  femoral  hernia;. 

Willi  regard  to  the  exciting  causes,  our 
knowledge  is  involved  in  less  doubt.  The 
grand  cause  of  this  kind,  is  the  powerful 
action  of  the  abdominal  muscles  and  dia- 
phragm on  the  viscera.  In  feats  of  agility, 
such  as  jumping,  Ik c.  the  pressure  which  the 
contents  of  the  abdomen  must  often  en- 
counter, sufficiently  accounts  for  their  pro- 
truding at  any  part,  where  the  abdominal 
parietes  do  not  make  adequate  resistance. 
The  same  consideration  explains,  w hy  her- 
niae very  often  take  place  in  lifting  and  car- 
rying heavy  weights,  running,  vomiting, 
straining  at  stool,  parturition,  kc.  and  in 
people  who  inhabit  mountainous  countries. 

This  diminution  of  the  capacity  of  the 
abdomen,  by  the  action  of  the  abdominal 
muscles  and  diaphragm,  in  many  occasional 
exertions,  must  take  place  in  every  body  by 
reason  of  the  common  habits  and  necessi- 
ties of  life.  But  as  only  a certain  number 
of  persons  meet  with  the  disease,  it  is  fair 
to  infer,  that  either  the  exciting  causes 
must  operate  with  greater  force  in  them, 
than  in  the  generality  of  people,  or  else  that 
their  abdominal  parietes  have  not  been  ca- 
pable of  the  ordinary  degree  of  resistance. 
Many  patients,  who  meet  with  hernia;,  in 
making  violent  efforts  and  exertions,  may* 
be  in  the  former  circumstance  ; while  others 
whose  viscera  protrude  from  such  trivial 
things  as  coughing,  sneezing,  crying,  kc. 
must  be  considered,  as  being  under  the 
influence  of  some  predisposing  cause.  A 
gentleman,  who  has  gained  great  honour  by 
a most  valuable  treatise  on  ln  rnia,  remarks, 
that  “ herniae,  which  originate  in  predispo- 
sition, generally  come  on  gradually,  and 
almost  imperceptibly  ; w’hile  those  which 
are  produced  by  bodily  exertions,  are  form- 
ed suddenly,  and  by  the  immediate  action 
of  the  exciting  cause.  The  occurrence  of 
the  complaint  is  often  indicated,  in  the  first 
instance,  by  a fulness,  combined  with  a 
sense  of  weakness,  about  the  abdominal 
ring.  The  swelling  is  increased  by  any  ac- 
tion of  the  respiratory  muscles,  and  disap- 
pears on  pressure,  and  in  the  recumbent  po- 
sition of  the  body.  It  gradually  finds  its 
way  through  the  tendon  of  the  external  ob- 
lique muscle,  into  the  groin,  and  afterward 
into  the  scrotum.  When  a hernia  takes 
place  suddenly,  it  is  generally  attended  w ith 
a sensation  of  something  giving  way  at  tlio 
part,  and  with  pain.”  ( Lawrence  on  Rup- 
tures, p.  29,  Edit.  3.) 

Upon  the  subject  of  the  immediate  cause 
of  hernia?,  it  Is  observed  by  Scarpa,  that  se- 


HERNIA. 


5 


veral  distinguished  modern  surgeons,  as,  for 
instance,  YVarton,  ( Adenograph . cap.  11.) 
Eenevoli,  ( Dissertazioni  Chirurgische , 1.) 
Rossius,  ( Acta  JVat.  cur.  T.  2,  Obs.  178.) 
Brendel,  (de  lierniarum  natalibus,)  and  Mor 
gagni,  (de  sed.  et  caus.  morb.  epist.  43,  art.  13,) 
consider  a relaxation  and  elongation  of  the 
mesentery  as  the  principal  cause  of  herniae 
in  general,  and  of  the  bubonocele  in  parti- 
cular. Hence,  say  they,  the  whole  mass  of 
intestines,  or  only  a portion  of  an  intestine, 
descends  against  the  inner  orifice  of  Ihe 
inguinal  ring,  presses  against  this  opening, 
and  gradually  makes  its  way  out  of  the 
abdomen.  In  examining  this  pathological 
point  without  prejudice,  it  is  incontesta- 
ble, says  Scarpa,  that  an  intestine  cannot 
be  moved  beyond  its  natural  limits,  unless 
that  part  of  the  mesentery,  which  retains 
and  fixes  the  bowel  in  its  proper  place,  be 
at  the  same  time  elongated.  But  it  does  not 
follow  from  this,  that  a relaxation  of  the 
mesentery  must  precede  the  displacement 
of  the  intestine.  It  appears  to  Scarpa  much 
more  probable,  that  these  two  events  are 
simultaneous,  and  depend  upon  one  and  the 
same  cause. 

“In  the  healthy  state  the  abdomen,  con- 
sidered altogether,  is  submitted  to  two  oppo- 
site forces,  which  reciprocally  balance  each 
other.  One  is  the  pressure  of  the  viscera 
against  the  abdominal  parietes;  the  other  is 
the  reaction  of  the  same  parietes  upon  the 
viscera  which  they  contain.  If  these  two 
forces  were  in  perfect  equilibrium  in  all  in- 
dividuals, and  under  all  the  circumstances 
of  life,  we  should  not  be  in  the  least  subject 
to  hernia?.  If,  when  the  equilibrium  has 
been  broken,  every  point  of  the  parietes  of 
the  belly  were  to  yield  equally  to  the  im- 
pulse of  the  viscera,  an  increase  of  the  vo- 
lume of  the  whole  abdomen  would  be  the 
con-equence  ; but  a true  hernia  would  never 
happen.  The  cavity  of  the  abdomen  is  al- 
ways completely  full.  The  containing  ar.d 
contained  parts  react  upon,  and  reciprocally 
compress  one  another.  It  is  by  the  effect 
of  this  moderate,  but  equal  and  unremitting 
pressure,  that  all  the  viscera  mutually  sup- 
port each  other.  Without  it.  the  ligaments 
of  the  liver,  those  of  the  spleen,  and  the 
various  membranous  bands  of  the  intestines 
in  general,  would  only  be  feeble  means  for 
fixing  such  parts  in  their  respective  situa- 
tions. But  there  are  certain  points  of  the 
abdominal  parietes  which  naturally  present 
much  less  resistance  than  others,  and  which 
react  with  much  less  power  against  the  pres- 
sure made  from  within  outwards  by  the  ab 
dominal  viscera.  Such  is  particularly  the 
part  which  extends  from  the  pubes  to  the 
anterior  superior  spinous  process  of  the  ili- 
um. This  relative  weakness  of  some  points 
of  the  abdominal  parietes  is  very  marked  in 
certain  individuals,  in  consequence  of  a 
defect  of  organization.  It  may  also  be  in- 
creased by  internal  or  external  causes,  which 
are  as  various  as  they  are  numerous.  When 
in  one  of  these  cases  the  pressure  made  by 
the  viscera  is  unusually  increased,  as  hap- 
pens in  a violent  effort,  a defect  in  the  equi- 


librium between  the  two  forces  above  men- 
tioned is  occasioned  ; that  is  to  say,  the  re- 
action of  the  abdominal  parietes  isno  longer 
proportioned,  at  least  at  certain  points, 
to  the  force  of  the  impulse  of  the  viscera. 
The  conjoined  powers  of  the  abdominal 
muscles,  diaphragm,  and  levator  ani,  are 
then  directed  and  concentrated  against  the 
most  feeble  point  of  the  abdomen,  towards 
which  they  propel  the  nearest  viscus,  or  that, 
which  from  its  moveableness,  is  the  most 
liable  to  displacement.  If  such  viscus  should 
happen  to  be  the  noose  of  an  intestine,  it  is 
evident  that  the  power  which  tends  to  make 
it  protrude  from  the  belly,  must  at  the  same 
time  act  upon  the  corresponding  portion  of 
the  mesentery  ; and  the  intestine,  in  passing 
through  the  parietes  of  the  abdomen,  drags 
the  mesentery  after  it,  and  makes  this  mem- 
brane yield  and  become  elongated.  When 
the  displaced  viscera  meet  with  little  resis- 
tance on  the  part  of  the  parietes  of  the  ab- 
domen, the  hernia  is  quickly  formed,  and 
the  elongation  of  the  mesentery  occurs  with 
equal  celerity.  We  have  an  example  of 
this  in  the  inguinal  congenital  hernia  : in 
this  case  the  intestine  is,  in  some  measure, 
precipitated  into  a sac  previously  prepared 
for  its  reception.  On  the  contrary,  in  the 
ordinary  inguinal  hernia,  a totally  different 
disposition  of  the  parts  renders  the  progress 
of  the  disease  much  slower.  In  most  in- 
stances, the  hernia  is  not  formed  immediate- 
ly the  equilibrium  between  the  impulse  of 
the  viscera  and  the  reaction  of  the  abdomi- 
nal parietes  is  broken.  But  in  the  groin,  a 
slight  elevation  is  first  observed,  in  the  di- 
rection from  the  anterior  superior  spinous 
process  of  the  ilium  towards  the  inguinal 
ring.  Some  lime  afterward,  when  the  intes- 
tine has  made  its  appearance  on  the  outside 
of  the  ring,  the  enlargement  of  the  hernia, 
and  the  elongation  of  the  mesentery,  make 
much  more  rapid,  though  always  simulta- 
neous progress. 

“ Numerous  practical  observations,  (says 
Scarpa)  concur  in  proving,  that  we  must  not 
search  for  the  immediate  cause  of  hernia;  in 
the  relaxation  of  the  mesentery  but  rather 
in  a want  of  equilibrium  between  the  pres- 
sure of  the  viscera  and  the  resistance  of  one 
or  several  points  of  the  abdominal  parietes. 
Indeed  hernia;  are  seen  occurring  from  the 
slightest  causes  in  infants,  in  whom  the  neck 
of  the  tunica  vaginalis  is  not  speedily  oblite- 
rated, and  in  individuals,  who  from  being  fat, 
have  all  on  a sudden  become  extremely  thin. 
Such  women  ns  have  had  children,  arc  more 
subject  to  the  disease  than  others.  Persons 
also  of  both  sexes,  who  carry  considerable 
burdens,  or  who  play  upon  wind  instru- 
ments, or  who  have  suffered  a forcible  con- 
tusion of  the  abdomen,  are  particularly  ex- 
posed to  the  disorder,  even  though  there  is 
not  the  least  reason  for  suspecting  in  them  a 
relaxation  of  the  mesentery.  Vaginal  her- 
nia;, which  arise  after  difficult  labours,  af- 
ford another  proof  of  the  same  truth  : their 
cause  is  owing  to  a laxity  and  weakness  of 
the  parietes  of  the  vagina,  which,  not  being 
capable  of  making  any  further  resistance  to 


0 


HERNIA, 


the  pl-essure  of  the  viscera,  situated  in  the 
cavity  of  the  pelvis,  at  length  suffer  these 
parts  to  protrude. 

“ With  respect  to  the  second  proposition, 
that  during  the  formation  of  a hernia,  the 
combined  force  of  all  the  abdominal  mus- 
cles is,  as  it  were,  directed  and  concentra- 
ted against  the  most  feeble  point  of  the  pa- 
rietes,  we  see  a proof  of  it  in  a fact  that 
occurs  to  our  observation  every  day.  In 
order  to.  convince  ourselves  of  this,  we 
need  only  notice  what  happens  in  indivi- 
duals afflicted  with  hernia? : if  they  cough, 
or  sneeze,  or  make  the  slightest  effort,  they 
instantly  find  the  size  of  the  swelling  in- 
creased, and  hasten  to  support  the  part 
with  their  hand.  During  the  slightest  ef- 
forts, which  render  the  hernia?  larger,  it  is 
also  indisputable,  that  the  mesentery  is  elon- 
gated in  the  same  proportion  as  the  intes- 
tine protrudes.  All  the  viscera  have  such 
a tendency  to  be  displaced  and  carried  to- 
wards the  weakest  point  of  the  parietes  of 
the  abdomen,  that  even  those,  which  are 
naturally  the  most  distant  from  it,  and  are 
the  most  firmly  fixed  by  the  folds  of  the  me- 
sentery, may  in  their  turn  descend  into  the 
hernia?.  Anatomical  knowledge  alone  would 
never  have  led  us  to  have  a suspicion  of  the 
possibility  of  these  occurrences.  Sandifort 
and  Paletta  have  found,  in  an  umbilical  her- 
nia, the  ccecurn,  with  a portion  of  the  ileum 
and  colon.  ( Obs.  Pathol,  cap.  4,  Nova  Gu- 
bernaculi  testis  Description  Mauchart,  Cam- 
per, and  Bose,  have  met  with  the  ccecum  in 
an  inguinal  hernia  of  the  left  side.  ( De 
Hern.  Incar c.  in  Halleri  Disput.  Chirurg.  Torn 
3.  Demonstrat.  anat.  paiholog.  lib.  2,  p.  18, 
Animadvers.  de  hern,  inguin.  p.  5.)  Lassus  has 
seen  the  left  colon  protrude  at  the  right  in- 
guinal ring.  ( Medecine  Operatoire , T.  1,  p. 
173.)  If  it  be  proved  by  all  these  facts,  that 
such  viscera, as  are  the  most  closely  united  to 
the  great  sac  of  the  peritoneum  arid  neigh- 
bouring parts,  are  nevertheless  liable  to  form 
hernia? ; and  if  such  displacements  cannot, 
happen  without  a considerable  elongation  of 
the  membranous  bands  fixing  these  bowels, 
in  their  natural  situation,  how  can  we  refuse 
to  admit,  that  a noose  of  intestine,  pushed 
by  degrees  through  the  inguinal  ring,  drags 
along  with  it  the  corresponding  portion  of 
the  mesentery  ? In  order  to  explain  this 
event,  there  is  no  necessity  for  supposing  a 
partial  relaxation  of  the  mesentery.”  ( Traitt 
Pratique  dts  Henries,  Par  A.  Scarpa,  trad,  de 
l' It  alien,  p.  37 — 43.) 

The  general  symptoms  of  a hernia,  which 
is  reducible,  and  free  from  strangulation, 
are  an  indolent  tumour  in  some  point  of  the 
abdomen,  most  frequently  descending  out  of 
the  abdominal  ring,  or  from  just  below  Pou- 
part’s  ligament,  or  else  out  of  the  navel ; but 
occasionally,  from  various  other  situations, 
as  will  be  presently  explained.  The  swelling 
often  originates  suddenly,  except  in  the  cir- 
cumstances above  related,  arid  it  is  subject 
to  a change  of  size,  being  smaller  when  the 
patient  lies  down  on  his  back,  and  larger 
when  be  stands  up,  or  holds  his  breath,  it 
frequently  diminishes  when  pressed,  and 


grows  large  again  when  the  pressure  is  renao 
ved.  Its  size  and  tension  often  increase  af- 
ter a meal,  or  when  the  patient  is  flatulent. 
In  consequence  of  the  unnatural  situation 
of  the  boweb,  many  patients  with  hernia 
are  occasionally  troubled  with  colic,  consti- 
pation, and  vomiting.  Sometimes,  however, 
the  functions  of  the  viscera  seem  to  suffer 
little  or  no  interruption. 

If  the  case  be  an  enteroeele,  and  the  por- 
tion of  intestine  be  small,  the  tumour  is 
small  in  proportion  ; but,  though  small,  yet, 
if  the  gut  be  distended  with  wind,  inflamed, 
or  have  any  degree  of  stricture  made  on  it, 
it  will  be  tense,  resist  the  impression  of  the. 
finger,  and  give  pain  upon  being  handled. 
On  the  contrary,  if  there  be  no  stricture, 
and  the  intestine  suffer  no  degree  of  inflam- 
mation, let  the  prolapsed  piece  be  of  what 
length  it  may,  and  the  tumour  of  what- 
ever size,  yet  the  tension  will  be  little,  and 
no  pain  will  attend  the  handling  it;  upon 
the  patient’s  coughing,  it  will  feel  as  if  it 
were  blown  into  ; and,  in  general,  it  will 
be  found  very  easily  returnable.  (Pott.)  A 
guggling  noise  is  often  made  when  the  bowel 
is  ascending 

If  the  hernia  be  an  epiplocele,  or  one  of 
the  omental  kind,  the  tumour  has  a raora 
flabby  and  a more  unequal  feel  ; it  is  in  ge- 
neral perfectly  indolent,  is  more  compressi- 
ble, and  (if  in  the  scrotum)  is  more  oblong, 
and  less  round,  than  the  swelling  occasion- 
ed in  the  same  situation  by  an  intestinal 
hernia  ; and,  if  the  quantity  be  large,  and 
the  patient  adult,  it  is  in  some  measure  dis- 
tinguishable by  its  greater  weight.  (Pott  ) 

If  the  case  be  an  enter o-epiplocele , that  is, 
one  consisting  of  both  intestine  and  omen- 
tum, the  characteristic  marks  will  be  less 
clear,  than  in  either  of  the  simple  cases  : but 
the  disease  may  easily  be  distinguished  from 
every  other  one,  by  any  body  in  the  habit 
of  making  the  examination.  ( Pott , P.  28.) 

As  the  smooth  slippery  surface  of  the  in- 
testine generally  makes  its  reduction  easier 
than  that  of  the  omentum,  we  may  infer, 
with  Mr.  Lawrence,  “ that,  if  a portion  of 
the  contents  slip  up  quickly  and  with  noise, 
leavingbehirid  something  which  is  less  easily 
reduced,  the  case  is  probably  an  enlero-epip- 
locele.  (See  Treatise  on  Ruptures , Edit.  3, 
p.  32.) 

On  the  subject  of  prognosis,  Mr.  Pott  re- 
marks, that  the  age  and  constitution  of  the 
subject,  the  date  of  the  disease,  its  being 
free,  or  not  free  from  stricture,  or  inflamma- 
tion, the  symptoms  which  attend  it,  and  the 
probability  or  improbability  of  its  being  re- 
turnable, necessarily  produce  much  variety. 

If  the  subject  be  an  infant,  the  case  is  not 
often  attended  with  much  difficulty  or  hazard, 
the  reduction  being  easy  as  well  as  the  de- 
scent ; and  though  from  neglect,  or  inatten- 
tion, the  bowel  may  fall  down  again,  yet  it 
is  as  easily  replaced,  and  mischief  seldom 
produced  : Mr.  Pott  says  seldom,  because 
lie  lias  seen  an  infant,  one  year  old,  die  ol’ 
a strangulated  hernia,  which  had  not  been 
down  two  days,  with  all  the  symptoms  of 
mortified  intestine.  (For  other  examples  of 


HERNIA, 


Strangulated  hernia  in  very  young  infants, 
refer  to  Gooch’s  Chir.  Works,  Vol.  2,  p 33  ; 
Lawrence  on  Ruptures,  p.  65,  Edit.  3 ; Edinb. 
Med.  and  Surgical  Journal,  Vol.  3,  p.  470, 
*c.) 

“ If  the  patient  be  adult,  and  in  the  vigour 
of  life,  the  consequences  of  neglect,  or  of 
maltreatment,  are  more  to  be  feared  than  at 
any  other  time,  for  reasons  too  obvious  to 
need  relating.  The  great  and  principal  mis- 
chief to  be  apprehended,  in  an  intestinal 
hernia,  is  an  inflammation  of  the  gut,  and 
an  obstruction  to  the  passage  of  the  aliment 
and  feces  through  it ; which  inflammation 
and  obstruction  are  generally  produced  by 
a stricture  made  on  the  intestine.  In  very 
old  people,  the  symptoms  do  not  usually 
make  such  rapid  progress,  both  on  account 
of  the  laxity  of  their  frame,  and  their  more 
languid  circulation  ; and  also  that  their  rup- 
tures are  most  frequently  of  ancient  date, 
and  the  passage  a good  deal  dilated  ; but 
then,  on  the  other  hand,  it  should  also  be 
remembered,  that  they  are  by  no  means  ex- 
empt from  inflammatory  symptoms ; and 
that  if  such  should  come  on,  the  infirmity  of 
old  age  is  no  favourable  circumstance  in  the 
treatment,  which  may  become  necessary. 
(Pott.) 

If  the  disease  be  recent,  and  the  patient 
young,  immediate  reduction,  and  constant 
care  to  prevent  another  protrusion,  are  the 
only  means  whereby  it  is  possible  to  obtain 
a perfect  cure. 

“ If  the  disease  be  of  long  standing,  has 
been  neglected  or  suffered  to  be  frequently 
down,  and  has  given  little  or  no  trouble,  the 
aperture  in  the  abdominal  muscle,  and  the 
neck  of  the  hernial  sac,  may  both  be  pre- 
sumed to  be  large  ; which  circumstances  in 
general  render  immediate  reduction  less 
necessary  and  less  difficult,  and  also  frus- 
trate all  rational  expectation  of  a perfect 
cure.  On  the  contrary,  if  the  rupture  be 
recent,  or,  though  old,  has  generally  been 
kept  up,  its  immediate  reduction  is  more  ab- 
solutely necessary,  as  the  risk  of  stricture  is 
greater  from  the  supposed  smallness  of  the 
aperture,  and  narrowness  of  the  sac.  If  the 
rupture  be  very  large  and  ancient,  the  pa- 
tient far  advanced  in  life,  the  intestine  not 
bound  by  any  degree  of  stricture,  but  does 
its  office  in  the  scrotum  regularly,  and  no 
other  inconvenience  be  found  to  attend 
it,  but  what  proceeds  from  its  weight,  it  will 
in  general  be  better  not  to  attempt  reduc- 
tion, as  it  will,  in  these  circumstances,  most 
probably  prove  fruitless,  and  the  handling 
the  parts  in  the  attempt,  may  so  bruise  and 
injure  them  as  to  do  mischief.” 

With  respect  to  the  correctness  of  the  ad- 
vice here  delivered,  some  doubt  may  be 
entertained,  because,  though  it  would  cer- 
tainly not  be  right  to  protract  the  attempts 
at  reduction,  so  as  to  do  mischief,  it  must 
be  equally  wrong  to  make  no  trial,  whether 
the  hernia  is  reducible  or  not;  and,  if  re- 
ducible, I should  say,  that  it  ought  to  be 
reduced  without  delay,  and  a truss  applied. 
This  opinion,  however,  seems  to  agree  with 
the  injunctions  delivered  by  Pott  in  another 


place,  as  will  be  seen  in  the  next  section  of 
this  article. 

With  regard  to  the  contents  of  a hernia, 
Mr.  Pott  observes,  that  “ if  it  be  a portion  of 
omentum  only,  and  has  been  gradually  ’ 
formed,  it  seldom  occasions  any  bad  symp- 
toms,though  its  weightwillsometimesrender 
it  very  troublesome.  But,  if  it  be  produced 
suddenly  by  effort  or  violence,  that  is,  if  a 
considerable  piece  of  the  caul  by  accident 
slip  down  at  once,  it  will  sometimes  prQve 
painful  and  cause  very  disagreeable  com- 
plaints ; the  connexion  between  the  omen- 
tum, stomach,  duodenum,  &c.  being  such 
as  to  render  the  sudden  descent  of  a large 
piece  of  the  first  sometimes  productive  of 
nausea,  vomiting, colic,  and  all  the  disagreea- 
ble symptoms  arising  from  the  derangement 
of  these  viscera.  When  the  piece  of  caul  is 
engaged  in  such  a degree  of  stricture  as  to 
prevent  the  circulation  of  blood  through  it, 
it  will  sometimes,  by  becoming  gangrenous, 
be  the  occasion  of  very  bad  symptoms  and 
even  of  death,  as  I have  more  than  once 
seen  : and  thus,  as  a mere  omental  hernia, 
it  may  sometimes  be  subject  to  great  hazard. 
But  even  though  it  should  never  be  liable  to 
the  just-mentioned  evil,  that  is,  though  the 
portion  of  the  caul  should  remain  uninjured 
in  the  scrotum,  yet  it  renders  the  patient 
constantly  liable  to  hazard  from  another 
quarter;  it  makes  it  every  moment  possible 
for  a piece  of  intestine  to  slip  into  the  same 
sac,  and  thereby  add  to  the  case  all  the 
trouble  and  all  the  danger  arising  from  an 
intestinal  rupture.  It  is  by  no  means  an  un- 
common thing  for  a piece  of  gut  to  be 
added  to  a rupture,  which  had  for  many 
years  been  merely  omental,  and  for  that 
piece  to  be  strangulated,  and  require  imme- 
diate help 

“ An  old  omental  hernia  is  often  rendered 
not  reducible,  more  by  an  alteration  made 
in  the  state  of  the  prolapsed  piece  of  caul, 
than  by  its  quantity.  It  is  very  common 
for  that  part  of  the  omentum,  which  passes 
through  the  neck  of  the  sac,  to  be  compress- 
ed into  a hard,  smooth  body,  and  lose  all 
appearance  of  caul,  while  what  is  below  in 
the  scrotum  is  loose  and  expanded,  and  en- 
joys its  natural  texture  ; in  this  case,  reduc- 
tion is  often  impossible,  from  the  mere 
figure  of  the  part ; and  I have  so  often  seen 
this,  both  in  the  living  and  the  dead,  that  I 
am  satisfied,  that  for  one  omental  rupture, 
rendered  irreducible  by  adhesions,  many 
more  become  so  from  the  cause  above-men- 
tioned. 

“In  the  sac  of  old  omental  ruptures  that 
have  been  long  down,  and  only  suspended 
by  a bag  truss,  it  is  no  very  uncommon  thing 
to  have  a pretty  considerable  quantity  of 
fluid  collected  : this,  in  different  states  and 
circumstances  of  the  disease,  is  of  different 
colour  and  consistence,  and  seldom  so  much 
in  quantity  as  to  occasion  any  particular  at- 
tention to  it ; but,  on  the  other  hand,  it 
sometimes  is  so  much  in  quantity  as  to  be- 
come an  additional  disease  to  the  original 
one.  I have  more  than  once  been  obliged 
to  let  it  out,  in  order  to  remove  the  incon- 


s 


HERNIA. 


venience  arising  from  its  weight,  and  the 
distention  of  the  scrotum,  which  I have  also 
seen  become  gangrenous  by  the  neglect  of 
this  operation. 

“If  the  hernia  be  of  the  intestinal  kind 
merely,  and  the  portion  of  gut  be  small, 
the  risk  is  greater,  strangulation  being  more 
likely  to  happen  in  this  case,  and  more 
productive  of  mischief,  when  it  has  hap- 
pened : for  the  smaller  the  portion  of  gut  is 
which  is  engaged,  the  tighter  the  tendon 
binds,  and  the  more  hazardous  is  the  con- 
sequence. I have  seen  a fatal  gangrene,  in 
a bubonocele,  which  had  not  been  formed 
forty-eight  hours,  and  in  which  the  piece 
of  intestine  was  little  more  than  half  an 
inch. 

Another  observation  made  by  Pott  is, 
that  “ if  the  hernia  be  caused  by  a portion 
of  the  intestine  ileum  only,  it  is  in  general 
more  easily  reducible,  than  if  a part  of  the 
colon  has  descended  with  it,  which  will  also 
require  more  address  and  more  patience  in 
the  attempt.  The  reduction  of  a mere  in- 
testinal hernia  too  ( ceeteris  paribus)  will  al- 
ways remain  more  practicable,  than  that  of 
a mere  omental  one,  after  it  has  attained 
to  a certain  size  and  state,  as  the  part  con- 
tained within  the  former  is  liable  to  less  al- 
teration of  form  than  that  within  the  latter  ; 
which  alteration  has  already  been  mention- 
ed as  no  unfrequent  hinderance  of  the  re- 
turn of  an  old  caul  rupture. 

“ Not  that  the  parts  within  a mere  intes- 
tinal hernia  are  absolutely  exempt  from 
such  an  alteration  as  may  render  their  re- 
turn into  the  belly  impracticable,  even 
where  there  is  no  stricture  ; for,  says  Pott,  I 
have  seen  that  part  of  the  mesentery,  which 
has  lain  long  in  the  neck  of  the  sac  of  an  old 
rupture,  so  considerably  hardened  and  thick- 
ened, as  to  prove  an  insuperable  obstacle  to 
its  reduction.” 

Upon  the  whole,  this  author  infers,  that 
an  intestinal  rupture  is  subject  to  worse 
symptoms,  and  a greater  degree  of  hazard, 
than  an  omental  one,  though  the  latter  is, 
by  no  means,  so  void  of  either  as  it  was 
formerly  supposed  to  be  ; that  bad  symp- 
toms are  more  likely  to  attend  a recent 
rupture,  than  one  of  ancient  date  ; that  the 
descent  of  a very  small  piece  of  intestine  is 
more  hazardous  than  that  of  a larger ; and 
that  the  hernia,  which  consists  of  gut  only,  is 
in  general  attended  with  worse  circumstan- 
ces, than  that  which  is  made  up  of  both  gut 
and  caul. 

Mr.  Hey  coincides  with  Pott,  in  thinking 
the  prognosis  more  unfavourable  when  the 
tumour  is  small.  I think  it  is  not  a bad 
general  rule,  that  the  smaller  the  hernia, 
the  less  hope  there  is  of  reducing  it  by  the 
taxis  Long-continued  efforts  to  reduce  a 
prolapsed  intestine,  are  most  likely  to  suc- 
ceed in  old  and  large  hernias,  when  no  ad- 
hesions have  taken  place.”  ( Tract . Observ. 
in  Surgery,  p.  203.) 

“The  opening  (says  Mr.  Lawrence) 
through  which  the  parts  protude,  is  narrow- 
er in  some  situations  than  in  others ; the 
progress  of  the  case  will  therefore  he  more 


rapid,  and  the  danger  of  the  patient  morer 
urgent.  The  aperture  is  generally  very 
small  in  femoral  hernia  ; this  kind  of  rup- 
ture in  men,  and  the  bubonocele  in  women, 
have  a particularly  narrow  entrance.  On 
the  same  grounds,  femoral,  inguinal,  and 
umbilical  ruptures  are  more  dangerous  thau 
the  ventral,  perineal,  or  vaginal  kinds. 
{Treatise  on  Ruptures,  p.  63,  Ed.  3.) 

TREATMENT  OF  A HERNIA  CAPABLE  OF  EASY 

AND  IMMEDIATE  REDUCTION,  AND  NOT 

ATTENDED  WITH  ANY  TROUBLESOME  OU 

BAD  SYMPTOMS. 

“ This  case,”  says  Mr.  Pott,  “ is  very  fre- 
quently met  with  in  infants  and  sometimes 
in  adults,  and  is  too  often  neglected  in  both. 
In  the  former,  as  the  descent  seldom  hap- 
pens but  when  the  infant  strains  to  cry,  and 
the  gut  is  either  easily  put  up,  or  returns  svu 
sponte , as  soon  as  the  child  becomes  quiet,  it 
often  is  either  totally  unattended  to,  or  an 
attempt  made  to  restrain  it  only  by  a ban- 
dage made  of  cloth,  or  dimity,  and  which 
being  ineffectual  for  such  purpose,  lays  the 
foundation  for  future  trouble  and  mischief. 

“ This  is,  in  great  measure,  owing  to  a 
common  opinion,  that  a young  infant  can- 
not wear  a steel  truss  ; a generally  prevail- 
ing error,  and  which  ought  to  be  corrected. 
There  is  no  age  at  which  such  truss  may 
not  be  worn,  or  ought  not  be  applied ; it  is, 
when  well  made,  and  properly  put  on,  not 
only  perfectly  safe  and  easy,  but  the  only 
kind  of  bandage  that  can  be  depended  upon  ; 
and  as  a radical  cure  depends  greatly  on 
the  thinness  of  the  hernial  sac,  and  its  being 
capable  of  being  so  compressed  as  possibly 
to  unite,  and  thereby  entirely  close  the  pas- 
sage from  the  belly,  it  must  therefore  appear 
to  every  one  who  will  give  himself  the 
trouble  of  thinking  on  the  subject,  that  the 
fewer  times  the  parts  have  made  a descent, 
and  the  smaller  and  finer  the  elongation  of 
the  peritoneum  is,  the  greater  the  probabili- 
ty of  such  cure  must  be. 

“ The  same  method  of  acting  must,  for  the 
same  reasons,  be  good  in  every  age  in  which 
a radical  cure  may  reasonably  be  expected  ~r 
that  is,  the  prolapsed  parts  cannot  be  too 
soon  returned,  nor  too  carefully  prevented 
from  falling  down  again,  every  new  descent 
rendering  a cure  both  more  distant  and  more 
uncertain. 

“ As  soon  as  the  parts  are  returned,  the 
truss  should  be  immediately  put  on.  and 
worn  without  remission,  care  being  taken , 
especially  if  the  patient  be  an  infant,  to  keep 
the  parts  on  which  it  presses  constantly 
washed,  to  prevent  galling. 

“ It  can  hardly  be  necessary  to  say,  that 
the  surgeon  should  be  careful  to  see  that  the 
truss  fits,  as  his  success  and  reputation  de- 
pend on  such  care.  A truss  which  does  not 
press  enough,  is  worse  than  none  at  all,  as 
it  occasions  los3  of  time  and  deceives  the 
patient,  or  his  friends  ; and  one  which  press- 
es too  much,  or  on  an  improper  part,  gives 
pain  and  trouble,  by  producing  an  inilarn- 


HERNIA. 


9 


mation  and  swelling  of  the  spermatic  chord, 
and  sometimes  of  the  testicle. 

“ In  adults,  whose  ruptures  are  of  long 
standing,  and  accustomed  to  frequent  de- 
scent, the  hernial  sac  is  generally  firm  and 
thick,  and  the  aperture  in  the  tendon  of  the 
abdominal  muscle  large  ; the  freedom  and 
ease  with  which  the  parts  return  into  the 
belly  when  the  patient  is  in  a supine  posture, 
dnd  the  little  pain  which  attends  a rupture 
of  this  kind,  often  render  the  persons  who 
labour  under  it  careless  : but  all  such  should 
be  informed  that  they  are  in  constant  dan- 
ger of  such  alteration  in  their  complaint,  as 
may  put  them  into  great  hazard,  and  perhaps 
destroy  them.  The  passage  from  the  belly 
being  open,  the  quantity  of  intestine  in  the 
hernial  sac  is  always  liable  to  be  increased, 
and  when  down,  to  be  bound  by  a stricture 
An  inflammation  of  that  portion  of  the  gut 
which  is  down,  or  such  obstruction  in  it  as 
may  distend  and  enlarge  it,  may  at  all  times 
produce  such  complaints  as  may  put  the  life 
of  the  patient  into  imminent  danger;  and 
therefore,  notwithstanding  this  kiud  of 
hernia  may  have  been  borne  for  a great 
length  of  time,  without  having  proved  either 
troublesome  or  hazardous,  yet  as  it  is  always 
possible  to  become  so,  and  that  very  sud- 
denly, it  can  never  be  prudent  or  safe  to 
neglect  it. 

“ Even  though  the  rupture  should  be  of 
the  omental  kind,  (which  considered  ab- 
stractedly is  not  subject  to  that  degree  or  kind 
of  danger  to  which  the  intestinal  is  liable) 
yet  it  may  be  secondarily,  or  by  accident, 
the  cause  of  all  the  same  mischief  *,  for 
while  it  keeps  the  mouth  of  the  hernial  sac 
open,  it  renders  the  descent  of  a piece  of  in- 
testine always  possible,  and  consequently 
always  likely  to  produce  the  mischief  which 
may  proceed  from  thence. 

“ They  who  labour  under  a hernia  thus 
circumstanced,  that  is,  whose  ruptures  have 
been  generally  down  while  they  have  been 
in  an  erect  posture,  and  which  liave  either 
gone  up  of  themselves,  or  have  been  easily 
put  up  in  a supine  one,  should  be  particularly 
careful  to  have  their  truss  well  made,  and 
properly  fitted  ; for  the  mouth  of  the.  sac, 
and  the  opening  in  the  tendon  being  both 
large  and  lax,  and  the  parts  having  been  used 
to  descend  through  them,  if  the  pad  of  the 
truss  be  not  placed  right,  and  there  be  not  a 
due  degree  of  elasticity  in  the  spring,  a piece 
of  intestine  will,  in  some  posture,  slip  down 
behind  it,  and  render  the  truss  productive  of 
that  very  kind  of  mischief  which  it  ought  to 
prevent.”  (See  Truss.) 

Mr.  Pott  then  comments  upon  the  im- 
portance of  having  the  parts  completely  re 
duced  before  the  truss  is  applied,  and  upon 
the  danger  that  may  be  incurred  by  laying 
such  bandagC  aside  alter  it  has  been  worn 
some  time;  since  the  partial  closure  of  the 
ring,  whereby  the  descent  of  the  gut  is  ren- 
dered less  easy,  will  also  make  the  reduction 
more  difficult,  if  a piece  should  happen  to 
slip  down  ; and  hence  he  insists,  that  a truss 
u should  be  long,  and  unremittingly  worn  by 
alt  those,  whose  time  of  life  makes  the  ex- 
Vbr„  11  o 


peofations  of  a perfect  cure  reasonable, 
many  of  the  ruptures  of  adults  being  owing 
to  the  negligent  manner  in  which  children 
at  school  are  suffered  to  wear  their  trusses.” 
Besides  the  danger  of  strangulation,  ant’ 
the  loss  of  all  chances  of  a radical  cure, 
when  a reducible  hernia  is  neglected,  and  al- 
lowed to  remain  down,  there  are  other  mo- 
tives for  keeping  up  the  tumour  with  a truss, 
and  preventing  its  increase  of  size.  “The 
vast  size,  to  which  neglected  herniae  some- 
times inertase,  not  only  prohibits  all  active 
exertion,  but  by  involving,  in  the  male,  the 
integuments  of  the  penis,  incapacitates  the 
subject  from  the  act  of  copulation,  and  gives 
rise  to  excoriation  from  the  discharge  of  the 
urine  over  the  swelling.  Probably  too,  the 
testis  may  be  affected  by  the  pressure  of  a 
very  large  scrotal  hernia.  ( Morgagni  dt 

Caus.  et  Sed.  Ep.  33,  Art.  12  ; Schmurker 
Vermischte  Chir.  Sc/iriften,  B.  3,  p.  195.) 
Disorders  of  the  intestinal  functions  invari- 
ably attend  these  large  ruptures,  and  in- 
crease in  frequency  and  violence  in  propor- 
tion to  the  size  of  the  swelling,  and  age  of 
the  patient.  All  the  moveable  viscera  of  the 
abdomen  gradually  find  their  way  into  the 
hernial  sac,  if  a rupture  be  entirely  neglect- 
ed. ( Lawrence  on  Ruptures,  p.  <57,  Edit.  3. 
1816.) 

TREATMENT  OF  IRREDUCIBLE  HERNI-ST,  FREE 
FROM  INFLAMMATION,  AND  UNATTENDED 
WITH  TROUBLESOME  OR  DANGEROUS  SYMP- 
TOMS. 

Mr.  Pott,  and  all  the  best  writers  on  rup- 
tures, ascribe  the  incapacity  of  reduction,  in 
most  cases,  either  to  the  largeness  of  the  quan- 
tity of  the  contents,  an  alteration  made  in  their 
form  and  texture,  or  to  adhesions,  which 
they  have  contracted  with  e^ch  other,  or 
their  containing  bag. 

Mr.  Pott  was  also  aware,  that  ruptures  are 
sometimes  rendered  difficult  to  be  reduced, 
by  the  cttCum  being  contained  in  the  hernial 
sac.  Of  which  fact,  he  was  as  much  con- 
vinced as  the  nature  of  such  kind  of  things 
would  permit  ; that  is,  by  observations  made 
both  on  the  living  and  the  dead.  This  state- 
ment, which  w A3  made  by  Mr.  Pott  very 
many  years  back,  deserves  particular  notice, 
because  its  truth  is  confirmed  by  the  modern 
observations  of  Scarpa,  whose  very  import- 
ant explanations  of  the  cause  of  the  diffi- 
culty ot  reduction,  may  be  seen  in  the  second 
vol.  of  the  First  Lines  of  Surgery. 

Air.  Pott  has  adverted  to  the  kind  of  im- 
pediment to  reduction,  produced  by  (lie 
thickening  of  the  neck  of  i he  sac,  when  the 
hernia  is  long  neglected,  and  suffered  to  re- 
main in  the  scrotum,  without  any  bandage  to 
support  its  weight. 

The  fame  author  reckons  an  alteration 
produced  by  time,  and  constant,  though 
gentle  pressure  in  the  form  and  consistence, 
or  texture  of  tlm  omentum,  as  no  infrequent 
cause,  why  neglected  omental  ruptures  be- 
come irreducible. 

When  a portion  of  omentum  “ has  b'*en 
suffered  to  remain  for  a great  length  of  time 


10 


IlERiMA. 


in  tlie  scrotum,  ^without  Laving  ever  been  re- 
turned into  the  belly,  it  often  happens,  that, 
although  that  part  of  it,  which  is  in  the  lower 
part  of  the  hernial  sac,  preserves  its  natural 
soft,  adipose,  expansile  state,  yet  all  that 
part  which  passes  through  what  is  called  the 
neck  of  the  sac,  is,  by  constant  pressure, 
formed  into  a hard,  firm,  incompressible, 
carnous  kind  of  body,  incapable  of  being 
expanded,  and  taking  the  form  of  the  pass- 
age in  which  it  is  confined,  exactly  filling 
that  passage,  and  rendering  it  impossible  to 
push  up  the  loose  part  which  fills  the  scro- 
tum. 

“ The  same  reason  for  incapacity  of  reduc- 
tion is  also  sometimes  met  wiih  in  ruptures 
of  the  intestinal  kind,  from  an  alteration 
produced  on  that  part  of  the  mesentery 
which  has  been  suffered  to  lie  quiet  for  a 
great  length  of  time  in  the  neck  of  an  old 
hernial  sac. 

“ The  other  impediment,  which  I mention- 
ed to  the  return  of  old  ruptures,  is  the  con- 
nexion and  adhesion  of  the  parts, either  with 
each  other,  or  with  the  bag  containing  them. 
This  is  common  to  both  the  intestinal  and 
omental  hernia,  and  is  produced  by  slight  in- 
flammations of  the  parts  which  have  been 
permitted  to  lie  long  in  contact  with  each 
other,  or  perhaps  in  many  cases  from  the 
mere  contact  only.  T ese  adhesions  are 
more  or  less  firm  in  different  cases,  but  even 
the  slightest  will  almost  always  be  found  an 
invincible  objection  to  the  reduction  of  the 
adherent  parts,  by  the  hand  only. 

“ Many,  or  perhaps  most  of  these  irreduci- 
ble ruptures  become  so  by  mere  time  arid 
neglect,  and  might  at  first  have  been  return- 
ed ; hut  when  they  are  got  into  this  state, 
they  are  capable  of  no  relief  from  surgery, 
but  the  application  of  a suspensory  bag.  to 
take  off  or  lessen  the  inconvemence  arising 
from  the  weight  of  the  scrotum. 

“People  in  this  situation  should  he  parti- 
cularly careful  not  to  make  any  attempts  be- 
yondtheir  strength,  nor  aim  at  feats  of  agility; 
they  should  take  care  to  suspend  the  loaded 
scrotum,  and  to  keep  it  out  of  the  way  of  all 
barm  from  pressure,  bruise,  &,c.  When  the  tu- 
mour is  very  large,  asoftquilted  bolster  should 
be  worn  at  the  bottom  of  the  suspensory,  to 
prevent  excoriation,  a id  the  scrotum  should 
be  frequently  washed  for  tlie  same  reason  ; 
a loss  of  skin  in  this  part,  and  in  such  cir- 
cumstances, being  sometimes  of  the  utmost 
importance.  They  ought  also  to  be  particu- 
larly attentive  to.  the  office  of  the  intestinal 
canal,  to  see  that  they  do  not  by  any  irregu- 
larity of  diet  disorder  it,  and  keep  themselves 
from  being  costive.”  Mr.  Pott  observes, 
however,  that  the  quiet,  inoffensive  state  of 
this  kind  of  hernia  is  by  no  means  to  be  de- 
pended upon  ; many  things  may  happen  to 
it,  by  which  it  may  be  so  altered,  as  to  be- 
come hazardous,  and  even  fatal  : an  inflam- 
mation of  that  part  of  the  gut  which  is  down, 
any  obstruction  to  tlie  passage  of  the  aliment 
or  feces  through  it,  a stricture  made  by  the 
abdominal  tendon,  either  on  what  has  been 
long  down,  or  on  a new  portion  which  may 
at  any  time  he  added  to  it,  are  always  capa- 


ble of  so  altering  the  stale  of  the  case,  as  to 
put  the  life  of  the  patient  into  danger. 

“Indeed  the  hazard  arising  from  a stric- 
ture made  on  a piece  of  intestine  contained 
in  the  sac  of  an  old  irreducible  hernia,  is  in 
one  respect  greater  than  that  attending  one 
that  has  been  found  at  times  reducible; 
since  from  the  nature  of  the  case  it  will 
haidly  admi'  of  any  attempl  toward  relief, 
but  the  operation,  which  in  these  circum- 
stances must  necessarily  be  accompanied 
with  additional  difficulty. 

“ Among  the  ruptures,  which  have  been 
thought  not  reducible,  and  treated  as  such, 
there  have  been  some  which,  upon  more  ju- 
dicious and  more  patient  attempts,  have  beeu 
found  capable  of  reduction. 

“ When  this  is  suspected  to  be  the  case, 
the  proper  method  is  by  absolute  rest,  in  a 
supine  posture,  for  a considerable  length  of 
time,  by  great  abstinence,  and  the  use  of 
evacuants,  so  as  to  lessen  the  size  of  the 
partsin  the  hernial  sac,  and  render  ihem  ca- 
pable of  passing  hack  again  into  the  belly.” 
(Pott  on  Ruptures.) 

Fabrn-ius  Hildanus  gives  an  account  of  a 
man  who  was  radically  cured  of  a rupture,  of 
twenty  years  date,  bv  six  months  confine- 
ment to  bed.  (Cent.  5.  Obs.  54.) 

Le  Dran  and  Arnaud  relate  instances  of 
monstrou-  bubonoceles,  which  disappeared 
entirely  after  the  patients  had  been  long 
confined  to  bed,  and  rendered  much  emaci- 
ated by  tedious  illnesses.  Some  of  the  mo- 
derns have  imitated  this  operation  of  nature, 
and  by  frequent  bleedings,  arid  repeated  pur- 
ges, h -ve  sometimes  so  far  reduced  the  size 
of  the  hernia,  that  it  has  been  returned  into 
the  abdomen.  Mr.  Hey  has  several  times 
succeeded  in  this  way.  (P.  219.)  But  the 
practice  cannot  prove  successful,  when  the 
viscera  adheres  to  the  sac,  or  to  the  perito- 
neum, just  within  the  abdomen  The  great- 
est objection  to  this  method  of  cure,  is  the 
want  of  an  absolute  criterion  for  distinguish- 
ing when  the  parts  do,  or  do  not  adhere  to 
the  hernial  sac,  and  in  advanced  years, 
though  one  were  sure  that  the  viscera  were 
free  from  the  sac,  the  possibility  of  hurting 
the  body  by  the  necessary  evacuations,  is 
also  another  objection.  ( Sharp’s  Critical 

Inquiry,  p.  15.) 

Were  the  plan  to  he  thought  worthy  of 
trial,  keeping  up  a constant  pressure  on  the 
tumour,  by  means  of  a suspensory  bandage, 
made  to  lace  in  front,  would  be  proper  for 
promoting  the  absorption  of  the  thickened 
parts  in  the  hernial  sac.  Mr.  A.  Cooper  has 
reduced  such  hernia?,  after  applying  ice  to 
them,  the  good  effects  of  which  he  imputes 
to  its  producing  a contraction  of  the  scro- 
tum, and  thus  a strong  and  permanent  com- 
pression of  the  tumour.  Mr.  Earle  lately  in- 
formed me  of  a method  of  keeping  up  a ge- 
neral pressure  on  the  swelling,  by  means  of 
a bladder  containing  quicksilver,  the  quanti- 
ty of  which  can  be  regulated  according  to 
circumstances. 

Whenever  any  attempts  of  this  kind  suc- 
ceed, a truss  should  he  immediately  put  on, 
und  \Vorn  constantly  without  remission 


HERNIA. 


11 


However,  there  are  instances  on  rpcord, 
where  the  capacity  of  the  abdomen  had  be 
come  so  adapted  to  the  diminished  quantity  of 
the  viscera,  that  when  the  contents  ot  the 
hernia  were  reduced,  serious  complaints 
arose  from  their  introduction  into  the  belly 
Sell  mucker  met  with  several  such  cases,  in 
which  he  wa*  obliged  to  take  off  the  truss 
again.  Petit  has  known  the  reduction  of  a 
hernia  of  this  kind  prove  fatal,  the  parts  not 
descending  again  when  the  truss  was  remo- 
ved, the  nausea  and  vomiting  continuing,  and 
peritonitis  taking  place.  ( Chirurgische 
Wahrnehm  ungen , Vol.  2,  p.  243.  Traiti  des 
Maladies  Chir.  T.  2.  p.  392.) 

Mr.  Pott  remarks,  that  “ an  omental  rup- 
ture, which  has  been  so  long  in  the  scrotum 
as  to  have  become  irreducible,  is  very  seldom 
attended  with  any  bad  symptoms,  considered 
abstractedly  ; but  it  is  constantly  capable  of 
being  the  occasion  of  an  intestinal  hernia, 
and  all  its  consequences  ; neither  is  that  all, 
for  the  omentum,  either  so  altered  in  form 
and  texture,  or  so  connected  as  to  he  incapa- 
ble of  reduction,  may  by  accident  inflame, 
and  either  become  gangrenous,  or  suppurate, 
and  the  occasion  of  a great  deal  of  trouble.” 
In  a few  instances,  epiploceles  produce  very 
bad  symptoms  indeed,  cases  of  which  are  to 
be  found  in  Garengeot,  Dionis,  Sz.c. 

Sometimes  in  old  cases  of  entero-epiplo- 
cele,  the  intestine  is  reducible,  but  the  omen- 
tum is  not,  in  which  case  some  writers  advise 
keeping  up  the  piece  of  bowel  with  a truss, 
the  pad  of  which  must  be  so  contrived  as  not 
to  press  on  the  omentum.  Mr.  Pott,  how- 
ever, considers  this  method  not  often  practi- 
cable, and  should  such  a truss  be  used,  he  re- 
commends great  caution  in  its  construction 
and  application,  lest  a small  piece  of  gut 
slip  down,  and  being  pressed  on  by  the  truss, 
produce  fatal  mischief. 

“ Irreducible  herniae  must  of  course  be  ex- 
posed to  all  the  consequences  of  external 
injury  and  violence  ; hence,  various  cases 
are  recorded,  in  which  the  bowels  have  hewn 
burst  by  blows,  falls,  &u.”  ( Lawrence  on 
Ruptures,  p.  1 10  Edit.  3.) 

For  examples  of  such  accidents.  .VIr.  Law- 
rence refers  to  A.  Cooper  on  Hernia , Part  2, 
Pref.  p.  2,  and  to  Travers's  Inq.  into  the  Pro- 
cess of  Nature , fyc.  p.  37.  A case  is  also 
quoted  from  Scarpa,  p.  310,  where  a violent 
exertion  caused  a sudden  return  of  a hernia, 
which  had  been  long  regarde  I as  cured.  The 
viscera  lay  in  the  tunica  vaginalis,  which 
was  burst  to  the  extent  of  an  inch. 

SYMPTOMS  AND  TREATMENT  OF  A STRANGU- 
LATED, OR  AN  INCARCERATED  ITERNI A. 

MEANS  TO  BE  TRIED,  BEFORE  AN  OPERA- 
TION. 

“ Difficulty  of  reduction  'says  Pott)  may 
be  owing  to  several  causes.  The  size  of  the 
piece  of  omentum,  or  the  inflamed  state  of 
it ; the  quantity  of  intestine  and  mesentery, 
an  inflammation  of  the  gut,  or  its  distention 
by  feces,  or  wind  : or  the  smallness  of  the 
aperture  of  trie  tendon,  through  which  the 
hernia  passes.  But  to  whatever  cause  it  be 


owing,  if  the  prolapsed  body  cannot  be  im- 
mediately replaced,  and  the  patient  suffers 
pain,  or  is  prevented  thereby  from  going  to 
stool,  it  is  called  an  incarcerated  hernia , a 
strangulated  hernia, or  a hernia  tcitli  stricture. 

l'  The  symptoms  are  a swelling  in  the 
groin,  or  scrotum,  resisting  the  impression  of 
the  fingers  : if  the  hernia  be  of  the  intestinal 
kind,  it  is  generally  painful  to  the  touch,  and 
the  pain  is  increased  by  coughing,  sneezing, 
or  standing  upright.  These  are  the  very 
first  symptoms,  and  if  they  are  not  relieved, 
are  soon  followed  by  others,  viz.  a sickness 
at  the  stomach,  a frequent  retching,  or  incli- 
nation to  vomit,  a stoppage  of  all  discharge 
per  anum,  attended  with  a frequent,  hard 
pulse,  and  some  degree  of  fever.” 

A patient,  thus  circumstanced,  is  in  some 
danger,  and  demands  immediate  assistance. 
A stricture  made  on  the  prolapsed  part  of 
the  gut,  by  the  aperture  through  which  it 
passes,  is  the  immediate  cause  of  all  the  bad 
symptoms,  and  of  course,  the  removal  of 
such  stricture  is  the  only  thing  which  can 
bring  relief.  This  object  can  only  be  accom- 
plished by  returning  the  bowel  back  into  the 
abdomen,  or  dividing  the  parts  which  form 
the  stricture.  The  former  plan  is  always 
the  most  desirable,  when  practicable. 

We  next  proceed  to  notice  the  various 
measures  to  be  adopted  for  the  relief  of  a 
strangulated  hernia,  so  as  to  obtain  the  best 
chance  of  doing  away  the  necessity  of  an 
operation.  After  treating  of  the  merits  of 
each  plan,  a few  remarks  will  he  offered  on 
the  order  in  which  the  means  should  be  put 
in  practice. 

Taxis — This  is  the  term  applied  to  the 
operation  of  reducing  a hernia  with  the 
hand.  It  is  much  promoted  by  the  position 
of  the  body  ; which  Winslow  thought  should 
be  placed  on  an  inclined  plane,  and  the 
thighs  bent  towards  the  trunk.  Mr.  A. 
Cooper  advises  the  same  practice,  observ- 
ing, that  this  posture,  by  relaxing  the  fascia 
of  the  thigh,  relaxes  also  the  aperture, 
through  which  the  hernia  passes.  Every 
degree  of  tension,  and  relaxation  of  the  fe 
moral  fascia,  must  undoubtedly  he  attended 
with  a corresponding  change  in  the  abdo- 
minal ring.  But  flexion  of  the  thigh,  besides 
relaxing  this  fascia,  also  relaxes  the  abdo- 
minal, internal  iliac,  and  psoas  muscles.  In 
cases  of  inguinal  hernia,  the  pressure  made 
on  the  tumour  by  (he  hands  of  the  surgeon, 
should  always  be  directed  upwards  and  out- 
wards, along  the  course  of  the  spermatic 
cord,  and  Mr.  A.  Cooper  advises  it  to  be 
continued  from  a quarter  to  half  an  hour. 
(On  Inguinal  and  ('ongenital  Hernia.) 

As  the  femoral  hernia  passes  downwards, 
and  then  forwards,  the  pressure  must  be  di- 
rected first  backwards,  and  then  upwards. 
No  violence  should  ever  he  used  ; for,  be- 
sides being  unavailing,  it  greatly  aggravates 
the  inflamed  state  of  the  contents  of  the  her- 
nial sac,  and  has  been  known  even  to  burst 
the  intestine.  (See  Cooper  on  Inguinal  Her- 
nia. <^*r.  p.  23.) 

Besides  bending  the  thigh,  care  should 
also  be  taken  to  rotate  it  inwards,  wljich  will 


1 2 


HERNIA. 


have  great  effect  in  relaxing  the  femoral 
lascia,  and  tendon  of  the  external  oblique 
muscle.  Suspension  of  the  patient  over  the 
shoulders  of  an  assistant  has  been  thought 
to  facilitate  reduction  : “ I have  tried  it  of- 
ten, (says  Mr.  Hey;)  but  have  not  found  it 
to  be  of  such  superior  efficacy,  as  some  au- 
thors have  represented.’’  (P.  144.) 

The  return  of  a piece  of  intestine  is  gene? 
rally  preceded  by  a peculiar  noise,  caused 
by  the  passage  of  air  through  the  stricture. 
It  recedes  at  first  gradually,  and  then  slips 
up  suddenly.  The  omentum  goes  up  slow- 
ly to  the  very  last  portion,  which  must  be 
actually  pushed  through  the  opening.  If  the 
taxis  should  not  succeed  at  first,  it  will  often 
do  so  after  the  warm  bath,  bleeding,  or  cold 
applications.  Small  hernias,  being  attended 
with  the  closest  stricture,  are  the  most  diffi- 
cult to  reduce,  and  for  the  same  reason,  cru- 
ral ruptures  do  not  so  often  yield  to  the 
taxis,  as  inguinal  hernia?  in  the  male  subject. 
The  taxis  becomes  less  likely  to  succeed, 
the  longer  the  inflamed  viscera  have  been 
down,  because  adhesions  are  liable  to  form. 
Mr.  Lawrence  observes,  ( p . 6^.)  a VVfien 
the  rupture  becomes  painful,  we  are  no 
longer  justified  in  persevering  in  attempts  at 
reduction  by  the  hand.  A sufficient  pressure 
cannot  now  be  endured;  and  the  force 
which  is  employed  only  tends  to  increase 
the  inflammation,  and  accelerate  the  ap- 
proach of  gangrene.  At  this  period  the  ope- 
ration is  required , and  should  be  performed 
vjithout  delay'"  Desault  even  proscribed  the 
taxis  altogether  in  the  inflammatory  strangu- 
lation, until  the  previous  use  of  other  means 
had  produced  a change  in  the  state  of  the 
swelling, 

That  the  taxis  is  frequently  abused,  and  the 
cause  of  serious  mischief;  is  a truth  which 
cannot  be  doubled.  “ Strangulated  herniae, 
(says  Scarpa)  very  frequently  mortify  from 
the  negligence  of  the  patients,  and  their  re- 
pugnance to  submit  to  an  operation,  and 
perhaps,  still  more  frequently  from  the  effect 
of  the  taxis,  unskilfully  exercised  by  unin- 
formed surgeons,  who  are  determined,  at 
any  price  whatsoever,  to  accomplish  the 
speedy  reduction  qf  the  viscera.  The  ma- 
jority of  them  make  no  distinction  between 
the  acuta  and  the  chronic  strangulation.  In 
both  cases,  no  sooner  are  the  symptoms  of 
strangulation  evinced,  than  they  begin  to 
handle  the  swelling  roughly,  and  to  push  the 
viscera  with  all  their  force,  in  order  to  make 
them  return  into  the  abdomen  ; whilst,  when 
the  strangulation  is  acute , and  the  patient 
young  and  strong,  the  taxis  ought  never  to 
be  practised,  before  all  the  means  proper  for 
diminishing  the  strength,  calming  spasm, 
and  relaxing  the  parts  which  are  to  be  re- 
duced, havr  been  employed  for  a certain 
time.  These  means  we  know,  are  bleed- 
ings, fomentations,  emollient  clysters,  and 
especially  the  warm  bath,  which,  next  to 
bleeding,  holds  the  first  rank.  At  this  school 
of  surgery,  I have  frequently  had  opportuni- 
ties of  observing  the  salutary  effect  of  this 
treatment.  My  pupils  have,  more  than 
once,  seen  hernia4,  which  had  been  painfully 


handled  without  any  good,  reduced,  as  it 
were,  spontaneously,  after  a bleeding,  or 
whilst  the  patient  was  in  the  bath.  If  what 
I have  said  upon  the  subject  of  the  acute 
strangulation,  and  the  treatment  that  it  re- 
quires, w<  re  generally  known  by  surgeons, 
I think  that  operations  for  strangulated  her- 
nia? would  be  less  frequent.  Things  are  dif- 
ferent with  regard  to  the  chronic  strangula- 
tion of  old  large  hernia?,  in  feeble,  or  aged 
persons  , for  in  these  cases,  it  is  of  great  im- 
portance to  support  the  patient’s  strength. 
Bleeding,  the  warm  bath,  and  other  weak- 
ening means,  should  also  be  avoided,  which, 
in  producing  a general  atony,  might  bring 
on  gangrene  of  the  intestine,  either  during 
the  strangulation,  or  after  the  reduction  of 
the  viscera.  It  is  ascertained  that  these 
kinds  of  strangulation  are  almost  always  oc- 
casioned by  an  accumulation  of  fecal  mat- 
ter, or  an  extraordinary  quantity  of  air  in 
the  hernia.  Nothing  is  more  efficacious  than 
cold  applications,  for  promoting  the  action 
of  the  bowel  on  the  matter  which  distends 
it,  or  for  lessening  t lie  volume  of  the  air. 
They  produce  a corrugation  of  all  the  scro- 
tum, and  contractions  of  the  cremaster, 
which  alone  sometimes  suffice  for  reducing 
the  viscera,  in  a much  better  manner  than 
could  be  done  by  the  hands  of  the  most  ex- 
perienced surgeon.”  ( Scarpa , Traitts  dcs 
Hernies , p.  244 — 247.) 

Bleeding. — The  inflammation  which  at- 
tacks the  protruded  viscera,  and  spreads 
thence  over  the  whole  abdomen,  and  the 
temporary  weakness  and  often  fainting, 
which  the  sudden  loss  of  blood  induces,  and 
vyhich  is  a peculiarly  favourable  opportunity 
for  reducing  the  hernia  by  the  hand,  are 
the  reasons  in  favour  of  bleeding.  Sharp, 
Pott,  B.  Bell,  Sabatier,  Richter,  Callisen, 
and  Scarpa,  names  which  can  never  be  sur- 
passed in  respectability,  are  all  subscribed 
in  favour  of  bleeding.  Wilmer,  Alanson,  and 
A.  Cooper,  have  published  against  the  prac- 
tice. Mr.  Hey  has  related  two  cases,  whiefi 
strongly  evince  the  manner  in  which  bleed- 
ing facilitates  the  return  of  a hernia  : the 
protruded  viscera,  in  one  instance,  went  up 
spontaneously,  on  blood  being  taken  away  ; 
in  the  other,  the  taxis  succeeded  immedi- 
ately afterward,  though  the  previous  attempt 
had  been  made  in  vain.  (P.  125, 126.)  Mr. 
Hey’s  experience,  however,  leads  him  to 
concur  so  far  with  Wilmer  and  Alanson,  as 
to  declare,  that  bleeding  has  generally  fail- 
ed to  procure  a reduction  of  the  strangula- 
ted intestine,  though  he  is  persuaded,  that 
in  many  cases  it  may  be  used  with  advan- 
tage. But  he  cannot  agree  with  Wilmer, 
that  it  generally  renders  the  subsequent 
operation  more  dangerous.  (P.  126.)  The 
majority  of  candid  practitioners  1 believe 
will  allowr,  that  bleeding  is  always  proper 
when  the  hernia  is  small  and  recent ; the 
abdomen  tense  and  painful  ; and  the  patient 
young,  strong,  and  plethoric. 

Purgative  Medicines. — My  experience,  (says 
Mr.  Hey)  leads  me  to  condemn  almost  uni- 
versally the  use  of  purgatives,  while  an  in- 
testine remains  firmly  strangulated.  In  the 


HERNIA. 


13 


entero-epiplocele,  when  the  intestine  has 
retired,  and  the  omentum  remains  strangu- 
lated : or  in  a simple  strangulation  of  the 
omentum,  where  the  intestine  has  not  been 
prolapsed,  purgatives  are  of  great  utility. 
So  likewise  in  very  large  and  old  hernias, 
where  there  is  reason  to  doubt,  whether  she 
disease  is  not  to  be  considered  as  a morbid 
affection  of  the  intestinal  canal,  rather  than 
the  effect  of  strangulation,  purgatives  may 
be  as  useful  as  in  the  simple  ileus  without 
hernia.  While  the  intestine  remains  firmly 
strangulated,  they  usually  increase  the  vo- 
miting, and  add  to  the  distress  of  the  patient. 
If  they  are  to  be  tried  at  any  time  with  hope 
of  success,  the  trial  would  appear  to  have 
the  greatest  advantage  when  the  vomiting 
has  been  removed  by  means  of  an  opiate  ; 
yet  I have  repeatedly  given  them  in  vain 
during  such  an  interval  of  relief  (Practi- 
cal Observations  in  Surgery,  p.  128.) 

Purgatives  are  supposed  to  operate  by  ex- 
eitinglhe  peristaltic  action  of  the  intestine, 
and  thereby  extricating  it  from  the  stricture. 
Besides  the  above  eminent  surgeon,  Pott 
and  Richter  have  joined  in  their  general 
condemnation,  and  to  all  appearances,  with 
very  great  reason.  Purgative  clysters  cer- 
tainly have  not  the  objection  of  increasing 
the  irritation  ; but  their  efficacy  is  not  de- 
serving of  much  confidence.  Mr.  Hey  says,, 
that  he  has  never  seen  one  case,  in  which 
either  purgative,  or  emollient  clysters,  pro 
duced  a return  of  a strangulated  hernia. 
Such  injections  will  empty  the  large  intes- 
tines ; but  they  do  no  more.  It  is  common 
also  for  a natural  evacuation  to  be  the  im- 
mediate consequence  of  strangulation.  (P 
131.) 

WarmBath. — u Many  instances  (says  Hey) 
are  upon  record  of  the  good  effect  of  warm 
bathing  in  procuring  the  reduction  of  a stran- 
gulated hernia.  I have  often  seen  it  use- 
ful ; but  I have  also  often  seen  it  fail.  When- 
ever it  is  used  in  this  disease,  the  patient 
should  be  placed,  if  possible,  in  a horizontal 
position.  Gentle  efforts  with  the  hand  to 
reduce  the  prolapsed  part  are  perhaps  at- 
tended with  less  danger,  and  with  greater 
prospect  of  success,  while  the  patient  lies 
in  the  bath,  than  in  any  other  position.  The 
free  use  of  opiates  coincides  with  that  of 
warm  bathing,  and  under  some  circumstan- 
ces, these  means  deserve  to  be  tried  in  con- 
junction ” (P.  132.) 

Cold  Bath , and  Cold  Applications. — The 
cold  bath,  and  dashing  of  cold  water  on  the 
patients,  are  little  to  be  depended  upon, 
though  success  has  sometimes  been  obtain- 
ed in  this  manner.  (Petit, Truitt  dcs  Chir. 
T.  2,  p.  325 ; Hey,  p.  136.) 

Wilmer  strongly  recommended  the  appli- 
cation of  cold  to  the  tumour  itself,  and  this 
plan  has  acquired  the  approbation  of  the 
most  celebrated  modern  surgeons.  It  is  gc 
nerally  tried  in  conjunction  with  the  effect 
of  tobacco  clysters,  which  will  be  j scntly 
noticed.  Cold  applications,  in  the  form  of 
ice,  were  indeed  particularly  recommended 
by  B.  Bell.  The  best  way  is  to  pound  the 
|ce,  tie  it  up  in  a bladder,  and  place  it  on 


the  rupture.  When  ice  cannot  be  procured, 
Mr.  A.  Cooper  employs  a mixture  of  equal 
parts  of  nitre  and  muriate  of  ammonia.  To 
one  pint  of  water,  in  a bladder,  ten  ounces 
of  the  mixed  salts  are  to  be  added  “ If, 
after  four  hours,  (savs  this  distinguished 
surgeon)  the  symptoms  become  mitigated, 
and  the  tumour  lessens,  this  remedy  may  be 
persevered  in  for  some  time  longer;  but,  if 
they  continue  with  unabated  violence  and 
the  tumour  resist  everv  attempt  at  reduction 
no  farther  trial  should  be  made  of  the  appli- 
cation.” (On  Inguinal  and  Congenital  Her- 
nia.) When  ice  is  not  at  hand,  aether  some- 
times proves  a good  substitute'  when  allow- 
ed to  evaporate  from  the  surface  of  the 
swelling. 

Care  must  be  taken,  that  the  cold  be  not 
so  applied  as  to  freeze  the  scrotum,  and 
bring  on  sloughing.  (A.  Cooper,  p.  15.) 

Opiates. — Mr.  Hey  met  with  several  cases 
in  which  opiates,  given  freely,  (in  athletic 
persons  after  bleeding)  procured  a reduc- 
tion of  strangulated  hernia. 

He  cannot  say,  however,  that  this  remedy 
is  generally  successful ; but  it  has  the  advan- 
tage of  removing,  for  a time,  the  pain  and 
vomiting  usually  attendant  on  strangulation, 
even  though  it  prove  ultimately  inefficacious. 
Opiates  should  he  given  in  large  doses,  when 
it  is  wished  to  try  their  effect  in  procuring 
reduction  ; and  whenever  the  symptoms  of 
strangulation  return,  after  having  been  re- 
moved bv  opiates,  the  operation  should  be 
performed  without  delay.  (P.  134,  135.) 

Tobacco  Clysters.—  For  this  purpose,  some 
surgeons  prefer  a decoction  of  tobacco, 
made  by  infusing,  or  boiling,  one  dram  of 
the  plant  for  ten  minutes  in  a pint  of  water  ; 
others  employ  the  smoke,  which  is  prepared 
and  introduced  into  the  rectum  by  means  of 
an  apparatus,  sold  at  almost  every  surgical 
instrument  maker's.  Perhaps  both  methods 
are  equally  efficacious  ; but,  as  one  requires 
an  apparatus,  while  the  other  does  not,  and 
is  equally  proper,  the  decoction  may  be 
entitled  to  most  recommendation.  The  ma- 
chine for  the  smoke  is  also  frequently  out 
of  order.  Next  to  the  operation,  tobacco 
clysters  are  the  most  certain  means  of  bring- 
ing about  the  reduction  of  the  strangulated 
parts.  Besides  exciting  the  action  of  the 
intestines,  they  exert  a peculiar  depress- 
ing influence  on  the  whole  system,  reducing 
the  pulse,  i.nd  causing  nausea  and  sickness, 
cold  sweats  and  fainting,  under  which  cir- 
cumstances the  parts  often  recede,  sponta- 
neously, or  may  be  easily  reduced.  Mr.  A 
Cooper  prudently  advises  injecting  half  the 
above  quantity  at  first ; for  he  has  seen  two 
drams,  and  even  one,  when  used  as  an  in- 
fo- on,  and  introduced  at  once,  prove  fatal. 
(P.  24.)  The  rest  should  he  injected  pre- 
sently, when  it  appears  that  the  tobacco 
does  not  operate  with  the  extraordinary  vio- 
lence with  which  it  does  in  a few  particular 
constitutions. 

A case  recently  published  by  Mr.  C.  Bell 
I oks  to  me  very  much  like  an  example  of 
t’  e occasional  poisonous  effects  of  the  to- 
bacco clyster,  though  not  reported  as  such 


14 


HERNIA. 


by  the  author.  At  least,  no  particulars  of 
any  fatal  mischief,  either  in  the  tumour  or 
abdomen,  are  detailed,  and  it  is  remarked 
of  the  patient:  “ His  strength  held  up  until 
the  tobacco  clyster  was  administered  to  him, 
after  which  he  very  suddenly  fell  low,  and 
sunk.”  (Surgical  Obs  Part  2 ,p  189.)  The 
smoke  proved  fatal  in  an  instance  witnessed 
by  Desault,  ((Euvres  >le  Chir.  T 2,  p.  344.) 
and  an  infusion  of  3'j-  1°  ^viij.  °f  water, 
seemed  to  produce  sudden  mortal  effects  in 
another  example  on  record.  ( Edinb . Med. 
and  Surgical  Journ.  Vol.  9 ,p.  159.) 

Poultices  and  Fomentations  have  not  the 
confidence  of  any  experienced  or  intelligent 
surgeon  Whoever,  in  these  urgent  cases, 
wastes  time  in  trying  the  effects  of  such 
applications,  merits  censure  for  his  credulity, 
ignorance,  and  unfitness  to  undertake  the 
treatment  of  a rapid  disease,  in  which,  as 
Pott  remarks,  if  we  do  not  get  forward,  we 
generally  go  backward  ; and  whatever  does 
no  good,  if  it  be  at  all  depended  upon,  cer- 
tainly does  harm,  by  occasioning  an  irre- 
trievable loss  of  time. 

OF  THE  ORDER  IN  WHICH  THE  PRECEDING 

METHODS  AND  REMEDIES  SHOULD  BE 

TRIED,  AND  OF  THE  TIME  WHEN  THE 

OPERATION  SHOULD  NOT  BE  DELAYED. 

In  the  treatment  of  a strangulated  hernia, 
a surgeon  cannot  be  too  deeply  impressed 
with  the  danger  of  spending  time  in  the 
triai  of  methods  of  inferior  efficacy,  or  of 
such  as  are  evinced  to  be  ineffectual  in  the 
cases  before  them. 

The  rapidity  with  which  gangrenous  mis- 
chief sometimes  arises,  and  the  palien'  loses 
his  life,  has  been  proved  in  a multitude  of 
unfortunate  examples,  and  should  operate 
as  a warning  to  all  practitioners  against  the 
danger  of  deferring  the  operation  too  long. 
In  the  course  of  rny  reading,  however,  I 
have  not  met  with  so  remarkable  an  instance 
of  the  sudden  mortification,  and  rapidly 
fatal  termination  of  a hernia,  as  the  follow- 
ing case  recorded  by  Baron  Larrey,  in 
speaking  of  the  fatiguing  and  forced  marches 
performed  by  the  French  soldiers  in  Egypt. 
These  marches,  he  says,  brought  on  in  one 
case,  ‘ a hernia  which  formed  suddenly,  and 
became  at  the  same  time  strangulated.  The 
man  was  immediately  brought  to  my  ambu- 
lance ; but  a spontaneous  gangrene,  which 
had  all  on  a sudden  attacked  the  intestine, 
and  extended  to  the  other  abdominal  vis- 
cera, caused  the  patient’s  death  in  the  space 
of  two  hours,  and  made  it  impossible  for  me 
to  do  the  operation  for  him.  This  is  the 
second  example  that  I have  been  acquainted 
with,  in  which  the  effects  of  the  accident 
were  thus  rapid.”  ( Larrey , in  Mem.  de  Chi- 
rurgie  MiUlaire,  T 1,  p 196.) 

The  taxis  is  generally  among  the  first 
things  to  be  tried,  and  Mr.  A.  Cooper 
thinks  the  attempts  should  be  continued  for 
a quarter  or  half  an  hour.  ‘When  these 
have  been  ineffectual,  the  patten'.  if  the 
circumstances  do  not  forbid,  should  be  im- 
mediately bled,  and  have  a large  opening 


made  in  the  vein,  so  that  the  suddenness  of 
the  evacuation  may  be  most  likely  to  bring 
on  fainting.  The  taxis  should  then  be  tried 
again. 

When  the  strangulation  is  very  acute,  and 
the  patient  young  and  strong,  perhaps  it 
may  be  most  adviseahle  to  follow  the  advice 
delivered  bv  Scarpa  and  Desault,  which  is 
to  bleed  the  patient  and  put  him  in  the 
warm  bath,  before  the  taxis  is  attempted  at 
all. 

If  bleeding  alone  has  been  practised,  and 
the  manual  efforts  at  reduction  should  not 
now  succeed,  the  warm  bath  may  be  em- 
ployed, provided  it  can  be  got  ready  in  a very 
short  time,  but  none  should  ever  be  lost  in 
waiting  for  it  to  be  prepared.  When  the 
bath  is  used,  the  taxis  may  be  attempted  as 
the  patient  lies  in  the  water  ; a situation  in 
which  I have  succeeded  in  reducing  several 
herniae. 

Certainly  not  more  than  one  hour  should 
ever  be  allotted  for  putting  in  practice  the 
first  attempts  at  reduction,  bleeding,  and  the 
warm  bath. 

The  plan  should  be,  while  the  trial  of  one 
thing  is  going  on,  another  should  be  pre- 
paring. So  when  the  preceding  measures 
have  been  tried  in  vain,  the  application  of 
a bladder  filled  with  ice,  or  the  solution  of 
nitre  and  muriate  of  ammonia,  and  the  in- 
jection of  tobacco,  in  the  form  of  smoke  or 
decoction,  should  never  be  delayed  for  want 
of  due  previous  preparation  of  all  the  requi- 
sites. Both  these  measures  should  be  prac- 
tised at  the  same  time,  immediately  after 
the  failure  of  the  taxis,  bleeding,  and  the 
warm  bath.  Mr.  A Cooper  computes,  that 
four  hours  are  enough  for  the  trial  of  the 
tobacco  clyster,  together  with  cold  appli- 
cations. 

In  omental  herniae,  the  necessity  for  ope- 
rating may  frequently  be  obviated  by  the 
good  effects  of  bleeding,  purgative  medi- 
cines, and  clysters,  and  leeches  applied  to 
the  tumour.  Mr.  Lawrence  has  justly  ob- 
served, that  “ when,  as  it  very  frequently 
happens,  the  aid  of  the  surgeon  is  not  requi- 
red until  the  complaint  has  lasted  for  some 
time,  a trial  of  the  tobacco,  together  with 
the  topical  use  of  cold,  should  be  immedi- 
ately resorted  to,  as  circumstances  will  not 
admit  of  delay  in  the  previous  use  of  less 
powerful  remedies  (P.  148,  Edit.  3.) 

Every  man  who  has  seen  much  of  herniae 
will  immediately  recognize  the  propriety  of 
the  following  sentiments  of  the  experienced 
Mr.  Hey: 

“ I can  scarcely  press  in  too  strong  terms 
the  necessity  of  an  early  recourse  to  the 
operation,  as  the  most  effectual  method  of 
preserving  life  in  this  dangerous  disease.  If 
Mr.  Pott’s  opinion  be  true,  that  the  opera- 
tion, when  performed  in  a proper  manner, 
and  in  due  time,  does  not  prove  the  cause 
of  death  often er  than  perhaps  once  in  fifty 
times;  it  would  undoubtedly  preserve  the 
lives  of  many,  to  perform  >t  almost  as  soon  as 
the  disease  commenced,  without  inc  reasing 
the  danger  by  spending  much  time  in  the 


HERNIA. 


15 


use  of  means  which  cannot  be  depended 
upon  for  a cure. 

“ I have  twice  seen  this  disease  prove 
fatal  in  about  twenty-four  hours.  In  such 
cases,  it  is  evident  there  is  little  time  for 
delay.  A surgeon  who  is  competent  to  per- 
form the  operation,  is  not  perhaps  consulted 
till  the  intestine  is  on  the  point  of  being 
mortified,  or  is  actually  in  a state  of  mortifi 
cation.  The  dilemma  into  which  he  is  then 
cast  is  painful  indeed.  But,  when  the  fullest 
opportunity  is  afforded  him  of  using  the  best 
mode  of  treatment,  I am  satisfied  that  his 
success  will  be  the  greatest  when  the  opera- 
tion is  not  long  delayed.  This,  at  least,  has 
been  my  own  experience.  When  I first  en- 
tered upon  the  profession  of  surgery,  its  the 
ear  1759,  the  operation  for  the  strangulated 
ernia  had  not  been  performed  by  any  of 
the  surgeons  in  Leeds.  My  seniors  in  the 
profession  were  very  kind  in  affording  me 
their  assistance,  or  calling  me  into  consulta- 
tion when  such  cases  occurred  ; but  we  con- 
sidered the  operation  as  the  last  resource, 
and  as  improper  until  the  danger  appeared 
imminent.  By  this  dilatory  mode  of  prac- 
tice, I lost  three  patients  in  five,  upon  whom 
the  operation  was  performed.  Having  more 
experience  of  the  urgency  of  the  disease,  I 
made  it  my  custom,  when  called  to  a patient 
who  had  laboured  two  or  three  days  under 
the  disease, to  wait  only  about  two  hours, 
that  I might  try  the  effect  of  bleeding  (if 
this  evacuation  was  not  forbidden  by  some 
peculiar  circumstances  of  the  case)  and  the 
tobacco  clyster,  fn  this  mode  of  practice, 
I lost  about  two  patients  in  nine,  upon  whom 
I operated.  This  comparison  is  drawn  from 
cases  nearly  similar,  leaving  out  of  the  ac- 
count those  cases  in  which  a gangrene  of 
the  intestine  had  taken  place. 

“ I have  now,  at  the  time  of  writing  this, 
performed  the  operation  tiiirty-five  times; 
and  have  often  had  occasion  to  lament  that 
I had  performed  it  too  late,  but  never  that 
I had  performed  it  too  soon.  There  are 
some  cases  so  urgent,  that  it  is  not  advisca- 
ble  to  lose  any  time  in  the  trial  of  means  to 
produce  a reduction.  The  delay  of  a few 
hours  may  cut  off  all  hope  of  success,  when 
a speedy  operation  might  have  saved  the 
life  of  the  patienf.  ” (P.  141,  fyc.) 

To  determine  the  exact  moment,  when  to 
give  up  the  trial  of  the  preceding  measures, 
and  to  have  immediate  recourse  to  the  ope- 
ration, is  certainly  difficult ; but  no  one  can 
doubt,  that  it  is  generally  better  to  operate 
too  early  than  too  late. 

All  directions  must  be  general  ones,  liable 
to  many  exceptions  : in  rapid  cases,  little 
or  no  time  should  be  allotted  to  the  trial  of 
any  plan,  and  the  operation  should  be  done 
without  the  least  delay.  In  other  instances, 
we  have  full  time  to  try  the  effects  of  every 
thing  at  all  likely  to  succeed.  The  symp- 
toms, which  ought  to  guide  us,  in  having 
recourse  to  the  operation,  arise  from  an 
attack  of  inflammation  in  that  part  of  the 
intestine  contained  in  the  hernial  sac,  and 
from  its  spreading  into  the  abdominal  cavity. 
It  is  in  proportion  to  their  violence,  that  we 


ought  to  urge  the  performance  of  the  ope- 
ration. Mr.  Cooper  considers  pain  on 
pressing  the  belly,  and  tension,  as  the  symp- 
toms w hich  point  out  its  immediate  neces- 
sity. He  adds,  “ Indeed,  there  is  scarcely 
any  period  of  the  symptoms,  which  should 
forbid  the  operation  ; for,  even  if  mortifica- 
tion has  actually  begun,  the  operation  may 
be  the  means  of  saving  life,  by  promoting 
the  ready  separation  of  gangrenous  parts.” 
(O  ' Inguinal  and  Congenital  Hernia,  p.  27.) 

Whenever  the  surgeon  has  succeeded  in 
reducing  the  parts,  without  having  recourse 
to  the  knife,  if  the  symptoms  of  pain,  inflam- 
mation, ran  high  before  such  reduction, 
they  will  not  alwrays  cease  immediately 
afterward.  As  they  probably  depend  on 
the  reduced  bowel  having  been  inflamed  by 
the  stricture,  the  body  should  be  kept  open, 
and  the  di^{  and  regimen  should  be  low  <.nd 
sparing,  whilst  the  least  degree  of  pain  and 
tension  remain  ; in  short,  till  all  complaint 
is  absolutely  removed  from  the  abdomen, 
and  the  intestines  do  their  office  freely,  and 
without  trouble.  (Pott) 

PROGRESS  OF  THE  SYMPTOMS  OF  A STRAN- 
GULATED HERNIA. 

The  earliest  symptoms  have  been  already 
related,  viz  “ tumour  in  the  groin,  or  scro- 
tum, attended  with  pain,  not  only  in  the 
part,  but  all  over  the  belly,  and  creating  a 
sickness  and  inclination  to  vomit,  suppres- 
sion of  stools,  and  some  degree  of  fever. 
These  are  the  first  symptoms,  and,  if  they 
are  not  appeased  by  the  return  of  the  intes- 
tine, that  is,  if  ttie  attempts  made  for  this 
purpose  do  not  succeed  ; the  sickness  be- 
comes more  troublesome,  the  vomiting  more 
frequent,  the  pain  more  intense,  the  tension 
of  the  belly  greater,  the  fever  higher,  and  a 
general  restlessness  comes  on,  which  is  very 
terrible  to  bear.  When  this  is  the  state  of 
the  patient,  no  time  is  to  be  lost;  a very  lit- 
tle delay  is  now  of  the  utmost  consequence, 
and  if  the  one  single  remedy,  which  the 
disease  is  now  capable  of,  be  not  adminis- 
tered immediately,  it  will  generally  baffle 
every  other  attempt.  This  remedy  is  the 
operation  whereby  the  parts  engaged  in  the 
stricture  rnay  be  set  free  If  this  be  not 
now  performed,  the  vomiting  is  soon  ex- 
changed for  a convulsive  hiccough,  and  a 
frequent  gulping  up  of  bilious  matter;  the 
tension  of  the  belly,  the  restlessness  and 
fever  having  been  considerably  increased 
for  a few  hours,  the  patient  suddenly  be- 
comes perfectly  easy,  the  belly  subsides, 
the  pulse,  from  having  been  hard,  full,  and 
frequent,  becomes  low,  languid,  and  gene- 
rally interrupted;  and  the  skin,  especially 
that  of  the  limbs,  cold  and  moist  ; the  eyes 
have  now  a languor  and  a glassiness,  a lack- 
lustre not  easy  to  be  described  ; the  tumour 
of  the  part  disappears,  and  the  skin  covering 
it  sometimes  changes  its  natural  colour  foi 
a livid  hue;  but  whether  it  keeps  or  loses 
its  colour,  it  has  an  emphysematous  feel,  a 
crepitus  to  the  touch,  which  will  easily  be 
conceived  bv  all  who  have  attended  to  it, 


16 


HERNIA. 


but  is  not  so  easy  to  convey  an  idea  of  by 
words  : this  crepitus  is  the  too  sure  indica- 
tor of  gangrenous  mischief  within.  In  this 
stale  the  gut  either  goes  up  spontaneously, 
or  is  returned  with  the  smallest  degree  of 
pressure ; a discharge  is  made  by  stool,  and 
the  patient  is  generally  much  pleased  at  the 
ease  he  finds  ; but  this  pleasure  is  of  short 
duration,  for  the  hiccough  and  the  cold 
sweats  continuing  and  increasing,  with  the 
addition  of  spasmodic  rigours  and  subsul- 
tus  tendinum,  the  tragedy  soon  finishes.” 
(Pott.) 

ANATOMY  OF  INGUINAL  HERNIA. 

This  subject  must  necessarily  precede  the 
account  of  the  operation,  which  would  other- 
wise be  unintelligible.  It  is  chiefly  in  the 
anatomical  information,  relative  to  herniee, 
and  in  the  mode  of  operating,  that  modern 
surgeons  have  a decided  superiority  over 
their  predecessors;  for  before  Girnbernat, 
Camper,  Hey.  Lawrence,  Cooper,  Scarpa, 
and  Hesselbach,  published  their  several 
works  on  hernia?,  the  anatomy  of  the  disease 
whs  only  imperfectly  understood. 

The  tendinous  fibres  of  the  aponeurosis  of 
the  external  oblique  muscle,  as  they  run 
downwards  and  forwards  toward  , the  pubes, 
separate  from  each  other,  so  as  to  leave  a 
triangular  opening,  called  the  abdominal 
ring,  which  is  usually  more  capacious  in  the 
male  than  (he  female  subject.  The  upper 
and  inner  pillar  (as  it  is  termed)  of  this  aper- 
ture is  inserted  into  the  symphysis  of  the 
pubes,  and  is  the  weakest  of  the  two  ; the 
lower  and  outer  one,  which  is  (he  strongest, 
is  chiefly  a continuation  of  Poupart’s  liga- 
menl,  (Hesselbach  nber  den  Ursprung,  fyc. 
dtr  Leisten-und-Szhenkelbruche,  p.  4.)  and  is 
fixed  into  the  angle  and  crista  of  the  same 
bone.  Some  tendinous  fibres  cross  the  upper 
and  outer  angle  of  the  ring,  so  as  to  diminish 
the  triangular  appearance  of  the  whole  aper- 
ture : these  are  said  to  be  very  strong  in  old 
hernia?.  The  anterior  and  thicker  layer  of 
the  aponeurosis  of  the  internal  oblique  mus- 
cle joins  the  tendon  of  the  external  oblique  ; 
the  posterior  and  thinner  one  joins  that  of 
the  transversalis  ; but  the  lower  portion  of 
this  tendon,  together  with  the  corresponding 
part  of  the  transversalis,  goes  wholly  in  front 
of  the  rectus  muscle.  Thus  the  inferior  borJ 
der  of  the  obliquus  internus  and  transversa- 
lis, which  originates  from  the  upper  part  of 
Poupart’s  ligament,  lies  behind  the  outer  pil- 
lar ot  the  abdominal  ring.  Mr.  A.  Cooper 
first  noticed,  that  a thin  fascia  proceeds  from 
the  inner  edge  of  Poupart’s  ligament,  and 
spreads  over  the  posterior  surface  of  the 
transversalis.  This  fascia  forms  the  only  par- 
tition between  the  peritoneum  and  the  outer 
opening  of  the  abdominal  ring,  and  were  it 
not  for  it>  existence,  inguinal  heroiae  would 
probably  be  much  more  frequent.  The  par- 
tition in  question,  however,  is  said  by  Scarpa 
to  be  formed  by  the  aponeuroses  of  the  in- 
ternal oblique  and  transverse  muscle*,  while 
Hesselbach,  who  has  named  the  small  smooth 
point,  situated  directly  behind  (he  outer 


opening  of  the  abdominal  ring,  its  crural 
surface , distinctly  states,  that  it  is  formed  by 
delicate  fleshy  and  tendinous  fibres  of  the 
internal  oblique  muscle;  (Utber  den  Ur- 
sprung, fyc.  der  Leisten-und-Schenkelbrnche , 
p.  4,)  and  that  behind  them  is  the  weakest 
part  of  what  he  names  the  internal  inguinal 
ligament , in  the  rear  of  which  is  the  perito- 
neum, with  the  intervention  of  a very  loose 
cellular  substance.  (Op.  cit.  p.  26.)  The 
internal  inguinal  ligament  of  Hesselbach,  is 
therefore  clearly  the  same  thing  as  the  above 
fascia  pointed  out  by  Mr.  A.  Cooper.  This 
point  of  the  abdomen  is  one  of  the  three 
weak  places  on  the  inside  of  the  inguinal 
region,  where  hernias  are  liable  to  occur; 
yet,  weak  as  it  appears  to  be,  it  is  not  the 
most  common  situation  of  such  tumours.  A 
computation  has  been  made,  that  in  an  hun- 
dred cases  of  inguinal  hernia,  not  ten  occur 
at  the  point  here  specified.  (H.  J.  Tirttnning- 
hausen , Unterricht  uber  die  Bril  eke,  fyc.  Wurzb. 
1811.) 

The  spermatic  vessels,  joined^by  the  vas 
deferens,  run  in  front  of  the  epigastric  artery, 
very  near  the  place  of  its  origin.  They  then 
pass  through  the  above  fascia,  go  under  the 
edge  of  the  internal  oblique  and  transverse 
muscles,  and  next  obliquely  downwards  and 
forwards,  between  the  above  fascia,  and 
aponeurosis  of  the  external  oblique  muscle 
to  tue  opening  of  the  ring.  When  arrived  on 
the  smooth  surface,  imcnedia:e!y  behind  the 
ring,  they  describe  an  obtuse  angle,  and  pass 
forwards  and  downwards  into  the  scrotum. 
( Hesselbach , op.  cit.  p.  5.) 

Thus  we  see.  that  the  spermatic  cord,  be- 
fore it  actual  emerges  a'  what  is  named  the 
abdominal  ring,  runs  through  a kind  of  canal, 
to  which  the  epithet  inguinal  is  often  applied. 
This  oblique  passage  of  the  cord  through  the 
abdominal  parietes,  was  well  known  to,  and 
elegantly  delineated  by  Albinus;  Girnbernat 
makes  distinct  mention  of  it  in  his  Account 
of  a jiew  Method  of  Operating  for  Femoral 
Hernia,  p.  19,  32  ; but  Mr.  A.  Cooper  has  the 
merit  ot  having  givenkthe  earliest  correct  ac- 
count of  the  inguinal  canal,  in  reference  to 
hernia  ; a subject  rendered  complete  by  the 
more  recent  elucidations  of  Hesselbach  and 
Scarpa. 

The  abdominal  ring  is  then  only  the  outer 
opening  of  the  canal,  or  passage,  through 
which  the  spermatic  cord  passes  betore  it 
emerges.  The  inner  one,  at  which  the  vis- 
cera first  protrude  in  tiie  most  common  cases 
ot  inguinal  hernia,  is  situated  about  an  inch 
and  a half  from  the  abdominal  ring,  in  the 
direction  towards  the  anterior  superior  spi- 
nous process  of  the  ilium  ; or,  according  to 
Hesselbach,  the  inguinal  canal  is  almost  an 
inch  and  a half  in  length,  the  average  dis- 
tance of  the  outer  pillar  of  the  abdominal 
ring,  from  the  inner  pillar  of  what  he  iertns 
the  posterioi  ring,  being  about  sixteen  Sines. 
(Op.  cit.  p.  14.)  This  inner  opening  is  rather 
nearer  the  pubes  than  the  ilium,  and  its  upper 
horde!  is  formed  by  the  lower  edge  ot  the 
internal  oblique,  and  transverse  muscles, 
which  can  he  plainly  felt  with  the  finger,  in 


HERNIA, 


17 


Produced  upward  aud  outward  into  the  abdo- 
minal ring. 

u The  precise  point  at  which  the  hernia 
most  commonly  begins,  (says  Scarpa,)  is  that 
which  corresponds, in  lhefoetus,tothe  commu- 
nication of  the  tunica  vaginalis  with  the  pe- 
ritoneum, and,  in  the  adult,  to  the  passage 
of  the  spermatic  cord  under  the  transverse 
muscle.  In  the  sound  state,  the  peritoneum 
presents  at  this  part  a small  funnel-like  de- 
pression, the  depth  of  which  increases  in  pro- 
portion as  the  spermatic  cord  is  pulled  from 
above  downwards.  It  is  this  small  pouch, 
this  sort  of  digital  appendage,  whose  pro- 
gressive augmentation  constitutes  the  hernial 
sac.  Resting  upon  the  anterior  surface  of 
the  spermatic  cord,  it  first  makes  its  appear- 
ance under  the  inferior  edge  of  the  trans- 
verse muscle  ; thence  if  extends  itself  in  the 
separation  of  the  inferior  fleshy  fibres  of  the 
internal  oblique  muscle,  always  following  (he 
spermatic  cord,  in  front  of  which  it  is  situa- 
ted ; and  after  having  in  this  manner  passed 
through  the  whole  of  the  canal,  which  ex- 
tends from  the  iliac  region  to  flic*  pubes,  it 
lastly  protrudes  at  its  external  orifice,  which 
is  the  inguinal  (or  abdominal)  ring,  properly 
so  called.  lu  all  this  track,  the  hernial  sac, 
ns  well  as  the  spermatic  cord,  is  situated 
above  file  femoral  arch,  the  direction  of 
which  it  follows.  The  canal,  which  it  tra- 
verses, is  of  a conical  shape,  the  apex  of 
which  is  towards  the  flank,  and  the  ba-e  at 
the  external  orifice  of  the  ring.”  ( Scarpa , 
TraiU  des  Hernies , p.  44,  45.) 

The  epigastric  artery  runs  behind  the 
spermatic  cord,  along  the  inner  margin  of 
the  interna!  opening  of  the  above  canal, 
then  upwards  and  inwards,  so  as  to  pass  at 
the  distance  of  half  an  inch  or  an  inch  from 
the  upper  extremity  of  the  outer  opening, 
or  abdominal  ring. 

In  common  cases  of  inguinal  hernia,  the 
viscera,  protruded  at  the  inner  opening  of 
t he  inguinal  canal,  lie  over  the  spermatic 
word,  and  form  a tumour  on  the  outside  of 
the  abdominal  ring. 

When  the  viscera  have  entered  the  above 
described  digital  pouch  of  the  peritoneum, 
but  do  not  protrude  through  the  abdominal 
ring,  the  case  is  sometimes  termed  an  incom- 
plete inguinal  hernia ; and  complete  when 
they  pass  out  of  that  opening.  The  viscera 
may  continue  for  a long  while  quite  within 
the  inguinal  canal,  and  even  become  stran- 
gulated there:  sometimes,  also,  they  are 
prevented  from  passing  further  towards  the 
ring  by  some  kind  of  impediment;  and,  in 
this  circumstance,  if  the  hernial  sac  have 
any  addition  made  to  its  contents,  it  may  ex- 
pand between  the  external  and  internal  ob- 
lique muscles,  as  Hesselbach  bad  an  opportu- 
nity of  seeing  in  the  body  of  a female. 

{ Ueher  den  Ur  sprung,  fyc.  der  Leisten-und- 
tSchenkelbriiche,  p.  28.)  The  stricture  may 
take  place  either  at  t tie  internal  or  external 
opening  of  the  inguinal  canal.  In  recent 
and  small  h'-rnia,  according  to  Mr.  A.  Cooper, 
the  strangulation  is  most  frequently  situated 
at  the  inner  opening  ; in  large  old  ruptures, 
nt  the  abdominal  rins:'.  Even  when  1 he  par(3 
Vol.  II.  w ' 3 


are  completely  protruded  out  of  the  latter 
opening,  the  strangulation  may  exist  at  the 
inner  one;  but  there  may  occasionally  be 
(wo  strictures,  viz.  one  at  each  opening. 
(See  Lawrence  on  Ruptures,  p.  183,  I. hit.  3.) 

The  hernial  sac  descends  through  the  ab- 
dominal ring  over  (lie  spermatic  cord,  a.  I ' 
covered  by  a fascia,  sent  off’  from  the  tend 
of  the  external  oblique  muscle.  Rem 
(bis  fascia,  the  cremaster  muscle  is  also  situ- 
ated over  the  sac,  which,  after  it  '-as  de- 
scended a certain  way,  lies  on  the  tunica 
vaginalis,  as  well  as  the  spermatic  cord. 

As  (lie  epigastric  artery  naturally  runs  first 
behind  the  spermatic  cord,  and  then  along 
the  inner  margin  of  the  internal  opening  of 
the  ring,  and  as  the  viscera  are  protruded 
over  the  cord,  they  must  be  situated  on  t lie 
outer  side  of  the  artery,  which  runs  first  be- 
hind the  neck  of  the  sac,  and  then  on  its 
inner  side.  Hence,  the  inner  margin  of  the 
sac,  when  inspected  on  the  side  towards  the 
abdomen,  seems  to  be  formed,  as  it  were,  by 
the  track  of  the  vessel.  (See  Lawrence , p. 
179)  That  this  is  the  ordinary  situation  of 
the  epigastric  artery,  in  relation  to  the  ingui- 
nal hernia,  is  confirmed  by  the  concurrent 
testimonies  of  Camper,  Chopart,  Desault, 
Sabatier,  A.  Cooper,  Hesselbach,  Scarpa, 
&ic.  and  by  preparations  to  be  seen  in  almos4 
every  museum. 

In  recent  inguinal  hernia?,  the  internal  and 
external  openings  of  the  ring  are  at  some 
distance  from  each  other,  the  first  being  • 
ated  obliquely  upwards  and  outwards  to.  r 
tion  to  the  former;  but  the  pressure  >- 
protruded  viscera,  gradually  forces  the  truer- 
rial  opening  more  towards  the  pnbo  and 
nearer  to  the  abdominal  ring,  so  as  to  r.  ..b  . 
the  posterior  side  of  the  neck  of  the  hernial 
sac,  and  of  the  inguinal  canal,  very  short. 

( Hesselbach . p.  £9.)  Thus,  in  large  i.  rroie 
of  longstanding,  the  opening  into  the  nb  io- 
men  is  almost  direct,  and  (be  epigastric  ; uy 
becomes  situated  nearer  the  pubes,  than  in 
the  natural  state. 

Though  such  is  the  ordinary  direction,  in 
which  a bubonocele  protrudes,  (here  are  oc- 
casional varieties.  In  one  of  these,  the  vis- 
cera, instead  of  descending  through  ihe 
canal  of  the  ring,  are  at  once  thrust  through 
the  abdominal  ring  itself,  and  the  opening 
into  the  belly  is  then  direct  : the  hernial  sac, 
instead  of  passing  op.  the  external  side  of 
the  spermatic  vessels,  as  is  usual,  now.iies 
on  their  inner, or  pubic  side  ; and  the  epigas- 
tric artery,  which  is  commonly  situated  be- 
hind, now  pursues  its  course,  in  front  of  the 
sac.  at  its  usual  distance  from  the  upper  and 
outer  angle  of  the  abdominal  ring.. 

The  following  is  Scarpa's  description  of 
the  displacement  of  the  epigastric  artery  in 
the  greater  number  of  cases  of  inguinal  her- 
nia. “ This  artery,  which  in  (he  natural 
state,  runs  about  ten  lines  from  the  abdomi- 
nal ring,  has  its  situation  and  direction  n; 
changed,  in  subjects  affected  with  cm: a, 
that  it  crosses  the  posterior  part  ot  the  nock 
of  (he  hernial  sac,  and  is  pushed  from  the 
outer  to  the  inner  side  of  the  abdominal  ring. 
In  order  to  comprehend  the  reason  of  this 


HERNIA. 


i3 


displacement,  it  is  necessary  to  recollect 
what  I have  elsewhere  said  of  the  formation 
of  inguinal  hernia,  and  of  the  manner,  in 
which  the  spermatic  cord  crosses  tiie  epi- 
gastric artery.  The  hernia  begins  to  form 
at  the  very  place,  where  the  spermatic  cord 
passes  under  the  inferior  margin  of  the 
transverse  muscle  ; and  this  place  is  rather 
nearer  the  flank,  than  that  where  the  epigas- 
tric urtery  passes  towards  the  rectus  muscle. 
In  its  progressive  extension,  the  hernial  sac 
constantly  follows  the  same  track  as  the 
spermatic  cord,  since  it  is  situated  upon  its 
anterior  surface.  As  has  been  already  ex- 
plained, this  cord  crosses  the  epigastric  artery ; 
consequently,  the  hernial  sac  must  necessa- 
rily pass  with  the  cord  above  this  artery, 
before  protruding  from  the  canal  of  the 
abdominal  ring.  At  the  same  time’,  the  inter- 
nal orifice  of  the  hernia  becoming  larger, 
and  the  inguinal  canal  shortened  by  the 
approximation  of  its  two  orifices  to  each 
other,  it  follows,  that  at  the  period  when  the 
hernia  begins  to  make  its  appearance  in  the 
groin,  the  epigastric  artery  is  unavoidably 
situated  behind  the  neck  of  the  hernial  sac, 
and  is  pushed  from  the  outer  to  the  inner 
side  of  the  ring.  Let  us  suppose  a piece  of 
string  to  be  passed  from  the  inside  of  the 
abdomen  into  the  scrotum,  all  through  the 
inguinal  canal,  and  the  middle  of  the  hernia  ; 
and  that  this  string  is  pulled  so  as  to  bring 
the  internal  orifice  of  the  hernia,  which  is 
situated  beyond  the  point  where  Hie  sperma- 
tic cord  crosses  the  epigastric  artery  ; this 
artery  will  immediately  be  found  to  be  car- 
ried from  the  outer  to  the  inner  side  of  the 
neck  of  the  hernial  sac.  The  same  thing 
happens  from  the  effect  of  the  enlargement  of 
the  hernia.  The  removal  of  the  epigastric  ar- 
tery from  one  side  of  the  ring  to  the  other, 
(says  Scarpa) isa  phenomenon, which  may  be 
regarded  as  almost  constant  in  the  inguinal 
hernia.  I have  examined  the  bodies  of  a 
great  number  of  subjects,  affected  with  this 
species  of  hernia  ; and  it  has  been  only  in  a 
very  few,  that  I met  with  the  epigastric  artery 
retaining  its  natural  situation  on  the  outer 
side  of  the  abdominal  ring.  In  investigating 
the  reason  of  this  exception,  I have  obser- 
ved, in  ail  the  individuals  who  presented 
it,  a very  remarkable  weakness  and  ilaccidity 
of  that  part  of  the  abdominal  parietes,  which 
extends  from  the  flank  to  the  pubes.  Iti  all 
the  displaced  viscera  had  passed  through  Ike 
aponeuroses  of  the  transverse  and  internal  ob- 
lique muscles , notin  the  vicinity  of  the  ilium, 
as  is  commonly  the  case,  but,  at  a little  dis- 
iance  from  the  pubes,  giving  to  the  upper  pil- 
lar of  the  ring  a curvature  that  is  extraordi- 
nary, and  disproportioned  to  the  smallness 
of  the  hernia.  I observed,  also,  that  the  neck 
of  the  hernial  sac  did  not  pass  in  an  oblique 
direction,  from  the  flank  to  the  pubes,  but, 
that  it  protruded  from  the  abdomen  almost 
in  a direct  line  from  behind  forwards.  In 
short,  in  these  individuals,  the  small  cul-de- 
sac  of  the  peritoneum,  which  constitutes  the 
prigin  of  the  hernial  sac,  had  not  begun  to 
be  formed  under  the  edge  of  th  : transverse 
muscle,  at  Ihe  point  where  flie  spermatic 


cord  runs  ouhVard ; but,  it  hud  passed  through 
the  aponeuroses  of  ihe  internal  oblioue  and 
transverse  muscles , at  a little  distance  from  th6 
pubes,  and  within  the  point  at  which  the  sper- 
matic eord  crosses  the  epigastric  artery.  The 
small  hernial  sac,  having  at  this  part  come 
into  contact  with  and  united  to  the  sperma- 
tic eord,  protrudes  at  the  external  orifice  of 
the  inguinal  canal,  without  displacing  the 
epigastric  artery  from  its  natural  situation. 

This  species  of  hernia,  properly  speaking, 
isa  mixture  of  the  ventral  and  inguinal,  it 
resembles  the  former,  inasmuch  as  the  her- 
nial sac  pierces  the  aponeuroses  of  the  transr 
verse  and  internal  oblique  muscles ; the  lat  - 
ter, inasmuch  as  it  passes  out  at  the  abdomi- 
nal ring,  conjointly  with  the  spermatic 
cord.”  ( Scarpa , Trade  des  Hernies,p.  68,  fc.} 

Hesseibach  particularly  adverts  to  a tri- 
angular space  to  be  seen  on  the  inside 
of  the  inguinal  region  : the  upper  bound- 
ary of  it  is  formed  by  the  outer  edge  of 
the  rectus  muscle  ; the  lower  by  the 
horizontal  branch  of  the  os  pubis  ; and 
the  external  shortest  boundary  by  the 
crural  vein  and  epigastric  artery.  Now, 
says  he,  when  it  is  considered,  that  this 
artery  ascends  obliquely  inwards,  between 
the  inner  opening  of  the  ring,  and  the 
above  triangular  space,  one  cannot  fail  to 
know  on  which  side  of  the  neck  of  the  sac 
the  artery  must  lie  in  the  two  species  of  in- 
guinal, as  well  as  the  crural,  hernia;  for,  in 
those  hernia?,  which  originate  in  the  above 
triangular  space,  this  artery  lies  at  the  outer 
side  of  the  neck  of  the  hernial  sac ; while,  in 
every  hernia  that  takes  place  through  the  in- 
ner opening  of  the  inguinal  canal,  the  same 
vessel  is  situated  at  the  inner  side  of  the  neck 
of  the  sac.  To  one  species  of  bubonocele, 
Hesseibach  applies  the  epithet  external ; and 
to  the  other,  internal ; according  to  the  si- 
tuation of  the  point  at  which  they  first 
protrude.  The  external  inguinal  hernia  is 
much  more  frequent  than  the  internal,  and 
is  said  to  happen  oftener  on  the  right,  than 
the  left  side  of  the  body : a circumstance, 
coinciding  with  another  observation,  viz. 
that  in  children,  the  tunica  vaginalis  remains 
longer  open  on  the  right  titan  the  left  side. 

The  circumstance  of  there  being  two 
forms  of  inguinal  hernia  formerly  caused 
considerable  perplexity : surgeons  knew', 

that  the  epigastric  artery  lay  sometimes  at 
the  inner,  sometimes  at  the  outer  side  of  the 
neck  of  the  hernial  sac,  but  knew  not  how 
to  account  for  this  variation.  Hence  arose 
the  very  different  opinions  about  the  proper 
method  of  dividing  the  ring  when  the  her- 
nia was  strangulated  ; some  authors  direct- 
ing the  incision  to  be  made  obliquely  in- 
wards and  upwards  ; and  others,  upwards 
and  outwards.  But,  as  a modern  writer  has 
judiciously  remarked,  had  they  paid  greater 
attention  to  the  direction  of  the  swelling, 
formed  by  the  neck  and  body  of  Ihe  hernial 
sac  in  the  groin,  and  to  the  position  of  the 
spermatic  cord,  which  is  as  inconstant  as 
that  of  the  epigastric  artery  ; and  had  they 
dissected  the  parts  in  the  diseased,  as  w:ell 
as  healthy,  state,  they  could  not  fail  soon  to 


have  suspected,  that  every  inguinal  hernia 
does  not  originate  exactly  at  one  and  the 
same  point.  For  the  first  establishment  of 
this  very  important  distinction,  the  world  is 
indebted  to  Mr.  A.  Cooper  ; and  the  tract, 
in  which  Hesselbach  pointed  out  the  fact  in 
a very  particular  manner,  I believe,  is  the 
next  publication  in  which  the  subject  is  ex- 
plained. {Anal.  Chir.  Abhandlnng  fiber  den 
Ur  sprung  der  Leistenbru  ke,  IVurxb.  180b  ; 
and  JVeuste  Anal.  Pathol.  Untersuehangen 
abcr  den  Ursprung,  fyc.  der  Leisten-und - 
Schenkelbriiche,  41  o.  IVurxb.  1814,  p.  18.  2(5, 
28,  4'C.)  According  to  the  latter  author, 
since  each  form  of  inguinal  hernia  also  pre- 
sents characteristic  appearances  externally* 
the  surgeon  can  have  no  difficulty  in  deter- 
mining the  species  of  hernia  ; which  dis- 
crimination must  he  highly  important  in  the 
taxis,  the  application  of  atruss,  and  especially 
the  operation.  The  sac  of  the  external 
scrotal  hernia  can  only  pass  down  within 
the  expansion  of  the  cremaster  as  far  as  this 
part  is  separate  from  the  cord  and  tunica 
vaginalis.  Hence,  the  testis,  covered  by  its 
tunica  vaginalis,  lies  under  the  lowest  part 
of  the  hernial  sac,  while  the  vessels' of  the 
spermatic  cord,  in  a more  or  less  separated 
form,  are  situated  behind  the  posterior  part 
of  the  sac  ; viz.  the  spermatic  veins  exter- 
nally, and  the  vas  deferens  internally,  and 
the  artery  in  the  middle.  Should  the  hernia 
descend  still  further,  the  testis  being  inclu- 
ded as  well  as  the  sac  within  the  tendinous 
expansion  of  the  cremaster,  it  cannot  glide 
out  of  the  way,  but  must  be  pressed  still  fur- 
ther downwards  by  the  sac,  so  as  to  con- 
tinue invariably  under  its  fundus,  but  some- 
times inclined  a little  behind  it.  {Hes^clbaeh, 
p.  34.)  And,  as  the  same  author  justly  ob- 
serves, the  position  of  (be  spermatic  cord  and 
testis,  and  the  oblique  direction  of  the  swell- 
ing in  the  external  species,  are  the  two 
strongest  characters  by  which  every  case  of 
inguinal  hernia  may  be  discriminated. 

Although  the  spermatic  cord  commonly 
lies  behind,  or  under,  the  hernial  sac,  there 
are  cases  in  which  t lie  vas  deferens  is  found 
on  the  cuter  side  of  it,  while  the  rest  of  the 
spermatic  cord  lies,  as  it  usually  does,  on 
the  inner  side,  or  rather  under  it.  (Cooper.) 
Le  Dran,  Schmucker,  and  Blizard,  found 
the  whole  cord  situated  in  front  of  the  sac. 
Sometimes  the  vas  deferens  runs  on  the  front 
and  inner  part,  and  the  rest  of  the  cord  on 
the  back  and  external  part  of  the  swelling. 
( Camper , Hey.)  The  cord  has  been  known 
to  be  before,  and  the. vas  deferens  behind, 
the  sac.  (Camper,  A.  Cooper.) 

Upon  this  part  of  the  subject,  the  reader 
may  deem  the  following  passage  interesting. 

While  the  hernia  is  of  moderate  size,  (says 
Scarpa)  the  surrounding  cellular  substance 
is  not  very  greatly  compressed,  and  no 
change  is  observed  in  the  situation  of  the 
spermatic  vessels.  The  artery  and  veins  of 
this  nanSe  always  form,  with  tiie  vas  defer- 
ens, one  single  cord,  which  is  intimately  ad- 
herent to  the  posterior  surface  of  the  hernial 
sac.  But,  in  proportion  as  the  tumour  in- 
creases in  size,  the  cellular  substance,  which 


immediately  surrounds  it,  and  unites  it  to  the 
spermatic  cord,  is  more  and  more  distended 
and  compressed.  At  length,  at  a certain  pe- 
riod, the  distention  is  carried  to  such  a pitch, 
that  the  spermatic  vessels  are  separated  from 
one  another,  and  change  their  position  with 
respect  to  the  hernial  sac.  This  kind  of 
gradual  unravelling  of  the  spermatic  cord 
is  quite  similar  to  that,  which  w ould  he  pro- 
duced by  pulling  the  surrounding  cellular 
substance  in  two  opposite  directions.  Such 
is  the  reason,  why  in  scrotal  hernia  of  large 
size,  the  spermatic  artery,  the  vas  deferens, 
and  the  spermatic  veins  are  found  separated 
upon  the  posterior  surface  of  the  sac.  All 
these  vessels,  instead  of  being  conjoined  in 
one  cord,  are  divided  by  interspaces,  which 
are  sometimes  very  considerable.  Ordina- 
rily, the  vas  deferens  is  less  separated  from 
the  spermatic  artery,  than  from  the  vein  of 
this  name.  In  some  subjects,  Camper  has 
seen  it  situated  on  one  side  of  the  sac,  and 
the  arlery  and  veins  on  the  other.  (leones 
Herniarym,  Tab.  5,  L.  O.  Tab.  8.  1,2.)  The. 
displacement  and  splitting  of  the  spermatic 
cord  take  place  equally  in  adults  and  in  chil- 
dren affected  with  1 urge  scrotal  hernia?. 
(Camper,  loco  cil.)  In  general,  towards  the  up 
per  part  and  neck  of  the  hernia,  the  vessels 
are  not  much  separated  ; but  as  they  proceed 
downwards,  they  diverge  more  and  more. 
Sometimes,  when  the  hernia  is  very  old  and 
bulky,  they  are  no  longer  found  at  the  pos- 
terior part,  but  rather  at  the  sides,  and  even 
on  the  front  surface  of  the  sac  ; tiiey  show 
themselves  thupugh  the  cremaster  muscle, 
which  covers  them,  and  form  a sort  of  vas- 
cular train,  which  arrests  the  hand  of  the 
operator  at  the  moment  when  he  is  about 
to  open  the  hernial  sac.  Le  Dran  relates, 
that  in  operating  upon  a large  scrotal  hernia, 
he  found  the  spermatic  cord  on  the  anterior 
surface  of  the  hernial  sac.  ( Operations  de 
Cftir.p.  127.)  This  fact  has  been  the  cause 
of  numerous  conjectures,  and  has  appeared 
altogether  inconceivable  to  such  surgeons 
as  have  not  been  acquainted  with  the 
changes,  to  which  the  spermatic  cord  is  ex- 
posed, in  cases  of  large^scrotal  hernia’. 
(Lassus  could  not  (Med.  Opemt.  T.  1,  p. 
152.)  conceive  the  possibility  of  the  occui- 
rence.)"  The  observation  of  Le  Dran  is  not 
the  less  true  and  exact ; it  exemplifies  a vety 
important  fact,  of  which  it  is  easy  to  give  a 
true  explanation  when  the  state  of  the  sper- 
matic cord  in  ordinary  inguinal  hernia’,  and 
in  those  which  have  obtained  a considerable, 
size,  has  bfeen  comparatively  examined.  In 
the  first,  the  'spermatic  cord  quite  entire  is 
always  found  situated  on  the  posterior 
surface  of  the  hernial  sac  ; but,  in  the  second, 
the  spermatic  vessels  are  so  separated  from 
one  another,  that  they  sometimes  extend 
over  the  sides  and  even  the  forepart  of  the 
hernial  sac.”  ( Scarpa , Trait ; des  Herhie.Si 
p.  (51.  <$-e.) 

The  hernial  sac  is  commonly  described  as 
an  elongation  of  peritonauim.  When  more 
minutely  examined,  however,  it  is  found,  in 
cases  of  inguinal  hernia,  to  consist  of  the 
portion  of  peritoh;euin:  pushed  out  with  the 


20 


Hernia 


viscera  ; of  a layer  6f  cellular  substance  on 
the  outside  of  this,  which  becomes  more 
or  less  thickened  by  the  pressure  of  the 
rupture  in  different  cases}  of  a fascia,  sent 
off  from  the  tendon  of  the  external  oblique 
muscle ; and  of  the  cremaster  muscle, 
which  latter  parts  form  the  exterior  cover- 
which  consisting  of  several  layers,  often 
■ ads  the  operator  to  fancy  that  he  has  open- 

• cavity  of  the  sac,  when,  in  reality,  he 
bus  not. 

It  is  observed  by  Professor  Scarpa,  that 
iho  cremaster  muscle,  in  cases  of  old  large 
rrotal  hernia;,  acquires  a thickness,  which 
•>  really  surprising.  Its  fibres,  which  are 
naturally  very  thin,  become  from  four  to 
mx  times  more  considerable.  Being  spread 
over  the  neck  and  body  of  the  hernial  sac, 
they  sometimes  present  a remarkable  con- 
rosience,  and  a yellowish  colour.  Such  al- 
teration, however,  does  not  prevent  the 
muscular  texture  from  being  discovered, 
ad  Haller  was  not  mistaken  about  it. 
{Op use.  Palkolo g.  p.  317.)  Pathology  fur- 
nishes us  with  several  examples  of  similar 
changes  of  organization.  In  certain  cases, 
muscular  coat  of,tlie  bladder,  that  of  the 
; roach  and  intestines,  and  even  the  ex- 
edingly  delicate  fleshy  fibres  of  the  liga- 
; its  of  the  colon,  are  found  to  have  be- 
me  yellow,  and  much  thickened. 

“ In  old  scrotal  hernia?  (says  Scarpa)  it  is 

• ! unusual  to  find  an  intimate  adhesion  of 

fibres  of  the  cremaster  muscle  to  the 
5 jges  of  the  abdominal  ring.  This  may  de- 
ad on  the  pressure,  which  the  contents 
; the  hernia  makes  on  those  edges,  and  per- 
; ps  it  may  also  depend  on  the  union  of 
, r ^ remaster  muscle  with  the  prolongation 
of  me  aponeurosis  of  the  fascia  lata,  which 
. i.  ouimued  from  the  margins  of  the  ring  to 
.coin  and  scrotum.  Howsoever  it  may 
bi , certain  it  is,  that  in  old  large  scrotal 
. - map  there  is  much  difficulty  in  introdu- 
cing a probe  between  the  fleshy  fibres  of 
cremaster  and  the  margin  of  the  abdomi- 
.1  ring  ; and  that,  on  the  contrary,  in  recent 
herniae,  a probe  passes  as  easily  between  the 
edges  of  the  ring  and  the  cremaster,  as  be- 
iveen  this  muscle  and  the  hernial  sac. 

“ Few  authors  (according  to  Scarpa)  have 
mken  of  tire  sheath,  formed  by  the  cre- 
ter  muscle,  in  which  are  enclosed  the 
- .ml  sac,  the  spermatic  cord,  and  the  tu- 
; ■>  vaginalis  of  the  testicle.  Sharp  (in 

Uical  Inquiry ) and  Monro,  the  father, 
and  Chirurg.  Works , p.  5£>3.)  were 
fhu  first  to  dwell  upon  this  important  patho- 
eal  point.  Monro  had  seen  the  cremas- 
t«.  prouscle  covering  the  hernial  sac  } but  he 
not  believe,  that  the  same  thing  occur- 
ln  all  individuals  affected  with  inguinal 
■ :a.  In  this  respect  he  was  mistaken  } 
this  disposition  of  the  cremaster  muscle 
j-.-  - of  the  essential  characters  of  the  dis- 

Petit  has  not  omitted  to  describe  the 
bn  us  which  exist  between  the  creraas- 
■ cl  the  hernial  sac.  (C Euvres  Post  hum. 

' > , p.  288.)  On  this  subject,  he  even  re- 
, an  interesting  fact,  from  which  it  re- 
that  in  verSarn  ^ases;  this  muscle  may 


by  its  contractions  alone  cause  a reduction 
of  the  hernia.  Guntz  explains,  with  tolera- 
ble perspicuity,  how  the  cremaster  and  its 
aponeurosis  form  one  of  the  coverings  of 
the  inguinal  and  scrotal  hernia.  (Libellus  de 
Ilerniis , p.  50.)  Morgagni  once  saw  its 
fleshy  fibres  extended  over  the  hernial  sac  } 
( Dc  sed.  et  cans.  morb.  epist.  34,  art.  9; 
cpist.  31,  art.  15.)  and  Neubaver  positively 
assures  us,  that  he  made  the  same  remark 
upon  the  dead  body  of  a man  affected  with 
an  emtero-epiplocele.  ( Dissert . de  Epiplo- 
oscheocele.)  After  these  facts,  so  positively 
and  accurately  observed,  I cannot  compre- 
hend (says  Scarpa)  how  in  our  time  Pott, 
.Richter,  and  several  other  authors,  should 
have  passed  over  in  silence,  or  only  men- 
tioned vaguely,  this  point,  so  important  in 
the  history  of  the  inguinal  and  scrotal  her- 
nia.” ( Scarpa , Traiti  des  Hernics , p.  48,  50.) 

When  surgeons  speak  of  a hernial  sac  be- 
ing usually  thicker  and  stronger,  in  propor- 
tion to  the  magnitude  and  deration  of  the. 
hernia,  their  language  is  not  at  all  correct ; 
for  in  fact,  the  peritoneal  investment  of 
the  hernia  is  seldom,  or  never,  thus  alter- 
ed. I can  declare  (says  Scarpa)  after  nu- 
merous observations,  that  in  the  majority  of 
cases,  the  hernial  sac,  strictly  so  called,  is 
not  perceptibly  thickened,  and  that  in  gene- 
ral it  does  not  differ  from  other  parts  of  the 
peritonaeum,  however  large  and  old  the 
scrotal  hernia  may  be.  ( Trait6  des  Her  nies, 
p.  53.) 

In  a very  enormous  hernia,  the  pressure 
of  the  contents  is  so  great,  that  instead  of 
thickening  the  sac,  it  renders  it  thinner,  and 
even  makes  it  ulcerate.  The  protruded  vis- 
cera have  been  met  with  immediately  be- 
neath the  integuments,  when  the  sac  has 
been  burst  by  a blow.  ( Cooper  ; J.  L.  Petit.) 

The  outer  surface  of  the  peritonaeal  part 
of  the  hernial  sac,  is  always  most  closely  ad- 
herent to  the  other  more  external  covering 
by  means  of  cellular  substance.  This  con- 
nexion is  formed  so  soon,  after  the  first 
occurrence  of  a hernia,  that  any  hopes  of 
returning  a hernial  sac  into  the  abdomen 
are  now  generally  considered  as  chimerical. 
There  must,  however,  be  a certain  space  of 
time,  before  adhesions  form,  though  it  is, 
no  doubt,  exceedingly  short. 

Upon  this  point,  Scarpa  does  not  adopt 
the  opinion  commonly  received. 

There  is  no  doubt,  he  observes,  that  in  re- 
cent and  small  inguinal  hernias,  the  intes- 
tine, strangulated  by  the  neck  of  the  hernial 
sac,  has  been  known,  in  more  instances  than 
one,  to  have  been  reduced  by  the  taxis,  and 
carried  with  it  the  whole  of  the  sac  into  the 
abdomen.  Observations,  not  less  authentic, 
inform  us,  that  after  the  operation  for  hernia, 
when  the  viscera  could  not  be  reduced  on 
acbount  of  their  adhesions  to  the  sac,  they 
have  been  seen,  notwithstanding  such  ad 
hesions,  to  get  nearer  to  the  ring  daily,  and 
at  length,  spontaneously  to  return  into  the 
belly  together  with  the  hernial  sac.  Louis, 
he  thinks,  was  wrong  in  denying  the  possi- 
bility of  these  facts.  (sJead.  Ptoyale  de  Chir. 
T.  11  : p.  4SC».) 


HKKNIA. 


Scarpk  argues,  that  i:  under  certain  cir- 
cumstances, the  cellular  substance  will  bear, 
without  laceration,  a considerable  elonga- 
tion, and  afterward  shrink  again.  Thus  we 
often  see  a viscus,  which  has  suffered  a con- 
siderable displacement,  return  spontaneous- 
ly into  its  natural  situation.  In  the  ingui- 
nal hernia,  the  spermatic  cord  is  elongated, 
and  descends  farther,  than  in  the  natural 
state.  No  laceration  of  the  cellular  sub- 
stance, however,  is  then  occasioned  ; for,  if 
the  hernia  be  kept  reduced,  the  spermatic 
cord  becomes  shorter,  daily  retracts,  and  at 
last  has  only  the  same  length,  which  it  had 
previously  to  the  disease.  When  a sarco- 
cele  becomes  large  and  heavy,  the  portion 
of  the  spermatic  cord  naturally  situated 
within  the  belly,  is  by  degrees  drawn  out 
into  the  scrotum  ; but,  after  the  tumour  is 
extirpated,  this  portion  ascends  again,  and 
of  itself  returns  into  its  original  situation. 

“ The  same  thing  happens  after  the  ope- 
ration for  the  strangulated  inguinal  hernia. 
All  practitioners  have  noticed,  that  the 
hernial  sac  retracts  and  reascends  progres- 
sively towards  the  ring.  This  alone  would 
prove,  that  the  cellular  substance,  which 
surrounds  the  spermatic  cord,  and  unites  it 
to  the  hernial  sac,  is  highly  endued  with 
the  property  of  yielding,  and  afterward  re- 
turning to  its  original  state.  Can  the  same 
property  be  refused  to  the  cellular  sub- 
stance, which  unites  the  sac  to  the  cremas- 
ter muscle  and  other  surrounding  parts  ? 

“ While  the  inguinal  hernia  is  recent,  and 
not  of  much  size,  the  cellular  substance  in 
question,  possesses  all  its  elasticity,  and 
lienee,  the  hernial  sac  and  the  spermatic 
cord,  may  easily  ascend  towards  the  abdo- 
minal ring.  I have  had  occasion  (says 
Scarpa)  to  make  this  observation  upon  the 
dead  body  of  a man,  who  had  an  incipent 
inguinal  hernia.  The  small  hernial  sac  was 
capable  of  being  pushed  back  into  the  ring 
with  the  utmost  facility  ; and  in  carefully 
examining  the  parts,  both  within  and  with- 
out the  belly,  it  appeared  to  me,  that  the 
cellular  substance,  which  united  the  sac  to 
the  spermatic  cord  and  cremaster  muscle, 
was  disposed  to  yield  equally  from  without 
inwards,  and  in  the  direction  precisely  op- 
posite ; that  is  to  say,  it  made  an  equal  re- 
sistance to  the  protrusion  and  the  reduction 
of  the  hernial  sac.  Monteggia  has  seen  a 
case  exactly  similar : although,  according 
to  his  own  expressions,  ( Inslituz . Chirurg. 
T.  3,  ses.  2,  p.  249,)  the  hernial  sac  was  not 
very  small,  it  adhered  very  loosely  to  the 
surrounding  parts,  and  it  admitted  of  being 
entirely  reduced  into  the  abdomen  with 
great  facility.” 

In  large  old  scrotal  hernias,  Scarpa  allows, 
that  such  reduction  is  quite  impracticable  : 
c;Iu  these,  the  cellular  substance,  which 
unites  the  sac  to  the  spermatic  cord,  and 
cremaster  muscle,  has  acquired  such  a den- 
sity, that  it  does  not  oppose  less  resistance 
to  the  further  enlargement  of  the  hernia, 
than  to  the  efforts  of  the  surgeon,  who  en- 
deavours to  effect  its  reduction.”  ( Scarpa , 
Traiti  das  Hernias,  p.  -57.  <*c.)  Though 


Scarpa  thus  reasons  about  the  elasticity  of 
the  cellular  substance,  as  forming  the  con  - 
nexion between  the  sac  and  surrounding 
parts,  many  surgeons  would  refer  the  con- 
nexion to  the  adhesive  inflammation,  and 
explain  the  diminution  and  shrinking  of 
parts,  after  the  distention  and  weight  are 
removed,  not  by  the  elasticity  of  the  cellu- 
lar substance  in  particular,  but  by  thesamo 
property  inherent  generally  in  the  elonga- 
ted parts,  which  elasticity,  and  the  action 
of  the  absorbents  together,  produce  the  al- 
teration in  question 

We  shall  conclude  this  anatomical  account 
of  the  inguinal  hernia,  with  the  following 
explanation  of  the  parts  as  they  appear  on 
dissection  : “ the  removal  of  the  integu- 
ments exposes  the  exterior  investment  of 
the  hernial  tumour,  continuous  with  the 
margins  of  the  ring,  and  formed  of  tendi- 
nous fibres  from  the  aponeurosis,  the  cre- 
master muscle,  &c.  This  is  connected  by 
cellular  substance  with  the.  proper  hernial 
sac,  formed  of  the  peritonamm.  This  pro- 
duction of  the  peritonaeum  passes  within 
the  ring  of  the  external  oblique,  and  then 
goes  upwards  and  outwards.  Behind  ami 
above  the  ring,  the  inferior  margin  of  the 
obliquus  internus  and  transversalis  crosses 
the  neck  of  the  sac  When  these  muscles 
are  reflected  towards  the  linea  alba,  the 
fascia,  ascending  from  Poupart’s  ligament, 
and  forming  the  upper  opening  of  the  ring, 
is  exposed,  and  the  epigastric  artery  is  dis- 
covered emerging  from  the  inner  side  of 
the  neck  of  the  hernial  sac,  ( Campari  leones, 
Tab.  X.  F.  M.)  which,  at  this  precise  point, 
becomes  continuous  with  the  peritonaeum, 
lining  the  abdomen.  The  removal  of  the 
hernial  sac  will  disclose  the  course  of  the 
spermatic  cord  in  its  descent  towards  the 
testicle  ; and  when  this  is  also  elevated,  the 
first  part  of  the  course  of  the  epigastric  ar- 
tery, and  its  origin  from  the  iliac  trunk,  are 
exposed.”  ( Lawrence  on  Hernia , p.  182 
Edit.  3.) 

In  females,  the  round  ligament  of  the  ute- 
rus bears  the  same  relation  to  the  tumour, 
as  the  spermatic  cord  in  males.  In  the 
former  subjects,  bubonoceles  are  uncommon. 
Mr.  Lawrence  had  a very  rare  instance 
pointed  out  to  him,  in  which  a bubonocele 
in  a female  was  situated  on  the  inner  side  of 
the  epigastric  artery.  A still  rarer  case  was 
examined  by  Hesselbach  : it  was  not  only 
an  example  of  internal  bubonocele  in  a 
woman,  but  of  one  in  which  the  epigastric 
artery  arose  from  the  obturatrix  artery  an 
inch  from  the  origin  of  this  latter  vessel 
from  the  inner  side  of  the  external  iliac  : 
the  obturatrix  first  passed  an  inch  obliquelv 
downwards  and  inwards  over  the  crural 
vein,  and  immediately  afterward,  on  the  ho- 
rizontal ramus  of  the  pubes,  made  a sudden 
turn  backward  and  downward  to  the  obtu- 
rator foramen  ; and  at  this  bend  arose  the 
epigastric  artery,  which  ran  transversely  in- 
ward along  the  horizontal  ramus  of  the 
pubes,  behind  the  neck  of  the  hernial  sac, 
at  the  inner  side  of  which  it  ascended  to 
the  rectus  muscle,  accompanied  by  the  llga- 


HERNIA. 


mentous  remains  of  the  umbilical  arteries, 
which  were  close  behind  it.  ( Uebcr  den 
Ursprung,  fyc.  der  Ltislen  und  Schenkel- 
brtiche,  p.  17.) 

MARKS  OF  DISCRIMINATION  BETWEEN  OTHER 
DISEASES  AND  INGUINAL  HERNIA:. 

The  disorders,  in  which  a mistake  may 
possibly  be  made,  are  Cirsocele,  Bubo , Hy- 
drocele, and  Hernia  Humoralis,  or  Inflamed 
Testicle. 

For  an  account  of  the  manner  of  distin- 
guishing the  first  complaint  from  a bubono- 
cele, see  Cirsocelc. 

u The  circumscribed  incompressible  hard- 
ness, the  situation  of  the  tumour,  and  its 
being  free  from  all  connexion  with  the 
spermatic  process,  will  sufficiently  point  out 
a bubo,  at  least  while  it  is  in  a recent  state; 
arid  when  it  is  in  any  degree  suppurated,  he 
must  have  a very  small  share  of  the  Indus 
eruditus , who  cannot  feel  the  difference  be- 
tween matter,  and  either  a piece  of  intes- 
tine, or  omentum. 

“ The  perfect  equality  of  the  whole  tu- 
mour, the  freedom  and  smallness  of  the 
spermatic  process  above  it,  the  power  of 
feeling  the  spermatic  vessels  and  the  vas  de- 
ferens in  that  process,  its  being  void  of  pain 
upon  being  handled,  the  fluctuation  of  the 
water,  the  gradual  formation  of  the  swelling, 
its  having  begun  below  and  proceeded  up- 
wards, its  not  being  affected  by  any  pos- 
ture or  action  of  the  patient,  nor  increased 
by  his  coughing  or  sneezing,  together  with 
the  absolute  impossibility  of  feeling  the  tes- 
ticle at  the  bottom  of  the  scrotum,  will  al- 
ways, to  an  intelligent  person,  prove  the 
disease  to  be  a hydrocele.”  Mr.  Fott,  how- 
ever, allows  that  there  are  some  exceptions, 
in  which  the  testicle  cannot  be  felt  at  the 
bottom  of  the  scrotum  in  cases  of  hernia. 
“In  recent  bubonoceles,  while  the  hernial 
sac  is  thin,  has  not  been  long,  or  very  much 
distended,  and  the  scrotum  still  preserves  a 
regularity  of  figure,  the  testicle  may  almost 
always  be  easily  felt  at  (lie  inferior  and  pos- 
terior part  of  the  tumour.  But  in  old  rup- 
tures, which  have  been  long  down,  in 
which  the  quantity  of  contents  is  large,  the 
sac  considerably  thickened,  and  the  scro- 
tum of  an  irregular  figure,  the  testicle  fre- 
quently cannot  be  felt,  neither  is  it  in  gene- 
ral easily  felt  in  the  congenital  hernia  for 
obvious  reasons.”  (Pott.) 

“ In  the  hernia  humoralis , the  pain  in  the 
testicle,  its  enlargement,  the  hardened  state 
of  the  epidydimis,  and  the  exemption  of  the 
spermatic  cord  from  all  unnatural  fulness, 
are  such  marks  as  cannot  easily  be  mistaken  ; 
not  to  mention  the  generally  preceding  go- 
norrhoea. But,  if  any  doubt  still  remains  of 
the  true  nature  of  the  disease,  the  progress 
of  it  from  above  downward,  its  different 
state  arid  size  in  different  postures,  particu- 
larly lying  and  standing,  together  with  its 
descent  and  ascent,  will,  if  duly  attended  to, 
put  it  out  of  all  doubt,  that  the  tumour  is  a 
true  hernia (Poll.) 

When  an  inguinal  hernia  docs  not  de- 


scend through  the  abdominal  ring,  but  only 
into  the  canal  for  the  spermatic  cord,  it  is  co- 
vered by  the  aponeurosis  of  the  external 
oblique  muscle,  and  the  swelling  is  small 
and  undefined. 

Now  and  then,  the  testicle  does  not  de- 
scend into  the  scrotum  till  a late  period,  and 
its  first  appearance  at  the  ring,  in  order  to  get 
into  its  natural  situation,  may  be  mistaken 
for  a hernia,  unless  the  surgeon  pay  atlen- 
tion  to  the  absence  of  the  testicle  from  the 
scrotum,  and  the  peculiar  sensation  occa- 
sioned by  pressing  the  swelling. 

POINTS  OF  DIFFERENCE  BETWEEN  THE  EX- 
TERNAL AND  INTERNAL  INGUINAL  HER- 
NIA, &ic. 

According  to  Hesselbach,  the  characteris- 
tic marks  of  the  external  bubonocele  and 
scrotal  hernia  are  ; 1st.  The  direction  of 
the  tumour  in  the  groin.  2dly.  The  fleshy 
fibres  of  the  cremaster.  3dly.  The  position  of 
the  spermatic  cord  and  testis.  4thly.  The 
situation  of  the  epigastric  artery.  5th ly. 
The  origin  of  the  hernia  itself.  6th ly.  A 
preternatural  shape  of  the  body  of  the  her- 
nial sac. 

1.  The  neck  of  the  hernial  sac,  distended 
by  the  protruded  viscera,  raises  up  the  front 
side  of  the  inguinal  canal,  and  superincum- 
bent integuments,  into  an  oblong  swelling, 
which  extends  obliquely  inwards  and  down- 
wards towards  (he  abdominal  ring,  and  ter- 
minates in  the  tumour,  formed  by  the  body 
of  the  hernial  sac.  From  its  origin  it  be- 
comes gradually  more  prominent  and  broad, 
and  the  greater  the  quantity  of  viscera  pro- 
truded, and  the  larger  the  body  of  the  sac, 
the  more  manifest  is  this  oblique  swelling, 
particularly  when  the  neck  of  the  hernia  is 
of  its  natural  length.  In  slrangulated  cases, 
the  direction  of  the  tumour  is  still  more 
striking,  every  part  of  the  hernial  sac  being 
then  considerably  distended.  When  the  in- 
guinal canal,  and  of  course  the  neck  of  the 
liernial  sac  are  shortened,  the  swelling  under- 
goes a proportional  diminution  in  its  length  ; 
and  then  its  resemblance  to  the  tumour  at- 
tending an  internal  inguinal  hernia,  where 
the  opening  through  which  the  parls  pass,  is 
long  and  slanting,  is  so  great,  that  the  cases 
can  only  be  discriminated  by  one  circum- 
stance, viz.  the  situation  of  the  spermatic 
cord,  and  even  this  criterion  is  of  course 
wanting  in  females.  ( Hesselbach , p.  57,  58,) 
Hesselbach  clearly  explains,  that  he  obli- 
quity of  the  swelling  is  seated  in  the  neck  of 
the  hernial  sac.  He  observes,  that  when  an 
internal  bubonocele  in  a female  subject 
passes  into  the  labium,  the  descent  takes 
place  in  a very  sloping  direction  inwards, 
and  therefore,  may  at  first  be  supposed  to  be 
an  external  case.  But,  on  further  examina- 
tion, the  oblique  swelling  will  be  found  to 
occupy  Ihe  body  of  the  hernial  sac,  and  to 
reach  upwards  and  outwards  from  the  la- 
bium to  the  abdominal  ring.  Now  this  her- 
nia cannot  bo  mistaken  for  an  external  bu- 
bonoceie,  the  course  of  which  from  the 
ring  is  obliquely  upwards  and  outwards. 


.HERNIA, 


llcsselbach  reminds  us,  that  an  internal, 
inguinal,  or  scrotal  hernia  may  be  conjoined 
with  an  external  incomplete  bubonocele  ; a 
kind  of  case  easily  made  out  with  a little  at- 
tention ; for  the  place  of  division  between 
the  two  sacs  is  indicated  by  a more  or  less 
deep  groove,  ihe  nature  of  the  disease  will 
also  be  still  dearer,  if  one  ot  the  tumours 
admit  of  reduction.  A specimen  of  such  a 
double  hernia  is  to  be  seen  in  the  museum  at 
Wurzburg. 

It  is  further  noticed  by  Hesselbach,  that, 
when  the  situations  of  the  external  and  in- 
ternal hernia)  are  compared,  the  first  of  these 
swellings  will  be  found  to  be  rather  further 
than  the  other,  from  the  symphysis  of  the 
pubes  : a difference  ascribed  to  the  effect  of 
the  internal  oblique  muscle,  the  lower  fibres 
of  which,  attached  to  the  horizontal  ramus 
of  the  pubes,  run  in  a curved  direction  trans- 
versely over  the  anterior  and  inner  part  ot 
the  neck  of  the  hernial  sac,  and  are  applied 
so  closely  to  it,  that  it  cannot  approach  quite 
so  much  towards  the  symphysis  of  the  pubes 
as  the  neck  of  the  internal  bubonocele  does. 
The  muscular  fibres  in  question  are  situated 
directly  behind  the  inner  pillar  of  the  abdo- 
minal ring. 

2.  Most  of  the  fibres  of  the  cremaster  lie 

on  the  back  of  the  neck  of  the  sac,  blit 
others  are  also  scattered  over  its  external 
and  internal  sides:  Some  fibres  may  also 

be  perceived  on  its  forepart,  which  are  re- 
markable, because  they  run  in  a transverse 
curved  direction  with  their  convexity  down- 
wards, and  two  fasciculi  of  which  descend 
below  the  abdominal  ring.  These  are  the 
fibres  of  the  cremaster,  which  proceed  within 
the  ring  transversely  upwards  over  the  sper- 
matic cord,  and  are  pushed  out  of  that 
opening  by  ihe  hernial  sac.  These  arched 
fleshy  fibres  are  not  always,  though  gene- 
rally, perceptible  ; and,  when  they  are  pre- 
sent on  the  forepart  of  the  hernial  sac,  Hes- 
selbach accounts  them  a sure  criterion  of  an 
external  scrotal  hernia ; but,  he  has  not  yet 
ascertained,  whether  they  are  visible,  while 
the  rupture  is  confined  to  the  groin. 

3.  The  situation  of  the  spermatic  cord  and 
testis  in  the  external  inguinal  hernia,  and, 

4.  That  of  the  epigastric  artery,  and  its 
displacement  inwards  by  the  neck  of  the  sac, 
have  been  sufficiently  explained. 

5.  With  respect  to  the  mode,  in  which  the 
hernia  originates,  the  disease  often  takes 
place  suddenly,  without  any  exciting  cause 
being  observed,  capable  of  accounting  for 
the  effect.  Here,  says  Hesselbach,  the  pre- 
disposing cause  must  have  been  great ; for 
instance,  the  communication  between  the 
cavity  of  the  peritonaeum  and  that  of  the 
tunica  vaginalis  has  remained  a long  while 
unclosed ; and,  when  a hernia  of  this  de- 
scription is  examined,  the  other  marks  of  an 
external  inguinal  hernia  are  associated  with 
the  sudden  formation  of  the  disease.  In  this 
quick  manner,  the  congenital  hernia,  which 
is  one  of  the  external  cases,  frequently 
.arises.  The  internal  inguinal  hernia  is  also 
observed  mostly  to  take  place  very  sud- 


denly, yet  only  after  violent  occasional 
causes. 

6.  A preternatural  form  of  the  body  of  the 
hernial  sac,  Hesselbach  remarks,  is  particu- 
larly sealed  in  the  shettth  of  the  spermatic 
cord,  and  can  never  happen  in  the  internal 
scrotal  hernia;  for,  it  is  only  in-  external 
cases,  that  the  above  sheath  is  ever  convert- 
ed into  the  hernial  sac.  Hesselbach  here 
refers  to  the  -partial  contraction,  often  no- 
ticed at  the  lower  part  of  the  above  sheath 
in  cases  of  congenital  hernia ; a circum- 
stance, which  is  always  discovered  previ- 
ously to  the  business  of  dividing  the  ring. 

In  adults,  an  external  inguinal,  or  scrotal 
hernia,  on  the  right  side,  contains  some 
of  the  ileum,  and,  when  the  swelling  is 
large,  it  may  include  the  ccecum,  and  some- 
times a piece  of  omentum.  In  one  child, 
ten  weeks  old,  and  in  another  still  younger, 
the  appendix  vermiformis  was  protruded  and 
connected  by  a natural  band  to  the  posterior 
side  of  the  peritonaeum.  When,  in  these 
ruptures  of  the  right  side,  the  ccecum,  or,  in 
those  of  the  left,  the  colon  are  met  with, 
closely  adherent  to  the  hinder  side  of  the 
hernial  sac,  the  adhesion  is  not  to  be  looked 
upon  as  the  effect  of  disease,  since  it  is  the 
perfectly  natural  connexion  of  those  bowels 
with  the  peritonaeum.  On  the  left  side,  the 
parts  most  commonly  protruded  are  the 
colon  and  omentum. 

With  regard  to  the  internal  inguinal  hernia, 
the  place  of  its  first  protrusion  has  , been 
already  described.  The  protruded  perito- 
naeum and  viscera,  accordingto  Hesselbach’s 
account,  pass  from  behind  straight  forwards , 
between  the  fibres  of  what  he  names  the  in- 
ternal inguinal  ligament,  and  the  fleshy  fibres 
of  the  internal  oblique  muscle  : they  then 
pass,  at  the  inner  side  of  the  spermatic  cord, 
out  of  the  abdominal  ring,  where  the  hernia 
presents  a circular  globular  swelling,  sud- 
denly formed  in  consequence  of  some  violent 
effort.  The  neck  of  the  hernial  sac  is  very 
short ; shorter  than  it  can  ever  be  in  an  ex- 
ternal inguinal  hernia,  and, when  the  tumour 
is  of  Uthe  above  shape,  the  passage  through 
which  it  passes  is  annular,  narrower. in  some 
instances  than  others,  and  its  margin  is  ten- 
dinous. From  the  few  cases,  which  Hessel- 
bach has  seen  of  this  form  of  the  disease,  he 
is  led  to  conjecture,  that  the  hernial  sac  is 
rarely  so  large  as  in  the  external  inguinal 
hernia.  (jP.  41.)  The  earlier  dissections 
made  by  Hesselbach,  led  him  to  suppose, 
that,  in  the  internal  inguinal  hernia,  the 
opening,  through  which  the  protrusion  hap- 
pens, is  always  annular,  and  the  swelling  in 
front  ot  the  ring  globular  ; b it  subsequent 
cases,  which  he  has  met  with,  have  informed 
him,  that  the  opening  is  frequently  sloping 
and  longisb,  in  which  circumstance,  the  re- 
semblance of  the  tumour  to  that  of  the  ex- 
ternal bubonocele  with  a shortened  neck,  is 
such,  that  the  only  mark  of  distinction  be- 
tween the  two  cases  is  the  position  of  the 
spermatic  cord.  In  females,  even  this  crite- 
rion is  of  course  deficient.  ( Hesselbach , p. 
57.)  Though  individuals  of  almost  every 
age  are  subject  to  internal  bubonoceles,  they 


24 


HERNIA. 


arc  much  less  common  than  external  cases. 
According  to  Hesselbach,  they  may  be 
known  by  the  following  characters.  1.  The 
swelling,  formed  by  the  body  of  the  hernial 
sac,  immediately  in  front  of  the  abdominal 
ring.  2.  The  situation  of  the  spermatic 
cord.  3.  That  of  the  epigastric  artery. 

1.  The  neck  of  the  hernial  sac,  besides 
being  very  short,  does  not,  like  that  of  an 
external  inguinal  hernia,  take  an  oblique  di- 
rection, but  advances  straight  from  behind 
forwards  through  the  abdominal  ring,  and  as 
the  body  of  the  sac  lies  directly  over  the 
neck,  none  of  the  swelling,  formed  by  the 
distention  of  the  latter  part,  can  bo  felt. 
Nor  does  any  other  tumour,  produced  by  the 
body  a hernial  sac,  ever  cause  a circular 
spherical  swelling  directly  before  the  abdo- 
minal ring.  The  situation  of  the  neck  of  this 
kind  of  hernia  must  already  apprise  us,  that 
the  internal  bubonocele  is  nearer,  than  the 
external,  to  the  symphysis  of  the  pubes.  In 
women,  the  shape  of  the  tumour  is  the  only 
character,  by  which  the  case  can  be  distin- 
guished. (Hesselbach,  p.  43.) 

2.  After  what  has  been  already  stated,  re- 
specting the  situation  of  the  spermatic  cord 
in  the  internal  inguinal  hernia,  I shall 
merely  notice  one  or  two  observations  of 
Hesselbach.  The  cord  lies  either  upon  the 
outer  side,  or  outer  half  of  the  forepart  of 
the  upper  portion  of  the  hernial  sac,  the 
blood-vessels  forwards,  and  the  vas  defer- 
ens backwards.  When  the  sac  is  adherent 
to  the  whole  length  of  the  cord,  the  testis  is 
not  situated  under  the  fundus  of  the  sac,  as 
in  the  external  scrotal  hernia,  but  either  at 
the  forepart  or  outer  side  of  the  body  of  the 
sac.  The  hernial  sac,  as  far  as  the  abdominal 
ring,  is  excluded  from  the  common  perito- 
naea! covering  of  the  spermatic  cord,  but  at 
this  opening,  it  descends  between  the  cord 
and  the  internal  thin  part  of  the  sheath  of 
the  cremaster,  which,  howrever,  is  somewhat 
stronger  towards  the  front  and  outer  side  of 
the  hernia,  over  which  part  alone  the  fleshy 
fibres  of  the  cremaster  are  spread.  (P.  44.) 

3.  The  epigastric  artery  always  ascends  ob- 
liquely Inwards  at  the  outer  side  of  the  neck 
of  the  hernial  sac.  Hesselbach  has  never 
seen  but  one  case  of  internal  bubonocele,  in 
which  there  was  a deviation  from  this  rule. 
The  example  has  been  already  mentioned, 
and  was  one  in  the  epigastric  artery,  arose 
from  the  obturatrix  about  an  inch  from  the 
origin  of  this  last  vessel.  The  viscera,  usually 
contained  in  an  internal  inguinal,  or  scrotal 
hernia,  on  the  right  side,  are  the  lower  part 
of  the  small  intestines,  and  sometimes 
omentum  ; on  the  left,  a paid  of  the 
small  intestines,  frequently  omentum,  and 
when  the  tumour  is  large,  the  colon 
may  also  protrude.  A protrusion  of  the 
bladder  may  accompany  the  disease,  but 
that  organ  is  of  course  always  excluded  from 
the  cavity  of  the  hernial  sac.  When  the  re- 
mains of  the  umbilical  cord  are  situated 
more  outward  than  usual,  and  lie  over  the 
centre  of  the  space,  at  which  the  protrusion 
happens,  an  internal  bubonocele  may  he 
double,  the  prolapsus  happening  on  each 


side  of  that  ligamentous  substance,  which  isf 
itself  also  pushed  outwards.  In  consequence, 
of  the  accidental  presence  of  some  very 
strong  tendinous  fibres  at  the  centre  of  the 
fascia,  called  by  Hesselbach  the  internal 
inguinal  ligament,  there  may  also  he  two 
distinct  protrusions,  with  separate  hernial 
sacs.  (P.  46.) 

When  the  surgeon,  by  a due  consideration 
of  the  foregoing  circumstances,  has  formed  a 
judgment  respecting  the  nature  of  the  her- 
nia, he  will  be  better  qualified  to  regulate 
the  treatment  of  the  case.  Thus,  in  the  ex- 
ternal inguinal  hernia,  he  will  know,  that 
the  pressure,  employed  for  the  reduction  of 
the  bowels,  should  be  made  in  the  direction 
of  the  neck  of  the  hernial  sac,  viz.  obliquely 
upwards  and  outwards,  towards  the  anterior 
superior  spinous  process  of  the  ilium; 
but  that,  when  the  neck  of  the  same 
kind  of  hernia  is  very  short,  and  the  poste- 
rior side  of  the  inguinal  canal  has  been  re- 
moved, the  pressure  should  he  made  nearly 
in  a straight  line  from  before  backwards. 
For  what  Hesselbach  terms  the  long-necked 
external  inguinal  hernia,  the  pad  of  a truss 
should  be  so  constructed,  as  not  merely  to 
press  upon  the  abdominal  ring,  but  also 
upon  the  neck  of  the  sac  and  the  inner 
opening  of  the  inguinal  canal.  But,  when 
the  neck  of  the  hernia  is  very  short,  the 
pad  should  be  nearly  of  the  same  form,  as 
that  required  for  an  internal  inguinal  hernia. 
( Hesselbach , p.  38;  and  Brunninghausen,  Ge- 
meinnutziger  Unlerricht  fiber  die  Bruche,  fyc. 
Wurzb.  1811.)  In  attempting  the  reduction 
of  an  internal  inguinal  hernia,  the  pressure 
should  be  directed  nearly  straight  back- 
wards ; and  the  pad  of  the  truss  should  only 
act  upon  the  abdominal  ring.  (Hesselbach, 
p.  46.) 

THE  OPERATION  FOR  STRANGULATED  INGUI- 
NAL HERNIA,  OR  BUBONOCELE 

Consists  in  dividing  the  integuments  ; dis- 
secting down  to  the  sac,  and  opening  it; 
removing  the  stricture  ; and  replacing  the 
protruded  viscera. 

The  external  incision  should  begin  an 
inch  above  the  external  angle  of  the  ring, 
and  extend  over  the  middle  of  the  tumour 
to  its  lower  part.  The  advantage  of  begin- 
ning the  wound  so  high,  is  to  obtain  con- 
venient room  for  the  incision  of  the  stric- 
ture. By  this  first  cut,  the  external  pudic 
branch  of  the  femoral  artery  may  be  divi- 
ded ; it  crosses  the  hernial  sac  near  the  abdo- 
minal ring,  and  sometimes  bleeds  so  freely, 
as  to  require  to  be  immediately  tied.  In 
general,  however,  a ligature  is  unneces- 
sary. 

When  this  incision  is  carried  low  down,  the 
caution,  given  by  Camper,  should  always 
he  remembered,  viz.  that  there  is  a possibili- 
ty of  dividing  the  spermatic  vessels,  should 
they  happen  to  be  situated,  as  they  some- 
times are,  in  front  of  the  hernia.  And, 
in  order  to  avoid  such  an  accident,  which  is 
particularly  apt  to  occur  in  cases  of  internal 
inguinal,  or  scrotal  hernia,  the  incision 


.'HERNIA. 


through  the  skin  should  be  made  obliquely 
downwards  and  inwards.  ( Hesselbach , jj. 

•46.)  The  division  of  the  integuments  brings 
into  view  the  fascia,  which  is  sent  off  from 
the  tendon  of  the  external  oblique  muscle, 
and  covers  the  hernial  sac. 

The  layers  of  tendinous  fibres,  cellular 
substance,  &.c.  intervening  between  the  skin 
and  sac,  should  be  carefully  divided,  one 
after  another,  with  the  knife  and  dissecting 
forceps,  the  edge  of  the  former  instrument  be- 
ing turned  horizontally,  lest  the  incisions  be 
carried  too  deeply  at  once,  and  the  viscera 
contained  in  the  sac  wounded. 

.After  making  a small  opening  through  a 
part  of  the  fascia  covering  the  sac,  some 
practitioners  introduce  a director,  and  di- 
vide this  fascia  upward  and  downward  as 
far  as  the  tumour  extends.  The  same  man- 
ner they  next  pursue  with  regard  to  the  cre- 
master muscle.  Thus  the  sac  .becomes 
completely  exposed.  When  this  method  is 
followed,  Mr.  A.  Coope;  advises  the  inci- 
sions not  to  be  carried  upward,  nearer  than 
ona  ;nch,to  the  abdominal  ring,  for  reasons 
which  will  be  presently  explained. 

However,  it  may  be  rationally  doubted, 
whether  there  is  any  good  in  these  formal 
and  successive  divisions  of  the  whole  length 
oftke  coverings  of  the  sac  ; and  it  is  certain, 
that  they  protract  the  operation  very  much  ; 
for  the  manner  in  which  the  sac  adheres  to 
the  outer  investment  of  it,  prevents  the  lat- 
ter from  being  raised  and  cut  without  trou- 
ble rnd  delay.  As  the  grand  object,  after 
the  skin  has  been  divided,  is  to  make  a small 
opening  into  the  sac,  sufficient  for  the  intro- 
duction of  a director,  dissecting  down  at  one 
particular  place  answers  every  purpose,  and 
enables  us,  in  the  end,  to  lay  open  the  whole 
of  the  sac  and  its  coverings  in  the  shortest 
time.  Let  the  operator  only  take  care  to 
raise  the  successive  layers  of  fibres  with  the 
forceps,  and  divide  the  apex  of  each  eleva- 
ted portion  with  the  knife  held  horizontally. 
As  there  is  commonly  a quantity  of  fluid  in 
the  sac,  and  it  gravitates  to  the  lower  part, 
to  which  place  the  intestine  seldom  quite 
descends  ; this  is  certainly  the  safest  situa- 
tion for  making  the  first  opening  into  the 
sac.  The  operator,  however,  should  not 
rely  upon  the  presence  of  such  fluid,  and 
cut  too  boldly , for  sometimes  it  is  absent, 
and  the  viscera  may  be  in  immediate  con- 
tact with,  nay,  adherent  to,  the  inner  sur- 
face of  the  sac. 

The  circular  arrangement  of  the  vessels  of 
a piece  of  intestine,  and  its  smooth  polished 
surface,  sufficiently  distinguish  it  from  the 
hernial  sac,  which  has  a rough  cellular  sur- 
face, and  is  always  connected  with  the  sur- 
rounding parts,  although  these  adhesions,  in 
a very  recent  case,  may  be  but  slight. 

( Lawrence  on  Ruptures , p.  214,  Edit.  3.) 

I have  mentioned,  that  Mr.  A.  Cooper 
only  advises  cutting  the  fascia,  and  other 
coverings  of  the  sac,  under  the  skin,  to 
within  an  inch  of  the  abdominal  ring;  and, 
of  course,  he  also  recommends  limiting 
the  division  of  the  sac  itself  to  the  same  ex- 
tent. His  reasons  for  this  practice,  are  to 
Vor  . I k 1 


avoid  making  the  closure  of  the  wound 
more  difficult,  and  to  lessen  the  danger  of 
peritonaial  inflammation. 

Having  laid  open  the  hernial  sac  with  a 
probe-pointed  bistoury,  guided  by  a direc- 
tor, or  the  fore-finger  introduced  into  the 
opening,  made  at  the  lower  part  of  the  sac, 
the  next  desideratum  is  to  divide  the  stric- 
ture, unless  the  viscera  admit  of  being  easily 
reduced,  without  such  an  incision  being 
made  as  occasionally  happens. 

From  the  anatomical  account,  which  has 
been  given  of  the  bubonocele,  it  appears, 
that  the  stricture  may  either  be  situated  at 
the  abdominal  ring,  and  be  formed  by  the 
margins  of  this  opening,  or  else  at  the  inner 
aperture  of  the  canal,  about  one  inch  and  a 
half,  in  a direction  upward  and  outward, 
from  the  outer  opening  in  the  tendon  of  the 
external  oblique  muscle.  This  latter  stran- 
gulation is  caused  by  the  semicircular  edge 
of  the  transversalis  muscle  and  its  tendon, 
which  pass  over  the  neck  of  the  hernial  sa(T, 
and  by  a fascia,  arising  from  Poupart’s  liga- 
ment, the  semicircular  border  of  which 
passes  under  this  part  of  the  sac. 

'file  common,  and  probably  the  best  prac- 
tice is  to  divide  the  hernia!  sac,  together 
with  the  stricture.  When  this  is  situated  at 
the  abdominal  ring,  the  surgeon  is  to  intro- 
duce the  end  of  a director  a little  way  into 
the  neck  of  the  sac,  within  the  aperture  in 
the  tendon,  and  with  a probe-pointed  bis- 
toury, guided  on  the  latter  instrument,  he  is 
to  cut  the  stricture  upward  and  outward,  or 
else  directly  upward ; a manner,  which  Mr. 
A.  Cooper  recommends,  because  it  is  appli- 
cable to  all  cases,  even  the  less  frequent 
ones,  in  which  the  hernia  protrudes  at  the. 
inner  side  of  the  epigastric  artery;  and,  in 
all  common  instances,  vre  know,  that  this 
vessel  runs  upward  round  the  inner  side  of 
the  neck  of  the  sac  ; a course  prohibiting 
the  division  of  the  stricture  upward  and  in- 
ward. 

fn  the  external  inguinal  hernia,  the  me- 
thod of  cutting  the  stricture  upward  and 
outward  is  perfectly  safe ; but  when  the 
case  is  what  Hesselbach  calls  internal,  and 
the  viscera  descend  on  the  inner  side  of  the 
epigastric  artery;  it  is  a plan  which  would 
endanger  the  latter  vessel,  and  ought  never 
to  be  adopted,  notwithstanding  any  state- 
ment made  in  its  favour  by  Rudlorfier.  Ab- 
handlung  iiber  die  einfachsle  und  sichersle 
opcrations-Methodc  eingesperrier  Leislcn-und- 
Schenkelbriiche.  Wien.  1808.)  Tn  this  work 
the  erroneous  plan  of  cutting  the  ring  in- 
wards is  inculcated,  both  in  the  external  and 
internal  inguinal  rapture.  The  author,  how- 
ever, seems  to  have  performed  many  opera- 
tions in  this  manner,  without  any  accident 
from  hemorrhage;  a piece  of  good  fortune, 
which  Professor  Langenbeck  ascribes  to  the 
circumstance  of  the  knife  having  always 
been  applied,  as  iludtorffer  directs,  to  the 
middle  of  the  inner  pillar  of  the  ring,  and  to 
the  cut  having  been  very  limited.  Langen- 
beck is  of  opinion,  that,  if  the  knife  bad  been 
applied  a little  lower,  and  the  incision  car- 
ried to  any  extent,  the  epigastric  artery,  in 


HERNIA. 


ordinary  oases,  would  not  have  escaped 
injury.  !\Ir.  A.  Cooper’s  rule  of  always 
cutting  in  one  direction,  viz.  upward,  which 
I believe  was  first  advised  by  Autenrieth,  D/s- 
serf.  Moment,  circa  Hernia  tom.  prcccipue  circa 
evitandam  art.  epigastr.  loesionem, , Tub.  1799) 
is  perhaps  a very  good  one,  because  it  is  at 
least  easy  for  the  memory,  and  will  answer 
very  well  even  when  it  is  not  in  the  power 
of  the  surgeon  to  pronounce  positively  whe- 
ther the  case  is  a short-necked  external  hu- 
bonocele,  or  an  internal  one  with  an  oblong 
oval  fissure,  cases  having  a great  external 
resemblance,  especially  in  women,  in  whom 
there  is  not  the  spermatic  cord  as  a crite- 
rion ; for,  after  all,  this  part,  when  present, 
is  the  surest  guide,  and  that  on  which  De- 
sault founded  his  perfectly  safe  advice,  viz. 
when  the  cord  is  at  the  posterior  or  inner 
side  of  the  neck  of  the  hernial  sack,  to  divide 
the  ring  upwards  and  outwards,  but  inwards 
and  upwards  when  it  lay  at  the  outer  or  on 
the  forepart  of  the  sac.  ( CEuvres  Chir.  de 
Bichat , T.  2.)  At  least,  this  advice  is  sub- 
ject but  to  one  exception,  which  is  the  very 
rare  one  of  the  epigastric  running  round  the 
inner  side  of  the  neck  of  the  sac  in  an  inter- 
nal bubonocele ; a possibility  which  has 
been  already  explained,  and  which  leads 
Hesselbach  particularly  to  recommend  the 
division  of  the  ring  in  every  internal  ingui- 
nal hernia,  to  be  made  straight  upwards. 
( P . 47.)  Indeed,  the  long-necked  external 
bubonocele  is  the  only  case  in  which  he 
thinks  the  latter  plan  should  give  way  to 
that  of  cutting  upwards  and  outwards.  The 
safety  and  propriety  of  the  method  of 
always  cutting  upward,  are  strikingly  illus- 
trated by  what  Scarpa  observes : he  states, 
that  the  right  direction  of  the  incision  of  the 
ring  is  directly  upwards,  parallel  to  the 
lineaalba.  “ I have  (says  lie)  operated  in 
the  way  which  1 recommend  upon  several 
dead  subjects,  who  had  either  external  or 
internal  inguinal  hernia?,  directing  my  inci- 
sion in  the  course  of  a line  drawn  from  the 
upper  part  of  the  ring  parallel  to  the  linea 
alba;  in  all, I constantly  left  the  epigastric 
artery  untouched,  even  when  I extended  the 
cut  about  an  inch  above  the  inguinal  ring.” 
( Scarpa , Traiti  Pratique  des  Ilernies,  p.  111.) 
Only  one  objection,  as  far  as  I know,  has 
been  made  to  this  plan,  and  it  is  founded  on 
the  alleged  impossibility  of  introducing  the 
knife,  so  as  to  cut  straight  upwards,  when 
the  neck  of  the  hernial  sac  is  long,  because 
then  the  posterior  side  of  the  inguinal  canal 
is  in  the  way.  ( Hesselbach , p.  40.)  No  more 
of  the  parts  forming  the  stricture,  should  be 
cut  than  is  just  sufficient  for  allowing  the 
protruded  viscera  to  be  reduced  without 
bruising  or  otherwise  hurting  them  ; and  I 
consider  the  middle  of  the  upper  margin  of 
the  ring  the  safest  place  for  making  the  ne- 
cessary incision. 

Mr.  A.  Cooper,  in  his  valuable  work  on 
the  Inguinal  Hernia,  advises  a mode  of  di- 
viding the  stricture,  considerably  different 
from  the  usual  method.  He  directs  the  fin- 
ger of  the  operator  to  be  introduced  into  the 
sac,  (which,  in  his  plan,  we  know  is  left  un- 


divided for  the  space  of  one  ipch  below  Ihc 
ring.)  When  the  stricture  is  felt,  a probe- 
pointed  bistoury  is  to  be  conveyed  over  the 
front  of  the  sac  into  the  ring  (between  the 
two  parts.)  and  the  latter  only  is  then  1o  be 
divided,  in  the  direction  upward,  opposite 
the  middle  of  the  neck  of  the  sack,  and  to 
an  extent  just  sufficient  to  allow  the  protru- 
ded parts  to  be  returned  into  the  abdomen 
without  their  being  hurt.  The  two  chief 
advantages  which  Mr.  A.  Cooper  imputes  to 
this  method,  are,  that  the  danger  of  perito- 
neal inflammation  will  be  less,  and  that  the 
epigastric  artery,  if  wounded,  would  not 
bleed  into  the  abdomen.  1 am  of  opinion, 
that  Mr.  Lawrence’s  remarks,  concerning 
this  proposal,  are  judicious  : “ An  accurate 
comparative  trial  of  both  methods  would  be 
necessary,  in  order  to  determine  the  weight 
of  the  first  reason.  The  second  circum- 
stance cannot  be  a matter  of  any  importance, 
if  we  cut  in  such  a direction  as  to  avoid  the 
risk  of  wounding  the  artery.  Many  circum- 
stances present  themselves  as  objections  to 
this  proposal.  The  manoeuvre  itself,  although 
perhaps  easy  to  the  experienced  hand  of 
such  an  able  anatomist  as  Mr.  C.,  would,  I 
am  convinced,  be  found  highly  difficult,  if 
not  impracticable,  by  the  generality  of  sur- 
geons. This  difficulty  arises  from  the  firm 
manner  in  which  the  sac  and  surrounding 
parts  are  connected,  we  might  almost  say 
consolidated,  together.  The  experience  of 
of  Richter  (Traitd  des  Hernies,  p.  118)  shows, 
that  this  objection  is  founded  in  reality.  He 
once  tried  to  divide  the  ring,  without  cut- 
ting the  sac,  but  lie  found  it  impracticable. 
If  the  stricture  is  so  tight  as  to  prevent  the 
introduction  of  the  finger,  there  must  be 
great  danger  of  wounding  the  protruded 
parts.  The  practice  would  still  be  not 
adviseable,  even  if  it  could  be  rendered  as 
easy  as  the  common  method  of  operating. 
Mr.  C.  leaves  an  inch  of  the  sac,  below  the 
ring,  undivided  ; thus  a bag  remains  ready 
to  receive  any  future  protrusion,  and  the 
chance  of  a radical  cure  is  diminished. 
It  would  be  better  to  follow  the  advice  of 
Richter,  and  scarify  the  neck  of  the  sac,  in 
order  to  promore  an  adhesion  of  its  side?. 
He  has  found  this  practice  so  successful  in 
accomplishing  a radical  cure,  that  he  ad- 
vises (p.  191.)  its  employment  in  every 
operation  for  strangulated  hernia.”  (See 
Lawrence  on  Ruptures,  p.  321,  Edit.  3.) 

If  the  stricture  should  be  at  the  inner 
opening  of  the  canal  for  the  spermatic  cord, 
Mr.  A.  Cooper  advises  the  operator  to  intro- 
duce his  finger  into  the  sac,  as  far  as  the 
stricture,  and  then  to  insinuate  a probe- 
pointed  bistoury,  with  the  flat  part  of  its 
blade  turned  towards  the  finger,  between 
the  front  of  the  sac  and  the  abdominal  ring, 
till  it  arrives  under  the  stricture,  formed  by 
the  lower  edge  of  the  transversalis  and  obli- 
quus  interims.  Then  the  edge  of  the  instru- 
ment is  to  be  turned  forward,  and  the  stric- 
ture cut  in  the  direction  upward.  This  plan 
of  not  cutting  the  neck  of  the  sac,  is  liable 
to  all  the  objections  stated  by  Mr.  Law- 
rence, in  regard  to  the  case  in  which  the 


HE  KM 


27 


strangulation  takes  place  at  the  abdominal 
ring.  Mr.  A.  Cooper’s  bistoury  is  a very 
proper  one  for  dividing  the  stricture,  as  it 
only  has  a cutting  edge  to  a certain  distance 
from  the  point.  Perhaps,  on  the  whole,  we 
may  infer,  that  it  is  botli  most  easy  and  ad- 
vantageous to  divide  the  neck  of  the  sac, 
together  witli  the  stricture,  whether  this  be 
situated  at  the  ring,  or  more  inward.  The 
method  of  cutting  the  stricture  from  without 
inwards  l consider  objectionable,  on  the 
ground  of  the  risk  of  wounding  the  bowels 
tu  this  mode,  being  greater,  than  that  of 
any  accident  wounding  the  epigastric  arte- 
ry, when  it  arises  in  an  unusual  manner, 
and  deviates  from  its  regular  course  ; a re- 
flection, which  has  made  Dr.  Hesselbach, 
junior,  an  advocate  for  the  practice.  (See 
Sicherste  Art  dts  Bruckschnilles,  4 to.  Bam- 
berg. 1819.) 

Room  being  made  for  the  reduction  of 
the  protruded  parts  into  the  abdomen,  by 
the  division  of  the  stricture,  they  are  imme- 
diately to  be  returned,  if  sound,  and  free 
from  adhesions.  This  object  is  considerably 
facilitated  by  bending  the  thigh.  The  intes- 
tines are  to  be  reduced  before  the  omentum, 
but  when  a portion  of  mesentery  is  protru- 
ded, it  is  to  be  returned  before  either  of  the 
preceding  parts.  The  intestine  should  al- 
ways be  reduced,  unless  it  be  found  in  a 
state  of  actual  mortification.  It  often  ap- 
pears so  altered  in  colour,  that  an  uninform- 
ed person  would  deern  it  improper  to  re- 
turn it  into  the  abdomen.  However,  if  such 
alteration  should  not  amount  to  areal  mor- 
tification, experience  justifies  the  reduction 
of  the  part.  Mr.  A.  Cooper  has  judiciously 
cautioned  the  operator  not  to  mistake  the 
dark  chocolate  brown  discolorations,  for  a 
state  of  gangrene.  With  these  the  protruded 
part  is  frequently  found  affected ; and  as  they 
generally  produce  no  permanent  mischief, 
they  ought  to  be  carefully  discriminated 
from  the  black-purple,  or  lead-coloured  spots 
which  usually  precede  mortification.  To 
determine  whether  a discoloured  portion  of 
ifitestine  be  positively  mortified,  some  re- 
commend pressing  forward  the  blood  con- 
tained in  the  veins,  and  if  they  fill  again,  it 
is  looked  upon  as  a proof  that  the  bowel  is 
still  possessed  of  life. 

In  returning  a piece  of  intestine  into  the 
abdomen,  the  surgeon  should  first  introduce 
the  part  nearest  the  ring  into  this  aperture, 
and  hold  it  there  until  another  portion  has 
succeeded  it.  This  method  is  to  be  continu- 
ed till  the  whole  of  the  protruded  bowel  is 
reduced. 

Writers  on  surgery  cannot  too  severely 
reprobate  the  employment  of  any  force,  or 
violence,  in  the  endeavours  to  return  the 
contents  of  a hernia  in  the  operation  : a 
method  the  more  pernicious,  because  such 
parts  are  more  or  less  in  a state  of  inflam- 
mation. It  is  always  better  to  enlarge  the 
stricture,  than  pinch  and  bruise  the  bowel 
in  trying  to  get  it  through  an  opening,  which 
is  too  small.  Distention  of  the  intestine 
Sometimes  prevents  the  reduction:  but  when 


this  is  the  only  impediment,  the  part  may 
generally  be  returned,  as  soon  as  its  con- 
tents have  been  compressed  into  the  intes- 
tinal canal  within  the  stricture.  It  is  better, 
however,  to  dilate  the  strangulation  a little 
more,  than  use  any  force  in  trying  to  get 
the  intestine  back  into  the  abdomen  in  the 
manner  just  suggested. 

Reduction  is  sometimes  impeded  by  the 
protruded  parts  adhering  to  each  other,  or 
to  the  hernial  sac.  The  intestines  are  not 
often  found  very  firmly  adherent  together. 
The  omentum  and  inside  of  the  sac  are  the 
parts  which  are  most  subject  to  become 
intimately  connected  by  adhesions.  The 
fingers  will  commonly  serve  for  breaking 
any  recent  slight  adhesions  which  may  have 
taken  place  between  the  intestines  and  in- 
side of  the  hernial  sac.  When  those  adhe- 
sions are  firm,  and  of  long  standing,  they 
must  be  cautiously  divided  with  the  knife  •, 
an  object  which  can  be  most  easily  and 
safely  accomplished,  in  case  they  are  long 
enough  to  permit  the  intestine  to"  be  eleva- 
ted a little  way  from  the  surface  of  the  sac. 

But,  provided  their  firmness  and  shortness 
keep  the  external  coat,  of  the  bowel  and 
inner  surface  of  the  sac  in  close  contact, 
the  greatest  care  is  requisite  in  separating 
the  parts  with  a knife,  so  as  to  avoid  wound- 
ing the  intestine  In  doing  this,  the  most 
prudent  and  safe  method  is  not  to  cut  too 
near  the  bowel,  but  vather  to  remove  the 
adherent  parts  of  the  sac,  and  return  (hem 
with  the  intestine  into  the  abdomen.  Every 
preternatural  connexion  should  always  be 
separated,  before  the  viscera  are  reduced  : 
Mr.  A Cooper  mentions,  that  a fatal  ob- 
struction to  the  passage  of  the  intestinal 
matter  has  arisen  from  the  mere  adhesion  of 
the  two  sides  of  a fold  of  intestine  together. 
( P . 8i.)  When  the  adhesions,  which  pre- 
vent reduction,  are  situated  about  the  neck 
efthe  sac,  and  out  of  the  operator’s  view, 
it  is  best  to  make  the  wound  through  the 
skin  and  abdominal  ring  somewhat  larger, 
so  as  to  be  able  to  separate  the  adhesions 
with  more  safety. 

Having  reduced  the  parts,  the  operator 
should  introduce  his  finger,  for  the  purpose 
of  being  sure  that  they  are  fairly  and  freely 
returned  info  the  abdomen,  and  no  longer 
suffer  constriction,  either  from  the  inner 
opening,  from  the  ring,  or  the  parts  just 
within  the  cavity  of  the  peritonajum. 

Treatment  of  the  omentum. 

In  an  entero-epiplocele,  this  part,  if  heal- 
thy and  free  from  gangrene,  is  to  be  redu- 
ced after  the  intestine.  When,  however,  it 
is  much  diseased,  thickened,  and  indurated, 
as  it  frequently  is  found  to  be,  after  remain- 
ing any  considerable  time  in  a hernial  sac, 
the  morbid  part  should  be  cut  oft’.  Its  re- 
duction, in  this  circumstance,  would  he 
highly  improper,  both  because  an  immode- 
rate enlargement  of  the  wound  would  be 
necessary,  in  order  to  be  able  to  put  the  dis- 
eased muss  back  into  the  abdomen,  arid  be- 


HERNIA. 


2 is 


cause,  when  reduced,  it  would,  in  all  pro- 
bability, excite  inflammation  of  the  sur- 
rounding parts,  and  bring  on  dangerous 
symptoms.  (See  Hey,  j>.  172.) 

The  diseased  omentum  should  always  be 
cut  oil' with  a knife;  and  if  any  of  its  arte- 
ries should  bleed,  they  ought  to  be  taken  up 
with  a tenaculum,  and  tied  separately  with 
a small  ligature.  An  unreasonable  appre- 
hension of  hemorrhage  from  the  cut  end  of 
the  omentum  has  led  many  operators  to  put 
a ligature  all  round  this  part,  just  above  the 
diseased  portion  which  they  were  about  to 
remove.  This  practice  cannot  be  reproba- 
ted in  terms  too  severe  ; for  a frequent  ef- 
fect of  it  is  to  bring  on  a fatal  inflammation, 
and  even  mortification  of  the  omentum,  ex- 
tending within  the  abdomen,  as  high  as  the 
stomach  and  transverse  arch  of  the  colon. 
Mr.  A.  Cooper  has  remarked  with  great 
truth,  that  it  is  surprising  this  custom  should 
ever  have  prevailed.  The  very  object  of 
the  operation  is  to  extricate  the  omentum 
from  its  strangulated  state,  arising  from  the 
pressure  of  the  surrounding  tendon,  and  no 
sooner  has  this  been  done,  than  the  surgeon 
includes  it  in  a ligature,  which  produces  a 
more  perfect  constriction,  than  that  which 
existed  before  the  operation  was  under- 
taken. 

“ When  the  omentum  has  suffered  stran- 
gulation for  a few  days  (says  Mr.  Lawrence) 
it  often  becomes  of  a dark  red,  or  livid  co- 
lour ; and  there  is  an  appearance,  on  cutting 
it,  as  if  some  blood  were  extravasated  in  its 
substance.  This,  I believe,  is  the  state 
which  surgeons  have  generally  described 
under  the  term  of  gangrene.”  (P.  262.) 

When  cut  in  this  state,  it  does  not  bleed. 
I need  hardly  observe,  that  the  dead  part 
must  be  amputated,  and  never  reduced. 
9ome  have  advised  leaving  the  omentum  in 
the  wound,  especially  in  cases  of  old  her- 
nice,  in  which  it  has  been  a long  while  pro- 
truded. Hey  mentions  cases,  showing  that 
granulations  form  very  well,  and  that  the 
wound  becomes  firmly  healed,  when  this 
plan  is  followed.  (P.  180,  fyc.)  Every  one; 
however,  will  acknowledge  the  truth  of 
what  Mr.  Lawrence  says  on  this  subject. 

The  method  “ is  attended  with  no  parti- 
cular advantage,  but  certainly  exposes  the 
patient  to  the  possibility  of  ill  consequences. 
The  omentum,  left  in  the  wound,  must  be 
liable  to  injury,  inflammation,  or  disease  ; 
and  hence  arises  a source  of  danger  to  the 
patient.  Unnatural  adhesions,  formed  by 
this  part,  have  greatly  Impaired  the  func- 
tions of  the.  stomach.  Cases  are  recorded, 
where  the  unfortunate  patient  has  never 
been  able  to  take  more  than  a certain  quan- 
tity of  food,  without  bringing  on  instant  vo- 
miting; and  even  where  it  has  been  neces- 
sary for  all  the  meals  to  be  taken  in  the  re- 
cumbent position,  with  the  trunk  curved, 
and  the" thighs  bent.  (Guns.)  To  avoid  the 
possibility  of  such  afflicting  consequences, 
we  Should,  after  removing  any  diseased  por- 
tion, carefully  replace  the  sound  part  of  the 
omentum  in  the  abdominal  cavity.”  (Spe 
Lawrence  on  Ruptures,  p.  274,  Edit.  3) 


Treatment,  when  the  intestine  in  t hr 
sac  is  mortified. 

Sometimes,  on  opening  the  hernial  sac. 
the  intestine  is  found  to  be  in  a gangrenous 
state,  although  the  occurrence  could  not  be 
previously  known,  owing  to  the  integuments 
and  the  hernial  sac  itself  not  being  affected 
with  the  same  mischief.  In  ordinary  cases, 
however,  both  the  skin  and  sac  become 
gangrenous  at  the  same  time  with  the  con- 
tents of  the  hernia.  The  tumour,  which  was 
previously  tense  and  elastic,  becomes  soft„ 
doughy,  emphysematous,  and  of  a purple- 
colour.  Sometimes  the  parts  also  now  spon- 
taneously return  ; but  the  patient  only  sur- 
vives a few  hours. 

Mr.  A.  Cooper  has  accurately  remarked, 
that  in  other  instances,  the  skin  covering 
the  swelling,  sloughs  to  a considerable  ex- 
tent, the  intestine  gives  way,  and  as  the 
feces  find  vent  at  the  wound,  the  symptoms 
of  strangulation  soon  subside.  When  the 
patient  continues  to  live  in  these  circum- 
stances, the  living  part  of  the  intestine  be- 
comes adherent  to  the  hernial  sac,  the 
sloughs  separate  and  come  away,  and  thus 
an  artificial  anus  is  established,  through 
which  the  feces  are  sometimes  discharged 
during  the  remainder  of  life.  (See  Anus,  Ar- 
tificial.) 

Frequently,  however,  things  take  a more 
prosperous  course  : the  feces  gradually  re- 
sume their  former  route  to  the  rectum,  and 
in  proportion  as  the  artificial  anus  becomes 
unnecessary,  it  is  shut  up.  Many  instances 
of  this  sort  have  fallen  under  my  own  ob- 
servation in  St.  Bartholomew’s  Hospital. 

The  chance  of  a favourable  event  is  much 
greater  in  some  kinds  of  hernia,  than  in 
others.  When  the  strangulation  only  in- 
cludes a part  of  the  diameter  of  the  gut, 
the  feces  are  sometimes  only  partially  dis- 
charged through  the  mortified  opening. 
This  quantity  lessens  as  the  wound  heals, 
and  the  patient  gets  perfectly  well.  (Louis, 
Mem.  de  VAcad.  de  Chir.  T.  3.  P.  S.  Palm , 
De  Epiplo-tnterocelc  crurali  incarcerata  spha- 
celata,  cum  deperditione  notabili  substantia: 
intestini , sponte  separati,  feliciler  cur  at  a alvo 
naturali  restituta,  4 io.  Tub.  1748.  Hallerf 
Disp.  Chir.  3,  2.)  A small  gangrenous  spot, 
or  two,  may  end  in  the  same  manner.  Mor- 
tification, as  well  as  wounds  of  the  large  in- 
testines) is  much  more  frequently  followed 
by  a recovery,  than  the  same  affection  and 
similar  injuries  of  the  small  intestines.  Mor- 
tification of  the  ccecum  and  its  appendix,  in 
a hernial  sac,  has  happened  several  times, 
without  materially  disturbing  the  usual 
course  of  the  feces  to  the  anus,  and  the  pa- 
tients very  soon  recovered.  (Med.  Obs.  and 
Inq.  Vol.  3.  p.  162;  Hey's  Pract.  Obs.  p. 
162,  fyc.) 

The  grand  thing,  on  which  the  establish- 
ment of  the  continuous  state  of  the  intesti- 
nal canal  depends,  in  all  these  cases,  is  the 
adhesion  which  the  living  portion  of  the 
bowel,  adjoining  the  mortified  part,  con- 
tracts with  the  peritonaeum  all  round.  In 
this  manner,  the  escape  of  the  content's  ot 


HERNIA. 


29 


\he  bowels  into  the  cavity  of  the  peritonae- 
um becomes  in  general  completely  prevent- 
ed. The  two  ends  of  the  sound  portion  of 
intestine,  after  the  mortified  part  has  separa- 
ted, open  into  a membranous  cavity,  which 
previously  constituted  a portion  of  the  peri- 
ton&'u'  sac,  and  now  unites  the  extremities  of 
the  gut.  The  gradual  contraction  of  the 
wound  closes  the  membranous  eaviiy  exter- 
nally, and  thus  (he  continuity  of  the  canal  is 
restored.  The  two  ends,  however,  are  not 
joined  so  ns  to  form  a continued  cylindrical 
tube,  like  that  of  the  natural  gut ; but  they 
are  united  at  an  angle  more  or  less  acute, 
and  the  matter,  which  goes  from  one  to  the 
other  describes  a half  circle  in  a newly  form- 
ed membranous  cavity  that  completes  the 
canal  ; a subject  which  has  been  more  fully 
explained  in  another  part  of  this  work.  (See 
Anus , Artificial.) 

It  is  ai«  observation  of  Mr.  A.  Cooper’s, 
that  the  degree  of  danger,  attending  an  arti- 
ficial anu^,  depends  on  the  vicinity  of  the 
sphacelated  part  of  the  intestinal  canal  to 
the  stomach.  Thus,  it  the  opening  in  the 
jejunum,  there  is  such  a small  extent  of  sur- 
face for  absorption,  between  it  and  the  sto 
mach,  that  the  patient  dies  of  inanition. 

Let  us  now  suppose,  that  the  mortified 
state  of  the  intestine  has  only  been  discover 
ed,  after  laying  Open  the  nernial  sac  in  the 
operation.  The  mischief  may  only  consist 
of  one  or  more  spots  ; or  of  the  whole  dia- 
meter of  the  protruded  bowel,  lu  the  first 
case,  the  proper  practice  is  to  divide  the 
stricture,  and  return  the  intestine  into  the  ab- 
domen, with  the  mortified  spots  towards  the 
wound.  Mild  purgatives  and  clysters  are 
then  to  be  exhibited.  The  most  favourable 
mode,  in  which  a case  of  this  kind  ends,  is 
when  the  intestinal  matter  gradually  resumes 
its  natural  course,  after  being  either  partly  or 
entirely  discharged  from  the  wound.  But 
sometimes  the  patient  sinks  under  the  dis- 
ease, or  an  artificial  anus  continues  for  life. 

The  repeated  observations  of  modern  sur- 
geons have  now  decided,  that  no  ligature, 
passed  through  the  mesentery,  to  keep  the 
gangrenous  part  of  the  bowel  near  the 
wound,  is  at  all  necessary.  The  parts,  in  the 
neighbourhood  of  the  ling,  have  all  become 
adherent  together,  in  consequence  of  inflam- 
mation, at  the  same  time  that  the  parts  in 
the  hernial  sac  mortify  ; and  of  course,  the 
partially  gangrenous  bowel,  when  reduced, 
is  mechanically  hindered,  by  these  adhesions, 
from  slipping  far  from  the  wound.  Desault 
and  De  la  Faye,  both  confirm  the  fact,  that 
the  intestine  never  recedes  far  from  the  ring; 
and  even  were  it  to  do  so,  the  adhesions, 
which  it  soon  contracts  to  the  adjacent  sur- 
faces, would,  as  Petit  ha3  explained,  com- 
pletely circumscribe  any  matter  which  might 
be  effused,  and  hinder  it  from  being  exten- 
sively extravasated  among  the  convolutions 
of  the  viscera.  (Mem.  de  VAcad.  de  Chir. 
T.  1,  2.) 

Where  the  chief  part,  or  the  whole  of  the 
diameter  of  the  protruded  bowel  is  mortified, 
the  first  and  most  urgent  indication  is  to  re- 
lieve the  bad  symptoms  arising  from  the  dis- 


tention of  the  Intestinal  canal  above  the 
stricture.  “ Let  a free  incision  (says  Mr. 
Lawrence)  be  made  through  the  mortified 
part  of  the  gut,  in  ord»-rto  procure  that  eva- 
cuation of  the  loaded  canal,  which  nature 
attempts  by  the  process  of  gangrene.”  If  the 
intestine  has  already  given  way,  a free  divi- 
sion of  the  integuments  and  sac  allows  the 
exit  of  the  accumulated  matter ; and  the 
opening  in  the  gut  may  be  enlarged,  if  ne- 
cessary. (Lawrence  on  Ruptures,  p.  283.) 

Here  the  division  of  the  stricture  is  unne- 
cessary, since  all  the  mischief,  which  the 
bowel  can  receive  from  it,  is  done  This 
subject  is  well  explained  by  Mr.  Travers. 
(See  Inq.  into  the  Process  of  Nature  in  Re- 
pairing Injuries  of  the  Intestines,  tyc.  p.  300, 
fyc.)  Mild  purgatives  and  clysters  will  be 
proper  to  unload  the  bowels,  and  determine 
the  course  of  the  feces  towards  the  anus. 
Should,  however,  the  stricture  appear  after 
Ihe  mortification,  to  impede  the  free  escape 
of  the  inteslina1  contents,  a moderate  dilata- 
tion of  it  must  undoubtedly  be  proper. 

Mr.  Lawrence,  in  his  valuable  Treatise  on 
Ruptures,  has  clearly  exposed  the  improprie- 
ty of  sewing  the  ends  of  the  intestinal  canal 
together,  introducing  one  within  the  iher, 
supported  by  a cylinder  of  isinglass,  &,c,  put 
in  their  cavity,  in  those  cases,  in  which  the 
whole  circle  of  the  intestine  lias  mortified, 
and  been  cut  away,  a?  was  advised  by  for- 
mer writers.  By  drawing  the  intestine  out 
of  the  cavity,  in  order  to  remove  the  dead 
part,  the  adhesion  behind  the  ring,  on  which 
the  prospect  of  a care  chiefly  depends,  must 
be  eo'irely  destroyed  ; and  new  irritation 
and  inflammation  must  be  unavoidably  pro- 
duced, by  handling  and  sewing  an  inflamed 
part.  (See  Lawrence  on  Ruptures , p.  298, 

4*.) 

Instead  of  such  practice,  this  gentleman 
judiciously  recommends  dilating  the  stric- 
ture, and  leaving  the  subsequent  progress  of 
the  cure  entirely  to  nature.  The  sloughs 
will  be  cast  off,  and  the  ends  of  the  gut  are 
retained  by  the  adhesive  process  in  a state 
of  apposition  to  each  other,  the  most  favour- 
able for  their  union.  Thus,  there  is  a chance 
of  the  continuity  of  the  intestinal  canal  be- 
coming established  again. 

Whatever  experiments  it  may  be  allow- 
able to  make  in  wounds  with  protrusion  and 
division  of  the  bowels,  nothing,  l think,  is 
now  more  completely  established,  than  the 
absurdity  and  danger  of  attempting  to  stitch 
the  bowels  in  cases  of  hernia. 

OPERATION  FOR  VERY  LARGE  INGUINAL 
HERNIAL 

When  the  tumour  is  of  long  standing,  ex- 
ceedingly large,  perhaps  extending  half  way 
down  to  the  knees,  and  its  contents  have 
never  admitted  of  being  completely  reduced, 
the  indication  is  to  divide  the  stricture,  pro- 
vided a strangulation  takes  place  ; but  with- 
out laying  open  the  hernia!  sac,  or  attempting 
to  reduce  the  parts. 

The  reasons  against  the  common  plan  of 
operating,  under  such  circumstances,  are, 


HERNIA 


30 

thfi  difficulty  of  separating  all  the  old  adhe- 
sions ; the  hazardous  inflammation,  which 
would  be  excited  by  laying  open  so  vast  a 
tumour,  and  the  probability  that  ports  so  long 
protruded,  might  even  bring  on  serious  com- 
plaints, if  reduced.  J.  L.  Petit,  and  after- 
ward Dr.  Monro,  advised  the  sac  not  to  be 
opened.  (See  Mai.  Chir.  T.  2,  p.  372.  De- 
scription of  Bar  see  Mucosae,  1788.) 

OPERATION  WHEN  THE  HERNIA  IS  SO  SMALL 

THAT  IT  DOES  NOT  PROTRUDE  EXTERNAL- 
LY THROUGH  THE  RING. 

In  this  kind  of  case,  there  is  little  appear- 
ance of  external  tumour;  consequently,  the 
disease  is  very  apt  to  be  overlooked  by  the 
patient  and  surgeon,  and  some  other  cause 
assigned  for  the  series  of  symptons.  The 
manner  of  operating,  in  this  form  of  the 
disease,  differs  from  that  in  the  common 
scrotal  hernia ; the  incision  is  to  be  made  pa- 
rallel to  the  direction  of  the  spermatic  cord, 
and  the  stricture  will  be  found  at  the  inter- 
nal ring.  (H.  Cooper  on  Inguinal  Hernia.) 

TREATMENT  AFTER  THE  OPERATION. 

Evacuations  from  the  bowels  should  be 
immediately  promoted  by  means  of  clysters, 
oleum  ricini,  or  small  doses  of  any  of  the 
common  salts,  dissolved  in  peppermint  water. 
For  some  time,  the  patient  must  only  be  al- 
lowed a low  diet.  When  symptoms  of  in- 
flammation of  the  bowels  and  peritonaeum 
threaten  the  patient,  general  bleeding,  leeches 
applied  to  the  abdomen,  fomentations,  the 
warm  bath,  blisters,  doses  of  the  oleum 
ricini,  and  clysters,  are  the  means  deserving 
of  most  dependence,  and  should  be  resorted 
to  without  the  least  delay.  When  all  danger  of 
peritonaeal  inflammation  is  past,  and  the  pa- 
t i e n t i s v e r y 1 o vv  a n d w e a k , b a r k , w i n e , c o r d ia]  s > 
and  a generous  diet,  must  be  directed.  The 
effervescing  saline  draught,  with  opium,  is 
the  best  medicine  for  quieting'  sickness, 
after  the  operation.  Opium  and  cordials  are 
the  most  eligible  for  checking  diarrhoea.  As 
the  operation  does  not  usually  prevent  the 
parts  from  becoming  protruded  again,  a truss 
must  be  applied  before  the  patient  leaves 
his  bed,  and  afterward  constantly  worn. 

PROPOSALS  FOR  THE  RADICAL  C\lRE  OF  THE 

Bubonocele, 

Of  castrating  the  patient,  applying  caustic, 
or  of  the  operation  of  the  punctum  aureum, 
with  this  view,  I need  only  say,  that  they  are 
barbarous,  and  not  at  all  adapted  for  the  at- 
tainment of  the  desired  end.  A description 
of  these  methods  may  be  found  in  Pare, 
Wiseman,  &c. 

The  old  operation,  termed  the  royal  stitch, 
was  one  of  the  most  promising  plans.  It 
consisted  in  putting  a ligature  under  the 
mc<  ko(  the  hernial  sac,  close  to  the  abdomi- 
nal ring,  and  then  tying  that  part  of  the  sac. 

as  to  render  it  impervious,  by  the  adhesive 
inflammation  tbu=  excited. 

The  royal  Milch,  performed  in  tins  manner, 


has  been  actually  attended  with  success, 

( Heist er , Vol.  2.)  The  umbilical  rupture 
was  cured  by  Saviard,  on  similar  principles  > 
and  Desault  radically  cured  nine  cases  of  the 
exomphalos  in  children,  by  tying  the  hernial 
sac. 

Sehmucker  cured  two  irreducible  ruptures, 
free  from  strangulation,  by  cutting  away  the 
body  of  the  sac,  after  tying  its  neck  (Chir. 
Wahrnehmungen , B.  2.)  In  one  case,  Mr. 
A.  Cooper  found  cutting  away  the  sac,  alone 
insufficient. 

Dissecting  away  ihe  whole  hernial  sac,  or 
even  laying  it  open,  must  be  a formidable 
operation,  compared  with  merely  making  a 
small  incision  down  to  the  neck  of  the  sac, 
and  applying  one  ligature.  If  the  hernia 
were  reducible,  and  the  upper  part  of  the 
sac  could  be  rendered  impervious  by  the  li- 
gature, all  other  more  severe  plans  would  be 
superfluous.  However,  Petit,  Sharp,  Acrel, 
&c.  record  cases,  which  tend  to  prove  the 
danger  and  inefficacy  of  the  royal  stitch ; 
though  it  is  true,  that  none  of  these  surgeons 
operated  exactly  in  the  simple  manner  above 
suggested. 

Richter  recommends  scarifying  the  neck 
of  the  sac,  with  the  view  of  producing  an  ad- 
hesion of  its  sides  to  each  other  ; a plan, 
which,  he  says,  he  found  very  successful. 

From  the  account,  however,  which  has 
been  given  of  the  anatomy  cf  the  bubono- 
cele, it  is  obvious,  that  none  of  these  me- 
thods could  do  more  than  obliterate  the  sac 
as  high  as  the  ring,  and  never  that  portion  of 
it,  which  is  within  the  inguinal  canal.  Hence, 
the  neck  of  the  sac  must  still  remain  open 
for  the  descent  of  the  viscera.  This  consi- 
deration, and  that  of  the  chances  of  bad 
and  fatal  symptoms  from  any  operation  un- 
dertaken solely  for  this  purpose,  and  not 
urgently  required  for  the  relief  of  strangula- 
tion, are  the  grounds  on  which  these  experi- 
ments are  now  disapproved. 

CRURAL,  OR  FEMORAL  HERNIA. 

Verheyen,  who  wrote  in  1710,  first  de- 
monstrated the  distinct  formation  of  crural 
hernia,  which  umil  then  had  been  generally 
confounded  with  bubonocele. 

The  parts,  composing  this  kind  of  hernia, 
always  protrude  under  PouparPs  ligament, 
and  the  swelling  is  situated  towards  the  inner 
part  of  the  bend  of  the  thigh.  The  rupture 
descends  on  the  inside  of  the  femoral  artery 
and  vein,  between  these  vessels  and  the  os 
pubis,  through  the  crural  ring,  or  canal  for 
the  transmission  of  the  same  vessels.  And, 
as  Hesselbach  has  remarked,  the  inner  open- 
ing of  this  ring  or  canal  is  the  predisposing 
cause  of  the  disease,  t lie  peritonaeum  spread 
over  it,  being  gradually  propelled  into  it  by 
various  occasional  causes,  so  as  to  complete 
the  tendency  to  hernia.  The  actual  pro- 
trusion of  the  bowels  may  be  formed  either 
suddenly,  or  by  degrees.  As  soon  as  the. 
bowels  have  once  passed  the  outer  npertare, 
or  what  Cloquet  terms  more  properly  the 
lower  opening  of  the  crural  canal,  the  hernia 
has  more  room  for  extending  itself  forwards', 


HERNIA. 


31 


and  (o  each  side,  and  (he  integuments  now 
become  elevated  into  an  aval  swelling , the 
long  diameter  of  which  is  nearly  transverse. 

( Hesselbach , p.  47.)  Girnbernat  names  the 
passage  through  which  the  femora!  hernia  pro- 
trudes from  the  abdomen,  the  crual ; Iley, 
the  femoral  ring;  and  Cloquet,  the  crural  ca- 
nal. 

Females  are  particularly  subject  to  this 
kind  of  rupture.  It  has  been  computed,  that 
nineteen  out  of  twenty  married  women,  af- 
flicted with  hernia,  have  this  kind  ; but,  that 
not  one  out  of  an  hundred  unmarried  fe- 
males, or  out  of  the  same  number  of  men, 
have  this  form  of  the  disease.  ( Arnaud .) 

“ The  crural  hernia,”  says  Scarpa,  is  fre- 
quently observed  in  women  who  have  had 
several  children ; it  very  seldom  afflicts 
young  girls ; and  still  more  rarely  men.  In 
the  latter,  the  viscera  can  more  easily  escape 
through  the  inguinal  ring,  by  following  the 
spermatic  cord,  than  they  can  descend  along 
the  crural  vessels,  and  raise  the  margin  of 
the  aponeurosis  of  the  external  oblique  mus- 
cle, that  forms  the  crural  arch.  In  women, 
an  opposite  disposition  prevails,  in  conse- 
quence of  the  smallness  of  the  inguinal  ring, 
which,  in  them,  only  gives  passage  to  the 
round  ligament  of  the  uterus,  and  besides,  is 
situated  lower  down,  and  nearer  the  pubes, 
than  it  is  in  men,  whilst  on  the  contrary,  the 
crural  arch  is  more  extensive,  by  reason  of 
the  wider  form  of  the  pelvis.  Morgagni  ex- 
pressly says,  that  Ire  never  met  with  the  cru- 
ral hernia  in  the  dead  body  of  any  inale  sub- 
ject. Mild,  ut  verum  fat  ear , nondum  nisi  in 
feeminis  accidit  lit  earn  viderem.  (De  sed.  et 
caus.morb.  Epist.  34,  15.)  Camper  gives  us 
" to  understand  almost  the  same  thing.  (I cones 
Herniarum , in  Prcefat.)  Hevin  often  opera- 
ted for  this  kind  of  hernia  in  females,  but 
only  once  in  the  male  subject.  ( Pathol . et 
Thttup.  p.  406.)  Sandifort  and  Walter  have 
both  seen  but  a single  instance  of  ii  in  the 
dead  body  of  the  male  subject.  ( Ohs . Anat. 
Pathol,  cap.  4,  p.  72.  Sylloge  comment,  anat. 
p.  24,  obs.  21.)  Arnaud  himself,  to  whom 
modern  surgery  is  highly  indebted  for  many 
important  precepts  on  the  operation  for  the 
strangulated  crural  hernia  in  both  sexes, 
candidly  confesses,  that  he  never  had  an  op- 
portunity of  dissecting  a hernia  of  this  kind 
in  the  male  subject.”  ( Scarpa , TraiU  dcs 
Hernies.p.  201.) 

Scarpa  bad  at  his  disposal  a male  subject, 
in  which  there  was  a crural  hernia,  and  he 
availed  himself  of  the  opportunity  of  exami- 
ning the  parts  with  the  utmost  care.  He 
first  injected  the  blood-vessels  ; he  after- 
ward attentively  dissected  all  the  parts  con- 
cerned in  the  disease  ; and  he  has  published 
an  exact  description  of  the  particulars,  illus- 
trated by  an  engraving. 

According  to  Hesselbach,  the  femoral 
hernia,  though  not  common  in  men,  is  more 
frequent  than  is  generally  believed,  and 
often  overlooked  on  account  of  its  being 
very  small.  ( Ueber  den  Ursprung,  Spc.  der 
Leisten-und-Schenkelbriiche,  p.  47.)  Thus, 
in  an  example  published  in  a modern  work, 
an  inguinal  and  femoral  hernia  were  met 


with  together  in  a gentleman,  sixty-three 
years  of  age.  On  examination  of  the  body 
after  death,  a small  piece  of  intestine,  form- 
ing a crural  hernia,  was  found  strangulated, 
and  concealed  under  an  inguinal  rupture  and 
a mass  of  fat.  (C.  Bell's  Surgical  Obs.  Vol. 

1, p.  187.) 

According  to  the  observations  of  Scarpa, 
and  all  the  best  modern  writers  upon  sur- 
gery, the  crural  hernia  forms,  both  in  the 
male  andfemale  subject,  in  the  cellular  sub- 
stance, which  accompanies  the  crural  ves- 
sels below  Poupart’s  ligament.  The  swelling 
follows  the  internal  side  of  those  vessels, 
and  gradually  descends  into  the  fold  of  the 
thigh,  between  the  sarlorius,  gracilis,  and 
pectineus  muscles.  u Many  surgeons  be- 
lieve (says  Scarpa,)  that  the  hernial  sac, 
and  the  intestines,  which  it  contains,  are  or- 
dinarily situated  above  the  crural  vessels 
arid  trunk  of  the  vena  saphena,  and  some- 
times between  these  vessels  and  the  anterior 
superior  spine  of  the  ileum.  But  as  far  as 
my  knowledge  extends,  this  assertion  is 
not  supported  by  a single  accurate  descrip- 
tion of  the  crural  hernia  in  the  early  stage. 
It  is  true,  that  when  the  tumour  has  in  time 
acquired  a large  size,  and  its  fundus  is  incli- 
ned in  a parallel  manner  to  the  fold  of  the 
thigh,  it  partly  or  entirely  covers  the  cru- 
ral vessels,  and  even  the  crural  nerve,  as 
Walter  says  he  once  observed.  ( Sylloge 
comment,  ana!,  p 24.)  But  it  is  not  thence 
to  be  concluded,  that  the  tumour  in  the  be- 
ginning descended  over  the  crural  vessels, 
much  less  betwixt  them  and  the  anterior 
superior  spinous  process  of  the  ileum.  Nei- 
ther must  it  be  imagined,  that  the  neck  of 
the  hernial  sac  becomes  removed  from  the 
inner  to  the  outer  side  of  these  vessels.  If 
these  two  cases  ever  happen,  they  must  be 
very  rare  ; and  the  best  authors  who  have 
treated  of  crural  hernia,  concur  in  stating, 
that  in  performing  the  operation,  they  have 
constantly  found  the  viscera  situated  on  the 
inside  of  the  crural  vessels,  but  never  on 
their  outsidTe.  Even  when  the  tumour,  after 
acquiring  a considerable  size,  is  situated 
transversely  over  the  crural  vessels,  the 
neck  of  the  hernial  sac  has  always  been 
found  upon  their  inner  side,  that  is  to  say, 
between  them  and  the  pubes.  Le  Dran, 
( Observ . de  Chir.  T.  2.  p.  2.)  La  Faye, 
( Cours  d' Operations  de  Dionis,  p.  358.) 
Petit,  ( (Euvres  Pasthurnes,  T.  2,  p.  219.) 
Morgagni..  (De  Sed.  et  Cans.  Mcrb  epist.  34, 
15.)  Arnaud,  (Mem.  de  Chir.  Tom.  2,  p. 
768.)  Gunz,  (De  Hcrniis  libeilus,  p.  78.) 
Bertrandi,  (Trallato  delle  Operazoni,  T.  1, 
annot.p.  218.)  Pott,  (Chirurg.  Works,  Vol. 

2,  p.  152.)  Desault,  (Traite  des  Mai.  Chi- 
rurg. p.  191,  195.)  B,  Beil,  (A  System  of 
Surgery , Vol.  1,  p.  387.)  Richter,  (Traite 
des  Hernies,  chap.  34.)  Nessi,  (Instituz.  Chir. 
T.  2,  p.  198.)  Lassus,  (Med.  Oper.  T.  1,  p. 
198.)  and  many  other  writers,  all  concur 
upon  this  point.  In  support  of  their  opi- 
nion, (says  Scarpa,)  I could  cite  a great 
number  of  cases  of  my  own,  which  I have 
collected  either  in  operating  on  several  in- 
dividuals for  crural  hernia,  or  in  dissecting 


32 


HERNIA. 


the  same  kind  of  hernia  in  the  bodies  of 
many  female  subjects,  and  in  that  of  the 
man,  from  whom  I have  taken  the  8th 
plate.  Lastly,  also,  having  had  an  oppor- 
tunity of  dissecting  in  a female  an  enor- 
mous crural  hernia,  which  descended  one- 
third  of  the  way  down  the  thigh,  I observed 
that  the  ne  k of  Ijjie  sac  did  not  encroach  at 
all  upon  the  r rural  vessels,  but  lay  entirely 
on  their  inner  side.”  ( Scarpa , Traili  des 
Hernies,  p.  203,  206.) 

The  tumour,  on  account  of  its  situation,  is 
liable  to  be  mistaken  for  an  enlarged  ingui- 
nal gland;  ant1  man;  fival  events  are  re- 
corded to  have  happened  from  the  surgeon’s 
ignorance  of  the  existence  of  the  disease. 
Air.  Lawrence  once  saw  an  hospital  sur- 
geon mistake  a crural  hernia  for  a glandu- 
lar tumour,  and  the  patient  died,  without 
any  attempt  being  made  to  afford  relief  by 
the  operation.  fP.  391.  See  also  Petit , 
Traiii  die s Mai.  Chir.  T.  2,  p 293,  fyc.)  A 
gland  can  only  become  enlarged  by  the 
gradual  effects  of  inflammation  ; the  swell- 
ing of  a crural  hernia  comes  on  in  a mo- 
mentary and  sudden  manner,  and  when 
strangulated,  occasions  the  train  of  symp- 
toms already  described  in  our  account  of 
the  inguinal  her  iu,  which  symptoms  an 
enlarged  gland  could  never  occasion.  Such 
circumstances  seem  to  be  sufficiently  discri- 
minative ; though  the  feel  of  the  two  kinds 
-of  swelling,  is  often  not  of  itself  enough  to 
make  the  surgeon  decided  in  his  opinion. 
It  is  particularly  remarked  by  Hesselbach, 
that,  while  a femoral  hernia  is  incomplete, 
that  is  to  say,  within  the  outer  opening  of 
the  passage,  through  which  the  parts  de- 
scend, ;the  disease  presents  itself  as  a round 
firm  swelling,  on  the  outer  side  of  which 
the  femoral  artery  can  be  felt  pulsating: 
this  small  hernia  may  be  mistaken  for  an  in- 
flamed giand,  and  the  case  can  only  be  dis- 
criminated by  the  history  of  its  origin  and 
symptoms.  ( JJeber  den  Ursprung  dcr  Leis- 
ten-i.  J-Schenkelbriiche,  p.  51.)  A femoral 
hernia  may  be  mistaken  for  a'  Bubonocele, 
when  the  expanded  part  of  the  swelling  lies 
over  Poupart’s  ligament.  As  the  taxis  and 
operation  for  the  first  case  ought  to  be  done 
differently  from  those  for  the  latter,  the  er- 
ror may  lead  to  very  bad  consequences. 
The  femoral  hernia,  however,  tr.ay  always  he 
discriminated,  by  the  neck  of  the  tumour  hav- 
ing Poup art's  ligament  above  it.  In  the  bu- 
bonocele, the  spine  of  the  pubes  is  behind  and 
below  this  part  of  the  sac;  but  in  the  femoral 
hernia , it  is  on  the  same  horizontal  level,  and 
a little  on  the  inside  of  it.  (See  Lawrence  on 
Ruptures,  p.  392,  393,  Ed.  3.) 

In  the  male  subject,  11  the  crural  hernia, 
in  the  early  stage,  (says  Scarpa)  is  situated 
so  deeply  in  the  bend  of  the  thigh,  that  it  is 
difficult,  even  in  the  thinnest  persons,  to 
feel  its  neck,  and  in  examining  its  circum- 
ference with  the  extremity  of  the  finger, 
the  tendinous  margin  of  the  opening, 
through  which  the  parts  are  protruded,  can 
only  be  perceived  with  considerable  diffi- 
culty. On  the  contrary,  the  inguinal  her- 
nia. however  small  it  may  he,  is  always  less 


deeply  situated ; it  is  about  half  an  inclt 
above  the  bend  of  the  thigh.  In  carrying 
the  finger  round  its  neck,  the  tendinous 
margin  of  the  inguinal  ring  can  be  easily 
felt  at  its  circumference  ; and  at  the  poste- 
rior part  of  the  small  tumour,  the  cord  com- 
posed of  the  spermatic  vessels  is  distin- 
guishable. When  the  crural  hernia  has  ac- 
quired a considerable  size,  its  neck  is  always 
deeply  situated  in  the  bend  of  the  thigh  ; but 
its  body  and  fundus  assume  an  oval  form,  and 
their  great  diam  eter  is  situated  transversely  in 
the  bend,  of  the  thigh.  Whatever  may  be  the 
size  of  the  inguinal  hernia,  it  al  ways  pre- 
sents a tumour  of  a pvramidal  form,  the 
base  or  fundus  of  which;  far  from  being  di- 
rected towards  the  ileum,  follows  exactly 
the  direction  of  the  spermatic  cord,  and 
descends  directly  into  the  scrotum.  Be- 
sides the  symptoms,  common  to  all  hernial 
swellings,  the  crural  hernia,  when  it  has 
attained  a certain  size,  presents  some  others 
which  are  peculiar  to  it,  such  as  a sense  of 
stupor  and  heaviness  in  the  thigh,  and  oedema 
of  the  leg , and  even  of  the  foot,  of  the  same 
side.”  The  reason,  why  oedema  and  numb- 
ness of  the  limb,  are  particularly  remark- 
able in  cases  of  femora  hernia,  is  justly  re- 
ferred by  Hesselbach,  to  the  circumstance  of 
the  femoral  vessel?  and  nr  es,  with  nume- 
rous lymphatics,  taking  their  course  through 
the  crural  ring,  and  according  to  his  observa- 
tion;, the  numbness  and  cedema  an  especial- 
ly great,  when  the  protrusion  is  omentum, 
which  makes  stronger  pressure  on  the  ves- 
sels and  nerve?,  than  commonly  happens  in 
a case  of  entereeele.  (P.  53.) 

“ In  women,  however,  as  Scarpa  observes, 
it  is  less  easy  j distinguish  the  crural  hernia 
from  the  inguinal.  In  fact,  the  absence  of  the 
spermatic  cord,  and  the  nearer  situation  of 
the  ring  to  the  crurat  arch,  may  easily  occa- 
sion a mistake.  Sometimes,  a woman  may 
even  be  supposed  to  have  a double  crural 
hernia  pf  the  same  side,  whilst,  of  these  two 
distinct,  though  neighbouring^!,  urniffi,  one 
may  be  inguinal,  and  the  other  crural.  Ar- 
naud  (Mem-  de  Chir.  T.2.p  605,)  relates  an 
instance  of  such  a mistake.”  ( Scarpa , 

Trait6  des  Hernies, p.  207,208.) 

This  interesting writer  take  occasion  to 
observe  further,  upon  t his  part  |of  the  sub- 
ject, that  the  portion  of  the  inferior  pillar  of 
the  abdominal  ring,  which  separates  this 
opening  from  the  internal  and  inferior  angle 
of  the  crural  arch,  is  so  ^slender  in  women, 
that  it  is  sometimes  hard  to  distinguish  the 
crural  from  the  inguinal  hernia,  which  is  not 
the  case  in  male  patients. 

Until  a few  years  ago,  the  stricture,  in 
cases  of  femoral  hernia,  was  always  supposed 
to  be  produced  by  the  lower  border  of  the 
external  oblique  muscle,  or,  as  it  isjtermed, 
Poupart’s  ligament.  A total  change  of  opi- 
nion on  this  subject,  however,  Ims  latterly 
taken  place,  in  consequence  of  the  observa- 
tions first  made  by  Gimberuat,  in  176S.  “ In 
the  crural  hernia,  (says  he)  the  aperture 
through  which  the  parts  issue,  is* not  formed 
by  two  bands,  (as  in  the  inguinal  hernia)  but 
it  is  a foramen  almost  round,  proceeding 


DERMA. 


33 


from  the  interna]  margin  of  the  crural  arch 
(Pounart’s  ligament,)  near  its  insertion  into 
the  branch  of  the  os  pubis,  between  this 
bone  and  thejiliac  vein  ; so  that,  in  thisjher- 
nia, the  branch  of  the  os  pubis  is  situated  more 
internally  than  the  intestine,  and  a little  be- 
hind ; the  vein, externally, and  behind ; and  the 
internal  border  of  the  arch, before.  Now  it  is 
tliis  border  which  always  forms  the  strangu- 
lation.’’ (See  A new  Method  of  Operating 
for  the  Femoral  Hernia , bp  Don  Antonio  dc 
Gimbernat , p.  6,  Trans,  by  Beddoes.) 

The  utility  of  knowing,  that  it  is  not  Pou- 
part’s  ligament  which  produces  the  strangu- 
lation, in  cases  of  femoral  hernia,  is  import- 
ant ; for  we  then  know,  that  cutting  the 
lower  and  outer  border  of  the  external  ob- 
lique muscle,  is  quite  erroneous.  This  pro- 
ceeding is  the  more  to  be  reprobated,  because 
the  lower  pillar  of  the  abdominal  ring,  in 
both  sexes,  will  be  divided  by  directing  the 
incision  upward,  or  upward  and  inward ; 
and  thus  the  abdominal  a id  crural  rings  will 
be  made  into  one  common  aperture,  large 
enough  to  make  the  future  occurrence  of 
hernia  very  likely  to  happen.  In  the  male, 
there  is  also  considerable  danger  of  the 
spermatic  cord  being  cut.  Cutting  Pou- 
part’s  ligament  obliquely  outwards,  is  attend- 
ed with  still  more  danger  ; for  the  epigastric 
artery  will  infallibly  be  divided  at  ils  origin  ; 
and  with  all  these  hazards,  the  incision  must 
be  quite  useless,  unless  carried  on  to  the  in- 
ternal edge  of  the  crural  arch.  ( Gimbernat , 
p.  16.) 

Tiie  inclination,  however,  of  several  mo- 
dern writers  to  refer  the  strangulation  en- 
tirely to Gimbernat’s  ligament,  is  not  sanction- 
ed by  the  most  careful  observers,  like  Hes- 
seibach  and  Langenbeck,  (JVeue  Bibl.  B.  2.  p. 
132.)  The  former  justly  remarks,  that  a 
complete  femoral  hernia  may  be  strangula- 
ted in  two  places,  either  at  the  out&r  or  in- 
ner opening  of  the  passage,  through  which 
the  protrusion  happens.  Nay,  says  he,  that 
the  strangulation  is  sometimes  caused  by  the 
outer  opening,  was  known  to  former  sur- 
geons, for  they  remarked,  that  the  constric- 
tion was  removed  by  dividing  the  fascia. 
(P.  53.)  And,  in  addition  to  these  two 
modes  of  strangulation,  is  to  be  enumerated 
a third,  in  which  the  viscera  are  constricted 
by  protruding  through'  some  weaker  point, 
or  accidental  opening,  in  the  anterior  parie- 
tes  of  the  crural  canal  (Hesselbach,  p.  4S  ; 
also  Langenbeck , Op.  cit.  p.  132,)  or  even 
through  an  aperture  in  the  inner  side  of  this 
passage,  ns  we  find  depicted  in  the  twentieth 
plate  of  Langenbeck’s  treatise,  “ De  Struc- 
ture Peritonmi.” 

1 know  of  no  surgical  writer,  who  has 
given  a clearer  account  of  the  anatomy  of 
the  femoral  hernia,  than  Langenbeck  (JVeue 
Bibl.  B.2,p.  112,  ^y-c.)  He  observes,  that 
when  the  dissection  is  begun  at  the  inside  of 
the  inguinal  region,  the  following  circum- 
stances are  noticed  : after  the  removal  of  the 
peritonaeum  from  the  abdominal  muscles, 
and  from  the  psoas,  iliacus  interims,  and  the 
great  vessels,  the  inner  surface  of  the  trans- 
versalis  still  has  an  investment,  which  Clo- 
Vol.  O.  5 


quet  terms  the  fascia  Iransversalis,  and  which 
is  always  a white  glistening  aponeurosis. 
From  the  place,  where  the  femoral  artery 
lies  under  Poupart’s  ligament,  to  the  anterior 
superior  spine  of  the  ilium,  the  preceding 
fascia  is  extended  in  a strong  fibrous  form 
behind  the  inner  surface  of  Poupart’s  liga- 
ment, and  a thin  continuation  of  it  is  ex- 
tended over  the  iliacus  interims  and  psoas 
muscles,  where  it  is  named  by  Mr.  A.  Coop- 
er and  Cloquet  the  fascia  iliaca.  The  fascia 
of  the  transverse  muscle  closes  the  belly  be- 
hind Poupart’s  ligament,  as  completely  as 
the  peritongeum  does,  so  that  between  the 
femoral  artery  and  the  anterior  superior 
spine  of  the  ilium  none  of  the  bowels  can 
protrude,  which  occurrence  is  still  further 
prevented  by  the  fascia  lata,  which  below 
Poupart’s  ligament  is  closely  attached  to 
the  muscles  of  the  thigh  By  the  pelvis 
being  thus  shut  up,  the  origin  of  a crural  her- 
nia on  the  outside  of  the  femoral  vessels  is 
rendered  quite  impossible.  (Langenbeck,  op. 
cit.)  This  part  of  the  explanation  very  nearly 
resembles  that  delivered  by  Mr.  A.  Cooper, 
except  that  the  latter  describes  the  iliac  fas- 
cia, and  not  what  Cloquet  calls  the  trans- 
verse fascia,  as  closing  the  pelvis  from  the 
spine  of  the  ilium  to  the  crural  vessels.  But, 
this  diiTerc.ee  is  easily  accounted  for  by  the 
circumstance  of  Mr.  A.  Cooper  extending 
the  name  fascia  iliaca  beyond  the  limits 
given  it  by  Cloquet  and  Langenbeck. 

Near  the  anterior  superior  spinous  process 
of  the  ilium,  Langenbeck  remarks  that  the 
fascia  of  the  transverse  muscle  has  some 
strong  fibres,  which  proceed  inwards  under 
the  internal  opening  of  the  inguinal  canal, 
of  which  they  form,  as  it  were,  the  bottom, 
and  are  named  by  Hesselbach  the  internal 
inguinal  ligament.  They  go  over  the  femo- 
ral artery  and  vein,  are  connected  above 
with  the  fascia  of  the  transverse  muscle,  and 
below  are  continued  into  the  fascia  of  the 
psoas  and  iliac  muscles.  Where  these  fibres 
pass  over  the  femoral  vessels,  they  expand 
into  a firm  aponeurosis,  which  passing  down- 
wards, is  intimately  attached  at  the  inner 
side  of  the  femoral  vein  to  the  horizontal 
branch  of  the  os  pubis,  close  to  the  symphv- 
sis,  and  then  joins  the  aponeurosis  of  the 
recti  muscles.  The  expanded  portion  of 
the  foregoing  tendinous  fibres,  thus  continu- 
ed along  the  crista  of  the  os  pubis  to  the 
sheath  of  the  rectus,  forms  the  inner  surface 
of  Gimbernat' s,  or  the  femoral  or  crural  liga- 
ment.. The  inner  edge  of  this  ligament  is 
falciform,  and  concave,  the  concavity  being 
turned  towards  the  femoral  vein.  Now 
where  the  fascia  of  the  transverse  muscle 
extends  downwards,  on  the  outer  side  of 
the  crural  artery,  to  the  fascia  of  the  psoas 
and  iliac  muscles,  so  as  to  close  the  pelvis 
between  that  vessel,  and  the  anterior  supe- 
rior spinous  process  of  the  ilium,  it  also 
forms,  like  Gimbernat’s  ligament,  a falciform 
edge,  the  concavity  of  which  lies  close  over 
the  external  convexity  of  the  crural  artery. 
Thus,  partly  by  the  concave  edge  of  Gimber- 
nat’s ligament,  directed  towards  the  crural 
vein, find  partly  by  the  conclave  edge  of  the 


ukrNU. 


34 


extension  of  the  fascia  of  the  transverse  mus- 
cle to  the  fascia  iliaca,  which  edge  is  turned 
towards  i he  crural  artery,  an  aperture  is  pro- 
duced, through  which  the  femoral  vessels 
pass  out  of  the  pelvis.  This  opening  is 
named  by  Cloquet  the  upper  opening  of  Ike 
crural  canal , or  as  many  English  surgeons 
would  say,  of  the  crural  or  femoral  ring.  By 
Hesselbach,  it  is  called  the  internal  opening 
for  the  femoral  vessels.  However,  as  these 
vessels  do  not  lie  loosely  and  uneonnectedly 
in  this  aperture,  the  opening  itself  is  shut  up, 
as  it  were,  and  cannot  be  seen  without  dis- 
section. 

On  the  above  described  fasciae,  there  is  a 
considerable  quantity  of  cellular  substance, 
which  covers  the  vessels  in  the  pelvis,  forms 
a sort  of  sheath  for  the  crural  artery  and 
vein,  and  accompanies  these  vessels  through 
the  inner  opening  of  the  crural  canal,  or 
ring,  which  is  itself  accurately  shut  up  by  it. 
When  this  celluiarsubstance  is  removed,  the 
white  glistening  fascia;  are  plainly  seen  pass- 
ing through  the  same  opening,  and  coming 
nearer  together  in  a funnel-like  manner. 
'Where  the  fascia  of  the  transverse  muscle 
forms  the  outer  falciform  edge  of  this  aper- 
ture, and  is  passing  over  the  arteria  circum- 
ilexa  ilii  to  the  psoas  and  iliac  muscles,  it 
sends  off'  through  the  opening  a process, 
which  becomes  connected  with  the  outer 
side  of  the  crural  canal,  or  ring : while  from 
the  internal  inguinal  ligament,  which  lies 
above  this  opening,  and  constitutes  the  upper 
edge  of  the  inner  aperture  of  the  crural 
canal, a production  is  sent,  which  is  connect- 
ed with  the  anterior  side  of  this  canal.  As 
for  the  posterior  and  inner  sides,  they  have 
a connexion  with  the  fasciae  of  the  psoas  and 
levator  ani. 

When  the  groin  is  externally  dissected,  in 
order  to  have  a view  of  the  crural  ring  or 
canal,  on  the  outside  of  the  pelvis,  the  fol- 
lowing appearances  present  themselves: 
after  the  removal  of  the  common  integu- 
ments, one  finds  below  Poupart’s  ligament,  a 
quantity  of  fat,  glands,  lymphatics,  veins,  and 
arteries,  which  vessels  come  out  through 
small  openings  in  the  fascia  lata.  As  soon 
as  the  outer  surface  of  the  external  oblique 
muscle  is  cleared,  its  aponeurosis  is  found  to 
become  stronger  at  the  anterior  superior 
spinous  process  of  the  ilium,  and  its  fibres 
to  collect  together,  and  assume  the  form  of 
a band,  which  is  Poupart’s  ligament,  called 
by  Hesselbach  the  external  inguinal  liga- 
ment, and  by  Gimbernat,  Cloquet,  and  others, 
the  crural  arch.  This  ligament,  as  is  well 
known,  passes  obliquely  inwards  and  down- 
wards towards  the  os  pubis,  and  after  form- 
ing the  external  pillar  of  the  abdominal  ring, 
is  first  closely  inserted  into  the  angle  or  tu- 
bercle of  the  os  pubis,  and  then  being  con- 
tinued inwards,  or  backwards,  in  the  form 
of  a firm  fascia,  is  attached  to  the  horizon- 
tal ramus  of  that  bone,  making  the  anterior 
or  outer  surf  ace  of  Gimbernal's,  or  the  femoral, 
ligament , w hich  is  consequently  produced 
by  the  junction  of  Poupart’s  w'ith  Hessel- 
bttch's  internal  inguinal  ligament  along  the 
?»j»ine  of  the  os  pubis.  Thus,  just  as  the  in- 


ternal inguinal  ligament  is  a strengthened 
part  of  the  fascia  of  the  transverse  muscle, 
the  outer  inguinal  ligament,  (or,  as  it  is  here 
commonly  called)  Poupart’s  ligament,  is  pro- 
duce! by  the.  strengthened  fibres  of  the  low 
er  portion  of  the  aponeurosis  of  the  external 
oblique  muscle,  the  fibres  of  it  making  the 
external  pillar  of  the  ring,  being  continued 
further  towards  the  symphysis  of  the  pubes, 
in  the  form  of  the  outer  surface  of  Gim- 
bernat’s  ligament.  ( Langenbeck , JYeue  Bibl. 
B.  2,  p.  120,  121.)  English  surgeons  make 
the  formation  of  Gimbernat’s,  or  the  fe- 
moral ligament  more  simple : thus  Mr. 
Lawrence  states,  that  w7hen  Poupart’s  liga- 
ment approaches  the  pubes,  “ it  becomes 
suddenly  broader;  that  it  is  fixed  by  this 
broad  portion,  along  the  whole  length  of  the 
angle  and  crista  of  the  pubes  ; that  it  has 
a rounded  and  strong  anterior  edge,  a thin 
and  sharp  posterior  margin ; and  that  the 
former  of  these  is  nearer  to  the  surface, 
while  the  latter  is  comparatively  deeply  seat- 
ed. The  breadth  of  this  part  varies,  in  dif- 
ferent subjects  : it  is  generally  from  three 
quarters  of  an  inch  to  an  inch  Sometimes, 
as  Gimbernat  has  stated,  it  measures  more 
than  an  inch.  Dr.  Monro  has  observed,  that 
it  is  broader  in  the  male  than  in  the  female 
subject;  and  from  this  structure,  he  ex- 
plains in  part  the  more  rare  occurrence 
of  this  rupture  in  the  male.”  (P.  368, 
Ed.  3.) 

The  fascia  lata,  which  is  spread  over  the 
muscles  of  the  thigh,  is  only  a continuation 
of  the  aponeurosis  of  the  external  oblique 
muscle,  and,  as  it  proceeds  downwards  from 
Poupart’s  ligament,  is  very  closely  attached 
to  the  muscles  of  the  thigh,  all  the  way  from 
the  anterior  superior  spinous  process  of  the 
ilium,  to  the  femoral  artery,  drawing  as  it 
Avere  Poupart’s  ligament  dowmwards  and  in- 
wards, or  backwards,  towards  the  cavity  of 
the  pelvis,  so  as  to  give  to  its  external  edge 
a convex  appearance,  and  shut  up  the  out- 
side of  the  pelvis,  from  the  anterior  superior 
spine  of  the  ilium  asfarasthe  crural  nerve  and 
artery,  so  firmly,  that  the  formation  of  a 
femoral  hernia  at  this  part  is  impossible. 
And,  if  small  apertures,  filled  with  fat,  be 
discernible  in  this  portion  of  the  fascia  lata, 
still  no  hernia  can  here  take  place,  because, 
as  Langenbeck  has  already  explained,  here 
the  interior  of  the  pelvis  is  again  shut  up  by 
fascia*  already  described. 

Under  the  fascia  lata  are  situated  the  an- 
terior crural  nerve,  the  vein  and  artery.  The 
vena  saphena  magna  lies  on  the  outside  of 
it,  and  passes  through  an  opening  in  it  into 
the  femoral  vein.  This  aperture  in  the  fas- 
cia lata  is  at  the  inner  side  of  the  groin,  op- 
posite the  internal  opening  of  the  crural 
ring,  or  canal  It  is  named  by  Hesselbach 
the  external  aperture  for  the  femoral  vessels , 
and  desci’ibed  by  him  as  an  oblique  fissure 
about  fifteen  lines  in  length.  He  takes  no- 
tice of  its  external  semilunar  edge,  and  two 
horns,  which  are  directed  inwards  ; the  parts 
first  particularly  described  by  Mr.  A.  Burns 
of  Glasgow,  under  the  name  of  the  semilu- 
nar, or  falciform  process  of  the  fascia  lain. 


HERNIA. 


3* 


The  lower  born  bends  rather  inwards  and 
upwards,  and  terminates  in  the  production 
oi'  the  fascia  lata  spread  over  the  pectinalis 
muscie.  The  upper  horn,  which  is  less  cur- 
ved, buries  itself  under  tiie  external  pillar  of 
the  abdominal  ring.  Over  the  lower  horn 
of  the  opening,  just  now  described,  the  vena 
saphena  magna  ascends  into  the  femoral 
vein.  Through  the  same  aperture  also  pass 
nearly  all  the  superficial  lymphatics  of  the 
lower  extremity.  According  to  Cloquet,  the 
fascia  lata  consists  of  two  layers,  of  whn  h 
the  anterior  superficial  one  is  closely  attach- 
ed to  the  crural  arch,  extends  over  the  femo- 
ral vessels,  and  forms  the  anterior  side  of 
the  crural  canal.  The  other  layer,  near  the 
pubes,  quits  the  former,  and,  covering  the 
pectinalis  muscle,  constitutes  the  hinder  side 
of  that  canal.  The  anterior  layer  of  the 
fascia  then  forms  an  oval  aperture,  through 
which  the  vena  saphena  passes,  and  which 
is  considered  by  Cloquet  as  the  lower- opening 
of  the  crural  canal.  This  opening,  called  by 
Hesselhach  the  external  foramen  for  the  femo- 
ral vessels,  is  well  delineated  both  in  li is  ex- 
cellent work,  and  in  the  twenty-third  plate 
of  Langenbeck’s  book  (De  Strudura  Perilo- 
ned,  testiculorum  tunicis,  fyc.  8vo.  Goll.  1817.) 
According  to  the  investigations  of  the  last 
anatomist,  as  soon  as  the  integuments  are 
removed,  this  opening  in  the  fascia  lata, 
with  its  external  semilunar  edge,  and  two 
horns,  are  regularly  seen.  The  front  side  of 
the  crural  canal  is  formed  by  the  fascia  lata. 
Where  this  fascia  proceeds  in  the  form  of  Hes- 
selbach’s  upper  horn  under  and  behind  the  ex- 
ternal pillar  of  the  abdominal  ring,  and  makes 
the  outer  layer  of  Gimbernat’s  ligament,  it  is 
continued  as  a thin  aponeurosis  over  the  vena 
saphena,  so  that  it  makes  not  merely  the  upper 
horn,  but  reaches  further  downwards,  and 
forms  the  outer  side  of  the  crural  canal.  The 
outer  side  then  of  the  crural  canal,  or  ring, 
according  to  Langenbeck,  extends  from  the 
outer  semilunar  edge  of  the  external  open- 
ing for  the  femoral  vessels,  or,  as  English 
surgeons  would  say,  from  tiie  edge  of  the 
falciform  process  of  the  fascia  lata.  The  larger 
the  preceding  thin  continuation  of  fascia 
is,  ihe  smaller  is  the  external  opening  for  the 
femoral  vessels,  the  more  is  the  upper  horn 
bent  downwards,  and  the  more  determinate 
is  the  form  of  the  canal.  ( Langenbeck , JYeue 
Bibl.  B.  2.  p.  124,  125.) 

According  to  Mr.  Lawrence,  “ the  fascia 
lata,  or  fascia  of  the  thigh,  has  two  distinct 
insertions  at  the  upper  and  anterior  part  of 
the  limb.  It  is  attached  to  the  front  edge 
of  the  pubes,  over  the  origin  of  the  pecti- 
neus,  the  fibres  of  which  it  closely  covers, 
and  it  is  also  fixed  to  the  front  of  the  crural 
arch.  The  former  of  these  is  continuous, 
behind  the  femora!  vessels,  with  the  iliac 
fascia  : the  latter  is  not  inserted  along  the 
whole  length  of  the  tendon,  its  attachment 
ceasing  on  the  inner  side  of  the  vessels, 
which  it  covers  anteriorly.  Here,  therefore, 
the  femoral  artery  and  vein  are  interposed 
between  the  two  divisions.”  (On  Ruptures, 
Edit.  3, p.  371 . ) 

Where  the  insertion  of  the  fascia  lata 


into  Poupart’s  ligament  ends,  it  forms  what 
Mr.  Burns  of  Glasgow  calls  the  falciform 
process,  the  upper  part  of  which  is  attached 
to  the  above  ligament,  while  the  lower  pro- 
ceeds further  down  the  thigh.  The  concavi- 
ty of  the  f-dciform  process  is  directed  to- 
wards the  pubes.  This  anatomical  connex- 
ion is  one  chief  cau^e,  why  extending  the 
thigh,  and  rotating  it  outward,  render  the 
crural  arch  tense. 

The  hernia,  being  situated  in  front  of  the 
pectineus,  must  of  course  be  exterior  to  the 
fascia  lata.  In  my  opinion,  surgeons  are 
very  much  indebted  to  Mr.  Lawrence  for 
his  able  explanation  of  this  fact.  As  for 
myself,  I am  candid  enough  to  own  that, 
until  I read  his  clear  and  concise  account 
of  the  anatomy  of  the  crural  hernia,  I could 
never  reap  any  accurate  notions,  concern- 
ing t!i e relative  situations  of  the  hernial  sac 
and  fascia  of  the  thigh,  from  other  more 
prolix  works,  with  the  exception  of  those  of 
H esselbach  and  Langenbeck,  by  whom  the 
anatomy  is  made  perfectly  intelligible.  Mr. 
Lawrence  reminds  us.  however,  that  the 
particular  crural  hernia,  contained  in  the 
sheath  of  the  femoral  vessels,  lies  under 
the  fascia  ; p.  382,  Edit.  3.  And  he  men- 
tions, that  the  falciform  process  of  the 
fascia  lata,  passes  along  the  upper  and 
outer  part  of  the  tumour.  The  iliac  vein  is 
placed  on  the  outer  side  of  the  neck  of  the 
sac  ; thf  pubes  is  directly  behind  it  ; and 
the  upper  and  inner  pans  are  bounded  by 
the  thin  posterioredge  of  Poupart’sligamCnt. 

The  inner  side  of  the  crural  ring  or  ca- 
nal, as  already  explained,  is  connected  with 
the  fascia  of  the  transverse  muscle.  And, 
according  to  Langenbeck,  below  the  part 
of  the  fascia  lata,  which  forms  the  external 
foramen. for  the  femoral  vessels,  the  front 
side  of  the  crural  canal  is  sometimes  form- 
ed by  a continuation  of  the  fascia  of  the 
transverse  muscle,  as  he  found  was  the  case 
in  both  groins  of  one  female  subject.  In 
such  a case,  there  is  a good  deal  of  fat  be- 
tween the  fascia  lata,  and  the  aponeurosis 
of  the  transverse  muscle,  and  the  two  parts 
are  easily  separable.  Langenbeck  admits, 
however,  that  the  same  appearance  may 
arise  from  a splitting  of  the  layers  of  the 
fascia  lata.  Frequently  the  front  side  of 
crural  ring  is  so  short,  that  the  opening 
cannot  rightly  be  termed  a canal,  and  it  is 
always  shorter  than  the  posterior  side. 
When  the  outer  side  exits,  it  is  extended 
across  the  inner  over  the  space  between 
the  two  horns,  and  is  then  connected  with 
the  aponeurosis  of  the  pectinalis  derived 
from  the  fascia  of  the  psoas  and  levator  ani 
muscles.  In  the  anterior  and  inner  sides  of 
the  crural  canal,  there  are  some  small  open- 
ings. Doubtless,  tills  stricture  is  referred  to 
by  Hesselhach,  when  he  says,  that,  in  the 
male  subject  the  outer  opening  for  the  fe- 
moral vessels  is  further  closed  by  a net-like 
web  of  tendinous  fasciculi.  The  posterior 
side  of  the  crural  canal,  or  ring,  is  entirely 
formed  by  the  part  of  the  fascia  of  the 
psoas,  which  enters  its  inner  opening,  and 
joins  the  aponeurosis  of  the  pectinalis  mus- 


36 


HERNIA. 


cle.  The  outer  side  of  the  canal  lies  under 
the  fascia  lata,  and  joins  the  anterior  and 
posterior  sides,  where  the  aponeuroses  of 
the  transverse  and  iliac  muscles  proceed  to 
the  outside  of  the  femoral  artery.  Langeu- 
beek  thinks  the  opening,  by  which  the  vena 
saphena  passes  over  the  lower  horn  of  the 
falciform  process  of  the  fascia  lata,  might 
be  named  the  lower  aperture  of  ilie  crural 
canal.  (See  Langmbeck's  JVeue  Bibl.  far 
die  Chirurgie,  B.  2,  p.  126,  127.  8vo.  Ha- 
nover 181b.) 

According  to  Hesselbach,  in  femoral  her- 
nia, tne  two  openings  of  the  passage  now 
termed  the  crural  or  femoral  ring,  are  one 
half  larger  than  natural.  The  outer  portion 
of  the  inner  of  these  apertures  is  propelled 
more  outward,  and  with  it  the  epigastric  ar- 
tery. The  femoral  vein  no  longer  lies  at 
the  external  end  of  this  opening,  but  rather 
at  the  back  of  the  canal  or  passage.  The 
external  semilunar  edge  (the  falciform 
process)  of  the  outer  opening,  is  carried 
more  outward  and  upward,  and  is  tightly  ap- 
plied over  the  distended  hernial  sac.  In 
this  state  of  the  parts,  the  outer  opening 
forms  an  oval  firm  tendinous  ring,  the  di- 
rection of  which,  like  that  ot  the  inner 
opening  for  the  passage  of  the  femoral  ves- 
sels, is  transverse.  The  neck  of  the  hernial 
sac  is  that  portion  of  it,  which  lies  within 
the  canal  between  the  two  openings.  The 
posterior  side  of  this  canal,  or  passage,  now 
frequently  named  the  crural,  or  femoral 
ring,  is  longer  than  the  anterior.  In  one 
large  hernia,  Hesselbach  found  it  an  inch 
and  a half  in  length,  but  the  anterior  side  of 
the  passage  more  than  one-third  shorter. 
The  greatest  diameter  of  the  inner  opening 
was  one  inch  five  lines,  while  that  of  the 
outer  one  was  only  one  inch  four  lines. 
Most  of  the  posterior  part  of  the  neck  of  tho 
hernial  sac,  with  the  hinder  side  of  the  ca- 
nal lies  upon  the  peetineus  muscle,  and 
towards  the  outerside  upon  the  femoral  vein. 
The  neck  of  the  hernial  sac  adheres  more 
firmly  to  the  anterior,  than  to  the  posterior 
side  of  the  passage.  At  the  outer  opening 
of  the  passage,  the  neck  terminates  at 
almost  a right  angle  forwards  in  the  body 
of  the  sac,  the  upper  portion  of  which  lies 
upon  Poupart’s  ligament,  but  the  largest 
part  of  it  is  situated  on  the  deep-seated  layer 
of  the  femoral  fascia,  by  which  the  outer 
side  of  the  body  of  the  sac,  as  bigh  as  the 
neck,  is  separated  from  the  crural  vessels 
and  nerves.  In  the  male  subject,  when  the 
tendinous  fibres,  mixed  with  the  cellular 
substance  covering  the  outer  opening  of 
the  passage,  make  great  resistance  at  par- 
ticular points,  the  hernial  sac  of  a femoral 
hernia  may  be  double,  or  even  divided  into 
several  pouches,  a preparation  exhibiting 
which  occurrence-  is  in  the  anatomical 
museum  at  Wurzburgh.  ( Hesselbach , p. 

48.)  Except  in  a few  cases,  in  which  the 
origin  and  course  of  the  epigastric  artery 
are  unusual,  this  vessel  runs  very  close  to 
the  external  side  of  the  neck  of  the  hernial 
sac,  much  nearer  than  it  does  in  an  internal 
bubonocele. 


The  sac  of  the  femoral  hernia  is  exceed- 
ingly narrow  at  its  neck  ; and,  where  its 
body  begins,  it  becomes  expanded  in  a 
globular  form  ; the  sac  of  the  bubonocele 
is  generally  of  an  oblong  pyramidal  shape. 
The  body  of  the  sac  of  the  femoral  hernia, 
makes  a right  angle  with  the  neck,  by  being 
throw  n forward  and  upward,  a circumstance 
very  necessary  to  be  known  in  trying  to 
reduce  the  parts  by  the  taxis.  Though  the 
tumour,  formed  by  the  body  of  the  sac,  is 
oval  and  nearly  transverse,  it  is  found,  when 
attentively  examined,  to  take  the  direction 
of  the  groin,  which  extends  obliquely 
downwards  and  inwards,  the  outer,  rather 
smaller  end  of  the  swelling  being  somewhat 
higher  than  the  inner.  (Hesselbach,  p.  60.) 

The  sac  of  the  femoral  hernia  is  said  by 
Mr-  A.  Cooper  to  be  immediately  covered 
by  a kind  of  membranous  expansion,  con- 
sisting of  condensed  cellular  substance,  and 
named  by  him,  the  fascia  propria.  Accord- 
ing to  the  same  gentleman,  a weak  aponeu- 
rosis derived  from  the  superficial  fascia  of 
the  bend  of  the  thigh,  also  covers  the  swell- 
ing, and  is  described  as  lying  immediately 
beneath  the  skin  and  adipose  substance. 
Under  this  fascia  is  the  condensed  cellular 
substance,  or  fascia  propria,  then  some  adi- 
pose substance,  and  lastly  the  true  perito- 
meal  sac  itself.  It  is  of  infinite  use  to  re- 
member these  circumstances  in  operating, 
lest  one  should  think  the  hernial  sac  divided 
w hen  it  is  not  so. 

All  late  writers  on  hernia,  have  remarked 
how  very  small  the  aperture  is,  through 
which  the  viscera  protrude  in  the  femoral 
rupture  ; how  much  greatertbe  constriction 
generally  is,  than  in  the  bubonocele  ; con- 
sequently, how  much  more  rapid  the  symp- 
toms are  ; how  much  less  frequently  th© 
taxis  succeeds  ; andhowr  much  more  danger- 
ous delay  proves.  (See  A.  Cooper , Hey , 
Lawrence,  ^-c.) 

Though  the  crural  ring  is  almost  always 
small,  yet  in  a few  instances,  in  which  the 
tumour  is  large,  and  of  long  standing,  it  be- 
comes very  capacious,  just  as  the  opening 
often  becomes,  through  which  the  inguinal 
hernia  protrudes.  Dr.  Thomson,  of  Edin- 
burgh, Mr.  Hey,  and  Mr.  Lawrence,  have 
related  examples  of  this  kind. 

The  remarks  already  made,  concerning 
the  treatment  of  hernia,  before  having  re- 
course to  the  knife,  are  all  applicable  to  the 
present  case,  and  need  not  be  repeated.  In 
attempting  to  reduce  the  femoral  hernia  by 
the  taxis,  the  surgeon  should  recollect,  how- 
ever, that  relaxing  Poupart’s  ligament,  and 
the  femoral  fascia,  is  of  the  higiiest  conse- 
quence. Hence,  the  thigh  should  be  bent, 
and  rolled  inwards.  The  pressure  ought 
also  to  be  first  made  downwards  and  back- 
wards, in  order  to  push  the  swelling  off 
Poupart’s  ligament  ; and  afterward,  the 
parts  should  be  propelled  upwards,  so  that 
they  may  return  through  the  crural  ring. 

OPERATION  FOR  THE  FEMORAL,  OR  CRURAL 
HERNI  A . 

Mr.  A.  Cooper  says,  “ the  incision  of  the 


IIEKNIA* 


n 


integuments  is  to  be  begun  an  inch  and  a 
half  above  the  crural  arch,  in  a line  with 
the  middle  of  the  tumour,  and  extended 
downwards  to  the  centre  ot  the  tumour  be- 
low the  arch.  A second  incision,  nearly  at 
right  angles  with  the  other,  is  next  made, 
beginning  from  the  middle  of  the  inner  side 
of  the  tumour,  and  extending  it  across  to 
the  outer  side,  so  that  the  form  of  this  double 
incision  will  be  that  of  the  letter  I rever- 
sed.” The  angular  flaps  are,  of  course,  to 
be  next  dissected  oft',  and  reflected. 

The  making  of  two  incisions,  however,  is 
not  deemed  necessary  by  the  majority  of 
surgeons  ; and,  in  all  the  numerous  opera- 
tions which  I saw  performed  in  St.  Bartholo- 
mew’s Hospital,  during  a space  of  nearly 
fifteen  years,  a transverse  wound  was  not 
found  necessary.  The  division  of  the  skin 
should  begin  about  an  inch  above  the  crural 
ring,  and  be  continued  obliquely  downwards 
and  outwards.  In  this  manner,  we  cut 
exactly  over  the  place,  where  the  incision 
of  the  stricture  should  be  made. 

“ The  first  incision  (says  Mr.  A.  Cooper) 
exposes  tbe  superficial  fascia,  which  is  given 
off  by  the  external  oblique  muscle,  and 
which  covers  the  anterior  part  of  the  hernial 
sac  ; but,  if  the  patient  is  thin,  and  the  her- 
nia has  not  been  long  formed,  this  fascia 
escapes  observation,  as  it  is  then  slight  and 
delicate,  and  adheres  closely  to  the  inner 
side  of  the  skin.  When  this  fascia  is  divi- 
ded, the  tumour  is  so  far  exposed,  that  the 
circumscribed  form  of  the  hernia  may  be 
distinctly  seen  ; and  a person  not  well  ac- 
quainted with  the  anatomy  of  the  parts, 
would  readily  suppose  that  the  sac  itself  was 
now  laid  bare.  This,  however,  is  not  the 
case,  for  it  is  still  enveloped  by  a membrane, 
which  is  the  fascia,  that  the  hernial  sac 
pushes  before  it,  as  it  passes  through  the  in- 
ner side  of  the  crural  sheath.  This  mem- 
brane, the  fascia  propria,  is  to  be  next  divi- 
ded longitudinally  from  the  neck  to  the  fun- 
dus of  the  sac  ; and  if  the  subject  is  fat,  an 
adipose  membrane  lies  between  it  and  the 
sac,  from  which  it  may  be  distinguished,  by 
seeing  the  cellular  membrane  passing  from 
its  inner  side  to  the  surface  of  the  sac. 

“ This  is,  in  my  opinion,  the  most  diffi- 
cult part  of  the  operation  : for  the  fascia 
propria  is  very  liable  to  be  mistaken  for  the 
sac  itself ; so  that  when  it  is  divided,  it  is 
supposed  that  the  sac  is  exposed,  and  the  in- 
testine is  laid  bare  ; following  upon  this 
idea,  the  stricture  is  divided  in  the  outer 
part  of  the  sac,  and  the  intestine,  still  stran- 
gulated, is  pushed,  with  the  unopened  sac, 
into  the  cavity  of  the  abdomen. 

11  The  hernial  sac  being  exposed,  is  to  be 
next  opened  ; and,  to  divide  it  with  safety, 
it  is  best  to  pinch  up  a small  part  of  it  be- 
tween the  finger  and  thumb  ; to  move  the 
thumb  upon  the  finger,  by  which  the  intes- 
tine is  distinctly  felt,  and  may  be  separated 
from  the  inner  side  of  the  sac  ; and  then  to 
cut  into  the  sac,  by  placing  the  blade  of  the 
knife  horizontally.  Into  this  opening,  a di- 
rector should  be  passed,  and  the  sac  opened 


from  its  fundus  lo  the  crural  sheath.  (0/t, 
Crural  and  Umbilical  Hernia.) 

Sometimes  the  content*  of  the  hernia, 
thus  exposed,  admit  of  being  returned,  with- 
out the  further  use  of  the  knife.  When  this 
object,  however,  cannot  be  readily  done, 
the  protruded  parts  should  never  sutler  in- 
jury from  repeated  manual  attempts  ; and 
it  is  safest  to  divide  the  stricture  at  once. 

The  merit  of  having  first  proposed  the 
safest  plan  of  cutting  Poupart’s  ligament, 
even  before  surgeons  were  aware  of  tbe 
parts  which  really  form  the  strangulation,  is 
assigned  by  Gimberrmi  to  Mr.  B.  Bell,  who 
introduced  his  finger  below  Poupart’s  liga- 
ment, between  the  ligament  and  the  intes- 
tine, (an  evident  proof,  says  Gimbernat, 
that  there  was  no  strangulation  there  ;)  he 
then  made  a very  superficial  incision  from 
above  downwards,  into  the  thickest  part  of 
the  ligament  to  its  lower  edge  ; and,  with- 
out rutting  quite  through  it,  he  continued 
his  incision  about  an  inch.  He  rested  the 
back  of  the  scalpel  upon  his  finger,  which 
served  as  a guide  to  the  instrument,  and,  at 
the  same  time,  as  a defence  to  the  intestine. 
The  incision,  however,  having  been  con- 
tinued for  an  inch,  would,  as  Gimbernat  re- 
marks, inevitably  cut  the  internal  edge  of 
the  crural  arch.  Now,  cutting  this,  only 
for  a few  lines,  gives  sufficient  room, for  the 
easy  reduction  of  the  parts,  and  there  is  no 
necessity  to  touch  the  ligament,  as  it  never 
occasions  the  strangulation. — ( Gimbernat 
V-  27.) 

Gimbernat’s  method  of  dividing  the  stric- 
ture, in  cases  of  femoral  hernia;,  is  now  fre- 
quently regarded  as  the  safest  and  most  ef- 
fectual. “ Introduce,  alongthe  internalsideof 
the  intestine,  a cannulated  or  grooved  sound, 
with  a blunt  end,  and  a channel  of  sufficient 
depth.  This  is  to  be  directed  obliquely  in 
wards,  till  it  enter  the  crural  ring,  which 
will  be  known  by  the  increased  resistance  ; 
as  also  when  its  point  rests  upon  the  branch 
of  the  os  pubis.  Then  suspend  the  intro- 
duction ; and  keeping  the  sound  (with  your 
left  hand,  if  you  are  operating  on  the- 
right  side,  and  v.  v.)  firmly  resting  upon  the 
branch  of  the  os  pubis,  so  that  its  back  shall 
be  turned  towards  the  intestine,  and  its 
can*l  to  th#symphysis  pubis,  introduce  gent- 
ly with  your  other  hand,  into  the  groove  of 
the  sound,  a bistoury,  with  a narrow  blade 
and  blunt  end,  till  it  enter  the  ring.  Its  en- 
try will  be  known,  as  before,  by  a little  in- 
crease of  resistance.  Cautiously  press  the 
bistoury  to  the  end  ot  the  canal : and  em- 
ploying your  two  hands  at  once,  carry  both 
instruments  close  along  the  branch  to  the 
body  of  the  pubis,  drawing  them  out  at  the 
same  time.  By  this  easy  operation,  you  will 
divide  the  internal  edge  of  the  crural  arch  at 
its  extremity,  and  within  four  or  five  lines  of 
its  duplieature  ; the  remainder  continuing 
firmly  attached,  by  the  inferior  band,  or  pil- 
lar, of  which  it  is  the  continuation.  This 
simple  incision  being  thus  made,  without  the 
smallest  danger,  the  internal  border  of  the 
arch,  which  forms  the  strangulation,  will  be 
considerably  relaxed,  and  the  parts  will  be 


HERNIA. 


3'S 


reduced  with  the  greatest  ease.”  ( Gimber - 
not , p.  45, 45.) 

Mr.  A.  Cooper  recommends  the  stricture 
t'o  be  divided  “ obliquely  inwards  and  up- 
wards, at  right  angles  to  the  crural  arch.’' 

After  advising  us  to  open  the  sac  of  a fe- 
moral hernia,  with  particular  care,  on  ac- 
count of  its  being  much  thinner  than  that  of 
a bubonocele,  and  (as  might  be  added)  on 
account  of  its  seldom  containing  any  fluid, 
and  often  having  no  omentum  in  it  covering 
the  intestine,  Mr.  Hey  remarks,  “ The  stric- 
ture made  upon  the  prolapsed  pails  is  very 
great,  as  1 have  already  observed;  but  if 
the  tip  of  the  huger  can  be  introduced 
within  the  femoral  ring,  to  guide  the  bubo- 
nocele knife,  a small  incision  (for  the  ring  is 
narrow)  will  be  sufficient  to  set  the  parts  at 
liberty.  If  the  tip  of  the  linger  cannot  he 
introduced  at  the  proper  place,  a director 
with  a deep  groove  must  be  used  instead  of 
the  linger  ; but  I prefer  the  latter.  Tne 
finger,  or  director,  should  not  be  introduced 
very  near  the  great  vessels ; but  on  that  side 
of  the  intestine  or  omentum  which  is  near- 
est to  the  symphysis  of  the  ossa  pubis.  The 
incision  may  then  be  made  directly  upwards. 
The  surgeon  must  take  especial  care  to  in- 
troduce his  finger  or  director  within  that 
part  where  he  finds  the  stricture  to  be  the 
greatest,  which,  in  this  species  of  hernia,  is 
the  most  interior  part  of  the  wound.”  (P. 
255.) 

Gimbernat’s  mode  is  preferable  to  Mr. 
Key’s,  because,  were  the  operation  done  on 
a male,  cutting  directly  upward  would  en- 
danger the  spermatic  cord. 

Mr.  Lawrence  has  noticed,  that  “ an  inci- 
sion oftiie  most  interior  part  of  the  stricture 
is  free  from  all  danger,  in  the  ordinary 
course  of  the  vessels.  But  that  variety,  in 
which  the  obturatrix  artery,  arising  from  the 
epigastric,  runs  along  the  inner  margin  of 
the  sac,  seems  to  preclude  us  from  cutting 
even  in  this  direction.  Hesselbacn  met  with 
a remarkable  instance  of  such  irregularity 
in  the  origin  and  course  of  the  obturatrix  ar- 
tery in  the  body  of  a female,  in  whom  there 
were  two  small  crural  hernias.  On  the  right 
side,  the  epigastric  and  obturatrix  arteries 
arose,  by  a common  trunk,  from  the  crural 
artery  below-  Poupart’s  ligament.  Vlliey  soon 
separated  from  one  another  ; the  epigastric 
taking  its  ordinary  course  upwards  at  the 
outer  side  of  the  neck  of  the  hernial  sac, 
while  the  obturatrix  made  a considerable 
turn,  and  ran  transversely  inwards  over  the 
strong  fibres  of  the  femoral  ligament,  and 
encircled  the  anterior  and  inner  side  of  the 
neck  of  the  hernia,  whence  it  afterward 
proceeded  obliquely  downwards  and  out- 
wards, behind  the  horizontal  branch  of  the 
os  pubis,  towards  the  obturator  foramen. 
( Hesselbach , p.  52.)  A mode  of  operating 
has  been  lately  proposed,  ( Edinb . Med.  and 
ISurg.  Journal , Pol.  2,  205.)  with  a view  of 
avoiding  this  danger.  We  are  directed  to 
make  an  incision  through  the  aponeurosis  of 
the  external  oblique  muscle,  just  above  the 
crural  arch,  and  in  a direction  parallel  to 
that  part ; to  introduce  a director  under  the 


stricture  from  this  opening,  and  to  divide  the 
tendon  to  the  requisite  extent,  by  means  of 
a curved  knife  passed  along  the  groove. 
( Treatise  on  Ruptures,  Edit.  3 ,p.  407  ) For 
reasons  which  Mr.  Lawrence  states,  this  plan 
is  certainly  not  altogether  eligible,-  and, 
upon  the  whole,  Gimbernat’s  method  of 
cutting  the  stricture  is  the  safest.  Monro 
computes  that  the  obturator  artery  may  arise 
from  the  epigastric,  once  in  twenty-five  or 
thirty  subjects.  But,  allowing  that  it  origi- 
nates more  frequently,  it  then  does  not 
always  deviate  from  its  usual  course  aiong 
the  outside  of  the  sac.  Mr.  A.  Cooper  says  : 
“ in  ad  cases,  wnich  i have  myself  dissected, 
where  tins  variety  existed  with  crural  her- 
nia, tne  obturator  has  passed  into  the  pelvis, 
on  the  outer  side  ot  the  neck  of  the  sac,  en- 
tirely out  ot  the  reach  of  any  danger  of  the 
knife.”  (On  Crural  Hernia,  p.  21.)  Mr. 
Lawrence  concludes,  that  the  comparative 
number  of  instances,  in  winch  it  is  found  on 
the  opposite  side,  cannot  be  more  than  one 
in  twenty,  and  consequently  if  we  admit, 
that  the  obturatrix  artery  arises  from  the 
epigastric  once  in  five  times,  it  wodld  only 
be  liable  to  be  wounded  once  in  a hundred 
operations.  (P.  412,  Edit.  3.) 

When  the  origin  and  course  of  the  epigas- 
tric artery  ditfV -r  from  what  is  common,  this 
vessel,  as  Hesselbach  remarks,  sometimes 
passes  inwards'  along  the  horizontal  branch 
of  the  os  pubis,  ere  it  ascends  towards  tiie 
rectus  muscle;  and  when  this  variation 
exists  in  a case  of  femoral  hernia,  the  artery 
does  not  pass  over  the  outer  side  of  the 
neck  of  the  sac,  but  first  under  it,  and  then 
round  its  inner  side.  Hesselbach  has  seen 
only  one  instance  of  this  irregularity  of  the 
epigastric  artery  in  a female,  and  never  in  a 
male  subject.  (Ueberden  Ur  sprung,  tyc.  dcr 
Leisten-und  Schenkelbriiciie , p.  6z.) 

The  industrious  Cloquet  examined  260 
bodies,  for  the  purpose  of  estimating  the 
average  number  of  cases,  in  which  the 
origin  and  course  of  the  obturatrix  artery 
are  different  from  what  is  most  common.  He 
found,  that  when  this  artery  and  the  epigas- 
tric arise  by  one  common  trunk,  they  some- 
times separate  from  each  other  above,  and 
rarely  below  the  upper  opening  of  the  crural 
canal.  In  the  first  case,  the  longer  their 
common  trunk  is,  the  closer  do  they  lie  to 
Gimbernat’s  ligament,  and  to  the  inner  edge 
of  the  upper  opening  of  the  above  canal. 
In  the  second  case,  the  common  trunk  of 
these  arteries  arises  within  this  canal,  and 
the  two  vessels  then  return  into  the  abdo- 
men. In  ICO  bodies,  of  which  87  were 
male,  and  73  female,  the  obturatrix  artery 
arose  on  both  sides  from  the  hypogastric, 
and  only  in  55,  ot  which  21  were  male,  and 
35  female,  did  it  originate  on  both  sides 
from  the  epigastric.  In  28,  of  which  15 
were  male,  and  13  female,  the  obturatrix 
arose  on  one  side  from  the  hypogastric,  and 
on  the  other  from  the  epigastric.  In  5 bodies, 
viz.  2 male,  and  4 female,  it  originated  from 
the  crural.  (See  liecherclies  Hnat.sur  Its  Her - 
nits,  4to.  Paris.) 

If  is  observed  by  Professor  Scarpa,  (hat 


HERNIA. 


3P 


“ 1 lie  vouml  ligament  of  the  uterus,  in  pass- 
ing through  the  abdominal  muscles,  tollows 
precisely  the  same  track  as  the  spermatic 
cord.  It  is  equally  situated  behind  Poupart’s 
ligament,  with  the  difference,  that  it  does 
not  become  so  distinct  from  the  internal 
extremity  of  this  ligament,  as  the  spermatic 
cord  does,  because  it  has  not  so  far  to  run,  in 
order  to  get  from  that  ligament  to  the  in- 
guinal ring,  the  latter  opening  being  situated 
lower  in  the  female,  than  the  male  subject. 
The  round  ligament,  like  the  spermatic  cord, 
also  crosses  the  epigastric  artery,  before 
reaching  the  inguinal  ring.  And  as  the 
crural  hernia  always  begins  at  the  internal 
and  inferior  angle  of  the  arch  of  this  name, 
as  well  in  the  male  as  the  female,  it  follows, 
that,  in  the  two  sexes,  the  epigastric  artery 
remains  in  its  natural  situation,  and  invaria- 
bly corresponds  to  the  external  side  of  the 
neck  of  the  crural  hernia  5 whilst  the  sper- 
matic cord,  in  men,  and  the  round  ligament, 
in  women,  pass  over  the  extremity  of  the 
front  of  the  neck  of  the  hernial  sac.  In  the 
operation  for  the  crural  hernia,  in  females, 
the  incision  of  the  neck  of  the  hernial  sac, 
and  crural  arch,  when  directed  upward  to- 
wards the  linea  alba,  cannot  wound  the 
epigastric  artery,  which  it  is  of  the  most 
consequence  to  avoid  ; but  it  always  divides, 
either  totally  or  partially,  the  round  liga- 
ment of  the  uterus,  which  cannot  lead  to 
any  dangerous  hemorrhage  ; for,  except  in 
the  period  of  pregnancy,  the  arteries  of  the 
round  ligament  are  very  small;  they  are 
almost  obliterated  in  women  advanced  in 
years ; and  in  general,  they  are  quite  capil- 
lary in  the  extremity  of  the  ligament  ad- 
joining the  ring.  Hence,  it  cannot  be  surpri- 
sing, that  so  many  crural  hernia?  have  been 
successfully  operated  upon  in  women,  by 
cutting  the  hernial  sac  and  crural  arch 
directly  upw  ard,  while  not  a single  instance 
can  be  cited  of  such  an  incision  being  made 
in  man  without  mischief,  although,  in  both 
sexes,  the  epigastric  artery  may  have  been 
avoided  in  operating  by  this  process.” 

( Scarpa , Trait 6 des  Hermes,  p.  240.) 

In  operating  for  the  crural  hernia  in  males, 
Scarpa  recommends  us  to  follow  a method, 
which  he  calls  new,  but  which,  in  fact,  is 
the  same  as  that  advised  by  Gimbernat.  I 
have  found  (says  Scarpa)  that,  in  man,  the 
neck  of  the  hernial  sac  maybe  divided  with- 
out danger,  by  giving  to  the  incision  a di- 
rection exactly  contrary  to  that  which  is 
practised  in  the  female  subject.  After 
having  opened  the  hernial  sac,  it  is  to  be 
drawn  outward  by  one  of  its  sides  suffi- 
ciently to  allow  the  introduction  of  a small 
director  between  its  neck  and  the  strangula- 
ted intestine,  the  groove  of  the  instrument 
being  turned  downwards  towards  the  internal 
and  inferior  angle  of  the  crural  arch.  A 
probe-pointed  bistoury,  the  edge  of  which  is 
also  to  be  directed  downwards  towards  the 
point  of  insertion  of  PouparVs  ligament  to  the 
pubes,  is  to  be  pushed  along  the  groove.  By 
this  means,  the  neck  of  the  hernial  sac  will  be 
divided  its  whole  length,  at  its  internal  and  in- 
ferior side,  and  PouparVs  ligament  mil  be  cut 


close  to  its  attachment  to  the  lop  of  the  os 
pubis.  The  epigastric  artery  will  certainly 
be  avoided,  because  it  ljes  upon  the  oppo- 
site side  of  the  hernial  sac.  As  for  the  sper- 
matic cord,  1 have  demonstrated,  that  it  is 
situated  on  the  forepart  of  the  neck  of  the 
hernial  sac  ; consequently,  it  cannot  be 
touched  by  an  incision  made  from  above 
dow  nwards,  whilst  it  is  ■constantly  cut  in  the 
ordinary  method,  since  the  knife  is  carried 
from  beiow  upwards.  In  the  first  case,  this 
part  may  be  the  more  easily  avoided,  as  it 
lies  at  some  distance  from  the  internal  and 
inferior  angle  of  the  crural  arch.  In  fact,  it  is 
at  this  place  that  it  quits,  as  we  have  seen, 
the  edge  of  Foupart:s  ligament,  in  order 
to  ascend  towards  the  inguinal  ring.  The 
incision  that  1 propose  (says  Scarpa)  not 
only  has  the  advantage  of  slitting  open  the 
neck  of  the  hernial  sac  its  whole  length,  it 
also  divides  a part  of  the  insertion  of  Pou- 
part’s ligament  into  the  upper  part  of  the  os 
pubis,  a thing  that  gently  contributes  to  re- 
lax the  crural  arch,  and  facilitate  the  re- 
duction of  the  viscera  ; of  those,  at  least, 
which  are  not  adherent  to  the  sac.”  ( Scarpa 
Op.  cit.  p.  235.) 

Although  this  accurate  anatomist  and  sur- 
geon appears  to  be  quite  unacquainted  with 
many  ot  the  late  valuable  publications  oa 
hernia,  which  have  made  their  appearance 
in  this  country,  it  is  curious  to  find,  both  in 
his  account  of  the  inguinal  and  crural  her- 
nia, how  strongly  his  doctrines  and  observa- 
tions tend  to  confirm  every  thing  that  has 
recently  been  insisted  upon  in  modem 
works,  respecting  the  place  where  the  bubo- 
nocele first  protrudes,  its  passing  through  a 
sort  of  canal  before  it  comes  out  of  the  ab- 
dominal ring,  the  advantage  of  cutting  in 
the  crural  hernia  the  internal  and  inferior 
angle  of  Poupart’s  ligament,  or,  in  other 
terms,  that  part  of  the  ligament  which  was 
first  particularly  pointed  out  by  Gimbernat, 
as  causing  the  principal  part  of  the  strangu- 
lation, and  about  which  so  much  has  been 
said  by  Mr.  A.  Cooper,  Mr.  Hey,  &,c. 

Hesselbach  considers  an  incision  through 
the  outer  side  of  the  crural  ring  safer  than 
one  through  Gimbernat’s  ligament,  and  safer 
in  women  than  men.  In  women,  he  recom 
mends  the  cut  to  be  made  through  the  mid- 
dle ol  the  forepart  of  the  ring,  nearly  straight 
upvyards,  or  a little  inclined  inwards,  in 
w hich  mode  the  epigastric  artery  cannot  be 
hurt,  whether  it  lie  at  the  outer,  or  inner 
side  of  the  neck  of  the  sac.  In  men,  this  in- 
cision, directed  obliquely  upwards  and  in- 
wards, he  says,  cannot  be  made,  on  account 
of  the  nearness  of  the  spermatic  cord • 
therefore,  in  the  male  subject,  he  advises 
cutting  the  inner  side  of  the  opening,  that  is 
to  say,  Gimbernat’s,  or  the  femorai  liga- 
ment directly  inwards  towards  the  symphy- 
sis of  the  os  pubis.  ( Ueber  den  Ur  sprung t 
tyc.  der  Leisteti-und-Schenkelbr « che,  p.  54.) 
YV  hen  the  epigastric,  or  obturator,  artery  de- 
viates from  its  usual  course,  and  surrounds 
the  inner  side  of  the  neck  of  the  hernia 
(which  variety  can  never  be  ascertained  n 


<Q 


HERNIA. 


priori,)  a wound  of  the  vessel  Hesselbach 
regards  ns  unavoidable 

From  the  views  taken  of  femoral  hernia 
in  this  article,  f consider  the  unrestricted 
direction  always  to  cut  Gimbe, mat’s  liga- 
ment in  the  operation  perfectly  erroneous. 
For,  as  Langenbeck  has  stated,  the  seat  of 
strangulation  may  either  be  in  the  external 
aperture  of  the  crural  canal,  or  in  an  open- 
ing of  the  front  or  inner  side  of  this  passage, 
or  in  its  inner  opening,  where  then  Gimber- 
nat’s  ligament  is  truly  concerned.  When 
the  strangulation  is  of  the  two  first  descrip- 
tions, only  the  fascia  lata  need  be  cut ; but, 
in  the  third,  most  frequent  case,  the  inner 
semilunar  edge  of  the  internal  opening  of 
the  ring  must,  of  course,  be  divided.  In  all 
cases,  says  Langenbeck,  whether  the  stran- 
gulation be  caused  by  the  inner  or  external 
opening  of  the  crural  canal,  or  by  an  aper- 
ture in  the  front  parietes  of  this  passage,  the 
stricture  must  be  cut  inwards,  as  directing 
the  cut  in  the  least  outwards  would  injure 
the  epigastric  artery.  When  it  is  perceived 
in  the  operation,  that  the  neck  of  the  hernial 
sac  is  strangulated,  close  below  and  be- 
hind the  external  pillar  of  the  abdominal 
ring,  then  the  inner  opening  of  the  crural 
canal  must  be  divided  inwards,  with  the 
knife  directed  along  the  horizontal  ramus  of 
the  os  pubis,  under  the  external  pillar  of  the 
ring,  towards  the  symphysis  of  the  pubes. 
If,  in  such  a case,  the  knife  were  carried  in- 
wards and  upwards,  that  part  of  Poupart’s 
ligament  forming  the  upper  side  of  the  cru- 
ral canal  might  be  cut,  and  the  spermatic 
artery  injured.  ( Neue  Bibl.  2 B.p.  133.) 

Dr.  TrUstedt  has  published  some  remarks 
in  favour  of  employing  dilatation  instead  of 
an  incision,  in  the  operation  for  the  strangu- 
lated crural  hernia.  He  observes,  that  even 
when  the  common  trunk  of  the  obturalrix 
and  epigastric  arteries  is  short,  the  bowels 
may  protrude  under  the  first  of  these  arte- 
ries, which  will  lie  upon  the  upper  and  inner 
side  ol  the  hernia.  In  an  operation  perform- 
ed upon  a woman,  in  la  Charite,  at  Berlin, 
for  a strangulated  femoral  hernia,  the  crural 
ligament  was  divided  in  Gimbernat’s  way 
by  an  incision  exactly  parallel  to  the  hori- 
zontal ramus  of  the  os  pubis,  and  the  obtu- 
ratrix  artery  was  wounded.  The  patient 
died  eight  days  after  the  operation,  having 
been  previously  attacked  by  trismus  and 
opisthotonos.  On  dissection,  about  six 
ounces  of  putrid  blood  were  found  in  the 
lesser  cavity  of  the  pelvis,  and  the  above 
artery  cut.  The  vessel  arose  from  the  epi- 
gastric, ran  over  the  upperjedge  of  the  inner 
opening  of  the  crural  canal,  or  ring,  and  then 
descended  along  its  inner  edge,  towards  the 
obturator  foramen.  This  occasional  course 
of  the  obturalrix  artery  leads  Dr.  Trtlstedt  to 
suggest  the  following  rules  : if,  after  the  her- 
nial sac  is  opened,  the  bowels  cannot  be  re- 
turned, the  outer  opening  of  the  crural  canal 
should  be  cut  directly  inwards,  in  order  to 
produce  a considerable  relaxation.  But,  if  the 
reduction  should  yet  be  impracticable,  (the 
strangulation  being  at  the  inner  opening  of 
the  canal)  then  an  attempt  is  to  be  made  to 


insinuate  the  end  of  the  finger  through  the 
constriction,  a plan  said  to  have  answered 
very  often  in  the  practice  of  Surgeon-Gene- 
ral Bust.  Should  the  resistance  be  too  great, 
however,  for  this  method  to  succeed,  Trtis- 
tedt  advises  the  crural  ligament  to  be  forci- 
bly drawn  inwards  and  upwards,  towards  the 
navel,  with  Arnaud’s  tenaculum,  assisted  by 
the  introduction  of  the  finger,  or  with  two 
hooks.  When  this  plan  fails,  he  recommends 
Schreger’s  practice  of  dividing  the  anterior 
edge  of  Poupart’s  ligament  with  a pair  of 
blunt-pointed  scissors,  and  then  the  u-?e  of 
Arnaud’s  tenaculum  again.  (See  Rust’s  Ma- 
gazin  far  die  gesammle  Heilkunde,  B.  3,  H. 
2.)  the  consideration,  however,  which 
will  ever  prevent  the  common  adoption  of 
Dr.  TrQstedt’s  suggestion,  is,  that  fifty  times 
more  lives  would  be  lost  by  the  mischief 
done  to  the  protruded  bowels  by  the  forcible 
introduction  of  the  fingers  and  hooks,  than 
by  hemorrhage  from  the  obturatrix,  or  epi- 
gastric artery,  when  the  course  of  the  vessel 
is  irregular. 

CONGENITAL  HERNIA. 

Before  the  beginning  of  the  sixth  month 
of  the  foetal  state,  the  testicle  is  situated  near 
the  kidney,  where  it  receives  a covering 
from  the  peritonaeum,  just  like  the  other  ab- 
dominal viscera.  Between  the  beginning  of 
the  sixth  month  and  end  of  the  seventh,  the 
testicle  has  either  descended  as  low  as  just 
above  the  abdominal  ring,  or  else  is  passing 
through  it,  or  arrived  a little  belowr  it. 
( Wrisberg . Comm.  Reg.  Societ.  Got  ting. 
1785.) 

When  the  testicle  passes  through  the  abdo- 
minal ring  into  the  scrotum,  it  is  received 
in  a production  of  the  peritonaeum,  which 
afterward  constitutes  the  tunica  vaginalis; 
while  that  peritoneal  investment,  which  was 
given  to  the  testicle  in  the  loins,  is  closely 
adherent  to  this  body,  and  forms  what  is 
named  the  tunica  albuginea. 

After  the  descent  of  the  testicle  into  the 
scrotum,  the  communication  between  the 
cavity  of  the  tunica  vaginalis  and  that  of  the 
abdomen  commonly  becomes  obliterated, 
w'hicb  latter  event  is  usually  effected  before 
birth,  sometimes  not  till  afterward,  and,  in  a 
few  subjects,  even  as  late  as  the  adult  state. 

In  the  congenital  hernia,  the  protruded 
viscera  are  situated  in  the  tunica  vaginalis, 
in  contact  with  the  testicle  : having  descend- 
ed into  this  position  before  the  closure  of  the 
communication  with  the  abdomen.  Of 
course,  the  tunica  vaginalis  itself  is  the  her- 
nial sac.  The  nature  of  this  case  was  not 
understood,  before  it  was  elucidated  by  Hal- 
ler in  1755,  and  the  two  Hunters  in  1752  and 
1764.  (S  Hunter’s  Med.  Comment.;  Hal- 
lers Opuscula  Patholog.  and  Opera  Minoru , 
T.  3.)  Many  particulars,  relating  to  the  ori- 
gin and  formation  of  this  hernia,  having  been 
described  in  the  2d  vol.  of  the  First  Lines  of 
Surgery,  I shall  not  here  repeat  them.  Be- 
fore the  periods  now  named,  surgeons  impu- 
ted the  circumstance  of  the  contents  of  the 
hernia  and  testicle  being  in  contact,  to  the 


liEUNJA. 


4.1 


bowels  having  made  their  way,  by  laceration, 
through  the  tunica  vaginalis,  (mm  the  ordi- 
nary hernial  sue  of  a bubonocele.  The  old 
surgeons,  indeed,  frequently  cite  this  in- 
stance in  proof  of  their  doctrine,  that  some 
hernias  were  attended  uilh  a laceration  ol 
the  p'oiionajum.  (See  Sharp's  Inquiry-) 

From  the  term  conge  ital,  we  might  sup- 
pose that  this  hernia  always  existed  at  t i.e 
time  of  birth.  The  protrusion,  however, 
seldom  occurs  till  after  this  period,  on  the 
operation  of  the  usual  exciting  causes  ol  her- 
nias in  general.  It  does  not  commonly  hap- 
pen till  some  moftths  after  birth;  and,  in  cer- 
tain instance^,  not  till  a late  period.  Mr. 
Hey  relates  a ca  ts  in  which  a hernia  conge 
nita  was  first  formed  in  a young  man,  aged 
sixteen,  whose  right  testis  had,  a little  while 
before  the  attack  of  the  disease,  descended 
into  the  scrotum.  In  ihe  generality  of  cases 
which  actually  take,  place  when  the  testicle 
descends  into  the  scrotum  before  birth,  the 
event  may  b<  referred  to  the  testicle  having 
contracted  an  adhesion  to  a piece  of  intes- 
tine. or  omentum,  in  its  passage  to  the  ring. 
In  an  infant,  v\ hich  died  a few  hours  after 
birth,  Whsberg  found  one  testicle  which  had 
not  passed  the  ring,  adhering,  by  means  of 
a few  slender  filaments,  to  the  om<  ntuui,ju>l 
above  this  aperture. 

The  appearance  of  a hernia  in  very  early 
infancy,  Mr.  Pott  observes,  will  always 
make  it  probable  that  it  is  of  ibis  kind;  but 
he  was  not  correct  in  asserting,  that  in  an 
adult,  there  is  no  reason  for  supposing  his 
rupture  to  be  of  this  sort,  but  Ins  having  been 
afflicted  with  it  from  his  infancy  ; and  that 
there  is  no  externa!  mark,  or  character, 
whereby  it  can  be  certainly  distinguished 
from  one  contained  in  a c immon  hernial 
sac.  fhis  statement  is  erroneous,  inasmuch 
as  the  hernia  congenita  is  attended  with  an 
Impossibility  of  feeling  the  testis,  which  part 
in  the  common  scrotal  hernia  is  always  dis- 
tinguishable under  the  fundus  of  the  hernial 
sac.  The  hernia  congenita,  when  returnable, 
tl  ought,  like  ail  other  kinds  of  ruptures,  to 
be  reduced,  and  constantly  kept  up  by  a pro- 
per bandage;  and  when  attended  with 
symptoms  of  stricture,  it  requires  the  same 
chinn'gic  assistance  as  the  common  her- 
nia."’ 

Mr.  Pott  notices,  “that  in  very  young 
children,  a piece  ol  intestine,  or  omentum, 
may  get  preo.y  low  down  in  the  sac,  while 
the  testicle  is  still  in  trie  groin,  or  even 
within  the  abdomen.  In  this  case,  the  appli- 
cation of  a truss  would  lie  highly  iuipioper; 
for,  in  the  latter,  it  might  prevent  the  de- 
scent of  the  testicle  from  the  belly  into  the 
scrotum  , in  the  former,  it  must  necessarily 
bruise  and  injure  it,  give  a great  deal  of  un- 
necessary pain,  and  can  prove  of  no  real 
use.  Such  bandage,  therefore,  ought  never 
to  be  applied  on  a rupture  in  an  infant  un- 
less the  testicle  can  be  fairly  felt  in  the  scro- 
tum, after  the  gut  or  caul  is  replaced  ; and 
when  it  can  be  so  felt,  a truss  can  never  be 
put  on  too  soon.” 

Many  additional  observations  on  the  fore- 
going topic  are  contained  in  the  2d  vol.  of 

w>i.  n o 


the  First  Lines  of  Surgery,  for  which  reason 
I do  not  here  expatiate  upon  it.  Mr.  Pott 
explains,  that  ati  old  rupture,  originally  con- 
genital is  subject  to  a stricture,  made  by  the 
sac  itself,  as  well  as  to  that  produced  by  the 
abdominal  ring,  or.  as  might  have  been  add- 
ed, to  that  caused  by  the  inner  opening  of 
tlm  inguinal  canal. 

The  fact  lie  noticed  several  times,  both  in 
the  dead  a d in  the  living.  “ I have  seen 
(says  he)  <snch  stricture  made  by  the  sac  of 
one  of  these  hernia?,  as  produced  all  those 
had  symptoms  which  render  the  operation 
necessary  : and  I have  met  with  two  differ- 
ent strictures,  at  near  an  inch  distance  from 
each  other,  in  the  body  of  a dead  boy, about 
fourteen,  one  of  which  begirt  the  intestine  so 
tight  that  f could  not  disengage  it  without- 
dividing  ijip  sac. 

11  In  (bis  kind  of  hernia  I have  also  more 
frequently  found  connexions  and  adhesions 
of  the  parts  to  each  other  than  in  the  com- 
mon one  ; but  them  is  one  kind  of  connexion 
sometimes  met  with  in  the  congenital  hernia 
which  can  never  he  found  in  that  which  is 
a common  hernial  sac,  and  which  may  re- 
quire ail  the  dexterity  of  an  operator  to  set 
free:  I mean  that  of  the  intestine  with  (he 
testicle. 

“ When  a common  hernial  sac  has  been 
laid  open,  and  the  intestine  and  omentum 
have  been  replaced,  there  can  be  nothing 
left  in  it  which  ran  require  particular  regard 
from  the  surgeon;  but  by  the  division  of  the 
sac,  of  a congenital  hernia,  the  testicle  is  laid 
bare,  and  after  the  parts  composing  the  her- 
nia have  been  reduced,  will  require  great 
regard  and  tenderness  in  all  the  future  dress- 
ings, as  it  is  a part  \ t ry  irritable,  and  very 
susceptible  of  ;iain,  inflatnm  tion,  &c. 

ii  a large  quantity  ol  lluid  should  be  col- 
lected in  (be  sac  of  a congenital  hernia,  and 
by  adhesions  and  connexions  of  the  parts 
within,  the  entrance  into  it  from  the  ab- 
domen shotiid  be  totally  closed,  (a  case 
which  I have  twice  seen)  the  tightness  of  the 
tumour,  the  difficulty  of  distinguishing  the 
testicle,  and  the  fluctuation  of  the  fluid,  may 
occasion  it  to  be  mistake  n for  a common 
hydrocele  ; and  if,  without  attending  to 
other  circumstances,  but  trusting  merely  to 
(he  fee!  and  look  of  the  scrotum,  a puncture 
be  hastily  made,  it  may  create  a great  deal 
of  trouble,  and  possihh  do  f j tai  mischief. 

“ By  what  lias  fallen  within  my  observa- 
tion, ! am  inclined  to  believe  that  the  sac  of 
a congenital  hernia  is  very  seldom,  if  ever, 
distended  to  the  degree  which  a common 
hernial  sac. often  is:  it  also,  from  being  less 
dilated,  and  ra  her  more  confined  by  the  up  - 
per part  of  the  spermatic  process^  generally 
preserves  a pyriform  kind  of  figure,  and  for 
the  same  reason,  is  also  generally  thinner, 
and  will  therefore  require  more  attention 
and  dexterity  in  an  operator  w hen  he  is  to 
open  it.  To  which,  1 believe,  I may  add, 
that  common  ruptures  or  those  in  a common 
sac,  are  generally  gradual!)  formed,  that  is, 
they  are  first  inguinal,  and  by  degrees  be- 
come scrotal ; hut  the  congenital  are  seldom, 
if  ever,  remembered  by  the  patient  to  havt? 


HEKN1  A. 


•42 

been  in  (he  groin  only.  ’ (Pott  on  Ruptures,  There  the  hernial  sac  must  unavoidably 
Vcl.  2.)  terminate.  On  the  contrary,  in  the  eongeui- 

The  sac  of  a congenital  hernia,  especially  tal  hernia,  the  viscera  may  descend  lower 
when  the  cas$  is  strangulated,  is  every  where  than  the  testicle,  with  which  they  are  in 
equally  tense,  (IRsselbach,  p.  36)  and'oelow  immediate  contact;  and,  at  length,  they 
it  the  testis  cannot  be  felt.  even  occupy  the  situation  of  this  organ, 

The  reader  must  not  conclude,  however,  which  is  then  pushed  upward  and  backward, 
from  the  above  account,  that  every  runtuie  2.  In  the  case  of  a congenital  hernia  the 


in  children  is  congenital.  Mr.  Laurence 
has  related  a case  of  strangulated  bubono- 
cele, which  took  place  in  an  infant  only 
fourteen  months  old.  (P.  65,  Edit.  3 ) 

The  common  inguinal  hernia,  which  first 
protrudesat  the  inner  opening  of  the  inguinal 
canal,  and  which  has  the  epigastric  artery 
on  the  inner  side  of  its  neck,  has  been  named 
by  Hesselbach  external , while  the  less  com- 
mon instance,  in  which  the  viscera  burst 
directly  through  the  aponeuroses  of  the 
transverse  and  internal  oblique  njuscles,  and 
pass  directly  out  of  the  abdominal  ring, 
leaving  the  epigastric  artery  on  the  outer 
side  of  the  neck  of  the  sac,  is  distinguished 
by  the  epithet  internal.  {Anal.  Chir.  Ab- 
handlung  uber  den  Ur  sprung  der  Lcidcnbruch, 
fVurzb.  1806.)  “ The  inguinal  congenital 

hernia  (says  Scarpa)  cannot  be  divided  into 
external  and  internal  : it  is  evident,  that  it 
must  always  be  external,  since  the  neck  of 
the  tunica  vaginalis  invariably  corresponds 
to  the  point,  at  which  the  spermatic  cord 
passes  under  the  margin  of  the  transverse 
muscle.  As  for  other  circumstances,  the 
tunica  vaginalis  lies  in  its  whole  course  in 
the  same  manner  as  the  sac  of  a common 
inguinal  hernia : like  this,  it  passes  com- 
pletely through  the  inguinal  canal  from  one 
end  to  the  other,  resting  upon  the  anterior 
surface  of  the  spermatic  cord.  Consequent- 
ly, it  passes  between  the  separation  of  the 
inferior  fibres  of  the  pbliquus  interims,  and 
the  principal  origin  of  the  cremaster  muscle. 
(See  IVrisberg.  syllog.  comment,  anal.  p.  23.) 
After  coming  out  of  the  ring,  as  it  is  always 
united  to  the  spermatic  cord,  it  is  enclosed  in 
the  muscular  and  aponeurotic  sheath  of  the 
cremaster  muscle,  which  accompanies  it  to 
the  bottom  of  the  scrotum.  Since  the  tunica, 
vaginalis,  including  the  displaced  viscera, 
enters  the  inguinal  canal  on  the  outside  of 
the  point,  at  which  the  spermatic  cord  crosses 
the  epigastric  artery,  it  is  manifest,  that,  as  it 
follows  exactly  the  direction  of  this  cord,  it 
must  also  cross  the  artery,  and  remove  it 
from  the  outer  to  the  inner  side  of  the  ring, 
according  to  the  mechanism  already  explain- 
ed in  speaking  of  the  common  inguinal 
hernia.  Hence,  the  displacement  of  the 
epigastric  artery  constantly  happens  in  the 
inguinal  congenital,  just  as  it  does  in  the 
ordinary  external  inguinal  hernia. 

“ But,  if  these  two  species  of  inguinal 
hernia?  have  some  analogy  to  each  other,  in 
regard  to  the  parts  which  constitute  them, 
yet,  they  present  some  remarkable  differ- 
ences. 1.  The  common  inguinal  hernia, 
whether  internal  or  external,  when  it  ex- 
tends into  the  scrotum,  cannot  descend 
beyond  the  point  at  which  the  spermatic 
vesselsenter  the  testicle.  There  the  cellular 
-ubstance  of  the  spermatic  cord  terminates. 


descent  of  the  viscera  from  the  eroin  to  the 
scrotum  commonly  takes  place  in  a very 
short  time,  and  in  some  measure  precipitate- 
ly : it  is  much  slower  and  more  gradual  in 
the  ordinary  inguinal  hernia.  The  reason  of 
this  difference  is  very  plain.  In  the  first 
case,  the  descent  of  the  testicle,  and  the 
formation  of  the  tunica  vaginalis,  have 
opened  and  prepared  the  way.  which  the 
viscera  must  follow  in  forming  a protrusion; 
while,  in  the  second,  the  hernial  sac  cannot 
descend  into  the  scrotum,  but  by  gradually 
elongating  the  layers  of  the  cellular  sub- 
stance, which  joins  it  to  the  surrounding 
parts.  This  fact  is  so  generally  known, 
that  experienced  practitioners  consider  the 
promptitude,  with  which  the  viscera  have 
descended  from  the  groin  to  the  bottom  of 
the  scrotum,  as  a characteristic  sign  of  a 
scrotal  congenital  hernia.”  ( Scarpa  Traite 
dts  Hemies , p.  73,  fyc. ; Ihsselbach,  p.  35  ; 
Pott  fyc.) 

If  circumstances  will  admit  of  a truss 
being  applied  and  worn,  in  cases  of  con- 
genital hernia,  in  young  subjects,  there  will 
be  a considerable  chance  of  a radical  cure 
being  effected,  in  consequence  of  the  natural 
propensity  of  the  opening  between  the 
abdomen  and  tunica  vaginalis  to  become 
closed. 

The  only  material  difference  in  the 
operation,  from  that  for  a bubonocele,  is, 
that  the  surgeon  has  to  lay  open  the  tunica 
vaginalis,  instead  of  a common  hernial  sac. 
The  stricture  is  to  be  divided  on  the  same 
principle  as  that  of  an  inguinal  hernia,  and 
much  in  the  same  manner.  As,  in  a case  of 
congenital  hernia,  the  parts  are  always  pro- 
iruded  on  the  outside  of  the  epigastric  artery, 
the  stricture  may  be  safely  divided  towards 
the  ilium,  as  well  as  direclly  upwards.  (Law- 
rence on  Ruptures,  p.  48 1 Edit.  3.)  The  parts 
having  been  reduced,  the  edges  of  the 
wound  are  to  be  immediately  brought  to- 
gether, and  retained  so  by  means  of  one  or 
two  sutures,  and  sticking  plaster,  which  is 
much  preferable  .to  the  plan  of  applying 
dressings  to  the  testicle  and  inside  of  the 
tunica  vaginalis,  so  as  to  heal  the  part  by  the 
granulating  process. 

A new  species  of  hernia  congenita  was 
described  by  the  late  Mr.  Hey,  in  which  a 
common  peritonseal  hernial  sac,  containing 
the  viscera,  is  included  in  the  tunica  vagina- 
lis. It  arises  from  the  parts  being  protruded 
after  the  communication,  between  the  abdo- 
men and  tunica  vaginalis,  is'closed,  so  that 
the  peritonaeum  is  carried  dov'  n along  with 
the  intestine,  and  forms  a hernial  sac,  within 
the  tunica  vaginalis.  It  is  evident  also,  that 
such  a hernia  can  only  be  produced,  while 
the  original  tunica  vaginalis  remains,  in  the 
form  of  a bag.  as  high  as  the  abdominal  ring. 


HERNIA. 


43 


Operators  should  he  aware  of  the  possibility 
of  having  a sac  to  divide  after  laying  open 
the  tunica  vaginalis.  (See  the  accounts  of 
this  hernia  in  Hep's  Practical  Observations,]). 
221,  <!y-e.  and  Ji  Cooper's  Work  on  Inguinal 
Hernia,  p.  59.) 

UMBILICAL  HERNIA,  OR  EXOMPHALOS. 

“ The  exomphalos,  or  umbilical  rupture, 
(says  Pott)  is  so  called  from  its  situation,  and 
has  (like  other  herniae)  for  its  general  con- 
tents, a portion  of  intestine,  or  omentum,  or 
both.  In  old  umbilical  ruptures,  the  quantity 
of  omentum  is  sometimes  very  great.  Mr. 
Ranby  says,  that  he  found  two  ells  and  a 
half  of  intestine  in  one  of  these,  with  about 
a third  part  of  the  stomach,  all  adhering 
together.  Mr.  Gay  and  Mr.  \ourse  found 
the  liver  in  the  sac  of  an  umbilical  hernia  ; 
and  Bohnius  says,  that  he  did  also.  But 
whatever  are  the  contents,  they  are  origi- 
nally contained  in  the  sac,  formed  by  the 
protrusion  of  the  peritonaeum.  In  recent 
and  small  ruptures,  this  sac  is  very  visible; 
but  in  old.  and  large  ones,  it  is  broken 
through  at  the  knot  of  the  navel,  by  the 
pressure  and  weight  of  the  contents,  and  is 
not  always  to  be  distinguished  ; which  is 
the  reason  why  it  has  by  some  been  doubted 
whether  this  kind  of  rupture  has  a hernial 
sac  or  not. 

“ Infants  are  very  subject  to  this  disease 
in  a small  degree,  from  the  separation  of  the 
funiculus;  but  in  general  they  either  get 
rid  of  it  as  they  gather  strength,  or  are  easily 
cured  by  wearing  a proper  bandage.  It  is 
of  still  more  consequence  o get  this  disorder 
cured  in  females,  even  than  in  males,  that 
its  return,  when  they  are  become  adult,  and 
pregnant,  may  be  prevented  as  much  as 
possible  ; for  at  this  time  it  often  happens, 
from  the  too  great  distention  of  the  belly,  or 
from  unguarded  motion  when  the  parts  are 
upon  the  stretch.  During  gestation,  it  is 
often  very  troublesome,  but,  after  delivery, 
if  the  contents  have  contracted  no  adhesion, 
they  will  often  return,  and  may  be  kept  in 
their  place  by  a proper  bandage. 

“ If  such  bandage  was  always  put  on  in 
time,  and  worn  constantly,  the  disease 
trjight  in  general  b<  kept  within  moderate 
bounds,  and  some  of  the  very  terrible  con- 
sequences whicV.  often  attend  it  might  be 
prevented.  The  woman  who  has  the  small- 
est degree  of  it,  and  who,  from  her  age  and 
situation,  has  reason  to  expect  children  after 
its  appearance,  should  be  particularly  care- 
ful to  keep  it  restrained. 

“ In  some  the  entrance  of  the  sac  is  large, 
and  the  parts  easily  reducible  . in  others 
they  are  difficult,  and  in  some  absolutely 
irreducible.  Of  the  last  kind  many  have 
been  suspended  for  years  in  a proper  bag, 
and  have  given  little  or  no  trouble.  They 
who  are  afflicted  with  this  disorder,  who  are 
advanced  in  life,  and  in  whom  it  is  large,  are 
generally  subject  to  colics,  diarrhoeas,  and, 
if  the  intestinal  canal  be  at  all  obstructed,  to 
very  troublesome  vomitings.  (Hence,  pa- 
tients are  often  supposed  to  labour  under  a 


stricture,  when  they  really  do  not.)  It 
therefore  behooves  such  to  take  great  care  to 
keep  that  tube  as  clean  and  free  as  possible, 
and  neither  to  eat  nor  brink  any  thing  likely 
to  make  any  disturbance  in  that  part.”  (Poll 
on  Ruptures,  Vol.  2.) 

Authors,  who  have  published  since  the 
time  of  this  celebrated  surgeon,  have  not 
added  much  to  the  stock  of  information 
which  he  has  left,  relative  to  the  exomphalos. 
The  writings  of  Mr.  A.  Cooper,  Scarpa, 
(Traitd  des  Hernies,  p.  327)  and  of  all  the 
most  accurate  moderns,  confirm  the  fact 
described  by  Pott,  that,  in  the  umbilical 
rupture,  there  is  a hernial  sac,  just  as  in 
other  instances  of  herniae  Every  one,  ac 
quaintedwith  anatomy,  knows,  that  behind 
the  opening  in  the  linea  alba  at  the  umbili- 
cus, the  peritonaeum  is  complete;  and  conse- 
quently must  protrude  along  with  the  viscera, 
in  cases  of  exomphalos.  In  the  only  two 
cases  which  Mr.  A.  Cooper  has  seen  of  a 
deficiency  of  the  sac,  the  membrane  had 
been  partially  absorbed,  or  lacerated,  so  as 
to  allow  the  protrusion  of  its  contents,  and 
threaten,  from  this  cause,  a double  stricture. 
Similar  appearances,  less  closely  inspected, 
probably  gave  rise  to  the  opinion  so  firmly 
maintained  by  Dionis,  De  la  Faye,  Garen- 
geot,  and  J.  L.  Petit,  that,  in  the  umbilical 
hernia,  the  peritonaeum  was  always  lacera- 
ted, and  there  was  no  hernial  sac.  Accord- 
ing to  Bichat,  early  infancy  is  most  subject 
to  the'  umbilical  hernia,  strictly  so  called,  in 
which  the  parts  protrude  through  the  navel  ; 
while  the  other  periods  of  life  are  more 
liable  to  false  umbilical  hernia?,  or  such  as 
arise  in  the  vicinity  of  the  umbilicus. 
( CEuvres  Chir.de  Desault,  T.  2./?.  315.) 

Besides  a true  hernial  sac,  the  exomphalos 
is  also  covered  by  a more  superficial  expan- 
sion, consisting  of  condensed  cellular  sub- 
stance. In  operating,  however,  a surgeon 
should  always  cut  with  great  caution  ; for, 
the  integuments  and  hernial  sac.  in  front  of 
the  tumour,  are  inseparably  adherent;  and 
sometimes,  in  large  cases,  when  an  absorp- 
tion of  part  of  tlie  sac  has  been  caused  by 
the  pressure  of  the  bowels,  they  are  even 
found  adherent  to  the  integuments. 

Pregnant  women,  and  dropsical  and 
corpulent,  subjects,  are  peculiarly  liable  to 
the  exomphalos.  In  adults,  when  there  is 
intestine  in  the  sac,  there  is  almost  always 
omentum.  The  transverse  arch  of  the  colon 
is  observed  to  be  particularly  often  contained 
in  umbilical  hernia?,  but  the  small  intestines 
are  not  (infrequently  protruded:  and 'even 
the  ccecum  has  been  found  in  a rupture  at 
the  navel.  (See  Lawrence  on  Ruptures,  p. 
427,  Edit.  3 ) 

In  the  true  umbilical  hernia,  the  stricture 
is  made  by  the  tendinous  opening  in  the 
linea  alba.  Let  us  next  consider  the  umbili- 
cal hernia  in  the  three  particular  forms,  in 
which  it  has  been  noticed  by  the  latest 
writers. 

CONGENITAL  UMBILICAL  ' HERNIA . 

Dr.  Hamilton  has  met  with  about  two 
cases  of  this  kind  annually,  for  the  space  of 


HERNIA. 


seventeen  years  ; arid  they  st>ictly  deserve 
the  epithet  congenital,  as  they  appear  at 
l*irth  The  funis  en  Is  in  a sort  of  bag, 
containing  some  of  the  viscera,  which  pass 
out  of  the  abdomen  through  an  aperture  in 
The  situation  of  the  navel  The  swelling 
is  not  covered  with  skin,  so  that  the  con- 
tents of  the  hernia  can  be  seen  through  the 
thin  distended  covering  of  the  cord.  The 
disease  is  owing  to  a preternatural  deficiency 
in  the  abdominal  muscles,  and  the  hope  of 
cure  must-be  regulated  by  the  size  of  the 
malformation,  and  quantity  of  viscera  pro- 
truded. 

The  plans  of  cure  proposed,  consist  of  the 
employment  of  a ligature,  or  of  a bandage. 
The  latter  seems  preferable,  and  was  prac- 
tised by  Mr.  Hey,  as  follows  : having  redu- 
ced the  intestine,  he  desired  an  assistant  to 
bold  the  funis  compressed  sufficiently  near 
the  abdomen,  to  keep  the  bowel  from  re- 
turning into  the  hernial  sac. 

“ I procured  (says  he)  some  plaster  spread 
upon  leather,  cut  into  circular  pieces,  and 
laid  upon  one  another  in  a conical  form. 
This  compress  I placed  upon  the  navel, 
after  I had  brought  the  skin  on  each  side  of 
the  aperture  into  contact,  and  had  laid  one 
of  the  lip's  a little  over  the  other.  I then 
put  round  the  end  . - abdomen  a linen  belt  : 
and  placed  upon  the  naval,  a thick,  circular, 
quilted  pad,  formed  about  two  inches  from 
one  extremity  of  the  be  it. 

“ This  bandage  kept  the  intestine  securely 
within  the  abdomen,  and  was  renewed 
occasionally,  The  f inis  was  separated  abo  t 
a.  week  afterbirth  ; and  at  the  expiration  of 
a fortnight  from  that  time,  the  aperture  at. 
the  navel  was  so  far  contracted,  that  the 
crying  of  the  child,  when  the  bandage  Was 
removed,  did  not  cause  the  least  protrusion. 
I thought  it  proper,  however,  to  continue 
the  use  of  the  bandage  a little  while  longer. 
A Small  substance,  S ■ k e fungous  flesh,  pro- 
jected, after  the  funis  had  dropped  off  about 
half  an  inch  from  the  bottom  of  that  de- 
pression which  the  nave!  forms.  A dossil  of 
lint  spread  with  cerat.  e lapide  calaminari, 
and  assisted  by  the  pressure  of  the  bandage, 
brought  on  a complete  cicatrization."’  (P. 
227.) 

This  gentleman  has  related  another  exam- 
ple, in  which  the  intestines  were  quite' un- 
covered and  inflamed,  the  sac  having  burst 
in  delivery  The  parts  were  reduced;,  but 
the  child  died.  (See  also  G.  A Fried  de  Fcetu 
intestims  plane  nudis  extra  abdomen  propen  -• 
dentibus  nalo.  Argent.  17**0.) 

UMBILICAL  HER  SI  A IN  CHILDREN. 

The  umbilical  hernia,  which  is  sometimes 
formed  in  the  fetus,  from  causes  difficult  of 
explanation,  takes  place,  in.  other  instances, 
at  t’ne  moment  of  delivery  ; and  then,  as 
Sabatier  remarks,  should  it  be  tied  by  mis- 
take, with  the  funis,  death  would  be  the  con- 
sequence. Most  frequently,  however,  it  is 
not  till  the  second,  third,  or  fourth  month 
after  birth,  that  the  disease  occurs  ; and  the 
numerous  cases  collected  by  Desault  prove 
that,  of  ten  infants  attacked  with  this  hernia. 


nine  become  afflicted  at  the  periods  just 
mentioned. 

The  umbilicus,  still  open,  now  begins  to 
contract,  so  as  to  close  the  cicatrix,  which 
soon  forms  an  obstacle  capable  of  prevent- 
ing a protrusion  of  the  viscera.  Sometimes, 
however,  the  repeated  crying  of  the  child 
propels  the  viscera  through  the  opening,  and 
thus  the  closure  of  the  cicatrix  of  the  navel 
is  prevented.  By  degrees,  the  umbilical  ring 
becomes  more  and  more  dilated,  the  quanti- 
ty of  protruded  bowel  increases,  and  thus 
a tumour  arises,  which,  from  being  of  trivial 
size  at  first,  at  length  attains  the  size  of  an 
egg,  or  large  walnut,  and  presents  itself  with 
all  the  characteristic  marks  of  a hernia. 

The  presence  of  a piece  of  intestine  and 
omentum  in  the  tumour,  keeps  the  umbilicus 
open,  and  opposes  the  continual  tendency 
which  it  has  to  close.  Such  tendency,  how  - 
ever, being  sometimes  superior  to  the  resist- 
ance of  the  protruded  parts,  forces  them 
back  info  the  abdomen,  obliterates  the  open- 
ing through  which  they  passed,  and  thus  the 
spontaneous  cure  of  the  umbilical  hernia  in 
children  is  accomplished.  Two  cases  illus- 
trative of  this  fact,  are  related  by  Bichat. 
((Entires  L'hir.  de  Desault,  T.  2,  p.  318  ) 

f'yature,  however,  does  no*  effect  many 
su<  h cures,  and  when  the  case  is  left  to  her 
alone,  she  not  only  fails  in  bringing  about  a 
radical  cure,  but  gradually  renders  it  impos- 
sible. In  short,  the  propensity  of  the  open- 
ing to  lose  diminishes,  and  is  lost,  as  the  sub- 
ject grows  older. 

Thus,  the  umbilical  hernia  of  children 
seems  to  be  essentially  different  from  that 
of  adults,  in  the  tendency  of  the  aperture 
to  contract.  Hence  the  ease  of  affecting  a 
radical  cure  in  children,  and  the  almost  utter 
impossibility  of  doing  so  in  adults.  In  the 
former,  it  is  enough  to  keep  the  intestines 
from  protruding,  and  the  opening  becomes 
of  itself  obliterated  ; in  the  latter,  the  open- 
ing always  remains,  whether  the  bowels  con- 
tinue in  it  or  not.  This  indisposition  of  the 
aperture  to  contract  in  the  adult,  also  fre- 
quently depends  upon  the  protrusion  not  be- 
ing through  the  umbilical  ring  itself,  but 
through  a fissure  in  the  vicinity  of  it,  not 
endued  with*  the  same  natural  tendency  to 
close,  which  the  umbilicus  possesses  in 
young  subjects.  In  fact,  it  would  appear 
from  the  observations  of  Scarpa,  detailed 
in  the  2d  vol.  o!  the  First  bines  of  Surgery, 
that,  unless  a grown-up  person  lias  the  pro- 
trusion from  infancy,  it  nevel*  occurs  exact- 
ly through  the  umbilical  ring  itself 

The  means  of  curing  the  umbilical  hernia 
of  children,  are  of  three  kinds  ; external  ap- 
plications; compression  ; and  the  ligature. 
The  first  are  totally  useless  ; and  as  t hey 
occasion  a waste  of  time,  are  improper. 
Compression,  and  the  ligature,  are  the  only 
rational  plans.  The  former  is  the  most 
modern  ; the  latter  the  most  ancient  treat- 
ment, as  it  is  mentioned  by  Celsus.  Desault 
tells  us,  that  the  design  both  of  the  ligature 
and  compression  is  the  same,  viz.  to  prevent 
the  lodgment  of  the  protruded  viscera  in 
the  opening  of  the  umbilicus,  and  thus  faci ' 


HERNIA. 


45 


litate  the  approximation  of  its  sides.  To 
accomplish  this  end,  the  ligature  retrenches 
the  hernial  sac,  and  skin  pushed  betore  it  ; 
and,  by  the  union  of  the  cut  parts,  a cicatrix 
is  produced  which  hinders  the  protrusion  of 
the  viscera.  At  the  same  time,  the  sides  of 
the  opening,  obeying  their  natural  tendency, 
compression  closes  the  deficiency,  or  open- 
ing, in  the  p rietes  of  the  abdomen,  hinders 
the  protrusion  of  the  bowels,  and  keeps  tiese 
parts  from  resisting  the  contraction  of  the 
sac.  Desault  remarks,  that  though  compres- 
sion occasions  no  pain,  it  is  irksome,  during 
the  great  length  of  time  its  employment  is 
necessary.  The  ligature  (he  says)  produces 
momentary  pain  ; but  it  is  not  at  all  irksome, 
and  it  effects  in  a few  days,  what  compres- 
sion, when  successful,  accomplishes  in  seve- 
ral months.  In  one  plan,  long  continual  at- 
tention is  requisite,  and  if  its  employment 
be  only  for  a sli  'rt  time  neglected,  the  pre- 
vious effect  becomes  almost  destroyed.  The 
other  method  alu  ays  accomplishes  its  object 
with  certainty,  independently  of  the  crying 
of  the  child,  and  the  care  of  its  attendants. 
When  compression  is  adopted,  it  is  executed 
either  by  means  of  a flat  compress  applied 
to  the  opening,  and  which  does  not  enter 
it,  or  else  by  means  of  some  round  or  oval 
body,  such  as  a ball  of  wax,  a nutmeg,  &c. 
adapted  to  the  shape  of  the  aperture,  and, 
as  Platner  and  Richter,  (in  his  Treatise  on 
Hernia)  advise,  continually  kept  within  the 
opening.  In  the  first  case,  Bichat  argues, 
that  if  the  bandage  be  exactly  applied,  the 
skin  and  sac  will  form  a fold  in  the  aperture 
of  the  navel,  hinder  its  closure,  and  operate 
in  the  same  manner,  from  without,  inward, 
as  the  protruded  intestines  did  from  within 
outward  In  the  second  case,  he  observes, 
the  foreign  body,  being  depressed  into  and 
maintained  in  the  opening,  will  occasion, 
notwithstanding  what  Richter  says,  the  same 
inconveniences,  and,  in  a more  striking  man- 
ner, similar  consequences,.  But,  on  the  con- 
trary, when  the  !i  ature  is  employed,  the 
sac  and  skin  of  the  tumour  are  removed, 
while  the  opening  remains  free,  and  nothing 
prevents  its  obliteration.  In  this  method, 
the  omentum  can  never  protrude  outward  ; 
but,  in  the  other,  if  the  compression  should 
ever  be  inexact,  the  parts  slip  out  again, 
above  or  below,  and  the  disorder  prevails  o>i 
one  side  of  the  useless  application.  The 
ligature  is  also  commended  as  producing  an 
adhesion  of  the  sides  of  the  opening,  either 
to  each  other,  or  the  adjacent  parts.  This 
adhesive  process  arises  from  the  inflamma- 
tion excited,  and  occasions  a degree  of  firm- 
ness, not  producible  by  any  other  mode  of 
cure. 

With  respect  to  compression,  Bichat  as- 
serts that  children,  on  whom  it  is  employed, 
are  miserably  annoyed  with  it  for  years, 
while  the  ready  success  of  the  treatment 
with  the  ligature,  is  attested  by  a series  of 
well-authenticated  cures,  which  in  Desault’s 
practice,  amounted  to  the  number  of  fifty. 
In  the  latter  years  of  his  practice,  says  Bi- 
chat,  many  persons  were  also  seen  bringing 
to' his  public  consultations  their,  children. 


which  were  immediately  operated  on  with- 
out any  preparation,  carried  home,  and 
b roug'd  the  next,  and  every  following 
day,  to  be  dressed,  till  the  cure  was  com- 
plete. 

The  children  of  the  poor  may  be  cured 
in  an  hospital,  with  the  ligature,  in  the  space 
of  a few  days  But,  when  compression  is 
adopted,  the  parents  are  frequently  put  to 
repeated  expense,  as  the  bandage  wears  out ; 
and  to  additional  loss  from  the  time  con- 
sumed in  payin,  die  necessary  attention. 

The  ancients  had  different  modes  of  ap- 
plying the  ligature.  One  consisted  in  redu 
ing  the  parts,  and  afterward  tying  the  in- 
teguments afid  sac,  without  opening  the  lat- 
ter at  all.  In  the  other,  an  incision  was 
made  ir.  the  sac,  either  before  or  after  tying 
it,  for  the  purpose  of  being  sure,  that  no 
piece  of  intestine  was,  and  could  become, 
strangulated  in  the  ligature  Celsus  adopted 
the  first  plan  ; Paulus  iEgiueta  preferred  the 
second  ; and  he  was  imitated  by  Avicenna, 
Atbucasis,  and  Guy  de  Chauiiac. 

The  first  of  these  methods  is  less  painful, 
and  equally  safe ; for,  we  soon  become 
habituated  to  ascertaining,  whether  there  is 
still  any  intestine  in  the  sac,  by  rubbing  the 
opposite  sides  of  this  bag  against  each  other. 
The  other,  which  is  unnecessarily  cruel,  in- 
creases the  pain,  without  making  the  method 
at  all  more  successful.  Some  of  the  old 
practitioners  simply  tied  the  base  of  the  tu- 
mour ; others  passed  through  it  one,  or  two 
needles,  armed  with  ligatures  for  the  pur- 
pose of  fixing  such  ligatures  in  a better  man- 
ner, and,  for  this  purpose,  they  even  some- 
times made  a circular  incision.  Desault’s 
method,  which  much  resembled  that  of 
Saviard’,  was  simple,  and  is  described  by 
Bichat  as  attended  with  little  pain. 

The  child  must  be  placed  on  its  back,  with 
its  thighs  a little  bent,  and  its  head  inclined 
towards  the  chest.  The  surgeon  is  to  re- 
duce the  protruded  parts,  and  to  hold  them 
so  with  bis  finger,  at  the  same  time  that  he 
raises  the  hernial  sac,  and  rubs  its  sides  be- 
tween his  fingers,  so  as  to  be  sure  that  there 
is  nothing  contained  in  it.  Being  certain, 
that  the  parts  which  he  lifts  up,  are  only  the 
skin  and  sac,  he  is  to  direct  an  assistant  to 
surround  their  base  several  t^mes  with  a 
waxed  ligature,  of  middling  size,  each  turn 
being  tied  with  a double  knot  in  such  a man- 
ner as  only  to  occasion  liple  pain.  The  tu- 
mour, thus  tied,  is  to  be  covered  with  lint, 
which  is  to  be  supported  with  one  or  two 
compresses,  and  a circular  bandage,  secu- 
red With  a sea  pulary.  By  the  following  day 
a slight  swell: i has  commonly  taken  place 
in  the  constricted  parts. 

On  the  second,  or  third  day,  the  parts 
shrink,  and  then  the  ligature  becomes  loose, 
so  that  a fresh  one  must  now  be  applied  in 
the  same  manner  as  the  first,  taking  care  to 
draw  it  a little  more  tightly.  The  sensibility 
of  the  parts,  increased  by  the  inflammation, 
which  the  constriction  of  the  ligature  has 
already  produced,  usually  renders  th  s second 
ligature  more  painful  After  the  operation, 
the  same  pressings,  as^at  first,  are  to  be  ap. 


46 


1IEKNIA. 


plied.  The  tumour  soon  becomes  discolour- 
ed, livid,  and  smaller.  A third  ligature,  put 
on  in  the  same  way  as  the  preceding  ones, 
entirely  obstructs  the  circulation  in  it.  The 
part  turns  black  and  flaccid,  and  commonly 
falls  off  oi  the  eighth  orter.lh  day.  A small 
ulcer  is  left,  which,  being  properly  dn-ssed, 
very  soon  heals,  and  leaves  a cicatrix  suffi- 
ciently strong  to  resist  the  impulse  occasion- 
ed by  coughing,  or  other  efforts  of  the  abdo 
initial  muscles.  For  two  or  three  months, 
however, afterthe  operation  the  child  should 
Wear  a circular  bandage,  in  order  to  prevent, 
with  still  greater  certainty,  the  vi  cera  from 
being  propelled  against  the  cicatrix,  so  as  to 
interrupt  the  process  of  nature,  which  is  now 
producing  a gradual  closure  of  the  umbilical 
opening.  Numerous  cases  might  here  be 
adduced,  in  confirmation  of  the  above  prac- 
tice ; but,  several  (nine)  are  already  publish- 
ed in  the  Parisian  Chirurgical  Journal. 

But  one  may  doubt,  (says  Sabatier)  quo- 
ting the  article  in  the  journal,  where  Desault 
treats  of  the  present  disease,  whether  the 
infants  got  rid  of  the  hernia,  as  it  might  have 
returned  some  time  afterward.  To  this  ob- 
servation, Bichat  replies,  that  numerous  facts 
remove  the  doubt ; for,  several  of  the  sub- 
jects were  brought  to  Desault’s  public  con- 
sultation, for  other  diseases,  a long  while 
after  they  had  been  operated  upon,  and  the 
great  number  of  students,  who  examined 
them,  all  acknowledged,  that  the  ring  was 
completely  obliterated,  and  there  was  no 
impulse  of  the  viscera  in  coughing,  sneezing, 
&c.  Other  children,  in  the  knowledge  of 
the  surgeons  of  the  H&tel-Dien,  remained 
perfectly  cured,  and  Bichat  was  acquainted 
with  two  young  subjects  on  whom  the  oper 
ration  had  been  performed  four  years,  and 
they  had  had  no  relapse. 

In  young  infants  the  operation  almost  con- 
stantly answered  ; but,  in  proportion  as  their 
age  increased,  it  was  tound  to  be  less  certain. 
Bichat  relates  three  cases,  v\  hich  tend  to 
prove,  that  success  may  be  completely  ob- 
tained at  the  age  of  a year  and  a half ; that 
the  cure  is  difficult,  when  the  child  is  four 
years  old  ; and  impossible,  when  it  is  nine. 
(See  CEuvres  Chir.  de  Desault , par  Bichat,  T . 
2,  p.  315,  fyc.) 

Mr.  Pott  notices  the  plan  of  curing  the 
exomphalos  with  the  ligature  and  expresses 
himself  strongly  against  the  practice  in  gene- 
ral. To  adults  the  plan  is  not  applicable, 
particularly  when  the  tumour  is  large.  Mr. 
Pott  was  decidedly  in  favour  of  compression, 
and  he  observes,  that,  in  young  subjects, 
and  small  herniae,  a bandage,  worn  a proper 
time,  generally  proves  a perfect  cure.  ( Vul . 
2.) 

Anxious  that  this  work  should  be  strictly 
impartial,  I next  proceed  to  relate  what  has 
been  more  recently  urged  against  the  em- 
ployment of  the  ligature  for  the  cure  of  the 
umbilical  hernia  in  children 

The  incessant  care  that  a bandage  requires, 
either  to  keep  it  clean  or  make  it  always 
keep  tip  the  proper  degree  of  pressure,  n ri- 
ders its  employment  difficult  in  the  children 
of  the  poorer  classes.  Scarpa  expresses  his 


opinion,  that  “this  was  what  induced  De- 
sault to  revive  the  Operation  for  the  umbili- 
cal hernia  by  tire  ligature,  nearly  such  as  is 
described  by  Celsus,  an  operation  (continues 
Scarpa)  which,  a long  while  ainc>  , and  for 
good  reasons,  was  altogether  abandoned. 
Celsus  has  sufficientlv  described  the  particu- 
lars of  it  : (Lib.  7,  Cap.  14,)  he  states,  that 
the  tumour  is  sometimes  to  be  mm  ply  lied, 
and  that,  in  other  instances,  its  base  is  to 
have  a needle  and  double  ligature  introduced 
through  it,  in  order  that  it  may  be  embraced 
almost  in  the  ••ame.  way  as  a staphyloma  is 
lied  Bui  among  the  causes  which  contra- 
indicate this  operation,  he  mentions  so  many 
circumstances  in  relation  to  age,  constitution, 
diseases  of  the  skin,  &c.  that  lie  seems  to  consi- 
der thecases  in  which  it  may  be  practised  with 
success  as  very  few.  The  same  reflections 
were  made  by  several  olher  ancient  surgical 
writers,  especially  by  Fabricius  ab  Aquapen- 
dente  Desault  himself  has  put  some  restric- 
tions to  the  employment  of  the  ligature, 
since  he  observes,  with  his  usual  candour, 
1 hat  this  method  docs  not  radically  cure  the 
umbilical  herma  of  children,  arrived  at  the 
age  ol  four  year?;  that  it  is  indispensable,  as 
Celsus  inculcates,  to  employ  a needle  and 
double  ligature,  v\  hen  the  base  of  the  tumour 
is  very  large  ; and  lastly,  that  even  in  the 
youngest  children',  a radical  cure  cannot  be 
effected  by  die  ligature,  unless  a methodical 
compression  of  the  navel,  by  means  of  a 
bandage,  be  kept  up  immediately  after  the 
operation,  and  for  two  or  three  months  It 
is  perhaps  to  the  omission  of  this  last  means, 
that  a relapse  is  to  be  ascribed  in  several  of 
the  children  operated  upon  by  Desault.  “ De- 
sault avoit  remis  en  vigueur  la  ligature  tom- 
b6e  en  ddsudtude.  It  s'abusoit  sur  sa  valeur  ; 
et  il  nest  pas  difficile  d’en  connoitre  la  cause. 
Tons  les  enfans  qu'il  opdroit  d VH&tel-Dieu 
sortoienf  gueris  el  n'y  revenoient  plus : on 
rtgardoit  alors  comme  radicale  une  gnirison 
morneutanee .”  (Riche rand , Nosographie  Chir. 
T.  2 ,p.  456.)  I have  carefully  watched  (says 
Scarpa)  the  immediate  effects,  and  the  more 
or  less  remote  consequences  of  tying  the 
umbilical  hernia,  either  simply  or  by  means 
of  a m edle  and  double  ligature  ; and,  after 
a considerable  number  of  such  cases,  I be- 
lieve I can  assert,  that  this  operation , how- 
soever performed , is  not  alway  exempt  from 
grave  and  sometimes  dangerous  accidents.  / 
can  also  add,  that  it  never  procures  a truly 
radical  cure  un'ess  the  cicatrix,  occasioned  by 
it  in  the  umbilical  region  be  submitted  for 
some  mouths  to  a methodical  ancbuninterrupted 
compression.  It  is  not  so  uncommon,  as  some 
surgeons  pretend,  to  set  arise  after  the  applica- 
tion of  the  ligature , a fever  attended  with 
symptoms  of  most  violent  irritation,  and  acute 
sufferings,  which  cause  incessant  crying,  and 
sometimes  convulsions.  The  ulcer,  which  is 
produced  by  the  detachment  of  the  swelling,  is 
ulv)uys  very  large  and  difficult  to  heal.  Every 
now  and  then  it  becomes  painful,  and  emits 
fungous  granulations , even  though  dressed 
ivith  dry  applications. 

u Latterly,  it  has  been  explained  by  a cele- 
brated surgeon,  (Palette,  Manor,  del'  lusti-, 


HERNIA. 


47 


tuie , Tom.  2,  Pur/  I.)  that  the  umbilical  vein 
and  the  suspensory  ligament  of  the  liver,  be- 
ing included  in  the  ligature  ot  the  umbilical 
hernia,  the  inflammation  which  originates 
in  these  pans  may,  perhaps,  in  certain  cases, 
be  communicated  to  the  liver,  so  a*  to  put 
the  child’s  life  in  great  danger.  W hen,  in 
consequence  of  the  ligature,  symptoms  ot 
violent  irritation  come  on,  they  are  ordina- 
rily attributed  to  certain  individual  circum- 
stances, such  as  extreme  sensibility,  or  a par- 
ticular/Imposition  to  spasm  Hence,  it  is 
believed,  that  they  should  be  considered  as 
exceptions,  which  do  not  exclude  the  gene- 
ral rule,  and  prove  nothing  against  the  utility 
of  the  operation.  But  how  (says  Scarpa) 
can  the  surgeon  ascertain  the  existence  or 
nonexistence  of  these  individual  dispositions 
in  the  children  upon  which  he  is  to  operate  ? 
Assuredly  those  subjects,  in  which  I have  had 
occasion  to  notice  the  >bove  accidents,  en- 
joyed, before  the  operation,  perfect  health 
in  < very  respect 

“ Whatever  process  be  adopted  for  tying 
the  umbilical  hernia,  it  is  evident  that  the 
tumour  can  only  bp  constricted  as  far  as  a 
little  way  on  this  side  of  the  aponeurotic 
ring  of  the  umbilicus,  whence  it  follows  that 
the  integuments  must  always  remain  promi- 
nent and  relaxed  for  a certain  extent,  at  the 
front  and  circumference  of  this  opening. 
Also,  after  the  separation  of  the  strangulated 
portion,  there  necessarily  remains,  under  the 
cicatrix,  a portion  of  the  hernial  sac,  and  of 
the  loose  integuments  W’hich  covered  it  ; and 
as  the  cicatrix  itself  never  acquires  sufficient 
firmness  to  resist  the  impulse  ot  the  viscera, 
which  tend  to  insinuate  themselves  into  the 
remains  of  (he  hernial  sac,  the  hernia  sooner 
or  later  reappears,  and,  in  a short  time,  be: 
comes  larger  than  it  was  before  the  opera- 
tion. If  the  subject  is  a little  girl,  it  may  he 
apprehended,  that  the  first  pregnancy  will 
eause  a recurrence  of  the  hernia  ; for,  it  is 
known,  that,  during  gestation,  the  external 
cicatrix  of  the  umbilicus  is  considerably  dis- 
tended, and  much  disposed  to  give  way.” 

Pott  has  seen  terrible  accidents  cau-ed  by 
the  rupture  of  the  cicatrix  a*  the  navel,  du- 
ring  pregnancy.  (C. hirurg . Works,  Vol.  2 , p. 
169.)  It  is  true  that,  according  to  this  writer, 
this  cicatrix  was  not  the  consequence  of  a 
hernia,  but  rather  of  an  abscess  in  the  umbi- 
lical region,  which  abscess  had  forme  ly 
been  opened  with  a bistoury  ; yet,  observes 
Scarpa,  it  would  not  be  impossible  to  raise 
doubts  upon  this  conjecture.  Lastly,  alter 
the  separation  of  the  tumour,  there  always 
remains,  between  (he  aponeurotic  ring  ot  (be 
navel  and  the  integuments,  a small  cavity, 
formed  by  the  neck  of  the  hernial  sac  ; a 
cavity  into  which  the  viscera  begin  to  insi- 
nuate themseives  after  the  operation,  so  as  to 
binder  the  complete  contraction  of  the  um- 
bilical ring.  The  demonstration  of  what  I 
have  advanced  is,  in  some  measure,  to  be 
found  in  ihe  old  method  of  operating  for  the 
inguinal  hernia,  not  in  a strangulated  state, 
by  (he  ligature  of  the  hernial  sac  and  sperma- 
tic cord.  Most  of  the  hernia?,  operated  upon 


by  (his  barbarous  process,  were  subject  to 
relapses,  because,  in  all  probability , the  cica- 
trix was  noi  sufficiently  firm  to  resist  the 
impulse  of  the  viscera,  w hich  entered  the 
remains  of  the  hernial  sac.  In  the  same  man- 
ner, after  the  common  operation  for  (he 
strangulated  inguinal  hernia  although  the 
cicatrix  is  formed  very  near  the  ring,  there  is 
no  piudent  surgeon  who  does  not  advise  the 
patient  to  wear  a bandage  the  rest  of  his  life, 
observation  having  prove  > that  the  hernia  is 
still  liable  t<>  recur. 

“ The  experience  of  several  ages  leaves 
no  doubt,  that  compression  alone  is  an  ex- 
tremely efficacious  method  of  radically 
curing  the  umbilical  hernia  of  young  sub- 
jects. It  is  attended  with  no  risk,  and,  pro- 
vided it  be  executed  with  the  requisite  cau- 
tion, it  is  hardly  ever  necessary  to  continue 
it  longer  than  two  or  thife  mouths  for  the 
purpose  of  obtaining  a complete  cure.  On 
the  olher  side,  ii  it  be  clearly  proved,  by  all 
that  J have  been  observing,  that  the  ligature 
never  accomplishes  a perfect  cure  without 
compression,  it  is  manifest,  that  it  cannot  be 
at  all  advantageous  for  the  children  of  the 
poor,  since  a bandage  cannot  be  dispensed 
with.  Il  may  be  said,  that  in  general  it  does 
not  shorten  the  treatment  ; for,  in  the  most 
successful  cases,  the  ulcer  caused  by  it  is 
not  healed  in  less  than  a month,  and,  in 
order  to  make  the  cure  certain,  an  exact 
compression  must  afterward  he  kept  up,  by 
means  of  a bandage,  two  months  longer.  It 
has  already  been  staled,  that  three  months 
are  ordinarih  sufficient  for  obtaining  a radi- 
cal cure  by  the  mere  employment  of  a tom- 
pres-ive  bandage.”  ( Scarpa , Traitt  des  Her- 
nies,p.  344 — 349.) 

In  the  Journal  G6n&ral  de  Medecine,  T.  41. 
1811,  M.  Girard  has  published  a memoir  on 
the  umbilical  hernia  of  children,  w hich  was 
read  to  the  Medical  Society  of  Lyons  in 
May,  1811,  and  the  object  of  which  was 
to  recommend  compression  as  an  effectual 
means  of  cure.  The  arguments  used  were 
very  similar  to  those  adduced  by  Scarpa.  In 
the  course  of  the  discussion,  M.  Cartier 
affirmed,  that  he  had  seen  many  children 
operated  upon  by  Desault,  who  were  not 
cured  of  their,  herniae. 

The  subject  was  afterward  taken  up  by 
the  Medical  Society  of  Paris,  and  the  result 
of  the  debate  was,  that  the  employment  of 
the  ligature  ought  to  be  rejected.  1.  Be 
cause  the  cure  ot  umbilical  herniae  is  often 
accomplished  by  nature  alone.  2.  Be- 
cause compression^  either  alone  or  aided  by 
tonic  remedies,  always  succeeds.  3.  Be- 
cause (he  operai ion  of  the  ligature  deserves 
the  triple  reproach  of  being  painful,  and  not 
free  from  danger,  if  unfortunately  a piece  of 
intestine  should  chance  to  be  included  in  the 
ligature  ; of  not  succeeding  in  general,  except 
with  the  as'istance  of  compression,*  and  of 
being  sometimes  uselessly  practiced,  a-  De- 
sault himself  give>  us  instances  of.  Accord- 
ing to  M.  Cayol.  the  insufficiency  of  the  liga- 
ture was  lung  since  acknowledged  by  8aba 
tier,  Lassus,  Richerand,  fee,  . 


48 


HERNIA. 


UMBILICAL  HERNIA  IN  ADULT  SUBJECTS. 

This  case  is  to  be  trailed  on  the  princi 
lies  common  to  nil  ruptures.  When  reduci- 
)le.,  the.  parts  should  be  kept  up  with  a band- 
age or  truss;  which  plan  howev  in  grown- 
up persons-  dFords  no  hope  ol  a radical  cure. 
Mr.  Hey  has  described  some  very  good 
trusses  for  the  exornphalos,  which  are  appli- 
cable 'o  children,  when  compression  is  pre- 
ferred, as  well  as  to  -»duh  -ubp  o s Om  was 
invented  by  the  la:e  Mr.  Marrison.  an  ingeni- 
ous mechanic  at  Leeds. 

“ It  consists  of  two  pieces  of  thin  elastic 
steel,  which  surround  the  sides  of  the  abdo- 
men, and  nearly  in  et  behind.  At  their  an- 
terior extremity  they  form  conjointly  an 
oval  ring,  to  one  side  of  which  is  fastened  a 
spring  of  steel  ol  the  form  (-presented.  At 
the  end  of  this  sprit)"  is  placed  the  pad  or 
bol  der  ( iiat  presses  upon  die  hernia.  By  the 
elasticity  of  this  spring  the  hernia  is  repressed 
in  every  position  of  the  body,  a d is  thereby 
retained  constantly  Within  the  abdomen.  A 
piece  of  calico  or  jean  is  fastened  to  each 
side  of  the  oval  ring,  .having  a continued 
loop  at  its  edge,  th'ough  which  a piece  of 
tape  is  put,  that  may  be  tied  behind  the  bodv . 
This  contrivance  helps  to  preserve  the  in- 
strument steady  in  itspropei  situation.  (Prac- 
tical Obs.  in  Surgery,  p.  231.)  And,  i . the 
second  edition  of  the  preceding  work,  ano- 
ther truss  for  the  exomphalos  is  described, 
the  invention  of  Mr.  England,  of  Leeds,  but 
as  some  account  is  given  of  this  instrument, 
with  an  engraving,  in  the  2d.  vol.of  the  First 
Lines  of  Surgery,  l shall  not  here  repeat  the 
description. 

When  the  exomphalos  i > irreducible,  and 
large,  the  tumour  must  be  supported  with 
bandages. 

e'  It  is  observed  by  Scarpa,  t hat  the  umbi- 
lical hernia,  arid  those  of  the  !i  tea  dii*,  are 
less  subjeetto  be  .strangulated  than  die  ingui- 
nal and  femora!  hernia  ; but  tha:,  when  they 
are  unfortunately  atfe.  ed  with  strangulation', 
the  symptoms  are  more  intense,  and  gan- 
grene comes  on  more  rapidly,  than  in  every 
other  species  of  rupture.  If  the  operation  be 
performed,  the  event  is  frequently  unfavour- 
able, because  it  is  generally  done  too  late. 
This  practical  fact  is  proved  by  1 he  experi- 
ence of  the  most  celebrated  surgeons  of. every 
age.  “ II  est  certain  (.says  Din  i ) que  de 
cette  operation  il  en  peril  plus  qu'il  n'en  re- 
chappe  ” ( Cours  d'  Operations,  p.  98,  Ed. 
1777,  avec  les  notes  de  la  Faye.)  He  also 
adds,  that  they  who  have  die  misfortune  to 
be  afflicted  with  an  exomplialos,  should  ra- 
ther dispense  with  (heir  shirt  than  a bandage. 
Heister  says  nearl\  the  same  thing.  (Insti- 
iut.  Chirurg.  T.  2,  Cap  94.) 

When  the  omentum  alo  >e  is  strangulated 
in  the  exomphalos,  or  hernia  of  the  liuea 
alba,  observation  proves,  that  the  symptoms 
are  not  less  intense,  than  when  the  intestine 
is  also  incarcerated.  There  is  this dill'-rcnce, 
however,  that  when  the  omentum  alone  is 
strangulated,  only  nausea  occurs,  and,  if  vo- 
miting should  likewise  lake  place,  it  is  less 
frequent  and  violent  them  when  the  bowel 


itself  is  strangulated.  In  the  first  case,  the 
stools  are  hardly  ever  entirely  suppressed. 
The  proximity  of  the  stomach  is,  no  doubt, 
t lie  reason  v\  hy  the  strangulation  of  the 
omentum,  in  the  umbilical  hernia,  ccasioris 
far  more  inten  -e  symptoms  ol  : ympathetic  ir- 
lation  than  the  strangulation  ol  the  same  vis- 
cus  ;:i  die  inguinal  or  crural  hernia. 

Here  the  operation  is  not  only  always  ne- 
cessary,  but  urgently  required.  It  is  not 
materially  different  from  that  which  is  prac- 
tised for  the  strangulated  inguinal  and  crural 
hernia} ; but . in  general,  it  demands'greater 
cirmm.ipee.tioi  , on  account  ol  the  connexion 
or  intimate  adhesions,  which  In  quenlly  exist 
between  die  integuments  and  hernial  sac, 
and  also  the  adhesions  which  often  prevail 
between  the  latter  part  and  the  omentum 
winch  it  contains.  The  situation  of  the  in- 
testine, which  is  frequently  covered  by  and 
enveloped  in  the  omentum,  is  another  cir- 
cumstance deserving  earnest  attention. 
( Scarpa , Trait 6 des  Hernies,  p.  361,  362.) 

M:\  Potl  is  not  such  an  advocate  as  Scar- 
pa for  the  early  performance  of  the  opera- 
tion in  cases  of  exomphalos  : “ The  umbili- 
cal, like  the  inguinai  hernia,  becomes  the 
subject  of  chirurgie  operation,  when  the 
parts  are  reducible  by  the  hand  only,  and 
are  so  bound  as  to  produce  bad  symptoms. 
But  though  1 have  in  the  inguinal  and  scro- 
tal hernia  advised  the  early  use  of  the  knife, 

I cannot  press  it  so  much  in  this  ; the  suc- 
cess of  it  is  very  rare,  and  1 should  make  it 
the  last  remedy  Indeed,  I am  much  incli- 
ned to  believe  that  the  bad  symptoms  v\  hich 
attend  these  cases  are  most  frequently 
owing  t disorders  in  the  intestinal  canal, 
and  not  .-<>  often  to  a stricture  made  on  it  at 
the  navel,  as  is  supposed.  1 do  not  say  that 
the  latter  does  rot  sometimes  happen  ; it 
certainly  does  ; b it  it  is  often  believed  to 
be  the  case  when  -t  is  not. 

“ When  the  operation  becomes  necessa- 
ry, it  consists  in  dividing  the  skin  and  her- 
nia! sac,  in  Luch  manner  as  shall  set  the  in- 
testine free  from  stricture,  and  enable  the 
surgeon  t<»  return  it  into  the  abdomen. 
( Pott  on  Ruptures.) 

The  rest  of  the  conduct  of  »he  surgeon  is 
to  be  regulated  by  the  usual  principles. 

The  division  of  the  stricture  is  properly 
recommended  to  be  made  directly  upward, 
in  the  course  of  the  liuea  alba. 

In  consequence  of  the  great  fatality  of 
the  usual  operation  for  the  exomphalos,  l 
think  the  plan  suggested,  and  successfully 
practised  by  Mr.  A.  Cooper  in  two  instan- 
ct  s,  should  always  be  ado  ted,  whenever 
the  tumour  is  lar  .e,  and  free  from  gangrene  ; 
a plan,  that  has  also  received  the  high  sanc- 
tion of  that  distinguished  anatomist  and  sur- 
geon, Professor  Scarpa.  ( Trait6  dcs  Her- 
nie  , p.  362.)  Perhaps  1 might  safely  add, 
that,  when  the  parts  admit  of  being  reduced, 
without  laying  open  the  sac,  this  method 
should  always  be  preferred.  It  consists  in 
making  an  incision  just  sufficient  to  divide 
the  stricture,  without  opening  the  sac  at  all, 
or  at  all  events,  no  more  of  it,  than  is  inevi- 
table. 


HERNIA. 


In  umbilical  hernia?,  ot’  not  a large  size, 
Mr.  C.  recommends  the  following  plan  of 
operating : “ As  the  opening  into  the  abdo- 
men is  placed  towards  the  upper  part  of  the 
tumour,  l began  the  incision  a little  below  it, 
that  is,  at  the  middle  of  the  swelling,  and  ex- 
tended it  to  its  lowest  part.  1 then  made  a 
second  incision  at  the  upper  part  of  the  first, 
and  at  right  angles  with  it,  so  that  the 
double  incision  w as  in  the  form  of  the  letter 
T,  the  top  of  which  Crossed  the  middle  of 
the  tumour.  The  integuments  being  thus 
divided,  the  angles  of  the  incision  were 
turned  down,  which  exposed  a considerable 
portion  of  the  hernial  sac.  This  being  then 
carefully  opened,  the  finger  was  passed  be- 
low'the  intestines  to  the  orifice  of  the  sac 
at  the  umbilicus,  and  the  probe-pointed  bis- 
toury being  introduced  upon  it,  I directed 
it  into  the  opening  at  the  navel,  and  divided 
the  linea  alba  downwards,  to  the  requisite 
degree,  instead  of  upwards,  as  in  the  former 
operation.  When  the  omentum  and  intes- 
tine are  returned,  the  portion  of  integument 
and  sac,  which  is  left,  falls  over  the  opening 
at  the  umbilicus,  covers  it,  and  unites  to  its 
edge,  and  thus  lessens  the  risk  of  the  peri- 
tonasal  inflammation,  by  more  readily  clo- 
sing the  wound.”  (Oil  Crural  and  Umbili- 
cal Hernia.) 

LESS  FREQUENT  KINDS  OF  HERNIA. 

The  ventral  hernia,  described  by  Oelsus,  is 
not  common  ; it  may  appear  at  almost  any 
point  of  the  anterior  part  of  the  belly,  but 
i-3  most  frequently  found  between  the  recti 
muscles.  The  portion  of  intestine,  he.  is 
always  contained  in  a sac,  made  by  the  pro- 
trusion of  the  peritonaeum.  Mr.  A.  Cooper 
imputes  the  disease  to  the  dilatation  of  the 
natural  foramina  for  the  transmission  of 
vessels,  to  congenital  deficiencies,  lacera- 
tions, and  wounds  of  the  abdominal  mus- 
cles, or  their  tendons.  In  small  ventral  her- 
nia?, a second  fascia  is  found-  beneath  the 
superficial  one  ; but,  in  large  cases,  tlie  lat- 
ter is  the  only  one  covering  the  sac. 

Hernia?  in  tiie  course  of  the  linea  alba 
sometimes  occur  so  near  the  umbilicus,  that 
they  are  liable  to  be  mistaken  for  true  um- 
bilical ruptures.  They  may  take  place 
either  above,  or  below  the  navel.  The  first 
1 case,  however,  is  more  frequent  than  the 
second,  and  the  following  is  the  reason  of 
this  circumstance  according  to  the  opinion 
of  Scarpa.  uThe  upper  half  of  the  linea 
alba,  that  which  extends  from  the  ensiform 
cartilage  to  the  umbilicus,  is  naturally 
broader  and  weaker,  than  the  lower  half, 
the  recti  muscles  coming  nearer  and  nearer 
together,  as  they  descend  from  the  navel  to 
the  pubes.  (Scarpa,  Traill  des  Her  nits,  p. 
333.) 

The  hernial  sac  of  ruptures  at  the  upper 
part  of  the  linea  aiba  may  contain  a noose 
of  intestine,  and  a piece  of  the  omentum, 
though  in  most  cases,  a portion  of  the  latter 
membrane  alone  forms  the  contents.  In 
some  subjects,  the  linea  alha  is  so  disposed 
! to  give  way,  that  several  hernia;  are  obser- 
1 Vol.  If. ' 7 


lit 

ved  to  be  formed  successively  in  the  inter- 
space between  the  ensiform  cartilage  and 
the  umbilicus. 

“ With  respect  to  the  small  hernia  (says 
Scarpa,)  w hich  is  considered  as  formed  by 
the  stomach,  and  concerning  which  Iloin 
and  Garengeot  have  written  so  much  (with- 
out either  of  them  having  related,  at  least 
to  my  knowledge,  a single  example  proved 
by  dissection,)  it  is  at  least  unproved,  that 
it  was  exclusively  formed  by  this  viscus. 
1 do  not  see,  why  the  other  viscera,  particu- 
larly the  omentum  and  transverse  colon, 
might  not  also  contribute  to  it.  In  my 
judgment,  it  only  differs  from  other  hernia; 
of  the  linea  alba,  in  being  situated  on  the 
left  side  of  the  ensiform  cartilage,  a situa- 
tion that  must  materially  influence  the 
symptoms  of  the  case.  In  fact,  whatever 
may  be  the  viscera,  which  form  it,  a sympa- 
thetic irritation  of  the  stomach  is  occasion- 
ed, tliat  is  much  more  intense,  than  that 
which  ordinarily  accompanies  umbilical 
hernia?,  those  of  the  lower  part  of  the  linea 
alba,  or,  in  short,  all  other  hernia;,  which 
are  more  remote  from  the  stomach.”  (Op, 
cit.  p.  334.) 

! he  following  are  said  to  be  the  circum- 
stances, by  which  the  umbilical  hernia,  and 
that  which  occurs  in  the  linea  alba  near  the 
navel,  may  be  discriminated. 

The  first,  w hether  in  the  infant  or  the 
adult,  has  a roundish  neck  or  pedicle,  at 
the  circumference  of  which  the  aponeurotic 
edge  of  the  umbilical  ring  can  be  felt. 
Whatever  may  be  its  size,  its  body  always 
retains  nearly  a spherical  shape.  Neither 
at  its  apex,  or  its  sides,  is  any  wrinkling  of 
the  skin,  or  any  thing  like  the  cicatrix  ot 
the  navel,  distinguishable.  In  some  points 
of  the  surface  of  the  tumour,  the  skin  is 
merely  somew'hat  paler  and  thinner,  than 
elsewhere. 

On  the  contrary,  the  hernia  of  the  linea 
alba  has  a neck,  or  pedicle,  of  an  oval  form, 
like  the  fissure  through  W'hich  it  is  protru- 
ded. The  body  of  the  tumour  is  also  con- 
stantly oval.  If  the  finger  be  pressed  deep- 
ly round  its  neck,  the  edges  of  the  opening 
in  the  linea  alba  can  be  felt  ; and,  if  the 
hernia  be  situated  very  near  the  umbilical 
ring,  the  cicatrix  of  the  navel  may  be  ob- 
served upon  one  side  of  it,  which  cicatrix 
retains  its  rugosity,  mid  all  its  natural  ap- 
pearance ; a certain  indication,  that  the  vis- 
cera are  not  protruded  through  the  umbili- 
cal ring.  (Scarpa,  Traill  des  Hernies,  p.  33b.) 

The  distinction  which  Scarpa  has  estab- 
lished between  the  umbilical  hernia?, proper- 
ly so  called,  and  those  of  the  linea  alba,  is 
not  useless  in  regard  to  practice.  Indeed, 
w hen  the  latter  are  left  to  themselves,  they 
make  much  slower  m’ogress,  than  the  form- 
er. On  account  of  their  smallness,  they 
frequently  escape  notice,  particularly  in  fat 
persons,  and,  wdien  situated  at  the  side  of 
the  ensiform  cartilage.  They  occasion, 
however,  complaints  of  the  stomach,  habitu- 
al colics,  especially  after  meals ; and,  un- 
fortunately for  the  patient,  he  may  be  tor- 
mented a very  long  time  by  these  indispa- 


HERNIA. 


AO 

sitions,  before  the  true  cause  of  them  is  dis- 
covered. 

The  umbilical  hernia  may  be  known, 
from  the  earliest  period  of  its  formation,  by 
the  alteration  which  it  produces  in  the 
cicatrix  of  the  navel,  and  the  rapidity  of  its 
increase. 

In  other  respects,  these  two  kinds  of  her- 
niffi  demand  the  same  means  of  cure  ; but 
those  of  the  linea  alba,  cceteris  paribus , are 
more  difficult  to  cure,  than  ruptures  at  the 
umbilicus.  This  is  probably  owing  to  the 
natural  tendency,  which  the  umbilicial  ring 
has  to  close,  when  tiie  hernia  is  kept  well 
reduced,  whilst  accidental  openings  in  the 
linea  alba  have  not  the  same  advantage. 
( Scarpa , p.  340.) 

Wnen  a common  ventral  hernia  is  redu- 
ced, it  should  be  kept  in  its  place  by  means 
of  a bandage  or  truss.  When  strangulated, 
it  admits,  more  frequently  than  most  other 
cases,  of  being  relieved  by  medical  treat- 
ment. If  attended  with  stricture,  which 
cannot  otherwise  be  relieved,  that  stricture 
must  be  carefully  divided.  Mr.  A.  Cooper 
recommends  the  valvular  incision,  and  the 
dilatation  to  be  made,  either  upward  or 
downward,  according  to  the  relative  situa- 
tion of  the  tumour  and  epigastric  artery, 
which  crosses  the  lower  part  of  the  linea 
semilunaris. 

Pudendal  Hernia. — This  is  the  name  as- 
signed by  Mr  A.  Cooper,  to  the  hernia 
which  descends  between  the  vagina  and  ra- 
mus ischii,  and  forms  an  oblong  tumour  in 
the  labium,  traceable  w ithin  the  pelvis,  as 
far  as  the  os  uteri.  He  thinks,  that  this  case 
has  sometimes  been  mistaken  for  a hernia 
of  the  foramen  ovale.  When  reducible,  a 
common  female  bandage,  or  the  truss  used 
for  a prolapsus  ani,  should  be  wrorn.  A pes- 
sary, unless  very  large,  could  not  well  keep 
the  parts  from  descending,  as  the  protru- 
sion happens  so  far  from  the  vagina.  Mr. 
A.  Cooper  is  of  opinion,  that,  w hen  strangu- 
lated, this  hernia,  in  consequence  of  the 
yielding  nature  of  the  parts,  may  generally 
be  reduced,  by  pressing  them  with  gentle 
and  regular  force,  against  the  inner  side  of 
the  branch  of  the  ischium.  If  not,  the  warm 
bath,  bleeding,  and  tobacco  clysters  are  ad- 
vised. Were  an  operation  indispensable, 
the  incision  should  be  made  in  the  labium, 
the  lower  part  of  the  sac  carefully  opened, 
and,  with  a concealed  bistoury,  directed  by 
the  finger,  in  the  vagina,  the  stricture  should 
be  cut  directly  inwrard,  towrards  the  vagina. 
The  bladder  should  be  emptied,  both  before 
the  manual  attempts  at  reduction  and  the 
operation.  (On  Crural  Hernia , fyc.  p.  64.) 

Paginal  Hernia. — A tumour  occurs  within 
the  os  externum.  It  is  elastic,  but  not  pain- 
ful. When  compressed,  it  readily  recedes, 
but  is  reproduced  by  coughing,  or  even 
without  it  when  the  pressure  is  removed. 
The  inconveniences  produced  are  an  ina- 
bility to  undergo  much  exercise  or  exertion  ; 
for,  every  effort  of  this  sort  brings  on  a sense 
of  bearing  down.  The  vaginal  hernia  pro- 
trudes in  the  space,  left  between  the  uterus 
and  rectum.  This  space  is  bounded  below 


by  the  peri  ton  senna,  whieh  membrane  is 
forced  downwards  towards  the  perinamm  ; 
but,  being  unable  to  protrude  further  in  that 
direction,  is  pushed  towards  the  back  part 
of  the  vagina.  In  one  case  Mr.  A.  Cooper 
advised  the  use  of  a pessary,  but  the  plan 
was  neglected.  Probably,  these  cases  are 
always  intestinal. 

Some  herniae  protrude  at  the  anterior  part 
of  the  vagina.  (si.  Cooper  on  Crural  Her- 
nia, fyc.  p.  65,  66.) 

Perinatal  Hernia. — In  men,  the  parts  pro- 
trude betw  een  the  bladder  and  rectum  ; in 
women,  between  the  rectum  and  vagina. 
The  hernia  does  not  project,  so  as  to  form 
an  external  tumour,  and,  in  men,  its  exist- 
ence can  only  be  distinguished  by  examin- 
ing in  the  rectum.  In  women,  it  may  be 
detected  both  from  this  part,  and  the  va- 
gina. 

In  case  of  strangulation,  perhaps,  this 
hernia  might  be  reduced  by  pressure  from 
within  the  rectum.  An  interesting  case  of 
perinaeal  hernia,  which  took  place  from  the 
peritonaeum  being  wounded  with  the  gor- 
get in  lithotomy,  is  related  by  Mr.  Brom- 
field  ; Chirurgical  Obs.  p.  264. 

The  reducible  perinaeal  hernia  in  wmmen 
may  be  kept  from  descending,  by  means  of 
a large  pessary.  Both  this  kind  of  rupture 
and  the  vaginal  may  prove  very  dangerous 
in  cases  of  pregnancy.  (See  Smellie’s  Mid- 
wifery,  Case  5.) 

Thyroideal  Hernia,  or  Hernia  Foraminis 
Ovale.  In  the  anterior  and  upper  part  of 
the  obturator  ligament,  there  is  an  opening, 
through  which  the  obturator  artery,  vein, 
and  nerve  proceed,  and  through  which,  oc- 
casionally, a piece  of  omentum,  or  intestine 
is  protruded,  covered  with  a part  of  the 
peritonaeum,  wdiich  constitutes  the  hernial 
sac. 

In  the  case  which  Mr.  A.  Cooper  met 
with,  the  hernia  descended  above  the  obtu- 
ratores  muscles.  The  os  pubis  w as  in  front 
of  the  neck  of  the  sac  ; three-fourths  of  it 
were  surrounded  by  the  obturatorligament ; 
and  the  fundus  of  the  sac  lay  beneath  the 
pectineus  and  adductor  brevis  muscles. 
The  obturator  nerve  and  artery  were  situa- 
ted behind  the  neck  of  the  sac,  a little  to- 
wards its  inner  side.  This  species  of  hernia 
can  only  form  an  outward  tumour,  when 
very  large.  Garengeot,  however,  met  with 
an  instance,  in  which  there  was  not  only  a 
swelling,  but,  one  attended  with  symptoms 
of  strangulation  : he  reduced  the  hernia, 
which  went  up  with  a guggling  noise  ; the 
symptoms  .were  stopped,  and  stools  soon 
followed. 

The  hernia  of  the  foramen  ovale,  when 
reducible,  must  be  kept  up  w ith  a suitable 
truss  ; and  if  it  were  strangulated,  and  not 
capable  of  relief  from  the  usual  means,  an 
operation  would  be  requisite,  though  at- 
tended  with  difficulties.  T he  division  of  the 
obturator  ligament  and  mouth  of  the  sac 
should  be  made  inwards,  to  avoid  the  obtu- 
rator artery.  If  this  vessel,  however,  were 
to  arise  in  common  with  the  epigastric  ar- 
tery, it.  would  be  exposed  to  injury  bv  fo! 


HERMA 


lowing;  this  plan.  (See  Garengeol  in  Mini, 
de  VAcad.  de  Cfiir.  T.  1 ; A.  Cooper  on  Cru- 
ral Hernia,  fyc.  p.  70  : and  First  Lines  of  Sur- 
gery, Vol.  2,  p.  80.  4'C.) 

< yslocele. — As  Mr.  Pott  observes,  “ The 
urinary  bladder  is  also  liable  to  be  thrust 
forth  from  its  proper  situation,  either  through 
the  opening  in  the  oblique  muscle,  like  the 
inguinal  hernia,  or  under  Poupart’s  liga- 
ment, in  the  same  manner  as  the  femoral. 

“ This  is  not  a very  frequent  species  of 
hernia,  but  does  happen,  and  has  as  plain 
and  determined  a character,  as  any  other. 

“ it  has  been  mentioned  by  Bartholin,  T. 
Dorn.  Sala,  Platerus,  Bonetus,  Ruysch,  Petit, 
Mery,  Verdier,  & c.  In  one  of  the  histories 
given  by  the  latter,  the  urachus,  and  imper- 
vious umbilical  artery  on  the  left  side,  were 
drawn  through  the  tendon  into  the  scrotum, 
with  the  bladder;  in  another  he  found  four 
calculi. 

“ Ruysch  gives  an  account  of  one  com- 
plicated with  a mortified  bubonocele.  Petit 
says,  he  felt  several  calculi  in  one,  which 
were  afterward  discharged  through  the  ure- 
thra. ^See  also  J.  G.  F.  Jahn  de  insoht ® 
Calculi  Ingentis  per  Scrotum  exclusiotie.  IVit- 
tenberg.  1750.) 

“ Bartholin  speaks  of  T.  Dorn.  Sala  as  the 
first  discoverer  of  the  disease,  and  quotes  a 
case  from  him,  in  which  the  patient  had  all 
the  symptoms  of  a stone  in  his  bladder  ; the 
stone  could  never  be  felt  by  the  sound,  but 
was  found  in  the  bladder  (which  had  passed 
into  the  groin)  after  death. 

“ As  the  bladder  is  only  covered  in  part 
by  the  peritonaeum,  and  must  insinuate  itself 
between  that  membrane  and  the  oblique 
muscle,  in  order  to  pass  the  opening  in  the 
tendon,  it  is  plain  that  the  hernia  cystica 
can  have  no  sac,  and  that  when  complica- 
ted with  a bubonocele,  that  portion  of  the 
bladder  which  forms  the  cystic  hernia  must 
lie  between  the  intestinal  hernia  and  the 
spermatic  cord,  that  is,  the  intestinal  hernia 
must  be  anterior  to  the  cystic. 

“ A cystic  hernia  may,  indeed,  be  the 
cause  of  an  intestinal  one  ; for  when  so 
much  of  the  bladder  has  passed  the  ring, 
as  to  drag  in  the  upper  and  hinder  part  of 
it,  the  peritonaeum  which  covers  that  part 
must  follow,  and  by  that  means  a sac  be 
formed  for  the  reception  of  a portion  of  gut 
or  caul.  Hence  the  diiferent  situation  of 
the  two  herniae  in  the  same  subject 

“ While  recent,  this  kind  of  hernia  is  easily 
reducible,  and  may,  like  the  others,  be  kept 
within  by  a proper  bandage  ; but  when  it  is 
of  any  date,  or  has  arrived  to  any  consider- 
able size,  the  urine  cannot  be  discharged, 
without  lifting  up,  and  compressing  the 
scrotum  ; the  outer  surface  of  the  bladder  is 
now  become  adherent  to  the  cellular  mem- 
brane, and  the  patient  must  be  contented 
with  a suspensory  bag. 

“ In  case  of  complication  with  a bubono- 
cele, it  the  operation  becomes  necessary, 
great  care  must  be  taken  not  to  open  the 
bladder  instead  of  the  sac,  to  which  it  will 
always  be  found  to  be  posterior.  And  it 
may  also  sometimes  by  the  inattentive  be 


51 

mistaken  for  a hydrocele,  and  by  being 
treated  as  such,  may  be  the  occasion  of 
great  or  even  fatal  mischief.”  (Vol.  2.) 

The  cystocele  is  always  easily  distinguish- 
able by  the  regular  diminution  of  the  swell- 
ing, whenever  the  patient  makes  water. 

Verdier  and  Sharp  have  accurately  de- 
scribed the  cystocle.  Pott  has  ottered  two 
cases,  which  fell  under  his  observation  ; 
Vol.  3.  Pipelet  le  Jeune  mentions  a cystic 
hernia  in  perinteo,  and  several  cases  of  its 
occurrence  in  the  female ; Acad,  de  Cliir. 
T.  4.  Pott  cut  into  one  cystocele,  by  mis- 
take. Mention  is  made  (Edinb.  Snrg.  Jour. 
Vol.  4,  p.  512.)  of  a cystic  hernia,  which 
protruded  between  the  origins  of  the  leva- 
tor ani,  and  obturator  internus  muscles  ; 
the  tumour  made  its  appearance  in  the  pu- 
dendum of  an  old  woman.  Much  additional 
information  respecting  the  cystocele,  and 
its  various  forms,  is  contained  in  the  second 
volume  of  the  First  Lines  of  Surgeiy,  p.  49, 
be.,  accompanied  with  references  to  all  the 
most  interesting  writers  on  the  subject.  An 
instance  of  protrusion  of  the  bladder  through 
a wound,  caused  by  a bullock’s  horn,  is  re- 
corded by  Larrey.  (Mem.  de  Cliir.  Mil.  T. 
4,  p.  289.) 

Ischiatic  Hernia. — This  disease  is  very- 
rare.  A case,  however,  which  was  strangu- 
lated, and  undiscovered  till  after  death,  is 
related  in  Mr.  A.  Cooper’s  second  pait  of 
his  work  on  hernia.  It  was  communicated 
by  Dr.  Jones,  so  celebrated  for  his  book  on 
hemorrhage.  The  disease  happened  in  a 
young  man,  aged  27.  On  opening  the  abdo- 
men. the  ileum  was  found  to  have  descend- 
ed on  the  right  side  of  the  rectum  into  the 
pelvis,  and  a fold  of  it  was  protruded  into  a 
small  sac,  which  passed  out  of  the  pelvis  at 
the  ischiatic  notch.  The  intestine  was  ad- 
herent to  the  sac  at  two  points:  the  stran- 
gulated part,  and  about  three  inches  on  each, 
side,  were  very  black.  The  intestines  to- 
wards the  stomach  were  very  much  distend- 
ed with  air,  and  here  and  there,  had  a livid 
spot  on  them.  A dark  spot  was  even  found 
on  the  stomach  itself  just  above  the  pylorus. 
The  colon  was  exceedingly  contracted  as 
far  as  its  sigmoid  flexure.  A small  orifice 
was  found  in  the  side  of  the  pelvis,  in  front 
of,  but  a little  above  the  sciatic  nerve,  and 
on  the  forepart  of  the  pyriformis  muscle. 
The  sac  lay  under  the  gluttons  maximus 
muscle,  and*  its  orifice  was  before  the  inter- 
nal iliac  artery,  below  the  obturator  artery, 
but  above  the  vein.  Mr.  A Cooper  remarks, 
that  a reducible  case  might  be  kept  up  with 
a spring  truss,  and  that  if  an  operation  were 
requisite,  the  orifice  of  the  sac  should  be 
dilated  directly  forwards.  (On  Crural  Her- 
nia,\c.p.  73.)  For  a further  account  of 
the  ischiatic  hernia,  and  references  to  the 
most  interesting  works  on  the  subject,  see 
First  Lines  of  Surgery , Vol.  2,  p.  84,  fyc. 

Phrenic  Hernia.— The  abdominal  visceri 
are  occasionally  protruded  through  the  dia- 
phragm, either  through  some  of  the  natural 
apertures  in  this  muscle,  or  deficiencies,  or 
wounds,  and  lacerations  in  it.  The  second 
kind  of  case  is  the  most  frequent:  Morgagni 


u.  of  u.  ua 


62 


hernia. 


furnishes  an  instance  of  the  fust.  Two  cases, 
related  by  Dr.  Macauley  in  Med.  Obs.  and 
Jnq.  Vol.  I,  two  more  detailed  in  the  Medi- 
cal Records  and  Researches,  and  two  others 
published  by  Mr.  A.  Cooper,  are  instances 
of  the  second  sort  : and  another  case  has 
been  lately  recorded  by  the  latter  gentle- 
man, affording  an  example  of  the  third  kind. 
A laceration  of  the  diaphragm  by  fractured 
ribs,  has  produced  a hernia.  A case  of  this 
kind  was  dissected  by  Mr.  Travers*  at  Guy’s 
Hospital.  (Med.  Ckir.  Trans  Vol.  0,  p.  375.) 
In  this  last  volume,  may  also  be  found  the 
particulars  of  an  interesting  example,  in 
which  a considerable  part  of  the  large  cur- 
vature of  the  stomach  was  protruded  through 
a fissure  of  the  diaphragm.  The  accident 
was  unattended  with  any  fracture  of  the 
ribs,  and  was  caused  by  the  upsetting  of  a 
stage  coach,  on  which  the  patient  was  an 
outside  passenger.  Before  death,  he  vomit- 
ed up  a large  quantity  cf  blood,  and  a small 
semicircular  aperture  was  discovered  on 
dissection  in  the  lower  part  of  t lie  strangu- 
lated portion  of  the  stomach.  (P.  378,  379.) 
See  also  B.  Stehelin,  Tentamen  Med.  quod 
vemriculum,  qui  in  Ihoracem  migraveral , SfC. 
describit,  1721  ; (in  Hallerii  Disp.  Anal.  6, 
675.)  Hildanus,  Parc,  Petit,  Sehenck,  Spc. 
also  mention  cases  of  phrenic  hernia.  The 
disease  is  quite  out  of  the  reach  of  art. 

Mesenteric  Hertua. — If  one  of  the  layers 
of  the  mesentery  be  torn  by  a blow,  w bile 
the  other  remains  in  its  natural  state,  the  in- 
testines may  insinuate  themselves  into  the 
aperture,  and  form  a kind  of  hernia.  The 
same  consequence  may  result  from  a natu- 
ral deficiency  in  one  of  these  layers.  Mr.  A, 
Cooper  records  a case,  in  which  ail  the 
small  intestines,  except  the  duodenum,  were 
thus  circumstanced.  The  symptoms  during 
life  were  unknown.  (On  Crural  Hernia, tyc. 
V-  82.) 

Mesocolic  Hernia. — So  named  by  Mr.  A. 
Cooper,  when  the  bowels  glide  between  tiie 
layers  of  the  mesocolon.  A specimen  of 
this  disease  is  preserved  at  St.  Thomas's 
Hospital. 

Every  surgeon  should  be  aware,  that  the 
intestines  may  be  strangulated  within  the 
abdomen  from  the  following  causes : 1 

Apertures  in  the  omentum,  mesentery,  or 
mesocolon,  through  which  the  intestine 
protrudes.  2.  Adhesions,  leaving  an  aper- 
ture, in  which  a piece  of  intestine  becomes 
confined  3.  Membranous  hands  at  the 
mouths  of  hernial  sacs,  which  becoming 
elongated,  by  the  frequent  protrusion  and 
return  of  the  viscera,  surround  the  intestine, 
so  as  to  strangulate  them  within  the  abdo- 
men, when  returned  from  the  sac.  (See 
A.  Cooper  on  Crural  Hernia,  ..Tc.  p.  85.) 

Pott  remarks,  that  “ Ruysch  gives  an  ac- 
count of  an  impregnated  uterus  being  found 
on  the  outside  of  the  abdominal  opening  ; 
and  so  do  Hildanus  and  Seunertus.  Ruysch 
also  gives  an  account  of  an  entire  spleen 
having  passed  the  tendon  of  the  oblique 
muscle.  And  1 have  myself  seen  the  ovaria 
removed  by  incision,  after  they  had  been 
gome  months  in  the  groin.”  (Vol.  2.)  More 


particulars  respecting  all  the  less  frequent 
kinds  of  hernia  are  given  in  the  second  vo- 
lume of  the  First  Lines  of  Surgery.  Franco , 
Traiti  des  He  rules,  fyc.  8 vo.,  Lyon,  1561  : 
Lud.  von  Hammen,  De  Herniis , 12mo.,  Lugd. 
1581.  M alack-  Geiger,  Kelegraphia,  sive  De- 
scriplio  Herniarurn,  cum  carundem  curatio- 
nibus,  lam  Medicis,  quam  Ckirurgicis,  12 mo., 
Monackii,  1631  ; Ant.  Le  Quin,  Le  Chirur- 
gicn  Herniaire,  \2mo.,  Paris,  1697.  J At  Ire, 
Observation  sur  ant  JVuuvelle  Espece  de  Her- 
nie, Mini,  de  l' Acad,  des  Sciences;  1700. 
Mery,  in  Ike  same  work;  1701.  Litlre,  sur 
une  Hernie  Rare;  same  work;  1 7 Id.  Mau- 
chart  de  Hernia  incarcerata  nova  encheiresi 
extricatd,  Tubing.  1722.  Heister,  Instil.  Chi- 
rurg.  el  De  Hernia  Incarcerata  Suppu- 
rala  non  semper  tethali.  Vogel,  Abhandlung 
alter  Arlen  der  Brucke  ; Lcipz.  1738.  Pey- 
ronie, Observations,  fyc.  sur  la  Cure  des  Her- 
nics  avec  Gangrene;  Mem  de  l' Acad,  de 
Ckir.  T.  1.  Gunz,  Observalionum  Anatomico- 
Ckirurgicarum  de  Herniis  lib  dies;  Lips. 
17-14;  el  Prolusio  Invdatoria  in  qua  de 
Eulero-Epiplocele  ugebat,  Lips.  1746.  P. 
Kirkschbaum,  De  Hernia  Venlriculi , Argent. 
1749.  P.  <S.  Kok , De  Herniis ; Roterod.  1782. 
Arnaud  on  Hernias,  1748  ; also  kis  Mem.  do 
Ckir.  Haller  de  Herniis  Congenilis,  1749.  Ca- 
l'eng  ect,  sur  plusieurs  Hernies  singulieres ; 
Mem.  de  T Acad,  de  Ckir.  tom.  2.  Moreau  sur 
les  suites  d'une  Hernie  op  trie ; Mem.  de 
I'Acad.  di  Ckir.  t.  3.  Benevoli , una  Ernict 
assai  p articular e ; Firenso , 1750.  G.  H. 
Troschel,  De  Morbis  ex  Alieno  Situ  Partium 
Abdominis,  Franco/.  1754:  (Haller,  Disp.  ad 
Morb.  4,  143.)  Haller  Herniarurn  adnota- 
iiones  ; extant  in  opuscul.palkol.  1755.  Blanc 
Aouvellc  Met  bade  d'opirer  les  Hernies  ; avec 
an  Essai  sur  les  Hernies,  par  M Hoin  ; Or- 
leans, 1767,  8vo.  Louis  Reflexions  sur  I'Opi- 
r at  ion  de  la  Hernie;  Mem.  de  I’Acad.  de  Chir. 
Tom.  4.  Hoin , Essai  sur  les  Hernies  rares  ct 
peu  connucs ; 1767.  Medical  Observations 
and  Inquiries.  Poll's  Works,  Vols.  2 and  3. 
Goursaud  sur  la  Difference  des  Causes  de 
I'itranglement  des  Hernies;  Mem.  de  I’Acad. 
de  Ckir.  Tom.  4.  Le  Dr  an,  Trail  i des  Ope- 
rations de  Ckir.  et  Observations  de  Ckir.  obs. 
57  E.  Hildanus,  cent.  5.  obs.  54.  J.  L.  Petit, 
Traili  des  Mai.  Ckir.  Tom.  2.  Sharp  on  the 
Operations , and  kis  Critical  Inquiry.  Ber- 
trandi,  Truitt  des  Operations  ; et  Exemple 
d'une  Hernie  formic  du  cote  droit  par  t'in- 
tesiin  ileum  settlement,  donl  une  portion  s’etoit 
echappee  par  une  des  ichancrures  isckiutiques, 
en  seglissant  sur  les  ligaments  sacro-sciatiques; 
Mem.  de  Ckir  Tom.  2.  Sallzmann,  Disp  de 
Vesica : Urinaria : Hernia;  1712.  Mery  sur 
des  Descentes  de  la  Vessie;  Acad,  ties  Sciences , 
1713.  J.  L.  Petit  sur  les  Hernies  dc  la  Vessie  ; 
Acad,  des  Sciences,  1717.  Vernier.  Reckerckes 
sur  la  Hernie  de  la  Vessie  ; Mini.  de.  I'Acad. 
de  Ckir.  Tom  . 2.  Divoux,  Disp.  de  Hernia 
Vesicce  - U rin  ar  ice , Argent.  1732.  Lev  ret,  Obs. 
sur  la  Hernia  de  la  l essie,  Mem.  dc  I'Acad. 
de  Ckir.  Tom.  2.  P.  Petit  ( lej>  une ) sur  les 
Hernies  de  la  Vessie,  el  de  I’Estomac  Acad, 
de  Ckir.  Tom.  4.  Voter  de  Lien  is  Prolapsione , 
1746.  M.  G.  Pfannius , De  Entero- Oscheo- 
cele antiqua,  restitntione  sacci herniosi  f clicilcr 


HERNIA. 


53 

Nevada,  absque  brachtrio  et  sccfionc  curata.  die  Ursache , fyc.  dtr  Hr  ache  am  Bauchen  and 
Erlangee,  1748  Peyronie  sur  un  Strangle-  Hecken,  ausser  der  Mabel  und  Leistengegend. 
menl  de  I'intestin,  cause  in terieurcmenl  }>ar  8vo.  Frankof.  181 1 . B.  G.  Schreger,  Versuche 
V adhArenct  de  (.'epiploon  au-dessus  de  Van - Chirargische , T.  1 , p.  149,  tjc.  Versuche  zur 
neau,  Mem.  de  VAcad.  de  i hir.  T.  1.  Tenon  VerMlkommung  der  Herniotomie,  8vo  JYarn- 
in  dead,  des  Sciences,  1764.  A.  G.  Zimmer,  berg,  lsl  I.  Also  B.  2,  Ueber  einige  Hernien 
Hcrninrum  communia  Allribula  el  Parlitio,  ausser  der  Mabel  und  Leistengegend.  v.  155. 
4lo.,  Gotl.  1754  Call, sen,  System  Chirurg.  8r o.  Murnberg,  1818.  F.  L.  ^ Trusiedl  Dc 
hodiernce,  pars  posterior.  Richter  Von  den  Extensionis  in  Svlrendis  Her niis  Cruralibus 
Brnchen,  in  2 Vvls  1778,  1779  or  the  French  incarceratis  pree  incisione  p ret  dunlin  4lo. 
transl.  by  Rougtmonl,  4 to.,  Bonn,  1788.  Also  Herol.  1616/A.  C.  He.  setback,  Die.  Sicherste 
liichler's  Bibliothck,  and  Anfang.  der  IV un-  Art  des  Bruchschriittes  in  der  Leisic,  4to. 
darzn.  B.  Ph.  Waefclaerts,  De  Herniis  ea-  Bamb.  et  Warzb.  1»19.  B.  G.  Seiler,  Ob- 
rumque  divisio  <e,  causis , uotis , ac  med  ndi  serrationes  nonnutltr  tesliculorum  ex  abdomint 
ratione  Bruxell.  1765.  A.  G Richter , De  in  Scrotum  Dtsctnsu,  et  Par  Hum  Genitulium 
Hernia  incarcerata,  unu  cum  sacco  sno  reponi  dnomalis , 4 to.  Lips.  1817.  J.  Cloquet  Re- 
per  annulum  a dominate  in  pass-  monel,  4 to  cherdi.es  Anal,  sur  les  Hernies  4lo.  Paris 
Gott.  1777.  C.  F.  Suadtcanus,  De  Remedus  1817.  C.  J.  M.  Lungenbeck,  < omrnent arias 
pretcipuis  ad  Hernias  incarcerata  , 4 lo.  Gott.  de  Struc-'Ura  Peril onoei,  Tesliculorum  Tunicis 
2774.  Winner's  Pract.  Obs.  on  Hernia: , 8 vo.  ear  unique  ex  Abdomine  in  Scrotum  Dtsctnsu 
Loud .1788.  SchmuckeFs  hir.  Wahrnehmun-  ctd  illuslrandam  Htrniarum  indoUm.  8 vo 


gen,8vo.  1774 — 1789.  Desault.  (Euvres  Chi- 
rurg. par  Bichat,  T 2.  Hey's  Pract.  Ob- 
serv.  in  Surgery,  Ed.  2 Sandifort,  Obs. 
Anat.  Pathol.  4 to.  Lugd.  1777,  et  hones  Her 
nice  Inguinalis  CdngenVce,  4io.  Lugd.  1781. 
Camper's  Demonstrat  Auat  Pathol.  1760, 
and  his  leones  Htrniarum,  edit,  u Soemmer- 
ring,fol.  Franc f 1801.  Dr.  Hunter's  Med. 
Comment.  1762,  1764. . Monro  in  Edinb. 
Med.  Essays  ; and  the  edition  of  his  works  by 
his  son.  Gimbernat's  Account  of  a 'ew  Me- 
thod of  operating  for  Femoral  Hernia,  trawl, 
from  the  Spanish' by  Beddocs,Svo.  1795.  Also 
the  German  transl.  with  additions  by  Schreger , 
12mo.  Murnb.  1817.  A.  Cooper  on  Inguinal 
and  t o:, genital  Hernia,  fol.  Loud.  1804;  and 
on  Crural  and  Umbilical  Hernia  fol.  Loud. 
le'07.  A.  Monro  on  Crural  Hernia,  1803; 
and  Ike  Morbid  Anatomy  of  the  Human  Gul- 
let, Stomach,  and  Intestines,  8 vo.  Edinb.  181 1. 
Sabatier , Mi decine  Opiratoirc,  T.  1.  Chopart 
et  Desnuft,  Traile  des  Mai.  Chir.  Desault, 
Parisian  Surgical  Journal.  Wrisbtrg,  in 
Comment. Reg.  Sociel.  Gelling.  1778.  Schmuck- 
cr  s Vtrmisc/ile  Chir.  Schriften.  Haller's 
Opera  Minora;  and  Dispuiationes  Chir  F. 
X.  Rudtorffer,  Abhandlung  uber  die  einfachste 
und  sicherste  Operal i o n s-meih o de  Eingesperr- 
ter 1 Lei sten-und- Schenkelbr&chc,  2 Bitnde,  8 vo. 
Wien,  1808.  Sull'ernie  Memorie  analomico- 
chirurgiche  di  Antonio  Scarpa,  Ediz.  nuora, 
3819  ; or  the  French  Transl.  by  Cayol.,  1812' 
or  the  English.,  by  fVishart.  C.  Bell's  Sur. 
gical  Observations,  pt.  2.  p.  177.  <^c.  London, 
1816.  Lassus , Pathologic  Chirurgicale,  T. 
1,  p.  \,  f 'c..  Ed.  1809.  Pelleian  Clinique 
Chirurgicale,  T.  3.  Travers  on  Injuries  of 
the  Intestines , fyc.  1812.  A case  of  hernia 
ventriculi  through  a laceration  of  the  dia- 
phragm, by  T.  Wheelwright,  in  Med.  f hir. 
Trans.  Col.  6,  p.  374.  F.  C.  Hcsselbach, 
Di.squinliones  Anatomico-Pathological  de  orlu 
et  progressu  Htrniarum  Inguinalium  et  Cru- 
rahum , cum  tab.  17.  ceneis,  4to.  Wurzburg, 
1816:  the  original  edition  in  German  was  first 
} published  in  j806.  Also  Beschreibung  und 
Abbildung  eines  neuen  instrumentes  zur  si- 
chern  Entdeckung  und  St  tilling  einer  beidtm 
Bruchschnitte  enstandenen  gefahrlichen  Blu- 
Utng.4(o.  War  zb.  1815.  Soemmcrring,  uber 


Gbit.  1817.  For  some  valuable  remarks  on  the 
two  preceding  works,  and  on  the  Anatomy  of 
Hernia,  see  Quarterly  Journal  of  Foreign  Me- 
dicine, Vol.  i,  p.  847,  Spc.  Lungenbeck,  Bibl. 
fur  die  Chir.  B.  4,  St.  3,  and  Meue  Bibl . 
B.  2 ,p.  112,  Spc.  Gott.  1819.  Wallhcr  de  Her- 
nia ( rurali  4to.  Lips  1820.  But,  above  all, 
the  work,  which  I feel  infinite  pleasure  in 
recommending,  from  a conviction  of  its  su- 
perior merit,  is  a Treatise  on  Hernia  by  IV. 
Lawrence,  8vo.  ; the  first  edition  of  which  was 
published  in  1807,  and  two  more  have  appear- 
ed since  that  period,  under  the  title  of  “ A 
Treatise  on  Ruptures.” 

HERNIA  CEREBRI  ( Fungus  Cerebri . 
Enccphafocele.)  There  are  two  principal 
kinds  of  hernia  cerebri:  one  presents  it- 
self in  young  infants,  before  the  ossification 
of  the  skull  is  completed  ; the  other  takes 
place  after  the  destruction  of  a part  of  the 
skull  by  the  operation  of  the  trephine,  acci- 
dental violence,  or  disease. 

The  congenital  hernia  cerebri  of  infants 
occurs,  however,  in  two  very  different 
forms  ; in  one  it  is  covered  by  the  scalp  ; in 
the  oiher,  the  corresponding  integuments  of 
the  head,  and  sometimes  even  the  dura  ma- 
ter, are  deficient. 

The  common  encephalocele,  met  with  iri 
new-born  children,  seems  to  originate  from 
the  imperfect  ossification  of  the  skull,  espe- 
cially in  the  situation  of  the  fentanclia.  and 
sutures.  This  case  is  characterized  by  a 
soft  swelling,  of  an  equal  round  shape, 
which  is  attended  with  a pulsation  corres- 
ponding to  that  of  the  pulse  ; it  yields  and 
disappears  under  pressure,  offers  no  alteration 
in  the  colour  of  the  skin,  and  is  circumscri- 
bed by  the  margin  of  the  defective  portion 
oi  the  skull.  ( b errand , in  Mini,  de  VAcad. 
de  Chir.  I1.  13,  in  12 mo.  p.  102.)  In  general, 
the  mental  faculties  are  not  affected  ; and 
we  read  of  one  example,  in  which  a patient 
had  such  a hernia  cerebri  thirty-three  years, 
without  his  intellects  ever  having  been  im- 
paired during  the  whole  of  that  period.  (Op. 
cit.  T.  5,  in  4lo.  p.  863.) 

It  is  tolerably  well  established,  that  the 
congenital  hernia  cerebri,  tvhich  arises  from 


tefiimiA, 


5 4 


the  incomplete  ossification  of  the  skulk  and 
is  covered  by  the  scalp,  ought  to  be  treated 
by  the  application  of  constant,  yet  moderate 
pressure.  M.  Salleneuve  communicated  to 
t he  Royal  Academy  of  Surgery  in  France 
on  example  of  the  good  effects  of  this  treat- 
ment, which  reduces  the  size  of  the  tumour, 
and  accomplishes  a perfect  cure  as  soon  as 
the  ossification  is  completed.  M.  Salleneuve 
put  a piece  of  thin  sheet  lead,  properly  co- 
vered with  soft  linen,  under  the  child's  cap, 
to  which  it  was  sewed  in  a suitable  situation, 
and  the  degree  of  pressure  was  increased, 
or  lessened,  according  as  circumstances  re- 
quired, by  tightening,  or  loosening  the  cap. 
(Op.  cit.  ft.  103,  T.  13,  Edit.  12 mo.) 

The  experience  of  Callisen  also  confirms, 
that  hernia  cerebri,  when  of  moderate  size, 
may  be  cured  by  the  foregoing  method,  the 
aperture  becoming  gradually  closed.  But  he 
adds,  that  large  tumours  of  this  description, 
especially  when  situated  about  the  occiput, 
scarcely  admit  of  any  means  of  relief,  ex- 
cept the  employment  of  some  contrivance 
to  protect  them  from  external  injury.  ( Cal- 
lisen, St/stem.  Cfiir.  Hodiernce,  Vol.  2,  p.  513, 
514,  Ed.  1800.) 

When  the  ossification  of  the  sutures  in 
children  is  late,  the  cerebellum,  as  well  as 
the  cerebrum,  is  liable  to  protrusion.  In 
1813,  two  such  cases  occurred  at  Paris  In 
one,  Professor  Lallemerit  mistook  the  disease 
for  a common  tumour,  and  commenced  an 
operation  for  its  removal,  when,  after 
making  some  of  the  necessary  incisions,  his 
proceedings  were  stopped  by  his  seeing  the 
white  silvery  colour  of  the  dura  mater,  and 
that  the  swelling  came  out  of  an  aperture  in 
the  occipital  bone.  The  day  after  the  ope- 
ration the  child  was  seized  with  violent  pain 
in  the  head,  had  a hard  pulse,  pros'ration  of 
strength,  vomiting,  &c.  and  died  in  the 
course  of  a week.  On  dissection,  a part  of 
the  tentorium,  and  an  elongation  of  the  two 
lobes  of  the  cerebellum,  about  as  large  as  a 
nut,  were  found  in  the  protruded  sac  of  the 
dura  mater.  Several  abscesses  were  also  dis- 
covered in  the  substance  of  the  cerebellum. 
The  other  example  fell  under  the  observa- 
tion of  M.  Baffos,  principal  surgeon  to  the 
Hopital  des  Enfans.  Upon  the  death  of  the 
child,  the  dissection  evinced  similar  appear- 
ances. ( Richerand , Nosographie  Chir.  T.  2, 
p.  319,  Ed.  4.) 

Such  facts  should  teach  the  surgeon  to  be 
particularly  cautious  in  ascertaining  the  na- 
ture of  tumours  about  the  back  part  of  the 
head,  before  he  ventures  to  attempt  their  re- 
moval. 

The  second  kind  of  congenital  encepha- 
locele  is  that,  in  which  not  only  large  por- 
tions of  the  cranium,  but  also  more  or  less  of 
the  integuments  of  the  head,  are  deficient. 
It  is  rather  to  be  regarded  as  a malformation 
than  a disease,  and,  indeed,  in  most  in- 
stances, the  infants  are  still-born.  The  case 
sometimes  consists  of  the  protrusion  of  most 
of  the  brain  through  the  inferior  and  poste- 
rior fontanella?,  so  that  the  child  is  born 
with  a largish  bag,  on  the  back  of  its  head, 
hanging  down  over  the  posterior  part  of  the 


neck.  Several  specimens  of  these  malfor- 
mations, taken  from  infants  born  in  the  Hos- 
pice de  la  Maternity,  are  preserved  in  the 
Museum  of  the  Faculte  de  Medecine  at 
Paris.  ( Richerand , JVosogr.  Chir.  T.  2,  p. 
316,  Edit.  4.)  In  the  year  1S10,  a remarka- 
ble case  of  this  last  description  of  congeni- 
tal hernia  cerebri  was  published  by  Dr.  Bur- 
rows. “ The  whole  of  the  forehead,  sum- 
mit, and  a great  part  of  the  occiput,  were 
deficient,  and  in  lieu  of  them,  a substance 
projected  of  a light  mulberry  colour,  and  of 
the  mushroom  form,  except  that  it  was  pro- 
portionably  broader.  From  the  deficiency 
of  bone,  the  eyes  appeared  to  project  much 
more  than  usual. — The  child  lived  six  days 
without  either  taking  sustenance,  or  having 
any  evacuation.”  On  dissection,  the  scalp, 
the  os  frontis,  the  parietal,  and  a great  part 
of  the  occipital  bones,  were  wanting. 
Through  the  parts,  at  which  these  bones 
were  deficient,  the  cerebrum  projected,  ex- 
hibiting its  usual  convolutions.  It  was  co- 
vered with  the  pia  mater;  was  of  a mul- 
berry colour  ; appeared  to  be  more  vascular 
than  the  pia  mater  usually  is  ; and  the  edge 
of  the  scalp  adhered  to  the  neck  of  the  tu- 
mour. The  cerebellum  was  not  more  than 
one-fourth  of  its  usual  size  ; for,  the  poste- 
rior part  of  the  os  occipitis  was  much  nearer 
to  the  sella  turcica  than  natural.  The  child 
was  destitute  of  the  power  of  voluntary  mo- 
tion, and  all  the  secretions  appeared  to  be 
stopped.  (See  Med.  Chir.  Trans • Vol.  2,  p. 
52.) 

The  most  interesting  species  of  hernia 
cerebri  to  the  practitioner,  is  that  which 
sometimes  arises  after  the  removal  of  a por- 
tion of  the  skull  by  the  trephine,  ortiie  des- 
truction of  pact  of  it  by  disease.  Various 
examples  of  this  disease  are  recorded  in  the 
Memoirs  of  the  French  Academy  of  Sur- 
gery, and  I have  myself  seen  many  instances 
of  it  Although  the  case  has  attracted  con- 
siderable notice,  modern  surgeons  are  far 
from  entertaining  settled  opinions  concern- 
ing the  exact  nature  of  the  tumour. 

In  one  example,  recorded  by  Mr.  Aberne- 
thy,  the  hernia  cerebri  arose  on  the  tenth 
day  after  trephining,  and  was  as  large  as 
a pigeon’s  egg.  The  pia  mater,  covering  it, 
was  inflamed  ; and  a turbid  serum  was  dis- 
charged at  the  sides  of  the  swelling,  from 
beneath  the  dura  mater.  On  the  eleventh 
day,  the  tumour  was  as  large  as  a hen’s  egg, 
smooth,  and  ready  to  burst.  The  man  died 
the  next  day.  On  examination,  the  swelling 
was  found  still  larger,  and  of  a dark  colour, 
with  an  irregular  granulated  surface.  This 
appearance  was  owing  to  coagulated  blood, 
which  adhered  to  its  surface,  as  the  part  had 
bled  so  much,  that  the  patient’s  cap  was 
rendered  quite  stiff  with  blood.  The  pia 
mater  was  in  general  much  inflamed,  and,  a3 
well  as  the  dura  mater,  was  deficient  at  the 
place  of  the  tumour.  The  deeper  part  of 
the  swelling  seemed  to  consist  of  fibrous 
coagulated  blood,  and  it  was  found  to  origi- 
nate about  an  inch  below  the  surface  of  the 
brain. 

Mr.  Abernetliy  explains  the  formation  ol 


IlERMA. 


the  disease,  a3  follows  : “ In  consequence  of 
the  brain  being  injured  to  some  depth  be- 
neath the  surface,  disease  ot  the  vessels, 
and  consequent  effusion  of  the  blood,  had 
ensued  ; the  effusion  was  for  a time  re- 
strained by  the  superincumbent  brain  and 
its  membranes  ; but,  these  gradually  yield- 
ing to  the  expansive  force  exerted  from 
within,  and  at  last  giving  way  attogejhei , the 
fluid  tdood  oozed  out  and  congealed  upon 
the  surface  of  the  tumour.”  An  organized 
fungus  can  hardly  be  produced  so  rapidly  as 
these  tumours  are  formed.  (On  Injuries  of 
the  Head , in  Surgical  Works , Vol.  2 p.  53.) 

On  the  contrary,  Mr.  C.  Bell  declares,  that 
the  swellingis  vascular  and  organized.  (Ope- 
rative Surgery , Vol.  1.) 

Dr.  John  Thomson  also  entertains  a dif- 
ferent opinion  from  that  of  Mr.  Abernethy, 
respecting  the  mode  in  which  these  hernia; 
cerebri  are  formed  ; but  I question  whether 
he  may  not  have  confounded  with  the  dis- 
ease now  under  consideration,  fungous  tu- 
mours of  the  dura  mater.  At.  least,  some  of 
the  cases  to  which  he  alludes,  as  a reason 
for  his  sentiment  concerning  their  mode  of 
formation,  must  have  been  the  disease  so 
well  described  by  M.  Louis.  (See  Dura 
Mater.)  The  reader,  however,  must  judge 
for  himself  from  the  following  passage  : “In 
a considerable  number  of  those  w ho  had  the 
cranium  severely  contused,  or  fractured  by 
musket-balls,  (says  Dr.  Thomson)  fungous 
growths  took  place  through  the  openings, 
which  had  been  made  at  first  by  the  ball 
or  afterward  by  the  trepan.  These  growths, 
I am  inclined  to  believe,  are  the  consequence 
of  a contusion  of  the  substance  of  the  brain 
and  of  the  membranes  that  cover  it,  which 
gives  rise  to  the  formation  of  a new  organi- 
zed substance,  different  in  its  texture  from 
brain,  and  are  not,  as  some  late  w iters  would 
endeavour  to  persuade  us,  simply  protrusions 
of  the  brain,  resulting  from  the  removal  of 
the  natural  resistance,  which  is  made  to 
them  by  the  dura  mater  and  cranium.  / 
have  known  instances  of  substances , similar  to 
these  growths,  forming  on  the  surface  of  the 
brain,  immediately  under  the  place , where  the 
cranium  had  received  a contusion , in  cases  in 
which  the  trepan  had  not  been  applied , or  any 
portion  of  the  cranium  removed. 

u Fungus  of  the  brain,  in  the  greater  num- 
ber of  instances,  in  which  we  had  an  oppor- 
tunity of  observing  it,  was  accompanied 
either  with  stupor  or  paralysis,  and  other 
symptoms  of  compressed  brain.  In  a frac- 
ture of  the  vertex  of  the  cranium,  produced 
by  a musket-ball,  and  followed  by  a fungus 
of  the  brain,  the  paralysis  took  place  in  the 
low7er  extremities.  In  a case  of  wound, 
made  by  a musket-ball  on  the  right  side  of 
the  forehead,  and  in  which  spiculae  iff  bone 
had  been  driven  in  upon  the  brain,  a large 
fungus  protruded.  The  formation  of  this 
fungus  was  followed  by  slow  pulse,  stupor, 
dilated  pupils;  slight  strabismus,  and  distor- 
tion of  the  mouth.  In  the  progress  of  this 
case,  escharotics  wrere  applied  to  the  fungus, 
portions  of  it  were  torn  off  by  the  patient, 
and  all  of  it  that  was  exterior  to  the  cranium, 


Go 

was  twice  pared  off  by  the  knife,  with  an 
apparent  alleviation,  rather  than  aggravation, 
of  the  symptoms.  On  the  deatli  of  this  pa- 
tient, nearly  the  w hole  of  the  right  hemis- 
phere of  the  brain  was  found  converted  into 
a soft  pulpy  mass.  The  left  hemisphere  was 
not  changed  in  structure,  though  much  vas- 
cular turgescence  appeared  on  its  surface.” 
(See  D‘.J.  Thomson's  Report  tf  Observations 
made  in  tnc  Military  Hospitals  in  Belgium , p. 
57,  58.) 

From  the  investigations  of  Mr,  Stanley, 
the  fact  is  placed  beyond  all  doubt,  that  a 
part  of  the  brain  occasionally  constitutes 
the  substance  of  berniae  cerebri ; and  he 
thus  confirms  the  opinion  formerly  entertain- 
ed upon  this  point  by  Quesnay  and  Louis. 
Thus,  in  the  first  case  which  Mr.  Stanley  has 
recorded,  u the  whole  tumour  wTas  sliced  off 
w ith  a scalpel.  During  the  operation,  the 
boy  gave  no  manifestation  of  positive  pain, 
although  not  unconscious  of  w hat  we  were 
doing.  Considerable  hemorrhage  took  plaee 
from  the  surface  of  the  brain,  exposed  by 
the  removal  of  the  tumour,  the  blood  being 
throwTn  with  great  force,  and  to  a consider- 
able distance  from  numerous  vessels,  w hich 
were  attempted  to  be  secured,  but  ineffect- 
ually, by  ligatures.  Affter  a short  time,  how- 
ever, the  bleeding  ceased.  On  examination 
of  the  part,  which  had  been  cut  off,  its  exte- 
rior was  found  to  consist  merely  of  a layer 
of  the  coagulated  blood  ; the  rest  of  the 
mass  was  brain,  possessing  a natural  appear- 
ance, the  distinction  between  the  cortical 
and  medullary  matter  being  readily  seen, 
with  the  convolutions  and  pia  mater  dipping 
dowm  between  them.”  In  the  dissection, 
after  death,  “ all  that  part  of  the  dura  mater, 
adjacent  to  the  ulcerated  aperture,  through 
which  the  brain  had  protruded,  was  black, 
sloughy,  and  much  thickened.  The  exposed 
surface  of  the  brain,  from  which  the  portion 
had  been  cut  off’,  exhibited  a softened  and 
broken  down  texture  , a state  of  disorgani- 
zation, which  extended  deep  into  its  sub- 
stance. About  an  ounce  of  fetid  and  dark- 
coloured  fluid  was  found  between  the  dura 
mater  and  arachnoid  membrane.  Several 
small  effusions  of  blood  were  met  with,  both 
between  the  membranes  and  in  the  substance 
of  the  brain.  The  arachnoid  membrane 
was  thickened  and  opaque  over  each  hemis  - 
phere. The  vessels  on  the  surface,  and  in 
the  substance  of  the  brain,  were  remarkably 
free  from  blood.  The  lateral  ventricles  were 
large,  and  filled  with  transparent  fluid,  and 
there  was  some  found  between  the  mem- 
branes at  the  basis,  so  that,  altogether  the 
quantity  from  these  two  sources  was  very 
considerable.”  (See  Med.  Chir.  Trans.  Vol. 
S,p.  15 — 17.)  In  another  dissection,  a con- 
siderable quantity  of  pus  was  found  on  the 
arachnoid  membrane,  on  each  side  of  the 
falx.  (P.  27.)  In  most  of  the  cases  of  her- 
nia cerebri,  which  I have  seen,  the  patient 
was  at  first  more  or  less  sensible,  but  labour- 
ing under  considerable  nervous  agitation. 
The  stupor,  paralysis,  and  other  symptoms 
of  compressed  brain,  noticed  by  Dr.  J.  Thom- 
son, did  not  take  place,  till  the  latter  stage 


HERNIA. 


66 

of  the  disease,  and  then  convulsive  twitches 
of  the  muscles  and  strabismus  occasionally 
came  on.  (See  Med.  Chir.  Trans,  p.  20.) 
The  disease  is  usually  attended  with  great 
frequency  of  the  pulse. 

With  regard  to  the  cause  of  the  protru- 
sion, it  is  a subject  very  diflicull  of  ex 
planation,  because,  if  the  origin  of  the  tu- 
mour depended  simply  on  the  removal  of 
a portion  of  the  skull,  or  on  any  changes  of 
the  dimensions  of  the  brain  in  expiration, 
the  effect  would  always  follow  such  causes, 
nnd  prevail  in  ail  patients.  From  the  par- 
ticulars of  the  dissections,  performed  by  Mr. 
Abernethy  and  Mr.  Stanley,  and  those  re- 
ferred to  by  Dr.  Thomson,  it  is  clear,  that 
the  hernia  cerebri  is  a disease  connected 
with  deep-seated  changes  throughout  a great 
part  of  the  brain.  (See  also  Larrey,  Mem. 
de  Chir  Mai.  T.  4,  p.  206.)  The  substance 
of  this  organ  is  found  more  or  less  pulpy 
and  disorganized  ; and,  after ,, death,  large 
effusions  of  serum,  and  even  sometimes  of 
blood,  and  purulent  matter,  are  observed. 
These  appearances  leave  no  doubt  of  the 
disease  being  associated  with  inflammatory 
action  within  the  head.  It  is  highly  proba- 
ble, therefore,  that  a hernia  cerebri  is  only 
produced  when  these  deep-seated  chan- 
ges are  conjoined  with  tiie  removal  of 
bone.  The  changes  alluded  to,  may  be  sup- 
posed to  cause  an  increase  in  the  general 
contents  of  the  skull,  and  thus  a disposition 
to  profusion,  as  rapid  as  the  serum  and  other 
fluids  are  effused.  This  statement,  however, 
can  only  be  received  as  an  hypothesis,  be- 
cause we  find,  that  in  one  of  the  dissections, 
described  by  Mr.  Stanley,  “ there  existed  a 
considerable  3pace  between  the  upper  sur- 
face of  the  right  hemisphere,  all  around  the 
-situation  of  the  protrusion  and  the  internal 
surface  of  the  dura  mater,  while  in  every 
other  part,  the  brain  and  dura  mater  were  in 
close  contact.”  (See  Med.  Chir.  Trans.  Vol. 
S.  p.  27.)  Now.  the  idea  of  an  empty  space 
within  the  cranium  is  rather  inconsistent 
with  the  supposition,  that  the  brain  is  thrust 
out,  in  consequence  of  changes,  which  aug- 
ment the  quantity  of  the  general  contents  of 
the  skull,  unless  such  space  were  filled  with 
air,  that  had  no  external  communication. 

When  the  bad  symptoms  disappear,  on 
the  tumour  being  no  longer  confined  by  the 
dura  mater,  some  practitioners  deem  it  best 
to  interfere  as  little  as  possible,  and  let  the 
tumour  drop  off  in  pieces.  (See  Edinb.  Med. 
Comment.  Vol.  i,p.98.  Med.  Museum,  Col.  4, 
p.  463.)  The  mildest  dressings  are  to  be  em- 
ployed ; but  whetherthe  protrusion  should  be 
resisted  by  pressure,  or  not,  seems  unsettled. 

When  the  tumour  acquires  a very  great 
size  it  may  be  pared  off  w ith  a knife,  as  was 
done  by  Mr.  Hill,  in  several  instances  with 
success.  (Castsin  Surgery, 8vo.  Edinb.  1772.) 

In  one  of  the  cases,  published  by  Mr. 
Stanley,  the  patient,  a boy  about  eleven 
years  of  age,  recovered  after  the  upper  part 
of  the  tumour  had  been  pared  off,  and  some 
of  the  removed  substance  found  to  consist 
decidedly  both  of  cortical  and  medullary 
substance.  In  this  instance,  the  reproduction 


of  the  tumour  was  cheeked  by  firm  pressure 
with  graduated  compresses,  and  a bandage. 
The  protruded  brain  gradually  lost  its  natural 
colour;  it  acquired  a light  yellow  appear- 
ance, was  -plii  into  several  portions,  and  a 
very  fetid  odour  exhaled  from  it.  its  sub- 
stance daily  became  softer,  ultimately  acquir- 
ing almost  a semi-fluid  state,  and  in  this  con- 
dition the  whole  mass  gradually  u asted  away. 
Fresh  granulations  arose  to  Jill  vp  the  vacancy , 
and  they  were  manifestly  produced  from  the 
exposed  substance  of  the  brain.  Compression 
being  continued,  Uie  part  now  quickly  healed 
up.  (See  Med.  Chir.  Trans,  p.  20,21.)  In  a 
third  case,  the  part  oi  the  tumour  cut  off, 
consisted  entirely  of  cortical  and  medullary 
substance,  quite  healthy  in  its  appearance 
(p.  24  ;)  and  subsequently  granulations  were 
formed  from  the  exposed  surface  of  the  brain. 
The  case,  however,  bad  a fatal  termination. 
By  the  removal  of  the  swelling,  and  the  use 
of  compression,  one  cure  wa?  effected  by  Mr. 
Bring.  (See  Edinb.  Med.  and  Surgical 
Journ.  Vol.  9.) 

Richerand  affirms,  indeed,  generally,  that 
when  the  brain  is  exposed,  in  consequence 
of  an  injury  of  the  head,  the  encephalocele 
should  be  cut  down  with  a knife,  and  re- 
pressed by  gentle  compression.  (See  JYosogr. 
Chir  T.  2,  p.  318,  Ed.  4.) 

The  cases  published  by  Mr.  Stanley  are 
rather  favourable  to  the  employment  of  pres- 
sure, inasmuch  as  it  appeared  evidently  to 
check  the  protrusion,  and  was  mostly  borne 
without  inconvenience. 

The  idea,  however,  that  when  the  brain 
protrudes  through  the  dura  mater,  pressure 
can  effect  its  return,  is,  as  Mr.  Stanley  judi- 
ciously observes,  quite  untenable.  (Med. 
Chir.  Trans.  Vol  8,  p.  36.) 

Quesnay  mentions  an  instance,  in  which  a 
patient  lore  off  the  protruded  mass  himself, 
and  t he  cavity  healed  up.  (M6m.  del' Acad, 
de  Chir.  T.  1.)  Van  Swieten  relates  a case,  in 
which  ihe  swelling  was  repeatedly  removed 
w ith  a ligature,  and  acure  ensued.  (Comment. 
T.  1.  p.  440.)  The  danger  of  applying  styp- 
tics, and  irritating  applications,  is  shown  by 
Hi  id  turns',  Obs.  14,  and  Mr.  Hill,  p.  198. 

Baron  Larrey  considers  the  treatment  by 
excision,  pressure,  and  spirituous  applica- 
tions, hurtful  arid  dangerous  : his  advice  is 
merely  to  apply  to  the  swelling  a pledget  of 
slightly  camphorated  oil  of  camomile;  to 
have  recourse  to  cooling  aperient  beverages; 
to  remove  all  kind-  of  irritation;  to  exclude 
the  air;  and  apply  the  dressings  with  great 
gentleness.  By  these  means,  the  only  case 
which  Larrey  ever  saw  recover,  was  saved, 
and  in  it  the  tumour  was  small.  (Mem.  de 
Chir.  Mil.  T.  4.  p.  206.) 

One  would  suppose,  that  cases  of  this  kind 
must  generally  require  the  employment  of 
every  thing  at  all  likelv  to  keep  off,  and  di- 
minish infill  intention  uf  the  brain.  Quesnay , 
sur  la  Multiplied  des  Trepans,  in  Mem.  dt 
I'Acad.  Roy  alt  de  Chirurgie,  T.  2,  p.  25,  56, 
Ed.  in  12 mo.  M.  Carvin' s Dissert,  in  Haller's 
Disputnl.  Chir.  Void.  Memoire  sur  l' Encc- 
phulocele par  M.  Ferrand,  in  Mem.  de  l',  lead. 
<lc  Chir.  T.  13,  p.  96.  Edit.  12mo.  Lassus,  Fa- 


HERNIA. 


57 


ihvhfth  Chirurgicale , T.2,p.  140, .Edit.  1809. 
Abernethy’s  Essay  on  Injuries  of  the  Head. 
Hill's  Cases  in  Surgery.  Burroics  in  Med. 
Chir.  Trans.  Vol.  2.  Callisen , Systema  Chi- 
rurgice  Hodiernts,  Vol.  2,  p.  512,  Ed.  1800. 
C.  Bell's  Operative  Surgery,  Vol.  1 . Richter's 
jSnsfi angsgrti nde  der  Wundarzneykunst,  B.  2, 
p.  197,  Ed.  1802.  Richerand,  Kosographie 
Chir.  T.  2,  p.  316,  Edit.  4,  Paris,  1815. 
Dr.  J.  Thomson’s  Report  of  Observations  made 
in  the  Military  Hospitals  in  Belgium , p.  57, 
Edinb.  1816.  Delpech,  Precis  EUmentaire 
des  Maladies  Chirurgicale s , T.  2,  p.  447,  et 
seq.  Paris,  1816.  Crell  and  Sand,  in  Haller's 
Disput.  Chir.  T.  1.  E.  Stanley,  in  Med.  Chir. 
Trans.  Vol.  8 ; a paper,  containing  many 
valuable  observations.  Larrey,  in  Mem.  de 
Chir.  Mil.  1 ’.  4,  p.  203,  fyc.  Hennen's  Milita- 
ry Surgery,  p.  311,  Spc.  Ed.  2.  A.  Solomons, 
De  Cerebri  Tumoribus,  Edinb.  1810.  J.  L. 
Schoenlein,  Von  der  Hirnmelamorphose,  S vo. 
IViirzb.  1816. 

HERNIA  HUMORALIS.  {Swelled or  in- 
flamed Testicle.)  A very  common  symptom, 
attending  a gouorrhoea,  is  a swelling  of  the 
testicle,  which  is  only  sympathetic,  mid  not 
venereal,  because  the  same  symptoms  follow 
every  kind  of  irritation  of  the  urethra,  whe- 
ther produced  by  strictures,  injections,  or 
bougies.  Such  symptoms  are  not  similar  to 
the  actions  arising  from  the  application  of 
venereal  matter;  for  suppuration  seldom 
occurs,  and  when  it  does,  the  matter  is  vene- 
real. The  swelling  and  inflammation  appear 
suddenly,  and  as  suddenly  disappear,  or  go 
from  one  testicle  to  the  other.  The  epidi- 
dymis remains  swelled,  however,  even  for  a 
considerable  time  afterward. 

The  first  appearance  of  swelling  is  general- 
ly a soft  pulpy  fulness  of  the  body  of  the 
testicle,  which  is  tender  to  the  touch  ; this 
increases  to  a hard  swelling,  accompanied 
with  considerable  pain.  The  epididymis, 
towards  the  lower  end  of  the  testicle,  is  ge- 
nerally the  hardest  part.  The  hardness  and 
swelling,  however,  often  pervade  the  whole 
of  the  epididymis.  The  spermatic  cord,  and 
especially  the  vas  deferens,  are  often  thick- 
ened and  sore  to  the  touch.  The  spermatic 
veins  sometimes  become  varicose.  A pain 
in  the  loins,  and  sense  of  weakness  there, 
and  in  the  pelvis,  are  other  casual  symptoms. 
Colicky  pains  ; uneasiness  in  the  stomach 
and  bowels  ; flatulence  ; sickness  ; and  even 
vomiting ; are  not  unfrequent.  The  whole 
testicle  is  swelled,  and  not  merely  the  epidi- 
dymis, as  has  been  asserted. 

The  inflammation  of  the  part  most  proba- 
bly arises  from  its  sympathizing  with  the 
urethra.  The  swelling  of  the  testicle  coming 
on,  either  removes  the  pain  in  making  water, 
and  suspends  the  discharge,  which  do  not 
return,  till  such  swelling  begins  to  subside; 
or  else  the  irritation  in  the  urethra,  first  ceas- 
ing, produces  a swelling  of  the  testicle, 
which  continues  till  the  pain  and  discharge 
return ; thus  rendering  it  doubtful,  which  is 
the  cause,  and  which  the  effect.  Occasion- 
ally, however,  the  discharge  has  become 
more  violent,  though  the  testicle  has  swelled  ; 
and  such  swelling  has  even  been  known  to 
Vol.  II.  8 


occur  after  the  discharge  has  ceased;  yet, 
the  latter  has  returned  with  violence,  and  re- 
mained as  long  as  the  hernia  humoralis.  (J. 
Hunter.) 

Irritation  at  the  mouth  of  the  vasa  defe- 
rentia,  has  been  mentioned  as  a cause  ; but 
were  this  true,  both  testicles  would  usually 
be  affected  at  the  same  time,  and  the  com- 
plaint would  occur  mere  frequently,  when 
the  irritation  of  the  urethra  extends  far  to- 
wards the  bladder,  than  when  it  only  reaches 
about  an  inch  and  a half,  or  two  inches  from 
the  orifice  of  the  passage. 

Hernia  humoralis,  with  stoppage  of  the 
discharge,  is  apt  to  be  attended  with  strangu- 
ry. It  is  singular,  that  the  inflammation 
should  more  frequently  come  on  when  the 
irritation  in  the  urethra  is  going  off,  than 
when  it  is  at  its  height. 

The  enlargement's  of  the  testicle,  from 
cancer  and  scrofula,  are  generally  slow  in 
their  progress  ; that  of  a hernia  humoralis 
very  quick.  {J.  Hunter.) 

Rest  is  the  best  remedy,  and  the  horizon- 
tal position  of  the  body  is  easiest.  At.  all 
events,  the  testicle  must  be  well  suspended  ; 
to  which  expedient  the  patient  will  readily 
have  recourse  as  soon  as  he  knows  the  ease 
which  it  affords.  The  case  is  treated  as  in- 
flammation in  general,  by  bleeding  and  purg- 
ing, and  applying  fomentations  and  poultices. 
In  the  hernia  humoralis  from  gonorrhoea, 
however,  cold  applications  are  sometimes 
preferred.  {James  on  Inflammation,  p.  164.) 
Leeches  have  often  proved  serviceable.  The 
swelling  not  being  venereal,  mercury  is  only 
useful  in  removing  the  induration,  after  the 
inflammation  has  subsided.  Vomits  have 
been  recommended,  and  found  beneficial. 
They  have  even  been  known  to  cure  the 
complaint  in  a surprisingly  sudden  manner. 
Opiates  are  useful.  When  suppuration  oc- 
curs, no  mercury  is  requisite,  only  common 
treatment. 

As  the  hernia  humoralis  often  appears  to 
depend  on  the  cessation  of  the  discharge, 
some  {Bromjield)  have  advised  irritating  the 
urethra  with  bougies  to  bring  on  the  gonnor- 
rhcea  again  ; but  the  practice  is  not  followed 
by  the  expected  good.  The  introduction  of 
venereal  matter  into  the  urethra  has  also 
been  most  absurdly  suggested. 

A hernia  humoralis  is  at  first  very  quick  in 
subsiding;  but  some  of  the  swelling  remains 
a long  while,  and  the  hardness  of  the  epidi- 
dymis may  even  continue  for  years,  nay,  for 
life.  However,  no  inconvenience  attends  the 
mere  induration.  In  such  instances,  the  vas 
deferens  may  occasionally  be  rendered  im- 
pervious, though  the  occurrence  must  be  by 
no  means  frequent. 

Frictions  with  camphorated  mercurial 
ointment;  fumigations  with  aromatic  herbs  ; 
and  electricity  ; are  the  best  means  for  dis- 
persing the  induration  in  question.  {J.  Hun- 
ter.) 

The  signs  distinguishing  a hernia  humora- 
lis from  a scrotal  rupture,  are  explained  in 
the  article  Hernia. 

I once  had  under  my  care  a patient  with 
hernia  humoralis,  whose  symptoms  were  se* 


HERPES. 


f}6 

verc  in  an  extraordinary  degree,  and  strongly 
resembled  those  of  a strangulated  hernia, 
being  attended  with  much  sickness,  and  ob- 
stinate constipation.  A swelling  of  the  tes- 
tis, accompanied  with  all  the  symptoms  of 
strangulated  hernia,  is  recorded  by  Guin- 
court.  (See  Journ.  de  Med.  par  Corvisart,  T. 
16.) 

Although  I had  never  seen  herr.ia  humora- 
lis  attended  with  symptoms  so  much  resem- 
bling those  of  strangulated  rupture,  as  in  the 
case  which  fell  under  my  own  notice,  and  the 
patient  would  not  own  that  he  had  had  any 
gonorrhoea,  yet  I remarked  some  circum- 
stances, which  made  me  avoid  an  erroneous 
judgment.  In  the  first  place,  1 could  dis- 
cover no  protrusion  from  the  abdominal  ring. 
Secondly  ; 1 observed  that  there  was  no  ten- 
sion, nor  swelling  of  the  belly,  as  in  common 
cases  of  strangulated  ruptures.  Thirdly,  I 
remarked,  that  the  inflammation  of  the 
scrotum  did  not  increase  as  the  symptoms 
advanced,  as  it  usually  does  in  the  latter  dis- 
ease. Fourthly  ; I took  notice  that  the  pain 
in  the  belly  was  most  severe  under  the  talse 
ribs  on  the  right  side,  though  at  periods  it 
was  certainly  very  diffused;  but  it  was  never 
augmented  by  pressure,  as  always  happens 
in  strangulated  hernia,  peritonitis,  enteritis, 
&ic.  from  all  which  disorders  too,  the  ab- 
sence of  tension  seemed  to  distinguish  it. 
Sometimes  likewise,  the  pain  was  entirely  in 
the  tumour;  sometimes  altogether  in  the  ab- 
domen. 

HERPES,  (from  ig7ru>,  to  creep.) 

Nothing  could  be  more  confused,  and  un- 
defined, than  the  idea  conveyed  by  the  term 
herpes , as  generally  employed  by  medical 
men  before  the  last  few  years.  In  fact,  nu- 
merous cutaneous  diseases,  of  the  most  op- 
posite kinds,  but  which  had  a tendency  to 
creep,  or  spread  slowly,  were  designated,  as 
specimens  of  herpes.  Thus,  when  I first 
entered  the  profession,  it  was  common  tor 
some  of  the  most  eminent  surgeons  in  Lou- 
don frequently  to  call  noli  me  tangere,  or 
lupus,  herpes  of  the  nose  ; and  to  apply  the 
same  term  to  tinea  capitis,  or  the  porrigo 
favosa. 

Happily,  this  vague  mode  of  regarding  dis- 
eases of  the  skin  is  beginning  to  give  way  to 
the  judicious  distinctions  proposed  by  the 
late  Dr.  Willan,  and  so  ably  perfected  by  Dr. 
Bateman.  The  appellation,  herpes,  is  limited 
by  these  physicians.  “ to  a vesicular  disease, 
which,  in  most  of  its  forms,  passes  through 
a regular  course  of  increase,  maturation,  and 
decline,  and  terminates  in  about  ten,  twelve, 
or  fourteen  days.  The  vesicles  arise  in  dis- 
tinct, but  irregular  clusters,  which  commonly 
appear  in  quick  succession,  and  they  ate  set 
near  together,  upon  an  inflamed  base,  which 
extends  a little  way  beyond  the  margin  of  each 
cluster.  The  eruption  is  preceded,  when  it 
is  extensive,  by  considerable  constitutional 
disorder,  and  is  accompanied  with  a sensa- 
tion of  heat  and  tingling,  sometimes  with 
severe  deep-seated  pain  in  the  parts  affected. 
The  lymph  of  the  vesicles,  which  is  at  first 
clearand  colourless,  becomes  gradually  milky 
and  opaque,  and  ultimately  concretes  into 


scabs  : but  in  some  cases,  a copious  discharge 
of  it  lakes  place,  and  tedious  ulcerations  en- 
sue. The  disorder  is  not  contagious  in  any 
of  its  forms.’'  (See  Bateman's  Practical 
Synopsis  of  Cutaneous  Diseases,  p.  221,  222, 
Edit.  3)  This  author  notices  six  species  of 
the  complaint:  viz.  herpes  phlyctaenodes  ; 
herpes  zoster;  herpes  circinatus;  herpes 
labialis;  herpes  praeputialis ; and  herpes 
iri9. 

As  most  of  these  cases  more  properly  be- 
long to  the  physician,  than  surgeon,  I shall 
briefly  describe  three  of  them. 

According  to  Dr.  Bateman,  the  Herpes 
Zoster,  or  shingles,  is  mostly  preceded  for 
two  or  three  days,  by  languor,  and  loss  of 
appetite,  rigours,  headacb, 'sickness,  andta  fre- 
quent pulse,  together  with  a scalding  heat, 
and  tingling  in  the  skin,  and  shooting  pains 
through  the  chest  and  epigastrium.  Some- 
times, however,  the  precursory  febrile  symp- 
toms are  very  slight.  Upon  some  part  of 
the  trunk,  several  red  patches  occur,  of  an 
irregular  form,  at  a little  distance  from  each 
other,  upon  each  of  which,  numerous  small 
elevations  appear  clustered  together.  These, 
if  examined  minutely,  are  found  to  be  dis- 
tinctly vesicular,  and  in  the  course  of  twenty- 
four  hours,  they  enlarge  to  the  size  of  small 
pearls,  and  are  perfectly  transparent,  being 
filled  with  a limpid  fluid.  For  three  or  four 
days,  fresh  clusters  continue  to  arise,  always 
extending  themselves  nearly  in  a line  with 
the  first,  towards  the  spine  at  one  end,  and 
towards  the  lines  alba  at  the  other.  While 
the  new  clusters  are  appearing,  the  visicles 
of  the  first  lose  their  trasparency,  and,  on 
the  fourth  day,  acquire  a milky,  or  yellowish 
hue,  which  is  soon  followed  by  a bluish,  or 
livid  colour,  of  the  bases  of  the  vesicles,  and 
of  the  contained  fluid.  They  now  become 
somewhat  confluent,  and  flatten,  or  subside. 
About  this  time,  they  frequently  break,  and 
discharge  for  three  or  four  days,  a serous 
fluid,  which,  at  length,  concretes  into  thin 
dark  scabs.  These  fall  off  about  the  twelfth 
or  fourteenth  day,  leaving  the  surface  of  the 
subjacent  skin  in  a red  and  tender  state  ; and 
when  the  ulceration  and  discharge  have  been 
considerable,  numerous^cicatrlces,  or  pits, 
are  left.  All  the  clusters  go  through  a simi- 
lar series  of  changes. 

Young  persons,  from  the  age'of  twelve  to 
twenty- five,  are  most  frequently  affected  ; 
although  aged  persons  are  not  altogether  ex- 
empt from  the  complaint,  and  suffer  severely 
from  the  pain  of  it.  Summer  and  autumn 
are  the  seasons,  in  which  it  is  most  common. 
Sometimes  it  supervenes  to  bowel  com- 
plaints, and  the  chronic  pains  remaining  af- 
ter acute  pulmonary  diseases.  In  the  treat- 
ment, Dr.  Bateman  thinks  gentle  laxatives, 
and  diaphoretics,  with  occasional  anodynes, 
when  the  severe  deep-seated  pains  occur,  all 
that  is  necessary.  No  external  application 
is  requisite,  unless  the  vesicles  be  abraded  by 
the  friction  of  the  clothes,  which  are  then 
liable  to  adhere  to  the  parts : in  this  case,  a 
little  simple  ointment  inny  fbe  interposed. 
For  a fuller  account,*  see  Bateman's  Pract. 
Synopsis,  p.  226,  &c. 


HER 


HOR 


rrj 


Herpes  circinatus , or  ringworm,  makes  its 
appearance  in  small  circular  patches,  in 
which  the  vesicles  arise  only  round  the  cir- 
cumference : these  are  small,  with  moderate- 
ly red  bases,  and  contain  a transparent  fluid, 
which  is  discharged  in  three  or  four  days, 
when  little  prominent  dark  scabs  form  over 
them.  The  central  area,  in  each  vesicular 
ring,  is  at  first  free  from  any  eruption  ; but 
the  surface  becomes  somewfeat  rough,  and 
of  a dull  red  colour,  and  throws  off  an  exfo- 
liation, as  the  vesicular  eruption  declines, 
which  terminates  in  about  a week,  with  a 
falling  off  of  the  scabs.  A succession  of 
these  vesicular  circles  usually  arise  on  the 
face  and  neck,  or  arms  and  shoulders,  thus 
protracting  the  case  for  two  or  three  weeks. 

The  itching  and  tingling,  which  are  the 
only  inconveniences  of  the  affection,  may 
be  relieved  by  the  application  of  the  popular 
remedy  ink,  solutions  of  the  salts  of  iron, 
copper,  zinc,  borax,  alum,  &.c.  Some  addi- 
tional interesting  observations  on  other  forms 
of  the  herpes  circinatus,  may  be  found  in  Dr. 
Bateman’s  Synopsis,  from  which  I have  ex- 
tracted the  few  preceding  particulars. 

Herpes  Prcepulialis.  This  local  variety  of 
herpes  was  not  noticed  by  Dr.  Willan,  and 
we  are  indebted  to  Dr.  Bateman  for  a de- 
scription of  it.  The  complaint  begins  with 
extreme  itching,  and  with  some  sense  of 
heat  in  the  prepuce,  on  which  one  or  two  red 
patches  occur,  about  the  size  of  a silver 
penny.  Upon  these  are  clustered  five  or  six 
minute  transparent  vesicles.  In  twenty-four 
or  thirty  hours,  the  vesicles  enlarge,  become 
of  a milky  hue,  and  lose  their  transparency  ; 
and  on  the  third  day,  they  are  coherent,  and 
have  almost  a pustular  appearance.  If  the 
eruption  is  seated  on  that  surface  of  the  pre- 
puce, which  is  next  the  glans,  so  that  the 
vesicles  are  kept  moist,  they  commonly 
break  about  the  fourth  or  fifth  day,  and  form 
a small  ulceration  upon  each  patch.  This 
discharges  a little  turbid  serum,  and  has  a 
white  base,  with  a slight  elevation  at  the 
edges  ; and  by  an  inaccurate,  or  inexperien- 
ced observer,  it  may  be  readily  mistaken  for 
chancre,  more  especially,  if  any  escharotic 
has  been  applied,  which  produces  irritation, 
and  a deep-seated  hardness,  like  that  of  a 
true  chancre.  If  not  irritated,  the  slight  ul- 
ceration begins  to  heal  about  the  ninth  or 
tenth  day.  When  the  patches  occur  on  the 
outside  of  the  prepuce,  the  duration  of  the 
eruption  is  shorter,  and  ulceration  does  not 
actually  take  place. 

In  the  treatment, Dr. Bateman  recommends 
the  avoidance  of  all  stimulating,  and  moist, or 
unctuous  applications ; and  if  the  complaint 
be  within  the  prepuce,  he  advises  the  inter- 
position of  a little  bit  of  dry  lint  between 
the  sore  and  the  glans. 

As  this  gentleman  has  truly  remarked,  this 
case  is  particularly  deserving  of  notice,  be- 
cause it  has  often  been  considered  and  treat- 
ed as  a chancre. 

For  a great  deal  more  valuable  informa- 
tion respecting  Herpes,  I beg  leave  to  refer 
the  reader  to  the  publications  of  Drs.  Willan 
and  Bateman,  and  also  to  the  article  Herpes , 


written  by  this  last  able  physician  for  Dr. 
Rees’s  Cyclopa?dia. 

HORDEOLUM,  (dim  of  hordcum , bar- 
ley.) A little  tumour  on  the  eyelid,  resem- 
bling a barley  corn.  A Stye.  As  Scarpa 
remarks,  the  stye  is  strictly  only  a little  boil 
which  projects  from  the  edge  of  the  eyelids, 
particularly  often  near  the  great  angle  of  the 
eye.  This  little  tumour,  like  the  furunculus, 
is  of  a dark-red  colour,  much  inflamed,  and 
a great  deal  more  painful  than  might  be  ex- 
pected, considering  its  small  size.  The  latter 
circumstance  is  partly  owing  to  the  vehe- 
mence of  the  inflammation  producing  the 
stye,  and  partly  to  the  exquisite  sensibility 
and  tension  of  the  skin  which  covers  the 
edge  of  the  eyelids.  On  this  account,  the 
hordeolum  very  often  excites  fever  and  rest- 
lessness in  delicate,  irritable  constitutions;  it 
suppurates  slowly  and  imperfectly  ; and, 
when  suppurated,  has  no  tendency  to  burst. 

The  stye,  like  other  furunculous  inflamma- 
tions, forms  an  exception  to  the  general  rule, 
that  the  best  mode,  in  which  inflammatory 
swellings  can  end,  is  resolution.  For,  when- 
ever a furunculous  inflammation  extends  so 
deeply  as  to  destroy  any  of  the  cellular  sub- 
stance, (he  little  tumour  can  never  be  resol- 
ved, or  only  imperfectly  so.  This  event, 
indeed,  would  rather  be  hurtful,  since  there 
would  still  remain  behind  a greater  or  smaller 
portion  of  dead  cellular  membrane;  which, 
sooner  or  later,  might  bring  on  a renewal  of 
the  stye  in  the  same  place  .as  before,  or  else 
become  converted  into  a hard  indolent  body, 
deforming  the  edge  of  the  eyelid. 

The  resolution  of  the  incipient  hordeolum 
maybe  effected  in  that  stage  of  it,  in  which 
the  inflammation  only  interests  the  skin,  and 
not  the  cellular  substance  underneath,  as  is 
the  case  on  the  first  appearance  of  the  dis- 
ease. Now  repellent,  cold  applications  are 
useful,  particularly  ice.  But  when  the  hor- 
deolum has  affected  and  destroyed  any  of 
the  cellular  membrane  underneath,  every 
topical  repellent  application  is  absolutely 
useless,  and  even  hurtful  ; and  the  patient 
should  have  recourse  to  emollient  anodyne 
remedies.  The  hordeolum  and  eyelids  should 
be  covered  with  a warm  soft  bread  and  milk 
poultice,  which  ought  to  be  renewed  very 
often.  When  a white  point  makes  its  ap- 
pearance on  the  apex  of  the  little  tumour, 
Scarpa  says,  the  surgeon  should  not  be  in  a 
hurry  to  let  out  the  small  quantity  of  serous 
matter  which  exists  between  the  skin  and 
dead  portion  of  cellular  membrane.  It 
is  better  that  he  should  wait  till  the  skin 
within  this  white  point  has  become  still 
somewhat  thinner,  so  as  to  burst  of  ilself, 
and  give  a ready  vent,  not  merely  to  (he 
little  serous  matter,  but  to  all  the  dead  cellu- 
lar membrane  which  constitutes  the  chief 
part  of  the  disease.  When  the  contents  of 
the  little  tumour  are  stow  in  making  their  way 
outward,  through  the  opening,  the  surgeon, 
gently  compressing  the  base  of  the  stye, 
ought  to  force  them  out.  After  this,  all  the 
symptoms  of  the  disease  will  disappear,  and 
the  cavity,  left  hv  the  dead  cellular  mem- 
brane, in  the  centre  of  the  little  tumour,  will 


CO 


HOSPITAL  GANGRENE. 


be  found  quite  filled  up  and  healed  in  the 
course  of  twenty-four  hours. 

Sometimes,  though  seldom,  this  process 
of  nature,  destined  to  detach  the  dead  from 
the  living  cellular  membrane,  only  takes 
place  incompletely,  and  a small  fragment  of 
yellow  dead  cellular  substance  still  continues 
fixed  in  the  cavity,  arid  hinders  the  cure.  In 
this  circumstance,  the  further  employment  of 
emollient  poultices  is  of  little  or  no  service. 
The  surgeon  should  dip  the  point  of  a camel- 
hair  pencil  in  sulphuric  acid,  and  touch  the 
inside  of  the  stye  with  it,  one  or  more  times, 
until  the  sloughy  cellular  membrane  comes 
away.  After  this,  the  small  cavity  remain- 
ing will  soon  close.  Should  the  eyelid  con- 
tinue aflervvard  a little  swollen  and  cedema- 
lous,  this  affection  may  be  removed  by  apply- 
ing the  lotioplumbi.  acet.,  containing  a little 
spirit  of  wine.  Some  persons  are  very  often 
annoyed  with  this  disease.  Scarpa  imputes 
this  most  frequently  to  a disordered  state  of 
the  primes  vice , often  met  with  in  persons 
who  live  on  acrid  irritating  food,  and  drink 
too  much  spirits.*  ( Scarpa , suite  Malattie 
degli  Occhi,  cap.  2.) 

HOSPITAL  GANGRENE.  (Phagedecna 
Gangreenosa;  Putrid,  or  Malignant  Ulcer; 
Hospital  Sore ; Gangroena  Contagiosa.)  A 
severe  and  peculiar  species  of  humid  gan- 
grene, or  rather  a combination  of  this  affec- 
tion, with  phagedenic  ulceration.  It  is  par- 
ticularly characterized  by  its  contagious  or 
infectious  nature  ; its  disposition  to  attack 
wounds  or  ulcers,  in  crowded  hospitals, 
or  other  situations,  where  many  of  these 
cases  are  brought  together  ; and  its  tendency 
to  convert  the  soft  parts  affected  into  a pu- 
trid glutinous,  or  pulpy  substance,  in  which 
no  trace  of  their  original  texture  is  discerni- 
ble. (Delpech,  Precis  EUm.  des  Mai.  Chir. 
T.  1 ,p.  123.)  It  is  generally  believed  to  be 
communicated  from  one  sore  or  wound  to 
another,  by  its  contagious  nature  ; but  whe- 
ther the  infection  can  be  transferred  onlybv 
actual  contact,  or  both  in  this  way  and 
through  the  medium  of  the  atmosphere,  is  a 
question  on  which  the  best  authors  differ. 
The  first  origin  ot  the  disease,  however,  is  a 
mysterious  subject,  which  cannot  invariably 
be  explained  on  any  certain  principles,  as 
will  be  hereafter  noticed. 

From  the  researches  of  Mr.  Blaekadder,  it 
appears  probable,  that  several  of  the  ancient 
writers,  in  their  descriptions  of  foul,  gangre- 
nous bleeding  ulcers,  must  have  alluded  to 
the  same  kind  of  disease,  which  is  now  usu- 
ally denominated  hospital  gangrene.  Besides 
the  use  of  the  actual  cautery,  which,  accord- 
ing to  the  modern  French  writers,  is  the 
surest  means  of  arresting  this  distemper,  seve- 
ral of  the  ancients  appear  also  to  have  em- 

*  I have  very  often  found  an  alum  curd,  applied 
over  night  in  the  form  of  poulliee,  of  great,  benefit  in 
this  disease.  When  made  use  of  just  after  suppuration 
has  commenced,  the  tumour  discharges  in  a tew  hours, 
and  the  patient  is  freed  from  a very  troublesome  and 
painful  companion,  it  is  prepared  by  putting  a piece 
oi  alum,  about  the  size  of  a pea,  into  a table  spoonftd 
ot  new  milk.  This^by  the  feme  of  a candle,  is  soon 
coagulated,  and  rendered  of  a consistence  fit  to  be 
matte  use  of  as  a cataplasm. — [Am.  Ed.) 


ployed  for  the  cure  arsenical  applications  ; 
as,  for  instance,  iEtius,  Paulus,  Rolandus, 
Avicenna,  Guido,  &.c.  The  only  doubt  whe- 
ther these  authors  actually  referred  to  hospi- 
tal gangrene,  depends  upon  their  not  having 
generally  described  its  contagious  nature. 
But,  on  this  point,  I would  particularly  wish 
the  reader  to  consult  Mr.  Blackadder’s  valu- 
able treatise.  (P.  76,  <^c.) 

Although  La  jMotte  made  cursory  mention 
of  hospital  gangrene  in  1722,  under  the  name 
of  pourrilure,  and  stated,  that  it  had  occurred 
in  the  H6tel-Dieu  at  Paris,  yet  the  first  dis- 
tinct modern  account  of  this  disease  is  con- 
tained in  the  3d  vol.  of  the  posthumous 
works  of  Pouteau,  published  in  1783.  In 
the  year  1788,  Dusassoy,  who  succeeded 
Pouteau  as  chief  surgeon  of  the  Hotel-Dieu 
at  Lyons,  also  published  a short  treatise  on 
the  disorder.  The  first  very  accurate  des- 
cription of  hospital  gangrene,  in  the  Eng- 
lish language,  appeared  in  the  6th  vol.  of 
the  London  Medical  Journal,  printed  in 
1785.  The  account  is  entitled  “ Observa- 
tions on  the  Putrid  Ulcer,  by  Mr.  Gillespie, 
surgeon  of  the  Royal  Navy.”  In  the  edition 
of  Dr.  Rollo’s  work  on  Diabetes,  published 
1797,  there  is  a section  on  this  subject,  enti- 
tled, “ A short  account  of  a morbid  poison, 
acting  on  sores,  and  of  the  method  of  de- 
stroying it.”  In  1799,  Sir  Gilbert  Blane, 
in  the  3d  edit,  of  his  book  on  the  diseases  of 
Seamen,  gave  an  account  of  hospital  gan- 
grene, under  the  name  of  malignant  ulcer; 
and  Dr.  Trotter,  in  the  2d  vol.  of  his  Medi- 
cina  Nautica,  published  in  the  same  year, 
described  that  affection  by  the  same  appella- 
tion. In  the  3d  vol.  of  the  same  work,  Dr. 
Trotter  has  added  to  his  first  account  seve- 
ral valuable  communications,  relating  to 
this  disease,  received  from  surgeons  of  the 
Royal  Navy.  Mr.  John  Bell  has  also  made 
hospital  gangrene  the  subject  of  particular 
remark,  in  the  1st  vol.  of  his  Principles  of 
Surgery,  published  in  1801.  According  to 
Dr.  Thomson,  two  excellent  theses  have 
likewise  been  published  on  the  subject  in 
the  University  of  Edinburgh  ; the  first  enti- 
tled “ De  Gangrtena  Contagiosa,”  by  Dr. 
Leslie  in  1804;  the  second  by  Dr.  Charles 
Johnson,  in  1805,  under  the  title  of  “ De 
Gangraena  Contagiosa  Nosocomiale.”  (See 
Lectures  on  Inflammation,  p.  456 — 458.) 

Professor  Thomson’s  account  of  the  sub- 
ject, published  in  1813,  contained  the  fullest 
history  of  the  disease  at  that  time  collected. 
Boyer  afterward  gave  a very  fair  account  of 
the  distemper.  (See  Trait6  des  Mai.  Chir. 
T.  \,p.  320,  8t?o.  Paris,  1814.) 

These  descriptions  were  followed  by  the 
valuable  essay  of  Delpech,  entitled  “M6- 
moire  sur  la  Complication  des  Plaies?et  des 
Ulccres  eonnue  sous  le  nom  de  Pourriture 
d’Hdpital;”  1815;  some  interesting  obser- 
vations by  Dr.  Hennen,  in  the  London  Me- 
dical Repository  for  March,  1815;  a paper 
by  Professor  Brugman,  of  Leyden,  “in  the 
Annales  de  LitteratUre  Med.”  vol.  19, 1815; 
and  lastly,  the  treatise  of  Mr.  Blaekadder, 
which  contains  some  of  the  best  remarks 
ever  made  concerning  this  affection,  and  i« 


HOSPITAL  GANGRENE.  <5T 


entitled  “ Observations  on  Phagedsena  Gan- 
graenosa,  Svo.  Edinb.  1818.” 

According  to  Mr.  Blackadder,  who  is  a 
believer  in  the  doctrine  of  the  complaint  be- 
ing only  communicable  by  the  direct  appli- 
cation of  the  infectious  matter,  when  the 
morbific  matter,  which  produces  the  disease, 
has  been  applied  to  some  part  of  the  surface 
of  the  body,  from  which  the  cuticle  has 
been  removed,  as  by  a blister,  one  or  more 
small  vesicles  first  appear,  which  are  filled 
with  a watery  fluid,  or  bloody  serum  of  a 
livid  or  reddish  brown  colour.  The  situa- 
tion of  the  vesicle  is  generally  at  the  edge 
of  the  sore.  Its  size  is  not  unfrequeutly 
that  of  a split  garden  pea,  and  is  easily  rup- 
tured, the  pellicle  which  covers  it  being 
very  thin.  When  the  vesicle  is  filled  with 
a watery  fluid,  and  has  not  been  ruptured, 
it  assumes  the  appearance  of  a grayish-white 
or  ash-coloured  slough  ; but,  when  it  con- 
tains a dark-coloured  fluid,  or  has  been  rup- 
tured, it  puts  on  the  appearance  of  a thin 
coagulum  of  blood,  of  a dirty,  brownish, 
black  colour.  During  the  formation  of  the 
vesicle,  there  is  generally  a change  in  the 
sensation  of  the  sore,  accompanied  writh  a 
painful  feel,  like  that  of  the  sting  of  a gnat. 

After  a slough  is  formed,  it  spreads  with 
more  or  less  rapidity,  until  it  occupies  the 
whole  surface  of  the  original  sore;  and, 
when  left  to  itself,  (which  seldom  happens) 
there  is  little  or  no  discharge,  but  the 
slough  acquires  daily  greater  thickness. 

“ When  the  formation  of  the  slough  has 
been  interrupted,  the  stinging  sensation  be- 
comes more  frequent  and  acute  ; phagede- 
nic ulceration  quickly  commences ; and 
such  is  frequently  the  rapidity  of  its  pro- 
gress, that  even  in  the  course  of  a few,  hours, 
a very  considerable  excavation  will  be 
formed,  while  the  parts  in  the  vicinity  re- 
tain their  usual  healthy  appearance.”  The 
cavity,  the  edges  of  which  are  well  defined, 
is  filled  with  a thick  glutiuous  matter,  which 
adheres  strongly  to  the  subjacent  parts. 
When  this  matter  is  removed,  the  surface 
underneath  presents  itself  of  a fine  granular 
texture,  which,  in  almost  all  instances,  is 
possessed  of  extreme  sensibility,  and  is  very 
apt  to  bleed  when  the  operation  of  cleaning 
is  not  performed  with  great  delicacy.  At 
each  dressing,  the  circumference  of  the  cavity 
is  found  enlarged,  and  if  there  are  more  than 
one,  they  generally  run  into  each  other. 
The  progress  of  the  disease  is  much  quicker 
in  some  inividuals  than  others,  but  it  never 
ceases , until  the  whole  surface  of  the  original 
sore  is  occupied.  The  stinging  pain  gradually 
becomes  of  a darting  or  lancinating  kind  ; 
and  either  about  the  fourth  or  sixth  day  from 
the  time  when  the  morbific  matter  had  access 
to  the  sore,  or  afterward,  at  the  period  of  what 
may  be  termed  secondary  inflammation , the 
lymphatic  vessels  and  glands  are  apt  to  become 
affected.  The  discharge  becomes  more  co- 
pious, its  colour  varying  from  a dirty  yel- 
lowish white  to  a mixture  of  yellow,  black, 
and  brown,  depending  upon  the  quantity  of 
blood  mixed  with  it. 

f(  The  soft  parts,  in  the  immediate  vicinity 


of  the  sore,  daily  become  more  painful, 
tumefied,  and  indurated ; and,  in  a great 
number  of  cases,  particularly  in  those  of 
plethoric  and  irritable  habits,  an  attack  of 
acute  inflammation  speedily  supervenes,  and 
is  acccompanied  by  a great  increase  of  pain, 
the  sensation  being  described  to  be  such  as 
if  the  sore  were  burning.  The  period  at 
which  this  inflammation  begins  to  subside, 
is  by  no  means  regular.  Sometimes  it  sub- 
sides in  the  course  of  two  days,  and  some- 
times it  continues  upwards  of  five;  depend- 
ing very  much  on  the  constitution  and  pre- 
vious habits  of  the  patient,  as  well  as  the 
treatment  that  has  been  adopted.  During 
its  progress,  the  thick,  putrid  looking,  and 
frequently  spongy  slough  which  is  formed 
on  the  sore,  becomes  more  and  more  moist, 
and  of  a pulpy  consistence.  (Hence  this 
form  of  disease  is  actually  named  by  Ger- 
son  pulpy  gangrene.)  In  the  course  of  a few 
days,  a very  otfensive  matter  begins  to  be 
discharged  at  its  edges.  The  slough  then 
begins  to  separate;  by  and  by  it  is  thrown 
off',  but  only  to  prepare  the  way  for  an  ex- 
tension of  the  disease  by  a continued  pro- 
cess of  ulceration,  and  by  a recurrence  of 
the  last-mentioned  symptoms.  (Blackad- 
der, on  Phagedcena  Gangrcenosa,  p.  28 — 30.) 

The  first  symptoms,  which  indicate  hospi- 
tal gangrene  in  a wound,  or  ulcer,  are,  a 
more  or  less  acute  pain,  and  a viscid  whi- 
tish exudation  on  the  surface  of  the  granu- 
lations, which  lose  their  vermilion  colour, 
and  present  at  several  points  spots  of  a gray- 
ish or  dirty-white  hue,  resembling  venereal 
ulcers,  or  aphthae.  These  ulcerated  points, 
thus  engrafted  (as  it  were)  upon  the  original 
ulcer,  soon  spread,  and  join  together,  so  as 
to  give  to  the  whole  surface  of  the  solution 
of  continuity  a gray  ash-colour.  The  surface 
also  becomes  more  or  less  indurated,  and 
sometimes  bleeds.  A red,  purplish  oedema 
tous  circle,  of  a greater,  or  lesser  extent,  is 
next  formed  in  the  surrounding  skin.  Some 
times,  when  the  patient  is  of  a good  habit, 
the  causes  of  infection  less  active,  and  the 
constitution  sufficiently  strong,  the  disorder 
now  stops.  According  to  Boyer,  it  may  not 
even  extend  to  the  whole  surface  of  the  ul- 
cer. But,  most  frequently,  its  progress  is  ex- 
tremely rapid,  and  occasionally  quite  terri- 
fying. The  edges  of  the  wound,  or  ulcer, 
become  hardened  and  everted,  the  granula- 
tions are  large  and  tumid,  being  swelled  up, 
as  Boyer  asserts,  with  a considerable  quan- 
tity of  gas.  They  are  afterward  detached  in 
the  form  of  soft  reddish  sloughs,  which  very 
much  resemble  the  substance  of  the  foetal 
brain',  in  a putrid  state.  From  day  to  day, 
until  either  nature  alone,  or  aided  by  art, 
puts  limits  to  the  disorder,  it  invades  new 
parts  both  in  breadth  and  depth,  so  that  its 
ravages  extend  to  aponeuroses,  muscles, 
blood-vessels ; nerves,  tendons,  the  perios- 
teum, and  even  the  bones  themselves. 

Among  a number  of  severe  cases,  which 
fell  under  the  notice  of  Mr.  Blackadder, 
there  was  one,  in  which  the  half  of  the  cra- 
nium was  denuded,  the  bones  having  be- 
come black  as  charcoal, and  the  integument? 


HOSPITAL  GANGRENE. 


r>2 

detached  posteriorly  to  the  second  cervical 
vertebra,  and  anteriorly  to  the  middle  of  the 
zygomatic  process  of  the  temporal  bone  ; 
and  this  was  originally  a superficial  wound 
of  the  scalp.  In  another  case,  the  muscles, 
large  arteries,  and  nerves  of  both  thighs 
were  exposed  and  dissected,  the  integu- 
ments and  cellular  substance  being  entirely 
removed,  with  the  exception  of  only  a nar- 
row strip  of  the  former,  which  remained  on 
the  outer  side  of  the  thighs.  This  was  also 
originally  a simple  flesh  wciuiid.  In  other 
instances,  the  cavities  of  the  knee,  ankle, 
elbow,  and  wrist,  joints,  were  laid  extensive- 
ly open,  and,  in  one  unfortunate  case,  the  in- 
teguments and  cellular  substance,  on  the 
anterior  parts  of  the  ueck,  were  destroyed, 
exhibiting  a horrid  spectacle,  the  trachea 
being  also  wounded.”  (On  Phagedcena  Gan- 
grcenenosa,  p.  3.) 

According  to  the  last  experienced  author, 
when  the  disease  attacks  an  old  sore,  where 
a considerable  depth  of  new  flesh  has  been 
formed,  the  first  thing  generally  observed  is 
a small  dark-coloured  spot,  usually  situated  at 
the  edge  of  the  sore.  But,  he  states,  that  in 
several  cases  of  ulcers,  the  disease,  when 
carefully  watched,  was  found  to  begin  in 
the  form  of  a vesicle,  filled  with  a livid,  or 
brownish-black  fluid,  which  afterward  burst 
and  assumed  the  appearance  of  the  dark-co- 
loured spot,  which  is  commonly  first  noticed. 
Mr.  Blackadder  always  found,  that,  when 
there  had  been  a considerable  bed  of  new 
flesh  formed,  the  phagedenic  ulceration 
made  comparatively  a very  slow  progress, 
and  put  on  rather  the  appearance  of  mercu- 
rial phagedaena,  until  the  morbific  matter 
had  found  access  to  the  natural  texture  of 
the  part,  when  the  progress  of  the  disease 
became  suddenly  accelerated  ; acute  inflam- 
mation supervened ; and  a large  slough 
xvas  formed.  (Op.  cit.  p.  31.)  He  notices, 
that  when  the  morbific  matter  is  inserted  in 
a puncture,  or  scratch,  the  first  progress  of 
the  disease  bears  a resemblance  to  that  of  a 
part  inoculated  with  vaccine  matter.  The 
primary  inflammation  in  gangrenous  phage- 
tiaena  commences  at  the  end  of  the  second, 
or  early  on  the  third  day  ; the  inflammation 
is  at  its  height  about  the  sixth  ; when  the 
scab  begins  to  form  in  one  disease,  phagede- 
nic ulceration  begins  in  the  other,  and  when 
allowed  to  proceed,  soon  affords  sufficient 
proof  of  the  non-identity  of  the  two  diseases. 
(P.  33.) 

According  to  Mr.  Blackadder,  when  the 
disease  attacks  a recent  gun-shot  wound,  the 
discharge,  two  or  three  days  after  infection, 
is  found  to  be  lessened,  and  to  have  become 
more  of  a sanious,  than  purulent  nature. 
The  sore  has  a certain  dry  and  rigid  appear- 
ance ; its  edges  are  more  defined,  somewhat 
elevated,  and  sharpened  ; the  patient  is  sen- 
sible of  a change  in  the  usual  sensation  in 
the  sore,  and  complains  of  the  occasional 
stinging  sensation,  resembling  that  produced 
by  the  sting  of  a gnat.  At  this  period,  but 
sometimes  a day  or  two  later,  the  integu- 
ments at  the  edge  of  the  sore  become  in- 
flamed, and  the  surface  of  the  sore  itself  as- 


sumes a livid  or  purple  colour,  and  appears 
as  if  covered  with  a fine  pellicle,  such  as  is 
formed  on  a coagulum  of  blood.”  (On 
Phagedcena  Gangrcenosa , p.  33.) 

At  Bilboa,  the  disease  in  cases  of  wound,  is 
said  generally  to  have  commenced  with  a 
sudden  attack  of  severe  pain  in  the  head  and 
eyes,  tightness  about  the  forehead,  want  of 
sleep,  loss  of  appetite,  a quick  pulse,  and 
other  febrile  symptoms  ; while  the  wound, 
which  had  been  healthy  and  granulating,  at' 
once  became  tumid,  dry,  and  painful,  losing 
its  florid  colour,  and  assuming  a dry  and 
glossy  coat.  (tlennen  on  Military  Surgery , 
p.  214,  Ed.  2.)  When  left  to  itself,  the 
above-described  pellicle  gradually  increases 
in  thickness,  forming  what  has  been  termed  a 
slough.  But,  Mr.  Blackadder  observes,  that 
at  this  period,  the  progress  of  the  disease  is 
hardly  in  any  two  instances  precisely  alike. 
Generally,  in  the  course  of  from  five  to  ten, 
or  fifteen  days,  a thick  spongy,  and  putrid- 
looking  slough  is  formed  over  the  whole 
surface  of  the  sore,  and  which  is  more  or  less 
of  an  ash,  or  blackish-brown  colour.  When 
the  pellicle  is  destroyed,  as  frequently  hap- 
pens in  the  process  of  cleaning,  it  is  not  in 
every  case  reproduced  ; but,  an  offensive 
matter  begins  to  be  discharged,  which  be- 
comes daily  more  copious,  is  of  a dirty  yel- 
low' colour,  and  ropy  consistence,  and  is 
very  adherent  to  the  sore.  The  substance, 
w'hich  formed  the  apparent  bottom  of  the 
wound,  is  raised  up,  and  pushing  the  edges, 
makes  the  sore  appear  considerably  enlarged, 
The  edges,  which  are  usually  jagged,  or 
pectinated,  become  extremely  irritable,  of  a 
deep  red  colour,  and  dotted  on  their  inner 
surface,  with  numerous  small  elevated,  and 
angry-looking  points,  which  may  be  consider- 
ed as  one  of  the  characteristics  marks  of  the 
disease.  The  surrounding  integuments  be- 
come indurated  and  inflamed,  assuming,  not 
unfrequently,  an  ansarine  appearance  ; and 
the  patient  complains  of  a constant  burning, 
lancinating  pain.  In  the  vicinity  of  the 
sore,  the  integuments  become  more  and 
more  of  a dark  red  colour,  in  consequence 
of  the  violence  of  the  inflammation,  w hich 
is  of  an  erysipelatous  nature,  and  apt  to  ter- 
minate in  sloughing,  and  carry  off'  the  pa- 
tient. However,  the  inflammatory  symptoms 
are  sometimes  mild,  and  in  other  cases,  ex- 
ceedingly violent ; a fact  accounted  for  by 
differences  oLconstitution.  ( Blackadder , p. 
34.) 

In  the  hospitals  at  Bilboa,  if  the  incipient 
stage  was  overlooked,  the  febrile  symptoms 
very  soon  became  aggravated ; the  skin 
around  the  sore  assumed  a highly  florid  co- 
lour, which  shortly  became  darker,  then 
bluish,  and  at  last  black,  with  a disposition 
to  vesicate;  while  the  rest  of  the  limb  be- 
trayed a tendency  to  cedema.  All  these 
threatening  appearances  occurred  within 
twenty-four  hours,  and  at  this  period  also, 
the  wound,  whatever  might  have  been  its 
original  shape,  soon  assumed  the  circular  form. 
The  sore  now  acquired  hard,  prominent, 
ragged  edges,  giving  it  a cup-like  appear- 
ance, with  particular  points  of  the  lip  of  a 


HOSPITAL  GANGRENE. 


G3 


dirty  yellow  hue,  while  the  bottom  of  the 
cavity  was  lined  with  a flabby  blackish 
slough.  The’gangrene  still  advancing,  fresh 
sloughs  were  rapidly  formed  ; the  increasing 
cup-like  cavity  was  filled  up  and  over-topped 
by  them,  and  the  erysipelatous  livor  and  ve- 
sication of  the  surrounding  skin  gained 
ground,  while  chains  of  inflamed  lymphatics 
could  be  traced  from  the  sores  tothe  adjoining 
glands,  these  exciting  inflammation  and  sup- 
puration, which  often  furnished  a new  nidus 
for  gangrene.  The  face  of  the  sufferer  as- 
sumed a ghastly  anxious  appearance;  his  eyes 
became  haggard,  and  deeply  tinged  with  bile; 
his  tongue  covered  with  a brownish,  or 
blackish  fur;  his  appetite  entirely  failed; 
and  his  pulse  was  feeble  and  accelerated. 
In  this  stage,  the  weakness  and  irritability 
of  the  patient  was  such,  that  the  slightest 
change  of  posture  put  him  to  torture,  in- 
creased by  his  inability  to  steady  the  iimb, 
which,  if  lifted  from  the  bed,  was  seized 
with  tremors  and  spasmodic  twitches.  (Hen- 
nen's  Military  Surgery,  p.  215,  216,  Ed.  2.) 
Authors  vary  considerably  in  their  descrip- 
tions of  the  state  of  the  tongue.  Dr.  Hen- 
nen  found  it  brownish,  or  blackish  ; Delpech 
whitish,  or  yellowish,  (Pr6cis.  Elem.  T.  1.  p. 
125,)  and  Mr.  Blackadder,  covered  with  a 
white  mucus.  (P.  39.) 

It  is  explained  by  Mr.  Blackadder,  that 
when  the  disease  attacks  a large  recent 
wound,  the  whole  surface  of  the  injury  is 
sometimes  affected  from  the  first ; while,  in 
other  instances,  the  disorder  commences  on, 
or  near  the  lips  of  the  sore.  When  the  pa- 
tient is  of  aa  inflammatory  diathesis,  the  sore 
is  generally  attacked  with  acute  inflammation 
between  the  seventh  and  fourteenth  days; 
the  slough  becomes  softer,  and  of  a pulpy 
consistence  ; matter,  of  a strong,  and  pecu- 
liar odour,  and  of  a dirty  brownish  gray  co- 
lour, begins  to  ooze  out  at  its  edges,  and  be- 
comes daily  more  copious.  The  inflamma- 
tion gradually  subsides  ; the  slough  becomes 
loosened,  and  finally  detached,  leaving  the 
subjacent  muscles,  bones,  fascia;,  or  liga- 
ments, completely  exposed.  When  the  con- 
stitution is  not  prone  to  acute  inflammation, 
the  slough  remains  long  adherent ; the  dis- 
charge is  very  copious,  and  burrows  under 
the  skin,  which  then  mortifies.  Sometimes, 
after  the  detachment  of  a slough,  florid  gra- 
nulations spring  up,  and,  notwithstanding  a 
slight  recurrence  of  the  phagedenic  ulcera- 
tion, the  parts  heal  up  by  the  almost  unasisted 
operations  of  nature.  However,  most  com- 
monly after  the  muscles  are  exposed,  they 
continue  to  be  gradually  dissected  ; their 
connecting  cellular  membrane  is  completely 
destroyed,  and  they  are  left  covered  with  an 
offensive,  greasydooking  matter. 

According  to  Mr.  Blackadder,  when  a 
muscle  has-been  wounded,  it  swells  some- 
times to  a great  size,  and  quickly  assumes 
the  appearance  of  a large  coagulum,  being 
altogether  deprived  of  irritability.  When  it 
has  not  been  wounded,  but  has  become 
inflamed,  it  generally  assumes  a pale  colour, 
with  an  appearance  as  if  distended  with  a 
fluid,  and,  occasionally,  before  losing  its 


vitality,  acquires  a very  surprising  bulk  ; but 
when  no  inflammation  has  supervened,  the 
muscles  become  of  a pale  brick  colour, 
waste  away  daily,  and  the  patient  loses  all 
power  in  them.  As  the  disease  advances, 
the  integuments  are  undermined  and  slough ; 
and  hemorrhage  from  small  vessels  is  a com- 
mon occurrence  ; but,  in  a more  advanced 
stage,  some  of  the  large  vessels  are  apt  to 
give  way,  and  the  bleeding  from  them  fre- 
quently destroys  the  patient. 

“ When  a stump  is  the  site  of  the  disease, 
and  the  patient  is  of  a plethoric  habit,  or  ac- 
customed to  live  freely,  the  symptoms  soon 
begin  to  indicate  the  existence  of  an  intense 
inflammatory  action  through  its  whole  sub- 
stance, the  tumefaction,  pain,  and  heat  in- 
ci'ease  rapidly,  so  that,  in  a few  days,  the 
stump  shall  have  acquired  more  than  twice 
its  former  size,  being  at  the  same  time  much 
indurated,  and  causing  the  most  excruciating 
pain.  In  this  state,  the  patient  has,  in  some 
instances,  become  delirious,  and  has  been 
cut  off  by  an  effusion  taking  place  into  some 
of  the  larger  cavities.  It  more  commonly 
happens,  however, that  gangrene  seizes  upon 
the  integuments,  and  cellular  substance ; 
large  sloughs  are  thrown  off ; and  some  of 
the  large  blood-vessels  giving  way,  the  pa- 
tient sinks  under  the  effects  of  repeated  he- 
morrhage. For  it  is  commonly  found,  that 
the  usual  modes  of  stopping  hemorrhage 
from  a stump  are,  in  such  cases,  either  inad- 
missible, or  totally  inefficacious. 

11  Sometimes,  the  progress  of  the  disease 
in  a stump  is  more  gradual,  but  in  the  end 
nearly  as  fatal ; the  inflammation  is  much 
less  acute  ; there  is  comparatively  but  little 
tumefaction,  and  the  pain  is  much  less  se- 
vere ; but,  the  discharge  is  much  more  co- 
pious, and  the  cellular  substance,  connecting 
the  integuments  and  muscles,  is  rapidly  des- 
troyed. Hemorrhage  generally  comes  on 
later  than  in  the  preceding  instance,  but  it 
is  the  most  common  cause  of  death,”  (Black- 
adder  on  Phagedcena  Gangrcenosa,  p.  33 — 
39.) 

It  is  observed  by  another  writer,  that  ar- 
tery seems  to  be  the  texture,  which  resists 
most  powerfully  the  destructive  action  of 
hospital  gangrene  ; (Thomson's  Lectures,  p. 
460)  a remark  quite  at  variance  with  the 
statement  of  Delpech;  (Precis  EUm.T.  1, 
129)  but  intended  to  refer,  as  I conceive, 
to  cases  in  which  the  femoral,  brachial,  or 
other  large  artery  is  seen  for  several  days 
completely  denuded,  in  the  midst  of  the  ra- 
vages of  the  distemper,  yet  not  giving  way.  I 
have  seen  the  same  thing  frequently  exem- 
plified in  mercurial  phagedama,  as  well  in 
the  groin,  as  in  the  arm.  As  for  the  smaller 
arteries,  they  are  quickly  destroyed,  to- 
gether with  other  parts. 

“ In  some  rare  cases  (says  Dr.  Hennen)  I 
have  seen  the  femoral  and  axillary  artery 
pulsating  awfully,  and  apparently  unaffected 
with  disease  ; while  all  the  surrounding  parts 
were  completely  destroyed  ; but  in  a vast 
majority  of  cases,  the  blood-vessels  partook 
of  the  general  disease,  in  which  they  were 
imbedded.  They  were  not  only  completely 


HOSPITAL  GANGRENE. 


<34 


separated  from  their  natural  connexions, 
but  their  coats  sloughed  away  at  the  imme- 
diate point  of  disease,  while  the,  disposition 
extended  far  beyond  the  apparently  affected 
spot.  Hence,  our  ligatures  but  too  often 
failed  on  the  main  branches,  and  any  attempt 
on  the  smaller  was  invariably  injurious.  VVe 
were  here  naturally  induced  to  lie  the  artery 
considerably  above  the  seat  of  the  disease  ; 
and  this  was  done  once  on  the  femoral,  and 
twice  on  the  axillary  artery  below  the 
clavicle  ; the  former  burst  on  the  third,  each 
of  the  latter,  on  the  second  day  afterward.” 
Dr.  Hen nen further  remarks,  that,  in  general, 
the  great  vessels  sloughed  long  after  the 
acute  symptoms  of  the  disease  had  abated, 
and  that,  in  severe  cases,  the  eleventh  day 
of  the  disease  was  always  dreaded.  {On 
Military  Surgery , p.  221,  Ed.  2.)  The  in- 
disposition of  the  large  vessels  to  close,  when 
taken  up  in  the  common  way,  appears  re- 
ferable to  three  causes,  viz.  the  tendency  to 
rapid  ulceration  in  the  arteries  in  the  situa- 
tion of  the  ligatures  ; the  formation  of  no 
effectual  coagulum  in  the  extremity  of  the 
vessel,  like  what  happens  in  other  cases  of 
mortification  ; and  the  general  incapacity 
of  nature  in  examples  of  hospital  gangrene 
to  establish  any  process,  which  can  be 
accompanied  with  healthy  adhesive  inflam- 
mation. 

In  the  last  stage  of  the  disease,  as  it  oc- 
curred in  the  military  hospitals  at  Bilboa, 
the  surface  of  the  sore  was  constantly  cover- 
ed with  a bloody  oozing,  and,  on  lifting  up 
the  edge  of  the  flabby  slough,  the  probe  was 
tinged  with  dark-coloured  grumous  blood, 
with  which  also  its  track  became  immediate- 
ly filled.  Repeated  and  copious  venous 
bleedings  now  came  on,  which  rapidly  sunk 
the  patient;  the  sloughs,  whether  they  fell 
off  spontaneously,  or  were  detached  by  art, 
were  quickly  succeeded  by  others,  and 
brought  into  view  thickly  studded  specks  of 
arterial  blood.  At  length,  an  artery  gave 
way,  which  was  generally  torn  through  in 
the  attempt  to  secure  it  with  a ligature  ; the 
tourniquet,  or  other  pressure  was  now 
applied,  but  in  vain  ; for,  while  it  checked 
the  bleeding,  it  accelerated  the  death  of  the 
limb,  which  became  frightfully  swelled  and 
horribly  fetid.  Incessant  retchings  came  on, 
and  with  coma,  involuntary  stools,  and 
hiccough,  closed  the  scene.  Often,  however, 
the  patient  survived  this  acute  state  of  the 
disease,  and  sunk  under  severe  irritation, 
absorption  of  putrid  matter,  and  extensive 
loss  of  substance,  with  common  hectic 
symptoms.  (See  Hennen's  Mil.  Surgery,  p. 
217,  Ed.  2.)  In  the  disease  at  Bilboa,  the 
skin  and  cellular  substance  seemed  to  be  the 
parts  originally  and  principally  affected. 
This,  says  Dr.  Hennen,  was  obvious,  even 
in  the  living  body  ; but,  on  dissection,  the 
disease  of  these  parts  was  frequently  ob- 
served to  spread  much  further,  than  external 
appearances  indicated,  as  a diseased  track 
was  often  found  running  up  into  the  groin, 
or  axilla,  and  completely  dissecting  the 
muscles  and  great  vessels.  (On  Military 
Surgery , p.  219,  Ed . 2.)  When  the  disease 


had  occupied  the  outside  of  the  chest,  the 
same  gentleman  found  the  lungs  in  two 
cases,  and  the  pericardium  in  a third,  cover- 
ed with  gangrenous  spots ; and,  when  the 
parietes  of  the  abdomen  had  been  attacked, 
lie  often  observed  the  same  appearances  on 
the  liver.  (P.  220.) 

Hospital  gangrene  must  be  regarded,  as 
one  of  the  most  serious  and  dangerous  com- 
plications, to  which  wounds  and  ulcers  are 
liable.  When  the  solution  of  continuity  is 
large,  or  of  long  standing,  the  disorder  com- 
mits great  ravages,  renews  its  attacks  repeat- 
edly, and  the  relapses  prove  exceedingly 
obstinate.  The  same  thing  is  said  to  happen, 
when  it  affects  persons  labouring  under 
scorbutic  or  venereal  complaints.  Hospital 
gangrene  proves  particularly  dangerous,  and 
mostly  fatal,  when  it  complicates  large  con- 
tused wounds,  attended  with  badly  fractured 
bones.  All  the  soft  parts  of  the  injured 
limb  are  then  frequently  observed  to  be 
progressively  destroyed,  and  the  unfortunate 
patient  falls  a victim,  either  to  typhoid 
symptoms,  frequent  hemorrhages,  or  hectic 
complaints.  From  what  has  been  stated, 
however,  the  disease  varies  considerably  in 
its  severity  in  different  cases,  being  some- 
times of  small  extent,  and  even  capable  al- 
most of  a spontaneous  cure.  Patients  have 
been  known  to  continue  afflicted  more  than 
a month,  and  when  the  duration  of  the  dis- 
ease was  thus  lengthened,  the  cases  almost 
always  had  a fatal  termination.  In  a few 
cases,  the  wound  puts  on  a favourable 
appearance  again  between  the  sixth  and 
ninth  days  ; and,  in  slight  examples,  the 
amendment  is  manifested  between  the  third 
and  fifth.  Whatever  may  be  the  period  of 
the  complaint,  its  wished-for  termination  is 
always  announced  by  a diminution  of  pain  ; 
the  pus  acquiring  a white  colour,  and  more 
consistence,  and  losing  its  fetid  nauseous 
smell.  The  edges  of  the  ulcer  subside, 
while  its  surface  Tvecoraes  less  irregular,  and 
puts  on  more  of  the  vermilion  colour.  The 
red,  purplish,  cedematous  circle,  which  sur- 
rounds the  disease,  assumes  a true  inflam- 
matory nature,  and  the  solution  of  conti- 
nuity, restored  to  a simple  state,  heals  up 
with  tolerable  quickness,  even  when  the 
destruction  of  soft  parts  is  somewhat  con- 
siderable, unless  any  fresh  untoward  circum- 
stances occur  to  interrupt  cicatrization.  But, 
sometimes,  when  (he  patient  is  on  the  point 
of  being  completely  well  again,  his  condition 
is  suddenly  altered  for  the  worse  ; ulcerated 
spots  make  their  appearance  on  the  cicatrix, 
and  these  spreading  in  different  directions 
occasion  a relapse,  which  may  happen  several 
times. 

From  numerous  cases  of  this  disease,  seen 
by  Mr.  Blackadder  at  Passage  in  Spain,  this 
gentleman  made  the  following  conclusions  : 

1.  That  the  morbid  action  could  almost 
always  be  detected  in  the  wound,  or  sore, 
previous  to  the  occurrence  of  any  constitutional 
affection. 

2.  That  in  Several  instances,  the  constitu- 
tion did  not  become  affected,  until  some 


HOSPITAL  GANGRENE. 


05 


considerable  time  after  the  disease  had  mani- 
fested itself  in  the  soie. 

3.  That  when  the  disease  was  situated  on 
the  inferior  extremities,  the  lymphatic 
Vessels,  and  glands  in  the  groin,  were  ob- 
served to  be  in  a state  of  irritation,  giving 
pain  on  pressure,  and  were  sometimes  en- 
larged, before  the  constitution  showed  evi- 
dent marks  of  derangement. 

4.  That  the  constitutional  affection, though 
sometimes  irregular,  was  in  many  cases 
contemporary  with  the  second,  or  inflamma- 
tory stage. 

5.  That  all  parts  of  the  body  were  equally 
liable  to  become  affected  with  this  disease. 

6.  That,  when  a patient  had  more  than 
one  wound,  or  sore,  it  frequently  happened, 
that  the  disease  was  confined  to  one  of  the 
sores,  while  the  other  remained  perfectly 
healthy,  and  that  even  when  they  were  at 
no  great  distance  from  each  other.  (On 
Phagedena  Gangrcenosa,  p.  19.) 

Thus  Mr.  Biackadder  espouses  the  opinion, 
that  hospital  gangrene  is  at  first  a local,  and 
not  a constitutional  disease,  that  is  to  say,  not 
necessarily  preceded,  or  originally  accom- 
panied by  any  diseased  action  in  the  system. 
It  is  highly  important  to  weigh  this  distinc- 
tion well,  not  only  because  it  is  yet  the  chief 
point  of  difference  among  the  best  writers 
on  the  subject,  but  because  it  involves  very 
directly  every  theory  respecting  the  causes 
of  the  disease,  and  the  great  question, 
whether  its  ravages  are  to  be  resisted  princi- 
pally by  local  or  constitutional  means,  or 
by  remedies  of  both  descriptions  together. 

In  the  hospital  gangrene,  observed  by  Dr. 
Rollo  in  the  artillery  hospital  at  Woolwich, 

“ The  action  of  the  poison  seemed  to  be 
limited  and  confined  to  specific  effects.  The 
Jirst  were  local,  producing  only  a general  affec- 
tion, by  a more  extensive  operation  on  the  sore. 
Five  or  six  days  from  the  appearance  of  (he 
small  ulcer  or  ulceration,  when  it  had  ex- 
tended over  one-third  of  the  former  sore, 
with  pain  and  redness  in  the  course  of  the 
lymphatics,  and  the  glands,  through  wfhieh 
they  led,  with  enlargement  of  them,  general 
indispositon  of  the  body  became  evident.” 
Delpech,  in  his  interesting  memoir,  particu- 
larly notices,  that  the  constitutional  symp- 
toms always  occurred  the  last  in  order  of 
succession. 

Mr.  Biackadder  distinctly  declares,  that, 
in  no  instance,  which  he  had  an  opportunity 
of  observing,  did  the  constitutional  symp- 
toms of  gangrenous  phagedama  precede  the 
local,  unless  the  case  be  held  an  exception, 
in  which  a stump  became  affected,  alter 
amputation  had  been  performed,  on  account 
of  Hie  previous  effects  of  the  disease.  The 
period  at  which  the  constitution  begins  to 
exhibit  symptoms  of  irritation  (he  says)  is 
extremely  irregular, — sometimes  as  early  as 
the  third,  or  fourth  day,  and  sometimes  even 
as  late  as  the  twentieth.  The  countenance 
assumes  an  anxious  or  feverish  aspect ; the 
appetite  is  impaired  ; the  desire  for  liquids 
increases  ; and  the  tongue  is  covered  with 
a white  mucus.  The  bowels  are  generally 
rather  constipated : and  the  pulse,  what 
Vol.  If  9 


may  be  termed,  rather  irritated,  than  accele- 
rated. Bur,  the  general  symptoms  may 
assume  an  inflammatory,  or  typhoid  charac- 
fer,  according  as  the  causes  of  one  of  these 
modifications  may  predominate.  According 
to  Mr.  Biackadder,  when  an  inflammatory 
diathesis  prevails,  the  system  becomes  gradu- 
ally more  irritated,  until  an  attack  of°acutc 
inflammation  seizes  upon  the  sore,  and 
which  frequently  happens  about  the  end  of 
the  second  week.  At  this  pe  iod,  the  pulse 
is  frequent  arid  sharp,  and  it  is  not  uncommon 
for  the  patient  to  be  seized  with  one,  or 
more  shivering  fits,  succeeded  by  a great 
increase  ot  heat,  but  seldom,  or  never  termi- 
nating in  a profuse  perspiration.  The  cold 
fit  is  sometimes  followed  by  a bilious  dis- 
charge from  the  intestines,  and  mitigation  of 
the  febrile  disorder.  If  the  local  mischief 
be  not  arrested,  the  strength  becomes  daily- 
more  and  more  exhausted  ; the  fever  losers 
its  inflammatory  character  ; and,  unless  the 
patient  be  cut  off  by  hemorrhage,  he  falls  a 
victim  to  extreme  debility.  When  the  dis- 
ease has  a typhoid  character,  the  pulse  is 
small  and  frequent  ; the  appetite  and 
strength  gradually  fail  ; and  the  patient  at 
last  sinks,  retaining  his  mental  faculties  to 
the  last.  Not  unfrequentlv  diarrhoea  has- 
tens the  event.  (Biackadder  on  Phagedccno, 
Gangrwnosa,  p.  39,  40.) 

On  the  other  band,  the  generality  of  wri- 
ters, nay,  even  some  of  those  who  represent 
the  disease  as  always  proceeding  from  a 
species  of  infection  applied  to  the  wound, 
take  into  the  account  the  operation  of  con- 
stitutional causes,  as  predisposing  to,  and  of 
course  preceding  the  local  symptoms.  Dr 
J.  Thomson  believes,  that  the  constitutional 
symptoms  mostly  precede  the  local.  (On 
Inflammation ,p.  459.)  The  same  sentiment 
is  professed  throughout  Dr.  Herinen's  re- 
marks, who  placed  reliance  chiefly  upon 
internal  remedies,  and  regarded  external 
applications,  as  merely  a secondary  object. 

( On  Military  Surgery,  p.  222,  Ed.  2.)  To 
this  part  of  the  subject,  I shall  return,  after 
adverting  to  the  causes  of  hospital  gangrene. 

The  hospital  gangrene,  which  occurred  in 
the  Artillery  Hospital  at  Woolwich,  and  was 
described  by  Dr.  Rolio,  did  not  attack  .speci- 
fic sores  : venereal,  scrofulous,  and  vario- 
lous ulcers  were  not  attacked,  although  (he 
patients  lay  in  the  wards,  where  the  disease 
prevailed. 

Professor  Thomson  admits,  that  specific 
sores  are  less  liable  to  attacks  of  hospital 
gangrene,  than  common  wounds  and  ulcers  • 
but,  he  declares,  that  he  has  frequently  seen 
it  attack  cancerous  and  venereal  ulcers 
(On  Inflammation,  p.  460.) 

Dr.  Hennen  mentions  a remarkable  in- 
stance, which  also  proves  the  possibility  of 
a specific  sore  becoming  affected,  and  fatal 
from  this  cause  in  forty-eight  hours  after  rhV 
patient  had  first  been  exposed  to  the  infec- 
tion. Dr.  Hennen  relates  the  tact  to  prove 
that  the  contagion  may  be  received,  without 
a long  residence  in  a tainted  air.  The 
patient,  “ who  had  just  landed  from  Eng- 
land, and  was  under  (he  influence  of  mereu- 


HOSPITAL  GANGRBNU. 


66 

vy,  employed  for  a venereal  complaint,  died 
within  forty-eight  hours  after  his  admission, 
the  gangrene  having  seized  on  an  open  bubo 
in  his  groin,  eroding  the  great  vessels  in  the 
neighbourhood,  and  absolutely  destroying 
the  abdominal  parietes  to  a large  extent.” 
(P  rinciples  of  Military  Surgery , p.  218,  Ed  2.) 

The  effects  of  hospital  gangrene  should 
be  carefully  discriminated  from  those  of  the 
scurvy.  Ulcers,  attacked  with  hospital  gan- 
grene, are  not  affected  in  any  degree,  like 
scorbutic  ulcers,  by  the  use  of  vegetable  diet 
and  lemon-juice,  and  they  occur  among  men, 
who  are  fed  upon  fresh  meat  and  vegetables, 
as  readily  as  they  do  among  those  who  have 
been  fed  altogether  upon  salt  provisions. 

( Thomson’s  Lectures  on  Inflammation, p.  482.) 
Hospital  gangrene  is  almost  always  accom- 
panied with  severe  febrile  symptoms  : but, 
as  to  fevers,  (says  Dr.  Lind.)  it  may  indeed 
be  doubted  whether  there  be  any  such  as 
are  purely  and  truly  scorbutic.  The  disease 
is  altogether  of  a chronic  nature  ; and  fevers 
may  be  justly  reckoned  among  its  adven- 
titious symptoms.”  ( Treatise  on  the  Scurvy , 
p.  106.)  In  cases  of  hospital  gangrene,  the 
geueral  symptoms  of  scurvy  are  also  abselit, 
such  as  soreness  and  bleeding  of  the  gums, 
livid  blotches  and  wheals  on  the  fleshy  part 
of  the  legs,  cedematous  ankles,  Lc. 

Hospital  gangrene  (says  Boyer)  is  a spe- 
cies of  humid  gangrene,  which  attacks  in 
some  degree  epidemically  the  wounds  and 
ulcers  of  patients,  who  happen  to  be  crowd- 
ed together  in  an  unhealthy  place. 

Its  occasional  causes  are  ; the  situation 
of  an  hospital  upon  a low  marshy  ground; 
the  vicinity  of  some  source  of  infection  ; 
the  uncleanliness  of  the  individuals,  or  of 
the  articles  for  their  use  ; the  crowded  state 
of  the  wards,  especially  when  they  are  small 
and  badly  ventilated  ; lastly,  every  thing 
that  tends  to  corrupt  the  air  which  the  pa- 
tients breathe  An  infected  atmosphere 
may  produce  in  the  most  simple  wounds 
unfavourable  changes,  partly,  as  Boyer  con- 
ceives, by  its  immediate  action  on  the  sur- 
face of  the  wound,  but  no  doubt  princi- 
pally by  its  hurtful  influence  upon  the 
whole  animal  economy.  The  foregoing 
causes  have  also  sometimes  produced  alarm- 
ing and  obstinate  gangrenes  of  an  epidemic 
kind,  or  at  least,  a state  of  the  constitution, 
under  the  influence  of  which  all  wounds 
and  ulcers  constantly  took  on  a bad  aspect, 
and  were  often  complicated  with  the  most 
gangrenous  mischief.  Vigaroux  saw  such 
an  epidemic  disease  prevail  for  twenty 
months  in  the  two  hospitals  of  Montpellier, 
and  he  states,  that  the  most  powerful  anti 
septics  were  of  little  avail  against  the  dis 
order,  which  often  invaded  the  slightest 
scratches. 

In  general,  this  epidemic  species  of  gan- 
grene is  not  observed  in  new-built  hospi- 
tals, nor  in  those  which  are  erected  out  of 
the  central  parts  of  cities,  upon  high  ground. 

Hospital  gangrene  may  occur  in  any  sea- 
son ; but,  it  is  most  common  after  the  sultry 
heat  of  summer. 

A bilious  constitution,  mental  trouble,  un- 


wholesome or  insufficient  food,  a scorbutic 
diathesis,  great  debility,  and  fevers  of  a 
dangerous  type,  are  also  reckoned  by  the 
French  surgeons  as  so  many  predisposing 
causes  of  hospital  gangrene. 

The  observations  of  Pouteau,  and  those 
of  some  other  practitioners,  convincingly 
prove,  that  hospital  gangrene  may  be  com- 
municated to  the  most  simple  wound,  or 
ulcer,  in  a subject  of  the  best  constitution, 
and  breathing  the  purest  air,  by  merely 
putting  into  contact  with  such  wound  or 
ulcer,  sponges,  lint,  or  charpie,  impregnated 
with  the  infection  of  this  peculiar  disorder. 
But,  this  inoculation  is  conceived  to  be  the 
more  alarming,  and  to  take  effect  the  more 
quickly,  in  proportion  as  patients  have  been 
more  exposed  to  the  influence  of  such  cau- 
ses as  are  themselves  capable  of  producing 
the  disease,  and  also  in  proportion  as  the 
kind  of  constitution  predisposes  to  it. 

Although  the  contagious  nature  of  hospi- 
tal gangrene  has  been  generally  admitted 
by  all  the  best  informed  writers  on  the  sub- 
ject, the  doctrine  was  not  considered  by  Dr. 
Trotter  as  having  a good  foundation.  Mo- 
dern authors,  however,  have  not  joined  this 
latter  gentleman,  and  Dr.  J.  Thomson,  Dr. 
Hennen,  and  Mr.  Blackadder,  all  believe, 
that  the  disorder  is  infectious.  “ The  con- 
tagious nature  of  hospital  gangrene  (says 
Professor  Thomson)  appears  to  me  to  be 
sufficiently  proved,  1st,  By  the  fact,  that  it 
may  be  communicated  by  sponges,  charpie, 
bandages,  and  clothing,  to  persons  at  a dis- 
tance from  those  infected  with  it.  2dly,  By 
its  having  been  observed  to  attack  the  slight 
wounds  of  surgeons,  or  their  mates,  who 
were  employed  in  dressing  infected  per- 
sons ; and  that,  even  in  circumstances, 
where  the  medical  men  so  employed,  did 
not  live  in  the  same  apartment  with  the  in- 
fected. 3d!y,  By  our  being  able  often  to 
trace  its  progress  distinctly  from  a single  in- 
dividual through  a succession  of  patients. 
4thly,  By  its  attacking  recent  wounds,  as 
well  as  old  sores,  and  that  in  a short  time 
after  they  are  brought  near  to  a patient  af- 
fected with  the  disease.  Stilly,  By  our  be- 
ing able  to  prevent  the  progress  of  the  dis- 
ease in  particular  situations,  by  removing 
the  infected  person,  before  the  contagion, 
which  his  sores  emit,  has  had  time  to  ope- 
rate. 6thly,  By  its  continuing  long  in  one 
particular  ward  of  an  hospital,  or  in  one 
particular  ship,  without  appearing  in  other 
wards,  or  ships,  if  pains  be  taken  to  prevent 
intercourse  between  the  infected  and  unin- 
fected.” (Lectures  on  Inflammation,  p. 
4S4.)  But,  although  there  can  be  no  doubt 
of  the  disease  spreading  partly  by  its  conta- 
gious nauire,  it  appears  to  me  equally  cer- 
tain, that  the  number  of  cases  is  also  often 
increased  by  the  continued  operation  of  the. 
same  causes,  which  produced  the  earliest 
instance  of  the  disorder  in  any  particular 
hospital. 

it  is  alleged,  that  when  once  a patient 
has  taken  the  infection,  he  cannot  avoid 
the  consequences,  whatever  precautions  he 
may  adopt.  Thus,  Boyer  informs  us,  that 


HOSPITAL  GANGRENE. 


67 


helms  seen  hospital  gangrene  take  place  in 
wounded  patients,  who,  in  the  hope  of  es- 
caping this  epidemic  affection,  had  quitted 
the  infected  hospital,  and  retired  to  elevated 
situations,  where  they  breathed  the  most 
salubrious  air.  (See  Traitd  de  Mai.  Chir , T. 
\,  p.  322.) 

The  bad  state  of  the  air  of  a crowded  hos- 
pital, as  Mr.  Blackadder  observes,  is  a ready 
means  of  accounting  for  the  origin  of  pha- 
gedena gangrenosa  ; but,  there  are  various 
reasons  fur  considering  such  explanation 
not  altogethersatisfactory ; and  he  mentions 
a case,  in  which  the  wound  of  a soldier  was 
found  affected  with  the  disease  on  his  first 
arrival  at  an  hospital,  after  having  been  ac- 
cidentally detained,  with  two  other  wound- 
ed comrades,  for  five  or  six  days,  partly  in 
an  open  building,  and  partly  in  a boat,  quite 
exposed  to  stormy  weather.  ( P . 45.)  Dr. 
Hennen  likewise  gives  an  account  of  about 
thirty  fresh  wounded  men,  in  whom  hospi- 
tal gangrene  first  appeared  in  their  journey 
from  Viltoria  to  the  hospital  near  Bilboa. 
(Principles  of  Military  Surgery,  p.  214,  Ed. 
2.)  Dr.  Rollo  also  remarked,  that  some 
men  in  quarters  were  affected  with  thisdis- 
ease.  And,  according  to  Air.  J.  Bell, ‘There 
is  no  hospital,  however  small,  airy,  or  well 
regulated,  where  this  epidemic  ulcer  is  not 
to  be  found  at  times.”  ( Principles  of  Sur- 
gery',  Vol.  1,  p.  112.)  For  a refutation  of 
the  opinion,  that  the  disease  ever  strictly 
merits  the  epithets  endemial,  and  epidemic , 

I must  refer  the  reader  to  the  observations 
of  Mr.  Blackadder.  (P.  143.  53.)  Delpech 
remarks,  that  the  causes  of  the  disease  do 
not  appear  to  have  depended  upon  the  state 
of  the  atmosphere,  (P.  25;)  and  in  almost 
every  instance,  he  traced  the  propagation  of 
the  disorder  to  the  direct  application  of  the 
morbific  mailer  to  the  sores.  However,  he 
joins  Pouteau  in  the  belief,  that  it  may  be 
communicated  through  the  medium  of  the 
atmosphere  ; an  occurrence,  which  Air. 
Blackadder  doubts,  or,  rather  considers  as 
very  rare,  and  only  possible  where  the  ef- 
fluvia are  allowed  to  accumulate  in  a most 
negligent  manner,  so  as  to  resemble  a va- 
pour bath,  which  mode  he  would  also  regard 
as  equivalent  to  inoculation.  (On  Phngedce- 
na  Gangrcenosa , p.  156.)  On  the  whole,  I 
am  disposed  to  think  the  views,  which  Mr. 
Blackadder  has  taken  of  the  manner  in 
which  the  disease  is  communicated,  the 
most  correct,  hitherto  published,  and  that, 
while  particular  states  of  the  air  and  consti- 
tution certainly  modify  the  disorder,  they 
cannot  generally  have  any  share  in  giving 
origin  to  the  disease  ; I say  generally,  be- 
cause as  various  facts  oblige  us  to  admit, 
that  hospital  gangrene  sometimes  arises, 
without  having  been  communicated  from 
any  patient  previously  affected,  it  is  impos- 
sible to  assert,  that  the  earliest  example  of 
it,  under  such  circumstances,  may  not  arise 
from  the  operation  of  some  unknown  and 
inexplicable  circumstances  on  the  constitu- 
tion, or  in  other  words,  from  the  state  of 
the  system  itself.  Nor  can  a doubt  be 'en- 
tertained, that,  at  all  events,  the  disorder  is 


most  apt  to  break  out  in  crowded,  Badly- 
ventilated  hospitals,  and  in  them  appear 
more  extensively  and  malignantly,  than  in 
others,  which  are  well-regulated,  properly 
ventilated,  and  healthily  situated.  But,  the 
idea,  entertained  by  Delpech,  that  hospital 
gangrene  may  originate  from  the  same  con- 
tagion as  typhus,  or  other  diseases,  is  a mere 
unsupported,  irrational  conjecture,  quite  as 
destitute  of  the  truth,  as  the  suppositions 
about  the  endemial  and  epidemic  character 
of  the  complaint,  independent  of  its  infec- 
tious nature.  The  question,  how  the  first 
example  of  the  disorder  originates,  is  at  pre- 
sent a perfect  mystery ; but,  as  ii  cannot  be 
referred  to  contagion,  or  inoculation,  we 
should  recollect,  that  whatever  produces  it 
in  one  individual,  may  produce  it  in  ano- 
ther, similarly  circumstanced,  and,  on  this 
principle,  the  disorder  may  sometimes  be 
formed  independently,  and  at  the  same  time, 
in  a greater  or  lesser  number  of  patients  in 
the  same  hospital,  as  well  as  spread  from 
these  to  others  by  infection. 

With  the  view  of  preventing  the  disor- 
der, the  wards.  in  which  the  wounded  are 
placed,  should  riot  be  crowded  ; they  ought 
to  be  freely  ventilated,  and,  if  possible,  not 
communicate.  The  utmost  attention  to 
cleanliness  should  be  paid  ; and  all  tilth 
and  stagnant  water  removed.  It  lias  been 
asserted,  but  with  what  accuracy  1 cannot 
determine,  that  the  predisposition  of  the 
wounded  to  this  species  of  gangrene  may  be 
lessened  bva  well-chosen  diet, by  drinksaci- 
dulated  with  vegetable  acids,  or  with  the  sul- 
phuric acid,  and  by  the  moderate  use  of  wine. 
The  state  of  the  stomach  and  bowels  should 
be  particularly  attended  to,  and,  if  out  of 
order,  emetics  and  purgatives  ought  to  be 
immediately  employed,  and  repeated  ac- 
cording to  circumstances.  The  dressings 
should  be  applied  with  extreme  attention  to 
cleanliness,  and  too  much  care  cannot  bo 
taken  to  prevent  the  infectious  matter  of 
one  wound  from  coming  into  contact  with 
another  through  the  medium  of  sponges,  in- 
struments, &c.  “ Whatever  may  be  the. 

source  of  this  disease  (says  a late  writer)  it 
is  atleast'sufliciently  ascertained,  that,  when 
it  occurs,  its  propagation  is  only  to  be  pre- 
vented by  the  most  rigid  attention  to  clean- 
liness, and  by  insulating  the  person,  or  per- 
sons affected,  so  as  to  prevent  all  direct  in- 
tercourse between  them  and  the  other  pa- 
tients ; for,  so  far  as  I have  had  an  oppor- 
tunity of  observing,  ninety-nine  cases  in  the 
hundred  were  evidently  produced  by  a di- 
rect application  of  the  morbific  matter  to 
the  wounds,  dressings,  &,c. ; while  others, 
who  were,  in  every  other  respect,  equally 
exposed  to  its  operation,  never  caught  the 
disease.  Tti  attempting  to  prove  this  by  ex- 
periment, I have  placed  three  patients  with 
clean  wounds  alternately  between  three 
other  patients,  severely  affected  with  the 
disease.  They  lay  in  a part  of  a ward, 
which  was  appropriated  for  patients,  who 
were  labouring  under  the  disease,  and  of 
whom  there  were  at  the  time  a considera- 
ble number.  Their  beds  were  on  the  floor, 


68 


HOSPITAL  GANGRENE. 


and  not  more  than  two  feet  distant  from 
each  other;  but,  all  direct  intercourse  Was 
forbidden,  and  they  were  made  fully  aware 
of  the  consequences  that  would  follow  from 
inattention  to  their  instructions.  The  re- 
sult of  this  trial  was,  that  not  one  of  the 
clean  wounds  assumed  the  morbid  action 
peculiar  to  the  disease,  nor  was  the  curative 
process  in  any  degree  impeded.”  (Black- 
adder  on  Phage  daena  Gangrrenosa,  p.  46.) 

As  many  experienced  writers  assert,  that 
the  disease  may  also  be  communicated  from 
one  person  to  another  through  the  medium 
'of  effluvia  in  the  air,  I am  firmly  persuaded 
that,  in  the  present  state  of  our  knowledge 
of  the  subject,  the  cautions,  respecting 
ventilation,  cleanliness,  (the  chief  practical 
deduction  from  the  latter  doctrine)  are  high- 
ly necessary  and  important.  This  sentiment 
may  be  adopted,  without  implicit  faith  be- 
ing placed  in  the  opinion,  that  the  disorder 
can  actually  be  transmitted  from  one  per- 
son to  another  through  contagion  in  the  air, 
because  whether  the  last  idea  be  true,  or 
not,  attention  to  cleanliness  and  ventilation 
must  be  beneficial  to  the  health,  in  this,  as 
in  every  other  species  of  gangrene  ; and,  on 
this  principle,  they  must  be  serviceable  in 
diminishing  the  severity,  if  not  the  frequen- 
cy and  extent,  of  the  disease,  as  I am  myself 
disposed  to  believe  from  the  consideration 
of  all  the  evidence  adduced.  Where  cir- 
cumstances will  permit,  an  entire  removal 
of  the  patients  from  the  place,  in  which 
the  disease  has  either  had  its  first  forma- 
tion, or  spread  to  any  extent,  appears  like- 
wise to  be  a most  beneficial  measure.  But, 
when  this  change  of  the  wards,  or  hospital, 
is  impracticable,  the  air  which  the  patients 
breathe,  should  be  purified,  by  renewing  it 
as  much  as  possible,  fixing  ventilators,  and 
especially  by  using  the  oxygenated  muriatic 
acid  fumigations,  as  recommended  by 
Guyton-Morveu,  or  else  those  of  the  nitric 
acid. 

The  nitric  acid  fumigations  are  made  by 
putting  into  a gla>s  vessel,  on  the  ground, 
half  an  ounce  of  concentrated  sulphuric 
acid,  to  which  an  equal  quantity  of  nitre  is 
to  be  added  gradatim.  The  mixture  is  to  be 
stirred  with  a glass  tube,  when  an  abundance 
of  while  vapour  will  be  produced. 

The  oxygenated  muriatic  acid  fumiga- 
tions are  made,  by  mixing  three  ounces  two 
drams  of  common  salt  with  five  drams  of 
the  black  oxide  of  manganese  in  powder. 
These  two  ingredients  are  to  be  triturated  to- 
gether; they  are  then  to  he  put  into  a glass 
vessel;  one  ounce  two  drams  of  water  are 
to  be  added,  and  then  if  the  ward,  or  cham- 
ber be  uninhabited,  one  ounce  seven  drams 
of  sulphuric  acid  are  to  be  poured  upon  the 
mixture  all  at  once  ; or  gradually,  if  the  pa- 
tients are  there.  This  quantity  will  be  suffi- 
cient for  a very  large  ward. 

When  one  or  more  of  the  patients,  afflict- 
ed with  the  disorder,  before  it  has  become 
general,  are  lying  in  a badly  ventilated  part 
of  the  ward,  the  surgeon  can  partly  counter- 
balance the  disadvantage  of  not  having  a 
fresh  ward,  by  causing  the  patients  to  be  put 


into  a more  airy  part  of  the  ward,  and  as  far 
as  possible  from  the  quarter,  in  which  they 
contracted  the  disease. 

With  regard  to  internal  medicines,  while 
irritation  and  febrile  heat  accompany  hospi- 
tal gangrene,  diluent  acid  drinks  are  proper, 
such  as  nitrated  whey  sweetened  with  syrup 
of  violets,  lemonade,  &c.  Blood- letting  is 
admissible  in  bur  few  instances,  not  merely 
because  the  orifice,  made  by  the  lancet,  is 
apt  to  become  gangrenous,  but  because  the 
fever,  which  accompanies  hospital  gangrene, 
is  usually  of  the  typhoid,  or  astheuic  cha- 
racter. ( Thomson , p.  49  ?.) 

Mr.  Blaeka  ider,  like  Dr.  Thomson,  does 
not  entertain  a favourable  opinion  of  vene- 
section, as  a general  practice,  though  he 
would  not  object  to  the  abstraction  of  a 
small  quantity  of  blood,  when,  owing  to  the 
plethoric  habit  of  the  patient,  previous  treat- 
ment, and  other  causes,  an  inflammatory  ac- 
tion in  the  system  is  present.  But  he  con- 
ceives, that  all  danger  of  the  disease  attack- 
ing the  A’oundj  made  with  the  lancet,  may  be 
obviated,  if  care  be  taken  that  the  arm  of 
the  patient,  the  hands  of  the  surgeon,  his 
lancet,  and  the  subsequent  dressings,  be  per- 
fectly free  from  contamination,  and  that  the 
patient  be  prevented  from  undoing  ihe  band- 
age, or  touching  the  incision  made  with  ihe 
lancet,  before  it  is  cicatrized.  (P.  135.)  Mr. 
Blackadder  thinks,  however,  that  blood-let- 
ting should  be  avoided,  as  much  as  possible, 
particularly  when  the  previous  injury  has 
been  extensive.  “ A general  debility  of  the 
system,  is  one  of  the  symptoms  which  are 
most  to  be  dreaded  ; for,  when  once  it  takes 
place,  there  is  no  other  disease  in  which  it 
is  removed  with  greater  difficulty.”  (P.  137.) 
Mow  different  these  sentiments  are  from 
those  of  Dr.  Hennen,  who,  in  speaking  of 
the  effects  of  venesection,  when  the  disorder 
was  accompanied  with  an  inflammatory  dia- 
thesis, employs  the  following  expressions: 
“ The  very  patients  themselves  implored  the 
use  of  the  lancet.”  For  several  months 
we  used  no  other  remedy,  cither  as  a cure, 
or  preventive.” — “We  never  observed  arty 
of  the  lancet  wounds  assume  a gangrenous 
appearance,  although  previously,  in  almost 
every  other  instance,  the  slightest  puncture 
festered.”  On  Military  Surgery , p.  224,  Ed. 
2-> 

In  the  beginning  of  the  constitutional  at- 
tack, Pouteau  and  Dussassoy  particularv  re- 
commended emetics,  and  Mr  Briggs,  Dr.  J. 
Thomson,  and  Dr.  Hennen,  are  all  advo- 
cates for  this  practice,  though  the  latter 
gentleman  makes  his  evidence  rather  ambi- 
guous, by  a subjoined  note,  in  which  he 
ment  ions  that  want  of  success,  &,c.  led  to  the 
trial  of  venesection.  (Op.cit.  222.)  As  for 
Mr.  Blackadder,  he  deems  the  employment 
of  emetics  at  the  commencement  of  hospital 
gangrene  useful  only  when  the  stomach  is 
foul.  (On  Phagedeena  Gang  ram  osa,  p.  134.) 
In  the  early  stage  of  the  case,  writers  seem 
all  to  agree  about  the  utility  of  purgative  and 
laxative  medicines.  When  there  is  debility, 
good  generous  wine  should  be  allowed,  either 
by  itself,  or  mixed  with  lemonade  according 


HOSPITAL  GANGRENE. 


09 


to  circumstances.  Bark,  whose  antiseptic 
qualities  have  been  so  highly  praised,  is  in 
general  more  hurtful,  than  useful ; and  Dr. 
Hennen  assures  us,  that  he  has  seen  great 
harm  done  by  large  and  injudicious  doses  of 
this  drug,  before  full  evacuations  had  taken 
pluce,  and  the  sloughs  begun  to  separate. 
Boyer  allows,  however,  that  it  may  be  bene- 
ficially given,  when  the  feverish  heat  has 
abated,  and  the  debility  is  very  great. 

In  all  stages  of  this  disease,  unattended 
with  diarrhoea,  acids  are  proper.  The  sul- 
phuric acid  is  that  which  is  given  With  most 
success ; but  the  acidulous  tars  rite  of  potassa 
is  also  an  excellent  medicine.  From  two 
drams  to  half  an  ounce  may  be  given  every 
day,  and  the  best  plan  is  to  make  an  acid 
drink  with  it,  which  should  be  sweetened 
and  strained. 

In  severe  cases,  attended  with  a quick  and 
feeble  pulse,  depression,  restlessness,  and 
anxiety,  an  opiate  becomes  necessary. 
“ So  long  as  we  wish  to  excite  a degree  of 
moisture  on  the  skin,  (says  Professor  Thom- 
son) Dover’s  powder,  or  laudanum  with  anti- 
monial  wine,  form  in  general  the  best  opi- 
ates.” This  gentleman,  however,  is  not  an 
advocate  for  the  employment  of  opium,  in 
the  early  stage  of  hospital  gangrene,  while 
the  heat  and  other  febrile  symptoms  are  at 
their  ne'ight  (See  Lectures  on  Inflammation, 
p.  494,495.)  For  these  cases,  camphor,  in 
large  and  frequent  doses,  was  highly  praised 
by  Pouteau. 

From  what  has  been  said  concerning  in- 
ternal remedies,  it  is  evident,  that  none  of 
them  can  be  regarded  as  neans,  which  can 
be  at  all  depended  upon  for  arresting  the  ra- 
vages of  hospital  gangrene,  however  advan- 
tageous they  may  prove  in  palliating  general 
symptom*,  removing  particular  complica- 
tions, enabling  the  system  to  support  the  ef- 
fects of  the  local  disorder  for  a greater  length 
of  time,  or,  in  a few  cases,  even  placing  na- 
ture in  a condition  to  throw  off  the  diseased 
parts  herself,  and  communicate  to  the  subja- 
cent living  flesh  a healty  action. 

If  credit  can  be  given  to  several  of  the 
authors,  who  have  had  the  most  extensive 
opportunities  of  attending  to  the  nature  of 
hospital  gangrene,  the  local  treatment  is  far 
more  effectual  than  internal  medicines. 

“ I was  told  by  several  of  the  French  sur 
geons  (says  a late  visiter  to  Paris  ) that  they 
did  not  rely  at  all  on  internal  means  for 
stopping  the  progress  of  hospital  gangrene, 
and  that  their  experience  had  proved  them 
to  be  insufficent,  if  no!  wholly  inefficacious. 
Dupuytren,  in  reply  to  the  account  I gave 
him  of  the  practice  and  opinions  of  English 
surgeons  on  this  subject,  assured  me,  that  he 
had  no  confidence  but  in  local  applications, 
and  that  internal  remedies  alone,  as  far  as  he 
had  found,  did  almost  nothing.  The  same 
remark  has  been  made  in  a very  recent  pub 
lication  on  hospital  gangrene,  ( Delpech , 
Mim.  sur  la  Complication  des  Plaies,  fyc. 
1815.)  although  it  seems  to  be  rather  at  vari- 
ance with  its  being  a constitutional  and  con- 
tagious disease,  which  the  author  has  admit- 


ted.” (See  Sketches  of  the  Medical  Schools 
of  Paris,  by  J.  Cross,  p.  83.) 

Perhaps,  there  is  not  a single  antiseptic  ap- 
plication, which  has  not  been  tried  as  a dress- 
ing for  wounds,  or  ulcers,  affected  with  hos- 
pital gangrene.  All  watery  applications,  and 
common  poultices,  and  fomentations,  are  ge- 
nerally condemned  as  inefficacious,  and  even 
hurtful. 

Dussassoy  was  convinced  by  the  observa- 
tion of  numerous  cases,  that  t lie  best  applica- 
tion is  powder  of  bark.  He  recommends 
the  wound  to  be  covereu  with  several  layers 
of  this  powder,  which  are  then  to  be  moist- 
enechwilh  turpentine.  When  this  composi- 
tion dries,  he  asserts,  that  it  forms  a fragile 
sort  of  coat,  at  the  sides  of  which,  and 
through  which,  the  discharge  escapes.  After 
twenty-four  hours,  the  first  coat  is  to  be  re- 
moved, an  I a fresh  one  applied.  In  general, 
according  to  this  writer,  four  or  five  such 
dressings  are  sufficient  in  sirnplfe  cases,  where 
the  disorder  is  confined  to  the  skin  and  cel- 
lular substance.  Healthy  inflammation  then 
occurs,  the  sloughs  come  away,  and  the 
wound  puts  on  a healing  appearance.  In  bad 
cases,  D-issassoy  sometimes  added  one-fifth 
of  powdered  muriate  of  ammonia  to  the 
bark  When  th's  treatment  failed,  the  actual 
cautery  was  used 

On  the  subject  of  bark,  as  a local  applica- 
tion to  hospital  gangrene,  I need  only  re- 
mark, that  it  is  now  entirely  relinquished, 
either  as  possessing  no  efficacy,  ( Delpech ) or 
even  aggravating  the  symptoms.  ( Blackad - 
der.) 

The  milder  forms  of  the  disease  appear 
sometimes  to  have  yielded  to  the  application 
of  the  vegetable  and  diluted  mineral  adds  ; 
lime  juice  ; lemon  juice  ; vinegar;  and  the 
diluted  nitric,  and  muriatic  acids.  And  the 
same  observation  may  be  made,  with  res- 
pect to  solutions  of  the  nitrates  of  silver  and 
mercury.  The  two  latter  substances,  and 
the  oxygenated  muriatic  acid,  and  ga«,  were 
found  by  Dr.  Rollo  to  be  capable  of  effecting 
a cure.  Delpech,  in  particular,  speaks  of 
the  benefit  derived  from  the  application  of 
strong  vinegar,  after  all  the  pulpy  viscid 
matter  has  been  carefully  wiped  away  from 
the  surface  of  the  living  flesh.  The  vinegar 
is  then  poured  on  the  ulcer,  which  is  to  be 
covered  with  charpie  wet  with  the  same 
liquid.  When  the  case  is  too  far  advanced 
for  this  trea’ment  to  answer  Delpech  tries 
caustics,  especially  1 he  nitrate  of  silver  ; and 
if  these  fail,  he  lias  recourse  to  the  actual 
cautery,  and,  when  the  sloughs  are  very 
thick,  so  as  to  hinder  the  cautery  from  act- 
ing to  a sufficient  depth,  he  prefers  thrusting 
into  the  sloughs  down  to  the  living  flesh  an- 
gular pieces  of  caustic  potash  at  small  dis- 
tances from  each  other!  (Prdcis.  Elem.  des 
Mai.  Chir.  T.  1,  p.  151.)  Surely,  this  must 
be  far  more  torturing,  and  less  certain  of 
success,  than  removing  the  sloughs,  and  ap- 
plying the  cautery. 

Though  the  actual  cautery  is  generally  ad- 
mitted to  be  one  of  the  most  powerful  means 
of  stopping  the  progress  of  hospital  gangrene, 
the  surgeons  of  this  country  entertain  a 


HOSPITAL  GANGRENE. 


SO 

strong  aversion  to  the  practice;  and  Icon- 
loss,  that  my  own  dislike,  to  it  is  such  as 
Mould  always  lead  tne  to  prefer  any  other 
treatment,  from  which  equal  efficacy  would 
result.  At  the  same  time,  if  must  be  grant- 
ed, that  if  the  actual  caulery  will  more  cer- 
tainlyarrest  sotneforms  of  hospital  gangrene, 
than  any  other  known  applications,  the  sur- 
geon’s duty  is  to  put  out  of  the  question  his 
own  prejudices  against  it,  and  consider  only 
his  patient’s  welfare.  I am  far  from  thinking, 
however,  that,  while  there  are  such  power- 
ful caustics  as  th^  undiluted  mineral  acids, 
and  a dressing  so  effectual  as  a solution  of 
arsenic,  it  can  often  be  absolutely  necessary 
to  employ  red-hot  irons. 

The  merit  of  having  pointed  out  in  mo- 
dern times  the  great  efficacy  of  Fowler’s 
solution  of  arsenic,  or  the  liquor  arseuiealis 
of  the  London  Pharmacopoeia,  as  an  appli- 
cation to  phagedaena  gangrenosa,  belongs  to 
]\Ir.  Biackadder.  In  answer  to  the  objection, 
that  the  external  use  of  arsenic  is  not  unat- 
tended with  danger,  he  assures  us,  that  he 
has  heard  but  of  one  instance  of  hospital 
gangrene,  in  which  any  deleterious  effects 
were  supposed  to  arise  from  the  absorption 
of  the  arsenic,  and  the  patient  in  question 
was  very  soon  cured  of  his  uneasy,  and  pos- 
sibly merely  nervous  symptoms  ” ( P . 50.) 

“ The  first  thing  to  be  attended  to  in  every 
case  of  disease  (says  Mr.  Biackadder)  is 
cleanliness , which,  if  always  of  great  im- 
portance, is,  in  this  instance,  indispensable. 
The  surface  of  the  body  ought  to  be  made, 
and  kept  perfectly  clean,  by  means  ot  the 
tepid  bath,  or  otherwise  by  a plentiful  use  of 
soap;  and  the  linen,  and  bed-clothes,  should 
be  frequently  changed,  particularly  when 
soiled  with  matter  from  the  sore.”  In  order 
to  make  the  sore  perfectly  clean,  and  free  it 
from  the  viscous  discharge,  without  produ- 
cing considerable  bleeding,  and  pain,  Mr. 
Biackadder  recommends  two  large  tin  hos- 
pital teapots  to  be  filled  with  a weak  solu- 
tion of  the  subcarbonate  of  potass.  One  of 
these  solutions  is  to  be  cold  ; the  o»her  tepid  ; 
because  sometimes  one,  and  sometimes  the 
other,  is  found  most  agreeable  to  the  patient’s 
feelings,  though  the  warm  is  the  most  effec- 
tual in  cleansing  the  sore.  The  liquid  is  to  be 
poured  over  the  sore,  and  received  into  a 
basin,  which  ought  to  be  immediately  empti- 
ed into  another  vessel  placed  at  a distance 
from  the  patient.  During  this  ablution,  the 
glutinous  matter,  which  adheres  to  the  sore, 
may  be  gently  detached,  by  means  of  small 
dossils  of  fine  tow,  or  lint,  but  these  (says 
Mr.  Biackadder)  should  never  be  used  lor 
two  different  patients,  rigid  ecomotny,  on 
occasions  such  as  this,  being  a very  mistaken 
principle.  In  these  cases,  the  use  of  sponges, 
(he  justly  observes)  ought  to  be  entirely 
laid  aside,  as  they  can  seldom  be  used  more 
than  once  with  safely.  When  the  sore  has 
been  thus  cleaned,  a fine  piece  of  dry  lint  is  to 
be  spread  over  its  surface,  and  gently  [tress- 
ed into  all  its  depressions  with  the  points  of 
the  fingers.  When  the  lint  is  removed,  a 
quantity  of  the  discharge  will  be  found  ad 
liering  to  it : and  this  operation  must  be  re- 


peated with  fresh  pieces  of  lint,  until  the 
surface  of  the  sore  is  made  perfectly  clean 
and  dry. 

According  to  Mr.  Biackadder,  the  solution 
of  arsenic  will  generally  be  found  strong 
enough,  when  diluted  with  an  equal  part  of 
water;  but,  in  slight  cases,  it  answered, 
when  weakened  with  twice  its  quantity  of 
Avater  ; and,  in  a few  examples,  it  was  em- 
ployed without  being  at  all  diluted.  Several 
pieces  of  lint  of  the  same  shape  as  the  sore, 
but  a little  larger,  are  to  be  prepared  : one 
of  these,  soaked  in  the  solution,  is  now  to 
be  applied  to  the  cleaned  surface  of  the  sore, 
and  renewed  every  fifteen  or  thirty  minutes, 
according  to  the  time  in  which  it  becomes 
dry.  When  the  heat  and  inflammation  are 
considerable,  great  relief  will  be  derived 
from  the  frequent-application  of  linen  cloths 
moistened  with  cold  water,  which  must  be 
kept  from  weakening  the  arsenical  solution 
by  means  of  a,  small  piece  of  oilskin  laid 
over  the  pieces  of  lint.  When  the  disease 
extends  into  the  track  of  a gunshot  wound, 
Mr.  Biackadder  uses  a syringe  for  cleaning 
the  sore,  and  introducing  the  solution.  “A 
slip  of  fine  lint,  well  soaked  in  the  solution, 
may  also  be  inserted  by  means  of  a probe, 
into  the  bottom  of  the  wound ; and  when 
the  openings  are  at  no  great  distance  from 
each  other,  aud  not  in  the  immediate  vici- 
nity of  the  large  nerves  and  blood-vessels, 
the  lint  may  be  drawn  through  the  wound  in 
the  form  of  a seton.  (P.  53.)  When  the 
pain,  caused  by  the  application,  is  very  se- 
vere, and  the  constitution  is  irritable,  and 
debilitated,  Mr.  Biackadder  prescribes  an 
opiate,  though  he  remarks,  that  this  practice 
will  seldom  be  absolutely  necessary.  The 
morbid  action  in  the  sore  is  destroyed  by 
the  arsenical  solution  sooner,  or  later,  in 
different  cases  : the  best  plan  is  to  continue 
the  application,  until  an  insensible,  dark- 
coloured , dry  slough  occupies  the  whole  surface 
of  the  sore ; and  until  the  patient  is  com- 
pletely relieved  from  the  burning  and  lancina- 
ting pain. 

After  the  slough  is  formed,  Mr.  Biackadder 
employs  an  ointment,  composed  of  equal 
parts  of  the  oil  of  turpentine,  and  the  yellow 
resinous  ointment,  or  of  two  parts  of  Venice 
turpentine  to  one  of  the  resinous  ointment. 
11  These  being  melted  and  mixed  together, 
are  to  be  poured  over  the  sore,  as  hot  as  the 
patient  can  possibly  bear.”  A pledget  of 
dry  lint,  or  tow,  and  a bandage,  are  then 
applied  ; and  this  dressing  may  be  renewed 
two  or  three  times  a day,  the  sore  being  each 
time  carefully  washed  with  the  solution  of 
potass.  As  soon  as  any  part  of  the  slough  is 
loosened,  Mr.  Biackadder  removes  it  with  a 
pair  of  curved  scissors.  With  the  view  of 
expediting  the  separation  of  the  slough,  he 
sometimes  employs  a linseed-meal  poultice, 
which  had  the  desired  effect,  but  was  found 
to  he  too  relaxing.  When  it  is  used,  there- 
fore, Mr.  Biackadder  found  it  expedient,  at 
each  dressing,  to  touch  the  new  granulations 
with  the  nitrate  of  silver. 

After  the  detachment  of  the.  slough,  Mr. 
Biackadder  dresses  the  sore  with  the  above- 


Hydrocele. 


tiieulioned  ointment  cold,  or  with  the  addi- 
tion of  a small  proportion  of  the  subacetale 
of  copper.  The  pledget  of  this  ointment  is 
covered  with  a piece  of  oilskin,  lightly  rub- 
bed over  with  soap;  and  a firm  bandage  is 
applied  to  the  whole  limb.  (See  Obs.  on 
P/iagedeena  Gangreenosa , p.  49,  fyc.  8vo. 
Edinb.  1818.)  The  author  declares,  that, 
after  the  introduction  of  the  above  treatment, 
(with  the  exception  of  stumps  attacked  with 
hospital  gangrene)  he  never  saw  an  instance 
in  which  the  remedy  failed,  when  applied  in 
time  and  in  a proper  manner;  that  is, before 
the  disease  had  made  such  progress  as  to 
preclude  all  rational  hope  of  success  from 
that  or  any  other  mode  of  treatment.  ( P . 
23.) 

In  Dr.  Rollo’s  treatise  on  Diabetes,  publish- 
ed in  1797,  the  opinion  is  plainly  stated,  that 
the  progress  of  hospital  gangrene  might  be 
slopped  by  very  active  topical  applications, 
and,  in  tae  same  work  Mr.  Cruickshank  says, 
that  “ it  an  actual  caustic  were  to  be  em- 
ployed, we  should  have  recourse  to  the 
strong  nitrous  acid.”  According  to  Mr. 
Blackadder,  the  oxygenated  muriate  of  mer- 
cury and  the  nitrous  acid  were  u.ucli  recom- 
mended, and  employed  by  surgeons  in  the 
16th  and  17th  centuries,  as  escbaroties,  in 
cases  of  gangrene  and  foul  ulcers.  ( P . 113.) 
Several  army  surgeons  have  informed  rue, 
that  the  undiluted  nitrous  acid  was  success- 
fully used  as  an  application  to  hospital  gan- 
grene in  the  military  hospitals  at  Antwerp  in 
the  year  1815;  but  that  other  strong  acids 
had  an  equally  good  effect.  Dr.  J.  Thom- 
son also  notices,  that  “the  application  of 
caustic  substances,  such  as  the  strong  mine- 
ral acids,  the  solutions  of  potass,  corrosive 
sublimate,  and  arsenic,  seemed  at  Antwerp 
to  arrest  the  progress  of  this  sore,  without 
exciting  inflammation.”  ( Report  of  Obser- 
xalions  made  in  the  Military  Hospitals  in  Bel - 
gium.) 

Delpech  was  informed  by  some  British 
surgeons,  belonging  to  the  Angio-Portugueze 
army  in  the  Peninsula,  that  the  muriatic 
acid  was  in  common  use  in  the  hospitals  of 
that  army  as  a local  application  for  checking 
the  ravages  of  hospital  gangrene,  being  em 
ployed  in  a diluted  state  for  slight  cases,  and 
in  a concentrated  caustic  form  for  others. 

In  St.  Bartholomew’s  hospital , the  undilu- 
ted nitric  acid  has  been  used  with  great  suc- 
cess as  a local  application  to  phagedenic  gan- 
grenous ulcers,  as  may  be  seen  by  an  inte- 
resting paper  recently  published  by  Mr.  Wel- 
bank.  (Med.  Chir • Trans.  Vol.  10.) 

Pouteau,  Dussasso) , Boyer,  and  Delpech, 
all  bear  testimony  to  the  efficacy  of  the  ac- 
tu<i;  cautery,  and  they  repeat  the  application 
©f  it,  until  the  whole  surface  of  (he  ulcer  is 
converted  into  a firm  hard  eschar.  Even  the 
edges  of  the  solution  of  continuity  should  not 
be  spa  rad — ils  duivent  etre  tor  rifts  et  rolls 
pour  ainsi  dire.”  (Boyer,  Trait 6 des  Mala- 
dies Chir.  T.  1 ,p.  332.)  The  latter  surgeon 
then  covers  the  eschar  with  a thick  stratum 
of  bark  moistened  with  turpentine.  This 
application  is  to  be  removed  in  twenty-four, 


thirty-six,  or  forty-eight  hours,  and  the  sur- 
geon is  then  to  judge  from  the  appearance 
of  the  flesh,  and  the  quality  of  the  discharge, 
whether  a further  repetition  of  the  cautery 
will  be  necessary. 

Pouteau,  QZurres  Poslfiumes,  T.  3,  publish- 
ed 1783.  Dussassoy  Dissertation  et  Observa- 
tions sur  la  Gangrene  des  Hbpilaux , fy-c.  8vo, 
Genive,  1788.  Moreau  et  Burdin,  Essai  sur 
la  Gangrene  Hu/nide  des  Hopilaux , 1796. 
Observations  on  the  Putrid  Ulcer,  by  L.  Gilles- 
pie, in  London  Medical  Journal,  Vol.  6, 1785. 
Rollo  on  Diabetes,  1797.  Sir  Gilbert  Blanc 
on  the  Diseases  of  Seamen , Ed  3 1797.  Trot- 
ter's Medicina  JYauiica,  Vols.  2 and  3,  publish- 
ed 1799.  John  Bell's  Principles  of  Surgery r 
Vol.  1,1801.  Wolf  Ploucquet,  De  G angr ve- 
na sic  dicta  Nosocomiorum,  Tub.  1802.  Leslie , 
De  Gangreena  Contagiosa.  Edinb.  1804, 
Johnston  De  Gangrcsn  ■ oulag  osa  JVosocomi- 
ale,  Edinb.  1805.  ./  Thomson's  , ectures  on 

Inflammation,  p.  456,  et  seq.  Edinb.  1813, 
and  Report  of  Observations , made  in  the  Mili- 
tary Hospitals  of  Belgium , 8 ro.  Edinb.  1816. 
J.  Hennen , Principles  of  Military  Surgery, 
p.  210,  fyc.  8 vo.  Edinb.  1820.  C.  J M.  Lan- 
genbeck,  JYeue  Bibl.  2 B.  p.  611,  fyc.  Hano- 
ver, 1820.  Memoir  e sur  la  Complication  des 
Plaies  et  des  Ulc&res,  connne  sous  le  nom  de 
Pourrilure  d'h6pital,par  J.  Delpech,  8vo.  Pa- 
ris, 1815.  Also  Precis  Element  air  e dss  Ma- 
ladies Chir.  T.  1,  p.123,  fyc.  Paris  1816, 
Brugmans  und  Delpech  liber  den  Hospital- 
brand , ubersezt  mil  Anmerkunvten  und  An  hang 
von  Kieser,  Jennal,  1815.  Boyer,  Traitd  des 
Maladies  Chir.  T.  1,  p.  320,  Paris,  1814. 
Sketches  of  the  Medical  Schools  of  Paris  by 
J.  Cross,  p.  82,  London , 1815.  H.  Home 
Blackadder,  Observations  on  Phagedcena  Gan 
greenosa,  8vo.  Edinb.  1818,  ivhich  is  unqu'es 
tionably  the  best  treatise  on  the  subject , whether 
his  sentiment  about  the  disease  being  always , 
or  nearly  always,  communicated  by  the  direct 
application  of  the  infectious  matter  to  the  parts, 
and  not  through  the  contagion  in  hie  air,  be 
correct  or  not ; or  whether  his  opinion  about 
the  local  nature  of  the  disease  in  the  beginning, 
audits  invariable  commencement  with  the  local 
mischief , and  not  with  constitutional  symp- 
toms, be  liable  to  exceptions  or  not.  The  rest 
of  the  subject  of  Gangrene  is  treated  of  in 
, the  article  Mortification. 

HYDRARGYRIA.  A peculiar  eruption 
occasioned  by  the  use  of  mercury,  and  na- 
med in  Dr.  Bateman’s  synopsis  eczema  ru- 
brum  (See  Mercury.) 

HYDROCELE,  (trom  deep,  water,  and 
xhah,  a tumour.)  The  term  hydrocele,  if 
used  in  a literal  sense,  means  any  tumour 
containing  water;  but.  surgeons  have  always 
confined  it  either  to  a collection  of  fluid  in 
the  cellular  membrane  of  the  scrotum  ; in  a 
cyst,  or  the  common  cellular  texture,  of  'he 
spermatic  cord  ; or  in  the  tunica  vaginalis  of 
the  testicle. 

The  celebrated  Dr.  Alexander  Monro  of 
Edinburgh,  and  Mr.  S.  Sharp,  were  almost 
the  only  writers,  before  Mr.  Pott,  who  sensi- 
bly and  rationally  explained  the  true  nature 
of  these  diseases. 


HYDROCELE. 


12 


ANASARCOUS  TUMOUR  OR  THE  SCROTUM  : 

The  hydrocele  by  infiltration  of  French 
writers;  hydrocele  cedematodes  ; is  most  fre- 
quently only  a symptom  of  a dropsical  habit, 
and  very  often  accompanies  both  anasarca 
and  the  particular  collection  within  the  ab- 
domen, called  ascites.  Mr.  Pott  describes 
it  as  “ an  equal,  soft  tumour,  possessing  every 
part  of  the  cellular  membrane,  in  which  both 
the  testicles  are  enveloped,  and  consequently 
it  is  generally  as  iarge  ori  one  side  as  on  the 
other  ; it  leaves  theskin  of  its  natural  colour  ; 
or,  to  speak  more  properly,  it  does  not  red- 
den or  inflame  it;  if  the  quantity  of  water 
be  not  large,  nor  the  distention  great,  the 
skin  preserves  some  degree  of  rugosity  ; the 
tumour  has  a doughy  kind  of  feel ; easily 
receives,  and  for  a while  retains,  the  im- 
pression of  the  fingers ; the  raphe,  or  seam, 
of  the  scrotum  divides  the  swelling  nearly 
equally;  the  spermatic  process  is  perfectly 
free,  and  of  its  natural  size  , and  the  testicles 
seem  to  be  in  the  middle  of  the  loaded  mem- 
brane. This  is  the  appearance  when  the  dis- 
ease is  in  a moderate  degree.  But  if  the 
quantity  of  extravasated  serum  be  large,  or 
the  disease  farther  advanced,  the  skin,  in- 
stead of  being  wrinkled,  is  smooth,  tense,  and 
plainly  show's  the  limpid  state  of  the  fluid  un- 
derneath : it  is  cold  to  the  touch,  does  not 
so  long  retain  the  impression  of  the  finger, 
and  is  always  accompanied  with  a similar 
distention  of  the  skin  of  the  penis  ; the  pre- 
putiurn  of  which  is  sometimes  so  enlarged, 
and  so  twisted  and  distorted,  as  to  make  a 
verv  disagreeable  appearance.  These  are 
the  local  symptoms:  to  which  it  maybe  add- 
ed, that  a yellow  countenance,  a loss  of  appe- 
tite, a deficiency  of  urinary  secretion,  swell- 
ed legs,  a bard  belly,  and  mucous  stools,  are 
its  very  frequent  companions. 

As  the  cellular  membrane  on  one  side  of 
the  scrotum  is  a continuation  of  that  which 
is  situated  on  the  other,  and  both  freely  com- 
municate ; the  accounts  delivered  by  certain 
authors  of  the  possibility  of  this  species  of 
hydrocele  being  confined  to  one  side  of  the 

scrotum  is  not  credited  by  some  modern 
surgeons.  (See  Did.  des  Sciences  Med.  T. 
22  v 193.)  At  all  events,  such  a case  is 
extremely  rare,  and,  when  it  happens,  is 
probably  induced  by  the  irritation  of  be 
urine  in  infants,  or  of  tbe  friction  of  the 
clothes  in  old  persons,  only  acting  upon  a part 
of  the  scrotum  ; for  occasionally,  though  not 
often,  the  disease  is  acknowledged  to  proceed 
from  these  local  causes.  ( Vol . et  loco  cit.) 

The  cure  of  the  original  disease,  when  it 
arises  from  constitutional  causes,  comes  with- 
in the  province'of  the  physician,  and  requires 
a course  of  internal  medicine:  hut  sometimes 
lhe  loaded  scrotum  and  penis  are  so  trouble- 
some to  the  patient,  and  in  such  danger  of 
mortification,  that  a reduction  of  their  size 
becomes  absolutely  necessary  : and  at  other 
limes,  a discharge  of  ,he  redund?nt  extrava- 
;ated  serum  is  ordered  as  an  assistant  to  the 
internal  regimen.  As  Mr.  Fott  observes,  the 
means  of  making  this  discharge  are  two,  viz. 
puncture  and  incision:  the  former  is  made 


with  the  point  of  a lancet;  the  latter  with 
the  same  instrument,  or  with  a knife.  Accord- 
ing to  the  same  author,  and  indeed  every 
man  of  experience,  wounds  in  anasarcous, 
or  dropsical  habits,  are  apt  to  inflame,  very 
difficultly  brought  to  suppuration,  and  often 
prove  gangrenous,  in  spite  of  all  endeavours 
to  the  contrary.  But  the  larger  and  deeper 
the  wounds  are,  the  more  probable  are  these 
bad  consequences.  Simple  punctures  with 
the  point  of  a lancet,  are  much  less  liable  to 
be  attended  by  them  than  any  other  kind  of 
wound  ; they  generally  leave  tbe  skin  easy, 
soft,  cool,  and  uninflamed,  and  in  a state  to 
admit  a repetition  of  the  same  operation  if 
necessary.  Incisions  create  a painful,  crude, 
hazardous  sore,  requiring  constant  care. 
Punctures  seldom  produce  any  uneasine  s at 
all  ; and  stand  in  need  of  only  a superficial 
pledget  for  dressing. 

It  is  further  explained  by  the  same  author, 
that  as  the  cavities  of  the  cellular  membrane 
of  the  scrotum  all  communicate  together,  a 
small  puncture  serves,  as  well  as  a large  in- 
cision, for  the  discharge  of  the  fluid  con- 
tained in  them,  and  consequently  upon  this 
ground  no  reason  exists  for  making  any  ex- 
tensive, painful,  and  hazardous  wound. 

With  respect  to  the  practice  of  making 
punctures,  in  cases  of  anasarcous  hydrocele, 
1 think  that  it  should  always  be  avoided  as 
much  as  possible,  because  it  sometimes  hap- 
pens, that  the  slightest  pricks  of  the  lancet 
occasion  sloughing.  The  method  should  only 
be  adopted,  when  the  distention  of  the  skin 
of  the  scrotum  is  such,  as  absolutely  to  re- 
quire the  fluid  to  be  discharged.  Care 
should  also  he  taken  not  to  multiply  the 
punctures  unnecessarily,  nor  to  let  them  be 
made  too  near  together.  (See  Did.  des  Sci- 
ences Med.  T.  23,  p.  195.) 

When  the  oedematous  state  of  the  scrotum 
is  not  the  effect  of  a general  constitutional 
disease,  but  proceeds  entirely  from  a local 
cause,  siicb  as  friction,  or  the  irritation  of 
the  urine,  the  mode  of  treatment  consists  in 
the  removal  of  the  cause,  the  use  of  astrin- 
gent lotions,  and  the  exhibition  of  a dose  of 
salts.  In  elderly  subjects,  the  wearing  of  a 
bag-truss  is  recommended  for  the  prevention 
of  the  complaint. 

HYDROCELE  OF  THE  SPERMATIC  CORl). 

Is  of  two  kinds;  the  first  is  described  as 
an  (edematous  affection,  extending  to  more 
or  less  of  the  cellular  substance  around  the 
spermatic  vessels,  and  sometimes  named  the 
encysted  hydrocele  of  the  cord ; the  second 
form  of  the  disease  is  that  in  which  the  fluid 
is  collected  in  a particular  cavity,  or  cyst, 
which  has  no  communication  with  the  cavi- 
ties of  the  common  cellular  substance  of  the 
cord.  This  case  is  denominated  according- 
ly, the  encysted  hydrocele  of  the  cord.  That 
the  cellular  membrane  of  the  cord  is  often 
distended  with  an  aqueous  fluid,  when  the- 
scrotum  is  anasarcous  and  the  habit  dropsi- 
cal, cannot  admit  of  doubt,  and  hence  it  is  a 
frequent  attendant  on  the  case,  which  has 
been  described  asthc  hydrocele cedeirmtodor. 


HYDROCELE. 


l7-> 


But  as  I have  never  seen  au  instance,  in 
which  such  disease  was  restricted  to  the  cel- 
lular texture  of  the  cord,  I am  led  to  sup- 
pose that  it  is  a very  uncommon  case.  The 
following  is  said  by  Mr.  Pott  to  be  the  stale 
of  the  disease,  while  of  moderate  size.  The 
scrotal  bag  is  free  from  all  appearance  of 
disease  ; except  that  when  the  skin  is  not 
corrugated,  it  seems  rather  fuller,  and  hangs 
lather  lower  on  that  side  than  on  the  other, 
and  if  suspended  lightly  on  the  palm  of  the 
hand,  feels  heavier:  the  testicle,  with  its 
©pididymus,  is  to  be  felt  perfectly  distinct 
below  this  fulness,  neither  enlarged,  nor  in 
any  manner  altered  from  its  natural  state  : 
the  spermatic  process  is  considerably  larger 
than  it  ought  to  be,  and  feels  like  a vanx, 
or  like  au  omental  hernia,  according  to  the 
different  size  of  the  tumour  : it  has  a kind  of 
pyramidal  form,  broader  at  the  bottom  than 
«t  the  top  : by  gentle  and  continued  pressure 
it  seems  gradually  to  recede  or  go  up,  but 
drops  down  again  immediately  upon  remo- 
ving the  pressure;  and  that  as  freely  in  a 
supine,  as  in  an  erect,  posture  : it  is  attend- 
ed with  a very  small  degree  of  pain  or  un- 
easiness ; which  uneasiness  is  not  felt  in  the 
scrotum,  where  the  tumefaction  is,  but  in 
the  loins. 

“ If  the  extravasation  be  confined  to  what 
is  called  the  spermatic  process,  the  opening 
in  the  tendon  of  the  abdominal  muscle  is  not 
at  all  dilated,  and  the  process  passing 
through  it  may  be  very  distinctly  felt  ; but 
if  the  cellular  membrane,  which  invests  the 
spermatic  vessels  within  the  abdomen,  be 
affected,  the  tendinous  aperture  is  enlarged  ; 
and  the  increased  size  of  the  distended  mem- 
brane passing  through  it,  produces  to  the 
touch  a sensation  not  very  unlike  that  of 
an  omental  rupture.” 

While  it  is  small,  it  is  hardly  an  object  of 
surgery,  and  maybe  kept  from  being  trou- 
blesome by  means  of  a suspen&orv  ; but 
When  it  is  large,  it  is  very  inconvenient  both 
from  size  and  weight,  and  according  to  Pott, 
the  only  method  of  cure  which  it  admits,  is 
far  from  being  void  of  hazard.  The  plan  is 
to  make  a free  incision  into  the  swelling, 
it  must  be  confessed,  with  a modern  writer, 
that  these  observations  on  the  diffused  hy- 
drocele of  the  cord  by  Mr.  Pott,  are  faf  from 
being  satisfactory,  and  the  symptoms,  by 
which  he  made  up  his  mind  to  lay  open 
the  disease,  were  but  of  an  equivocal  de 
scription,  and  might  have  arisen  from  cases 
of  another  nature.  (See  Did.  dcs  Sciences 
Med.  T 22,  p.  215.) 

the  encysted  hydrocele  of  the  sperm  a. - 

TiC  CORD 

Is  a complaint  by  no  means  infrequent, 
especially  in  children,  it  was  very  well 
known  to  many  of  the  ancients,  and  has 
been  accurately  described  by  Albucasis,  Cel- 
su>,  Pauius  iEgineta,  &,c.  When  Mr.  Pott 
says,  that  the  disease  is  not  infrequent,  it 
ought  to  be  understood,  that  its  frequency, 
though  much  greater,  than  that  of  the  dif- 
fused hydrocele  of  the  cord,  considered  as 
Vor  . If.  10 


a distinct  disease  independent  of  general 
anasarca,  is  not  at  all  equal  to  that  of  the 
hydrocele  of  the  tunica  vaginalis.  Riche- 
rand  has  calculated,  that  the  average  pro- 
portion of  encysted  hydroceles  of  the  cord 
to  those  of  the  latter  description,  is  not  more 
than  as  1 to  200.  ( JYosogr . Chir  T.  4,  p. 
262,  Ed.  4.)  According  to  Mr.  Pott,  the 
swelling  is  mostly  situated  at  the  middle 
part  of  the  cord,  between  the  testicle  and 
groin,  and  is  generally  of  an  oblong  figure  ; 
whence  it  has  by  some  peoplebeen  compared 
to  an  egg,  by  others  to  a fish’s  bladder.  Whe- 
ther it  be  large  or  small,  it  is  generally  pretty 
tense,  and  consequently  the  fluctuation  of 
the  water  within  it,  not  always  immediate- 
ly or  easily  perceptible.  It  gives  no  pain, 
nor  (unless  it  be  very  large  indeed)  does  it 
hinder  any  necessary  action,  ft  is  perfectly 
circumscribed  ; and  has  no  communication, 
either  with  the  cavity  of  the  belly  above,  or 
that  of  the  vaginal  coat  of  the  testicle  below 
it.  The  testis  and  its  epididymis,  are  per- 
fectly and  distinctly  to  be  felt  below  the 
tumour,  and  are  absolutely  independent  of 
it.  The  upper  part  of  the  spermatic  process 
in  the  groin  is  most  frequently  very  distin- 
guishable. The  swelling  does  not  retain  the 
impression  of  the  fingers  ; and  when  lightly 
struck  upon,  sounds  as  if  it  contained  wind 
only.  It  undergoes  no  alteration  from  change 
of  the  patient’s  posture  ; it  is  not  affected 
by  his  coughing,  sneezing,  &,c.  and  it  has  n» 
effect  on  the  discharge  per  anum. 

The  two  diseases  with  which  this  kind  of 
hydrocele  is  most  likely  to  be  combined, 
are,  an  hydrocele  of  the  tunica  vaginalis  tes- 
tis, and  a true  hernia. 

“ One  mark,  or  characteristic  of  an  hydro- 
cele of  the  tunica  vaginalis  testis  is,  that  it  pos- 
sesses and  distends  the  inferior  part  ofthe  scro- 
tum; and  that  thetesticle  be  iug  nearly  (though, 
not  absolutely)  surrounded  by  the  water,  it. 
very  seldom  happens  that  the  former  can  be- 
clearly  and  plainly  distinguished  by  the  fin- 
gers of  an  examiner;  whereas,  in  the  en- 
cysted collection,  in  the  membranes  of  the 
cord,  the  tumour  is  always  above  the  tes- 
ticle, which  is  obvious  and  plain  to  be  felt 
below  it. 

“ Another  circumstance  worth  attending 
to  is,  that  although  the  fluid  in  a hydrocele 
ofthe  vaginal  coat  does  so  nearly  surround 
the  testis  as  to  render  it  often  not  very  easy 
to  be  distinguished,  yet  the  different  parts  of 
the  tumour  have  always  a very  different  feel : 
for  instance,  in  all  those  points  where  the 
vaginal  tunic  is  loose,  and  unconnected  with 
the  tunica  albuginea,  the  tumour  is  soft  and 
compressible,  and  gives  a clear  idea  of  the 
contained  fluid  : but  where  these  two  coats 
are  continuous,  or  make  one  and  the  same 
membrane,  and  have  no  cavity  between 
them  (which  is  the  case  on  the  middle  and 
posterior  part)  there  will  always  be  found 
a hardness  and  firmness  very  unlike  to  what 
is  to  be  found  in  ail  those  places  where  the 
distance  between  the  two  tunics  leaves  room 
for  the  collection  of  a fluid  ; now -the  hydro 
cele  of  the  cord  being  formed  in  the  mere 
cellular  membrane  of  it,  is  the  fame  tolltf* 


"4 


TlYDPiOCELE. 


touch  in  all  the  parts  of  the  tumour,  and 
feels  like  a distended  bladder  through  every 
point  of  it. 

u The  free  state  of  the  upper  part  of  the 
spermatic  process,  while  the  tumour  is  form- 
ing below;  the  gradual  accumulation  of  the 
fluid,  and  consequently  the  gradual  growth 
ot  the  swelling  ; the  indolent  and  unaltering 
state  of  it ; its  being  incapable  of  reduction, 
or  return  into  the  belly  from  the  first;  its 
being  always  unaffected  by  the  patients 
coughing  or  sneezing;  and  the  uninterrupted 
freedom  of  the  fecal  discharge  per  anum, 
will  always  distinguish  it  from  an  intestinal 
hernia  ; and  he  who  mistakes  it  for  an  omen- 
tal one,  must  be  very  ignorant,  or  very 
heedless.” 

Mr.  Pott  met  with  an  encysted  hydrocele 
situated  so  high  toward  the  groin,  as  to  ren- 
der the  perception  of  the  spermatic  vessels 
very  obscure,  or  even  impracticable;  but 
then,  the  state  and  appearance  of  the  testi- 
cle, and  the  absence  of  every  symptom  pro- 
ceeding from  confinement  of  the  intestinal 
canal,  were  sufficient  marks  of  the  true  na- 
ture of  the  complaint.  Several  writers  de- 
scribe this  kind  of  hydrocele,  as  in  fact  a 
common  encysted  tumour,  formed  in  the 
cellular  substance,  between  the  vas  deferens 
and  spermatic  vessels.  ( Delpech , Precis  Elem. 
dts  Mai.  Chir.  T.  3,p.  464.)  Yet,  since  or- 
dinary encysted  swellings  are  very  difficult 
to  disperse,  there  is  probably  some  differ- 
ence between  the  two  affections,  at  least, 
if  the  observation  of  Mr.  Pott  be  correct, 
that  in  young  children,  the  encysted  hydro- 
cele of  the  cord  frequently  dissipates  in  a 
short  time,  especially  if  assisted  by  warm  fo- 
mentation, and  an  open  belly. 

If  it  be  not  absorbed,  “ the  point  of  a lan- 
cet will  give  discharge  to  the  water ; and  in 
young  children,  will  most  frequently  pro- 
duce a cure  : but  in  adults,  the  cyst,  formed 
by  the  pressure  of  the  fluid,  does  sometimes 
become  so  thick,  as  to  require  division 
through  its  whole  length  ; which  operation 
may  in  general  be  performed  with  great 
case,  and  perfect  safety.”  Mr.  Pott  says,  in 
general,  because  it  is  most  frequently  so  : 
though  he  has  even  seen  this,  slight  as  it  may 
*eem,  prove  troublesome,  hazardous,  and 
fatal.  (See  Pott  on  Hydrocele.) 

The  late  Sir  J.  Earle  proposed  treating 
this  case  in  the  same  way  as  the  hydrocele 
of  the  tunica  vaginalis,  viz.  by  an  injection 
of  red  wine  and  water;  which  method  is 
often  successful.  (On  Hydrocele , p.  i 54, 
edit.  2.)  However,  the  cure  of  an  encysted 
hydrocele  of  the  spermatic  cord,  by  means 
of  an  injection,  is  generally  regarded  by 
modern  surgeons,  as  less  certain  and  advan- 
tageous, than  the  excision  of  a part  of  the 
cyst.  The  operation  which  is  described  by 
Bertrandi,  Mr.  Hey,  Richerand,  &.c.  consists 
in  cutting  down  to  the  cyst,  and  removing 
the  forepart  of  it,  while  the  portion,  closely 
attached  to  the  cord,  is  to  be  allowed  to  re- 
main. For  additional  observations  on  this 
species  of  hydrocele.  (See  the  First  Lines  of 
tltc  Practice  of  Surgery , Vol.  2,p,  121.) 


hydrocele  of  the  tunica  vaginalis. 

If  the  quantity  of  limpid  fluid,  which  na- 
turally moistens  the  surface  of  the  tunica 
albuginea  and  the  inside  of  the  tunica  vagi- 
nalis, be  secreted  in  an  undue  quantity,  or 
if  regular  absorption  of  it  be  by  any  mean3 
prevented,  it  will  gradually  accumulate,  and 
distend  the  cavity  of  the  latter  membrane, 
so  as  to  form  the  present  species  of  hydro- 
cele. The  case  in  which  the  fluid  is  sup- 
posed to  descend,  either  partly  or  entirely 
from  the  cavity  of  the  abdomen,  in  conse- 
quence of  the  communication  not  being 
shut  up  in  the  usual  time,  between  the  ca- 
vity of  the  peritoneum  and  that  of  the  tunica 
vaginalis,  is  well  known  to  surgeons  under 
the  appellation  of  a congenital  hydrocele  ; 
a disease,  of  which  particular  notice  has 
been  taken  in  the  2d  Vol.  of  the  last  edition 
of  the  First  Lines  of  Surgery , 8 vo.  Lond.  1820, 
and  to  which  I shall  therefore  very  briefly 
advert  in  this  article.  Hydrocele  of  the 
vaginal  coat  is  a disease  from  which  no 
time  of  life  is  exempt ; not  only  adults  are 
subject  to  it,  but  young  children  are  fre- 
quently afflicted  with  it  : and  infants  some- 
times born  with  it.  (Pott.)  And  it  is  re- 
marked to  be  common  in  old  men,  and  per- 
sons who  ride  a good  deal  on  horseback. 
(Delpech  Precis  Elem.  des  Mai . Chir . T.  3f 
p.  177.) 

The  causes  of  hydrocele  of  the  tunica 
vaginalis  can  scarcely  be  said  to  be  at  all 
understood  ; and  when  Mr.  Pott  observes, 
that  whatever  tends  to  increase  the  secre- 
tion of  fluid  into  the  cavity  of  that  mem- 
brane, beyond  the  due  and  necessary  quan- 
tity, or  to  prevent  its  being  taken  up,  and 
carried  off  by  the  absorbent  vessels  must 
contribute  to  the  production  of  the  disease, 
nearly  as  much  is  stated,  as  can  be  advanced 
with  safety  in  the  present  state  of  our  know- 
ledge. Ruysch  had  a suspicion,  that  this 
hydrocele  might  arise  from  a varicose  state 
of  the  spermatic  veins  ; but  though  Mr.  Pott 
acknowledges  that  these  vessels  are  very 
frequently  found  varicose  in  patients  afflict- 
ed with  this  disorder,  he  was  unable  to  pro- 
nounce what  real  foundation  might  exist 
for  the  foregoing  conjecture,  or  whether 
the  varicose  state  of  the  spermatic  veins 
were  a cause,  or  an  effect  of  the  hydrocele. 
In  most  instances,  the  accumulation  of  fluid 
takes  place  without  any  evident  cause ; 
though,  in  a few  cases,  it  has  appeared  to  be 
the  effect  of  a contusion,  or  of  rough  long- 
continued  friction  of  (lie  scrotum.  The  dis- 
ease is  observed  to  affect  persons  of  the  best: 
health,  and  most  robqst  constitutions,  as 
well  as  others,  and  its  existence  seems  quite 
unconnected  with  dropsy,  or  debility.  In 
short,  it  may  be  regarded  as  a disease  en- 
tirely of  a local  nature.  As  Mr.  Pott  ob- 
serves, its  production  is  so  slow  and  gradual, 
and  at  the  same  time  so  void  of  pain,  that 
the  patient  seldom  attends  to  it,  until  it  has 
arrived  to  some  size.  Not  but  that  it  some- 
times is  produced  very  suddenly  ; and  in  a 
very  short  space  of  time  attains  considerable 
magnitude. 


HYDROCELE. 


75 


In  general,  at  its  first  beginning,  the  tu- 
mour is  rather  round  ; but  as  it  increases,  it 
frequently  assumes  a pyriform  kind  of  figure, 
vith  its  larger  extremity  downward  ; some- 
times it  is  hard,  and  almost  incompressible  ; 
so  much  so,  that,  in  some  few  instances,  it 
has  been  mistaken  for  an  induration  of  the 
testicle:  at  other  times,  it  is  so  soft  and  lax, 
that  both  the  testicle,  and  the  fluid  surround- 
ing it,  are  easily  discoverable,  it  is  perfectly 
indolent  in  itself ; though  its  weight  some- 
times produces  some  small  degree  of  un- 
easiness in  the  back.  According  to  Mr. 
Pott,  the  transparency  of  the  tumour  is  the 
most  fallible  and  uncertain  sign  belonging 
to  it : it  is  a circumstance,  says  he.  which 
does  not  depend  upon  the  quantity,  colour, 
or  consistence  of  the  fluid  constituting  the 
disease,  so  much  as  on  the  uncertain  thick- 
ness, or  thinness  of  the  containing  bag, 
and  of  the  common  membranes  of  the  scro- 
tum. 

If  they  are  thin,  the  fluid  limpid,  and  the 
accumulation  made  so  quick  as  not  to  give 
the  tunica  vaginalis  time  to  thicken  much, 
the  rays  of  light  may  sometimes  be  seen  to 
pass  through  the  tumour : but  this  is  accident- 
al, and  by  no  means  to  be  depended  upon. 
The  fluid  is  most  frequently  of  a pale  yellow, 
or  straw-colour  ; sometimes  it  is  inclined 
to  a greenish  cast ; sometimes  it  is  dark,  tur- 
bid, and  bloody  ; and  sometimes  it  is  per- 
fectly thin  and  limpid. 

With  respect  to  Mr.  Pott’s  remarks  on  the 
transparency  of  the  swelling,  as  a symptom 
of  hydrocele,  they  are  correct,  inasmuch  as 
the  absence  of  this  sign  is  no  proof,  that  the 
disease  is  not  of  this  nature  ; since  thickness 
of  the  tunica  vaginalis,  and,  as  ought  also 
to  have  been  admitted,  the  opaque  quality 
of  the  fluid,  sometimes  prevent  the  rays  of 
a candle  from  passing  through  the  swelling. 
But,  on  the  other  hand,  it  should  have  been 
explained  by  Mr  Pott,  that  when  the  transpa- 
rency is  present,  it  is  one  of  the  surest  marks  of 
this  species  of  hydrocele. 

It  is  next  noticed  by  Mr.  Pott,  that  in  the 
beginning  of  the  disease,  if  the  water  has  ac- 
cumulated slowly,  and  the  tunica  vaginalis 
is  thin  and  lax,  the  testicle  may  easily  be 
perceived  ; but  if  the  said  tunic  be  firm,  or 
the  water  accumulated  in  any  considerable 
quantity,  the  tetis  cannot  be  felt  at  all.  In 
most  cases,  the  spermatic  vessels  may  be 
distinctly  felt  at  their  exit  from  the  abdomi- 
nal muscle,  or  in  the  groin  ; which  will  al- 
ways distinguish  this  complaint  from  an  in- 
testinal hernia.  But,  in  a few  examples,  the 
vaginal  coat  is  distended  so  high,  and  is  so  full 
that  it  is  extremely  difficult,  nay,  almost  im- 
possible, to  feel  the  spermatic  cord:  and  the 
same  kind  of  obscurity  is  sometimes  occa- 
sioned by  the  addition  of  an  encysted  hydro- 
cele of  the  cord  ; or  by  the  case  being  com- 
bined with  a true  enterocele. 

in  a hydrocele  of  the  tunica  vaginalis,  the 
swelling  is  first  noticed  at  the  lower  part  of 
the  scrotum,  whence  it  ascends  in  front  of 
the  testicle  and  spermatic  cord.  The  pro- 
gress of  the  disease  is  generally  so  slow, 
*hat  six  or  even  eighteen  months  elapse,  be- 


fore the  tumour  approaches  the  abdominal 
ring.  And,  among  other  characters  of  the 
case,  are  to  be  noticed  the  disappearance  of 
the  corrugations  of  the  scrotum  by  the  effect 
of  the  distention  ; inclination  of  the  raphe 
to  the  opposite  side  ; and  the  possibility  of 
feeling  a fluctuation,  when  (lie  fingers  of  one 
hand  are  applied  to  one  side  of  the  tumour, 
and  the  surgeon  slightly  taps  with  the  fingers 
of  his  other  hand  upon  an  opposite  point  of 
the  swelling. 

In  the  hydroceles  of  children,  the  testis 
occupies  a lower  situation,  than  the  the  same 
organ  in  the  hydroceles  of  adult  persons, 
and  the  swelling  passes  further  up  towards 
the  abdominal  ring. 

It  is  well  explained  by  Mr.  Pott,  that  the  tu- 
nica vaginalis  and  tunica  albuginea,  are  so 
inseparably  united  at  the  posterior  and  supe- 
rior, or  rather  the  posterior  and  middle 
part  of  the  tumour,  that  no  fluid  can  collect 
between  them  ; and  therefore,  the  fingers 
of  an  intelligent  examiner  must  immediately 
discover  here  the  firmness  and  hardness 
arising  from  the  union  of  these  parts;  while 
in  all  others,  the  two  membranes  being  un- 
connected, and  affording  a void  space  for 
the  collection  of  water,  the  fluctuation  of  it 
will  always  be  distinguishable. 

“ This  (says  Pott)  must  for  ever  discrimi- 
nate the  simple  hydrocele  of  the  tunica  va- 
ginalis from  the  anasarcons  swelling  of  the 
scrotum  ; from  the  encysted  hydrocele  of 
the  cord  ; and  from  the  intestinal  hernia. 
The  first  is  every  where  equal,  tumid,  and  soft; 
and  every  where  equally  receives  and  retains 
the  impression  of  the  fingers  , the  second, 
though  circumscribed,  not  very  compressi- 
ble, and  affording  the  sensation  of  fluctuation, 
yet  does  not  pit,  and  is  alike  to  the  touch  in  all 
parts  of  it ; and  in  the  third,  if  the  testicle 
be  distinguishable  at  all,  it  is  found  at  the 
inferior  part  of  the  whole  tumour.” 

A collection  of  fluid  in  the  tunica  vagina- 
lis, complicated  with  a scirrhous  or  chronic 
induration  and  enlargement  of  the  testicle, 
is  well  known  under  the  name  of  hydro-ca r> 
cocele ; a case,  which  should  be  carefully 
discriminated  from  a simple  hydrocele,  “ one 
of  the  marks  of  the  latter  being  the  natural, 
soft,  healthy  state  of  the  testicle  : and  the 
characteristic  of  the  former  being  its  disea- 
sed and  indurated  enlargement.” 

Mr.  Pott  does  not  mean  that,  in  a true 
simple  hydrocele,  the  testicle  is  never  altered 
from  its  natural  state.  He  admits  the  con- 
trary, and  that  it  is  often  enlarged  in  size, 
and  relaxed  in  structure,  and  that  the  sper- 
matic vessels  are  frequently  varicose.  But, 
the  testicle  is  never  indurated.  These  two 
diseases  are  extremely  unlike  each  other,  and 
require  very  different  treatment.  That 
which  would  cure  a simple  hydrocele,  would 
dangerously  aggravate  the  hydro-sarcocele. 

Mr.  Pott  observes,  that  “ it  may,  and  does 
sometimes  become  necessary  to  let  out  the 
water  from  the  vaginal  coat  of  a testicle,  in 
some  degree  diseased  ; but  this  should  al- 
ways be  done  with  caution,  and  under  a 
guarded  prognostic  ; lest  the  patient  be  not 
only  disappointed,  by  not  having  that  per- 


76 


HYDROCELE. 


manent  relief,  which,  foT*  want  of  better  in- 
formation, he  may  be  induced  to  expect  ; 
but  be  also  (possibly)  subjected  to  other  un- 
expected inconveniences  from  the  attempt. 

“ When  the  disease  is  a perfect,  true,  sim- 
ple hydrocele,  the  testicle,  though  frequently 
somewhat  enlarged,  and  perhaps  loosened 
in  its  vascular  texture,  is  nevertheless  sound, 
healthy,  and  capable  of  executing  its  proper 
office  ; neither  is  the  spermatic  cord  any 
way  altered  from  a natural  state,  except  that 
its  vessels  are  generally  somewhat  dilated  ; 
neither  of  which  circumstances  are  objec- 
tions either  to  the  palliative  or  radical  cure 
of  the  disease.  But  in  those  disorders, 
which  in  some  degree  resemble  this,  the 
case  is  different ; either  the  testicle,  or  sper- 
matic cord,  or  both,  bearing  evident  marks 
of  a diseased  state.” 

According  to  Richerand,  a hydrocele  may 
be  known  from  a sarcocele  by  the  following 
circumstances:  in  a sarcocele,  the  tumour 
mostly  retains  the  shape  of  the  testicle,  being 
oval  and  a little  flattened  at  the  sides,  and  its 
size  becomes  considerable  in  a short  time, 
without  ascending  so  near  the  abdominal 
ring,  as  a hydrocele  does,  when  of  the  same 
magnitude.  A large  hydrocele  leaves  no 
interspace  between  that  opening  and  the 
tumour,  so  that  it  is  difficult  to  take  hold  of, 
and  lift  up  the  spermatic  cord  ; but,  in  a sar- 
cocele, there  is  always  a space  between  the 
tumour  and  the  ring,  where  the  cord  can  be 
distinctly  felt.  Lastly,  in  a sarcocele,  the 
tumour  is  always  opaque,  and  its  weight,  in 
reference  to  its  size,  much  more  consider- 
able, than  that  of  a hydrocele.  ( JYosogr . 

Chir.  T.  4,  p.  267,  Ed.  4.)  The  hardness  is 
not  a symptom  which  can  be  trusted  alone, 
as  a criterion  of  a diseased  testicle  ; for, 
when  a hydrocele  is  extremely  distended,  it 
©ften  feels  so  indurated  as  to  deceive  prac- 
titioners of  great  experience,  and  a thick- 
ened, hardened  state  of  the  tunica  vaginalis 
may  facilitate  the  mistake.  In  some  instan- 
ces of  hydro-sarcocele,  the  nature  of  Ike  dis- 
ease sometimes  remains  questionable,  until 
the  evacuation  of  the  fluid  gives  the  surgeon 
a fair  opportunity  of  ascertaining  the  disea- 
sed state  of  the  testicle. 

The  complication  of  an  hydrocele  of  the 
tunica  vaginalis  with  an  encysted  one  of 
the  spermatic  cord,  may  generally  be  known 
by  the  swellings  having  begun  at  two  differ- 
ent points,  and  by  a kind  of  constriction  be- 
tween them.  The  latter  symptom,  however, 
is  not  infallible,  because  the  tunica  vaginalis 
of  a common  hydrocele  is  sometimes  more 
or  less  contracted  at  the  middle  of  the  tu- 
mour, which  is  thus  made  to  appear  as  if 
there  were  two  distinct  pouches. 

The  size  of  a hydrocele,  and  the  thick- 
ness of  the  tunica  vaginalis,  are  generally 
5 , a ratio  to  the  time, which  thejdisease  has  con 
tinued.  Sometimes  the  latter  membrane 
acquires  nearly  a cartilaginous  hardness; 
and  portions  of  it  have  been  found  in  an 
ossified  state  ; the  only  circumstance,  in 
which  any  free  excision  of  it  is  now  account- 
ed, necessary.  A hydrocele  has  been  known 


to  contain  foul*  pints  of  fluid.  (V riglel, 

Jlandbueh  der  Pract.  Jinat.  B.  3,  p.  388.) 

METHODS  OF  CURING  THE  HYDROCELE  OF  THE 
VAGINAL  COAT. 

A hydrocele  is  by  no  means  a dangerous 
complaint,  though  its  weight  and  size  are  a 
disagreeable  incumbrance,  and  the  patient 
is  always  obliged  to  wear  a bag  truss,  in 
order  to  prevent  a painful  extension  of  the 
spermatic  cord.  Troublesome  excoriations 
are  also  frequently  caused  by  the  friction  of 
the  tumour  against  the  inside  ot  the  thigh  ; 
and  when  the  swelling  is  very  large,  it  draws 
over  itself  the  integuments  of  the  penis, 
w hich  appears  buried,  as  it  were,  in  the  tu- 
mour, and  its  functions  are  seriously  inter- 
rupted. Hence,  the  greater  number  of 
patients  are  very  anxious  for  relief. 

“ The  methods  of  cure  (says  Pott)  though 
various,  are  reducible  to  two,  (viz.)  the  pallia- 
tive, or  that  which  pretends  only  to  relieve 
the  disease  in  present,  by  discharging  the 
fluid  ; and  the  radical,  or  that  which  aims 
at  a perfect  cure,  without  leaving  a possibi- 
lity of  relapse.  The  end  of  the  former  is 
accomplished  by  merely  opening  the  con- 
taining bag  in  such  manner  as  to  let  out 
the  water : that  of  the  latter  cannot  be  ob- 
tained, unless  the  cavity  of  that  bag  be  abo- 
lished, and  no  receptacle  for  a future  accumu - 
lation  left ; (a  proposition,  on  which  the  ob- 
servations of  Mr.  Ramsden  and  Mr.  Wadd, 
published  since  Mr.  Pott’s  time,  have  thrown 
a degree  of  doubt.)  One  may  be  practised 
at  all  times  of  the  patient’s  life,  and  in  almost 
any  state  of  health  and  habit : the  other  lies 
under  some  restraints  and  prohibitions  ; ari- 
sing from  the  circumstances  of  age,  constitu- 
tion, slate  of  the  parts,  &.c. 

“ The  operation,  by  which  the  fluid  is  let 
out,  is  a very  simple  one.  The  only  circum 
stances  requiring  our  attention  in  it,  are,  the 
instrument  wherewith  we  wrould  perform 
it ; and  the  place  or  part  of  the  tumour,  into 
which  such  instrument  should  be  passed. 

u The  two  instruments  in  use,  are  the  com- 
mon bleeding-lancet,  and  the  trocar. 

“The  former  having  the  finer  point,  may 
possibly  pass  in  rather  the  easier,  (though 
the  difference  is  hardly  perceptible)  but  is 
liable  to  inconveniences,  to  which  the  latter 
is  not.  The  trocar,  by  means  of  its  cannula, 
secures  the  exit  of  the  whole  fluid  without 
a possibility  of  prevention  ; the  lancet  can- 
not. And  therefore  it  frequently  happens 
when  this  instrument  is  used,  either  that 
some  of  the  water  is  left  behind,  or  that 
some  degree  of  handling  and  squeezing  is 
required  for  its  expulsion  ; or,  that  the  in- 
troduction of  a probe,  or  a director,  or  some 
such  instrument,  becomes  necessary  for  the 
same  purpose  The  former  of  these  may  in. 
some  habits  be  productive  of  inflammation  . 
the  latter  prolongs  what  would  otherwise 
be  a short  operation,  and  multiplies  the  ne- 
cessary instruments  ; which,  in  every  ope- 
ration in  surgery,  is  wrong.  To  which  it 
may  be  added,  that  if  any  of  the  fluid  be 
left  in  the  vaginal  coat,  or  insinuates  itself 


HYDROCELE,  # 


into  the  celte  of  the  scrotum,  the  patient 
will  have  reason  to  think  the  operation  im- 
perfect, and  to  fear,  that  he  shall  not  reap 
even  the  temporary  advantage  which  he 
expected.  The  place  where  this  puncture 
ought  to  be  made,  is  a circumstance  of 
much  more  real  consequence  ; the  success 
of  the  atiempt,  the  case,  and  even  some- 
times the  safety  of  the  patient,  depending 
upon  it. 

“ All  the  anterior  and  lateral  parts  of  the 
vaginal  coat  are  loose  and  detached  from 
the  albuginea  ; in  its  posterior  and  superior 
part,  these  two  tunics  make  one  ; conse- 
quently the  testicle  is,  as  it  were,  affixed  to 
the  posterior  and  superior  part  of  the  cavity 
of  the  sac  of  an  hydrocele  ; and  conse- 
quently, the  water  or  fluid  can  never  get 
quite  round  it.  This  being  the  state  of  the 
case,  the  operation  ought  always  to  be  per- 
formed on  that  pari  of  the  tumour,  where 
the  two  coats  are  at  the  greatest  distance 
from  each  other,  and  w here  the  fluid  must 
therefore  be  accumulated  in  the  largest 
quantity  ; and  never  on  that  part  of  it  where 
the  fluid  cannot  possibly  be.  The  conse- 
quence of  acting  otherwise,  must  not  only 
produce  a disappointment,  by  not  reaching 
the  said  fluid  ; but  may  prove,  and  has  pro- 
ved, highly  and  even  fatally  mischievous 
to  the  patient. 

“ After  performing  this  operation,  present 
practitioners  content  themselves  with  a bit 
of  lint  and  a plaster;  and  if  the  scrotum 
has  been  considerably  distended,  they  sus- 
pend it  in  a bag  truss  ; and  give  the  patient 
no  farther  trouble. 

“ In  most  people  (continues  Pott)  the 
orifice  thus  made  heals  in  a few  hours,  (like 
that  made  for  blood-letting  ;)  but  in  some 
habits  and  circumstances,  it  inflames  and 
festers  ; this  festering  is  generally  superfi- 
cial only,  and  is  soon  quieted  by  any  sim- 
ple dressing  ; but  it  sometimes  is  so  consi- 
derable, and  extends  so  deep,  as  to  affect 
the  vaginal  coat,  and  by  accident  produce 
a radical  cure.  Mr.  Pott  has  also,  seen  it 
prove  still  more?  troublesome,  and  even  fa- 
tal ; but  then  the  circumstances  both  of 
the  patient,  and  of  the  case,  have  been  par- 
ticular. 

“ Wiseman  and  others  have  advised  de- 
ferring the  puncture,  till  a pint  of  fluid  has 
collected.  When  there  is  a sufficient  quan- 
tity, however,  to  keep  the  testicle  from  the 
instrument,  there  can  be  no  reason  for  de 
ferring  the  discharge  ; and  the  single  point 
on  which  this  argument  ought  to  rest,  is 
this  : Whether  the  absorbent  vessels,  by 
which  the  extravasation  should  be  prevent- 
ed, are  more  likely  to  reassume  their  office, 
while  the  vaginal  coat  is  thin,  and  has  suf- 
fered but  little  violence  from  distention  ; 
or  after  it  has  been  stretched  and  distended 
to  ten  or  perhaps  twenty  times  its  natural 
capacity  ; and  by  such  distention  is  (like  all 
other  membranes)  become  thick,  hard,  and 
to  idi  ? Mr.  Pott  thinks  the  probability  so 
much  more  on  the  side  of  the  former,  that 
he  should  never  hesitate  a moment  about 
Getting  out  the  water,  as  soon  as  be  found 


that  the  puncture  could  be  made  securely. 
And  from  what  has  happened  within  the 
small  circle  of  his  own  experience,  he  is  in  - 
clined to  believe,  that  if  it  was  performed 
more  early  than  it  generally  is.  it  might 
sometimes  prevent  the  return  of  the  disease.’' 

Ihe  foregoing  passage  deserves  to  be  par- 
ticularly recollected,  because  it  evidently 
implies  a belief  by  Mr.  Pott  himself,  that, 
under  certain  circumstances,  a radical  cure 
may  be  effected,  though  the  cavity  of  the 
tunica  vaginalis  be  not  obliterated  ; an 
opinion  since  promulgated,  as  I have  already 
said,  by  Mr.  Ramsden,  Mr.  Wadd,  and  Mr. 
Kinder  Wood,  indeed,  itappears  probable, 
that  generally  when  a hydrocele  is  perma- 
nently cured,  by  means  of  such  external  ap- 
plications, as  do  not  excite  inflammation, 
but  operate  by  quickening  the  action  of  the 
absorbent  vessels,  the  cavity  of  the  tunica 
vaginalis  is  not  destroyed  ; and  there  cau 
be  but  little  doubt  of  the  same  thing,  when- 
ever what  is  termed  a spontaneous  cure 
happens,  as  it  sometimes  does  in  young  sub- 
jects. But,  unless  the  fact  were  demonstrated 
by  dissection,  I should  not  believe  that  the 
cavity  is  not  annihilated,  after  the  comple- 
tion of  a radical  cure  by  any  of  the  methods, 
calculated  to  excite  inflammation  of  tho 
tunica  vaginalis  and  tunica  albuginea. 

The  palliative  cure  should  in  general  be 
performed  at  least  once  on  those,  who  de- 
termine to  undergo  a radical  one,  as  it  gives 
an  opportunity  of  examining  the  state  of 
the  testis,  and  also  of  permitting  the  cavity 
to  be  filled  again  only  to  such  a size,  as 
may  bethought  to  be  best  calculated  to  en- 
sure success  in  any  future  operation.  (Sir 
J.  Earle  on  Hydrocele,  p.  13,  ed.  2.) 

Upon, the  subject  of  performing  the  opera- 
tion of  tapping  hydroceles,  Professor  Scar- 
pa gives  us  some  useful  cautions.  The 
analogy,  which  exists  between  large  scrotal 
herniae  and  hydroceles  of  considerable  size, 
led  this  writer  to  suspect,  that,  irr  the  latter 
disease,  the  displacement  and  separation  of 
the  vessels  of  the  spermatic  cord  from  each 
other  might  also  happen.  Careful  invest! 
gations,  made  upon  the  dead  subject,  fully 
justified  the  conjecture.  In  all  considerable 
hydroceles,  he  found  the  spermatic  vessels 
so  displaced  and  separated,  that  the  artery 
and  vas  deferens  were  ordinarily  situated  on 
one  side  of  the  tumour,  and  the  veins  on  the 
other.  Sometimes  these  vessels  all  extend- 
ed over  the  lateral  parts  of  the  tumour,  as 
far  as  its  anterior  surface,  principally  towards 
the  bottom. 

It  is  well  known,  that  in  many  instances, 
the  operation  of  puncturing  a hydrocele 
has  been  followed  by  a large  extravasation 
of  blood  within  the  tunica  vaginalis;  but 
Scarpa  informs  us,  that  until  lately,  he  was 
unacquainted  with  any  case  of  this  kind, 
which  was  well  detailed  and  authentic 
enough,  to  be  cited  as  an  example  of  injury 
of  the  spermatic  artery  in  the  puncture  of 
a hydrocele.  This  learned  Professor,  how- 
ever, has  had  such  a fact  recently  commu- 
nicated to  him  by  Gasparoli,  a distinguished 
surgeon  of  Pallanza,  who,  in  introducing 


HYDROCELE. 


*3 


the  trocar  into  the  lower  part  of  the  swell- 
ing, had  the  misfortune  to  injure  the  sper- 
matic artery,  and  the  patient  was  after- 
ward castrated.  The  wound  of  this  vessel 
Was  most  clearly  proved  by  the  particulars 
of  the  case,  as  detailed  in  Scarpa’s  work, 
to  which  I must  refer  the  reader. 

From  the  accurate  knowledge,  (says 
Scarpa)  which  we  now  have  upon  this  pa- 
thological point,  such  an  accident  may  be 
avoided,  by  observing  the  rules,  which  are 
elsewhere  given  for  opening  the  sac  of  a 
very  large  scrotal  hernia.  In  this  last  ope- 
ration, as  well  as  that  of  puncturing  an  old 
and  voluminous  hydrocele,  care  must  be  ta- 
ken to  introduce  the  instrument  at  a consi- 
derable distance  from  the  bottom  of  the  tu- 
mour, that  is  to  say,  a little  below  its  mid- 
dle part,  and  on  a line,  which  would  divide 
the  swelling  longitudinally  into  two  perfect- 
ly equal  parts.  Experience  proves,  that 
for  the  purpose  of  completely  emptying  an 
hydrocele,  it  is  unnecessary  to  make,  the 
puncture  very  near  the  bottom  of  the  tu- 
mour. The  corrugation  of  the  scrotum, 
and  a slight  pressure,  made  by  the  surgeon’s 
hand,  will  suffice  for  discharging  all  the 
fluid  contained  in  the  tunica  vaginalis,  even 
when  the  puncture  is  made  at  the  middle 
part  of  the  swelling.  ( Scarpa , Traits  des 
Hernies,  p.  64 — 68.)  On  account  of  the 
lower  situation  of  the  testicle  in  the  hydro- 
cele of  a child,  than  in  that  of  a grown-up 
erson,  these  directions  of  Scarpa  will  also 
e of  value. 

RADICAL  CURE  OF  THIS  HYDROCELE. 

Besides  the  employment  of  external  ap- 
plications, wherewith  a permanent  cure  has 
occasionally  been  accomplished,  as  related 
in  my  other  work,  six  different  operations 
have  been  practised  for  the  same  purpose  ; 
Yiz.  incision  ; excision  ; the  application  of 
caustic  ; the  introduction  of  a tent  ; the 
employment  of  a seton,  and  injecting  some 
stimulating  fluid  into  the  cavity  of  the  tuni- 
ca vaginalis. 

The  principle,  on  which  the  success  of 
every  plan  of  this  kind  is  commonly  be- 
lieved to  depend,  is  the  excitement  of  such 
a degree  of  inflammation  in  the  tunica  vagi- 
nalis, and  tunica  albuginea,  forming  the  ca- 
vity which  contains  the  water,  as  shall  end 
in  a mutual  and  general  concretion  of  those, 
membranes  with  each  other,  by  which  it  is 
evident,  the  receptacle  for  a future  accu- 
mulation of  fluid  is  completely  obliterated. 

All  the  above  plans  are  not  equally  eligi- 
ble. Some  of  them,  indeed,  are  now  quite 
exploded  ; and  some,  which  are  still  practi- 
sed by  a few,  are  not  more  successful, 
though  certainly  more  severe,  than  one, 
which  will  be  presently  recommended  ; 
while  others  are  very  uncertain  in  their  ef- 
fect, as  well  as  painful. 

Incision. 

Making  an  incision  so  as  to  lay  open  the 
cavity  containing  the  fluid,  is  the  most  an- 
cient method,  being  described  by  Celsus. 
T*aulus  jEgineta  says,  the  incision  is  to  com- 


mence at  the  middle  of  the  tumour,  and 
be  carried  to  the  upper  part  of  it,  in  a line 
parallel  to  the  raphe.  This  incision  is  on- 
ly to  go  through  the  integuments  ; the  bag, 
which  contains  the  water,  is  then  to  be 
opened,  and  part  of  the  sides  of  the  sac  ta- 
ken away.  A director  is  next  to  be  intro- 
duced, and  a division  of  the  tunica  vaginalis 
made  to  the  bottom  of  the  swelling.  The 
cavity  is  afterward  to  be  dressed  with  lint, 
and  healed  by  granulations.  Hildanus,  Do- 
donaeus,  Wiseman,  Cheselden,  Heister,  and 
Sharp,  all  coincide  instating  the  dangerous 
and  even  fatal  consequences  sometimes  fol- 
lowing this  mode.  Mr.  B.  Bell,  who  pre- 
ferred this  operation  to  every  other  one, 
acknowledges,  that  he  has  seen  it  produce 
great  pain  and  tension  of  the  abdomen,  in- 
flammation, and  fever.  Pott  observes,  that 
it  can  never  be  said  to  be  totally  void  of 
danger,  and  that  it  bears  the  appearance  of 
an  operation  of  some  severity.  This  emi- 
nent surgeon  abandoned  the  method,  du 
ring  the  last  twenty-six  years  of  his  life. 
Severe  as  it  is,  it  has  also  been  known  to 
fail,  as  Sabatier  and  Earle  have  confirmed. 

Excision. 

Albucasis  gave  the  first  clear  accouut  of 
this  operation,  though  Celsus  has  certainly 
mentioned  removing  some  of  the  sac. 
White  and  Douglas  used  to  adopt  this  me- 
thod. The  latter  advises  making  two  in- 
cisions, so  as  to  form  an  oval,  from  the  up- 
per to  the  lower  part  of  the  tumour ; dis- 
secting off  the  oval  piece  of  the  scrotum, 
and  then  making  an  opening  into  the  sac, 
and  enlarging  it  with  scissors.  The  tunica 
vaginalis  was  next  to  be  entirely  cut  away, 
close  to  where  it  was  connected  with  the 
spermatic  vessels.  The  cavity  was  afterward, 
filled  with  lint.  Sir  James  Earle  justly  noti- 
ces, that  this  plan  must  have  been  tedious,  ex- 
quisitely painful  in  the  performance,  and, 
as  subsequently  treated,  attended  with  vio- 
lent and  dangerous  symptoms.  In  modern 
days,  excision  is  only  sanctioned,  when  the 
tunica  vaginalis  is  more  or  less  in  an  ossifi- 
ed state,  for  a mere  thickening  of  it  does  not 
prevent  the  success  of  milder  plans  of 
treatment.  With  respect  to  a mode  of  ex- 
cision, recently  proposed  by  Mr.  Kinder 
Wood,  it  differs  entirely  from  the  ancient 
method,  inasmuch  as  it  is  perhaps  the  mild- 
est of  every  plan  yet  suggested  for  the  ra- 
dical cure,  since  it  simply  consists  in  punc- 
turing the  hydrocele  with  an  abscess  lan- 
cet, drawing  out  a little  bit  of  the  sac  with 
a tenaculum,  and  cutting  it  off.  (See  Med. 
Cfiir.  Trans.  Vol.  9,  p.  33.)  But,  further  ex- 
perience is  requisite  to  determine,  whether 
this  very  easy  plan  is  as  certain  as  that  with 
an  injection.  Whether  the  cavity  is  oblite- 
rated or  not,  as  Mr.  Kinder  Wood  himself 
believes,  appears  also  still  questionable. 

Caustic. 

Paulus  JF.gineta  advises  destroying  the 
skin  with  a cautery  of  a particular  form, 
dissecting  off  the  eschar,  and  then  cauterizing 
the  exposed  membrane.  Guido  di  Cauliaco 


HYDROCELE. 


•79 


is,  perhaps,  the  first  who  described  the  ap- 
plication of  caustic  for  the  cure  of  hydro- 
cele. Wiseman  practised  this  method. 
Dionis  advises  it  ; but  De  la  Faye  and 
Garengeot  make  objections  to  it.  Mr. 
Else  has  left  the  best  account  of  the  manner 
of  using  caustic.  He  recommends  laying 
“ a small  caustic  upon  the  anterior  and  in- 
ferior part  of  the  scrotum,  which  it  is  intend- 
ed to  affect,  and,  if  possible,  penetrate 
through  the  tunica  vaginalis.” 

The  objections  to  the  employment  of 
caustic  are,  its  causing  an  unnecessary 
destruction  of  parts,  and  producing  a tedious 
painful  sore.  The  action  of  caustic  can 
never  be  so  regulated  as  to  make  an  opening 
with  certainty  through  the  tunica  vaginalis, 
so  that  either  its  application  must  sometimes 
be  repeated,  or  else  a lancet,  or  trocar,  used 
after  all.  Its  success  is  also  less  sure,  than 
that  of  an  injection  ; but,  it  is  preferable  to 
all  the  other  methods,  except  this  latter,  the 
modification  of  excision  proposed  by  Mr. 
K.  Wood,  and,  perhaps,  the  seton. 

Tent. 

This  is  first  mentioned  by  Franco.  The 
operation  consists  in  making  ah  opening 
into  the  tunica  vaginalis,  and  keeping  the 
wound  open  with  a tent  of  lint,  linen,  or 
sponge,  so  as  to  make  the  cavity  suppurate, 
in  which  the  water  was  contained.  Pare, 
15 uilleman,  Covillard,  Ruysch,  Heister,  and 
Marini,  have  all  described  the  plan  with 
some  variations,  one  of  which  consisted  in 
smearing  the  tents  with  irritating  substances. 
Dr.  A.  Monro  senior  devised  the  plan  of 
keeping  a cannula  in  the  tunica  vagmaiis  ; 
so  as  to  bring  on  a cohesion  ot  the  parts 
without  suppuration.  Fabricius  ab  Aqua- 
pendente,  however,  has  made  allusion  to 
some  surgeons  before  his  time,  who  used  to 
keep  the  wound  open  a few  days  with  a 
cannula.  Mr.  Pott  tried  the  cannula,  but 
found  it  very  inconvenient,  as  its  inflexibili- 
ty hurt  the  testis  whenever  the  patient  mo- 
ved with  inattention,  and  consequently, 
he  preferred  a tent,  or  bougie,  though  he 
speaks  of  the  plan  as  a very  uncertain  one. 

Of  late,  Baron  Larrey,  in  consequence  of 
having  seen  several  instances,  in  which  the 
symptoms,  following  the  use  of  an  injec- 
tion, were  violent,  and  one  case,  in  which 
a fatal  peritonitis  was  produced,  has  recom- 
mended exciting  the  necessary  degree  of 
inflammation  by  keeping  a short  piece  of  an 
elastic  gum  catneter  in  the  puncture,  which 
instrument  also  serves  afterward  to  let  any 
fluid  escape  from  the  tunica  vaginalis. 
(Mem.  de  Chir.  Militaire,  T.  3,  p.  109,  &pc.) 
This  author,  of  course,  speaks  of  the  plan  as 
having  fully  answered  his  expectations  ; 
but,  1 much  doubt  whether  it  has  any  parti- 
cular superiority  over  several  of  the  former 
methods  of  employing  the  tent;  methods, 
which  the  wisdom,  arising  from  experience, 
has  long  since  rejected', 

Seton 

Was  first  mentioned  by  Guido  di  Cauliaco,  in 
1498,  as  a means  of  curing  the  hydrocele. 


In  modern  times,  Pott  preferred  it  to  everv 
other  method,  if  we  except  injection,  of 
which,  according  to  Sir  J.  Earle,  he  express- 
ed his  approbation  before  his  decease.  Mr. 
Pott  found,  that  the  best  mode  of  making 
the  seton  was  as  follows.  He  employed, 
three  instruments:  the  first  was  a trocar,  the 
cannula  of  which  was  about  one-fourth  of 
an  inch  broad.  The  second  was  what  he 
called  the  seton-cannula,  which  was  made 
of  silver,  was  just  small  enough  to  pass  with 
ease  through  the  cannula  of  the  trocar,  and 
five  inches  long.  The  third  instrument  was 
a probe  six  inches  and  a half  long,  having  at 
one  end  a fine  steel  trocarppint,  and,  at  the 
other,  an  eye,  which  carried  the  seton.  The 
seton  consisted  of  so  much  white  sewingsilk, 
as  would  just  pass  easily  through  the  cannu- 
la, arid  yet  fill  it.  The  thickness  of  the 
seton,  however,  was  not  so  great  in  the  lat- 
ter part  of  his  practice.  Having  pierced  the 
inferior  and  anterior  part  of  the  tumour 
with  the  trocar,  withdrawn  the  perforator, 
and  discharged  the  water,  Mr.  Pott  used  to 
pass  the  seton-cannula  throm  h that  of  the 
trocar,  to  the  upper  part  of  the  tunica  vagi- 
nalis, so  as  to  be  felt  there.  The  probe, 
armed  with  the  seton,  wras  next  conveyed 
through  the  latter  cannula,  a id  its  point 
pushed  through  the  upper  part  of  the  tunica 
vaginalis,  and  scrotum.  The  silk  was  then 
draw  n through  the  cannula,  until  asulficient 
quantity  was  brought  out  of  the  upper  orifice. 
The  two  cannula  being  withdrawn,  the  ope- 
ration was  finished. 

Injection. 

Dr.  Monro  attributes  the  first  use  of  injec- 
tions for  the  radical  cure  of  hydroceles  to  an 
army-surgeon  of  his  own  name,  who  em- 
ployed spirits  of  wine.  This  produced  a 
cure,  but  the  inflammation  was  so  violent, 
that  he  afterward  tried  a milder  injection, 
which  consisted  of  wine.  However,  Lam- 
bert, in  his  (Euvres  Chir.  published  at  Mar- 
seilles early  in  the  seventeenth  century  ad- 
vised injecting  a solution  of  sublimate  in 
lime  water,  and  he  has  related  cases  of  suc- 
cess. Mr.  5.  Sharp  also  made  trial  of  spirit 
of  wine,  which  cured  the  hydrocele,  but  not. 
without  causing  dangerous  symptoms,  and 
two  subsequent  abscesses  in  the  scrotum. 
(Operations  of  Surgery.)  Douglas,  Le  Dran, 
and  Pott,  all  disapprove  of  injections  in  their 
works  ; though  Sir  James  Earle  informs  us, 
that  the  latter  lived  to  alter  his  opinion  on 
the  subject. 

The  violence  of  the  inflammatory  symp- 
toms, consequent  to  the  first  employment  of 
injections  for  the  radical  cure  of  hydroceles, 
arose  from  the  fluids  used  being  too  irrita- 
ting. Sir  James  Earle,  at  last,  preferred 
wine  for  several  reasons.  He  found,  that 
it  had  been  used  with  success  in  France ; 
its  strength  is  never  so  great  as  to  render  it 
unsafe  ; and  it  may  be  readily  weakened. 
This  injection,  in  short,  produces  less  pain 
than  any  other  mode  of  cure,  does  nothing 
more  than  is  intended,  and  is  as  certain 
as  any  plan. 

I have  commonly  used  ('says  Sir  James 


HYDROCELE; 


80 


Earle)  about  two-thirds  of  wine  to  one- 
third  of  water;  if  the  parts  appeared  in- 
sensible, and  no  pain  at  all  was  produced  by 
the  first  quantity  thrown  in,  I have  with 
drawn  the  syringe,  and  added  to  the  propor- 
tion of  wine  ; on  the  contrary,  if  the  corn- 
plaint  was  recent,  and  the  parts  irritable,  I 
have  increased  the  proportion  of  water,  so 
that  1 have  hitherto  been  principally  guided 
by  the  degree  of  sensation,  which  the  pa- 
tient has  expressed.  I have  lately  used  pure 
water  mixed  with  wine,  and  found  it  answer 
as  well  as  when  astringents  were  added/’ 

( P • 103,  Treatise  on  the  Hydrocele,  Ed.  2.)  In 
the  preface,  the  author  says,  that  he  has 
long  disused  the  pipe  with  a stop-cock, 
which  he  once  employed,  on  account  of  not 
being  well  able  to  spare  a hand,  during  the 
operation,  to  turn  it,  and  its  consequently 
being  found  awkward.  A pipe,  one  end  of 
which  is  made  to  fit  into  the  cannula  ot  a 
trocar,  the  other  adapted  to  receive  the  neck 
ot  an  elastic  bottle,  with  a valve,  or  ball,  in 
the  centre  of  the  pipe  to  permit  the  en- 
trance, and  prevent  the  exit,  of  the  injection, 
will  be  found  infinitely  more  convenient  and 
useful.  (Earle.)  When  the  hydrocele  is 
very  large,  Sir  James  recommends  simply 
letting  out  the  fluid,  and  waiting  till  the  tu- 
mour acquires  a more  moderate  size  before 
attempting  the  radical  cure  by  injection. 

It  appears  from  Sir  James  Earle’s  interest- 
ing cases,  that  a cure  may  be  accomplished 
in  this  manner,  even  when  the  tunica  vagi- 
nalis is  considerably  thickened.  The  follow- 
ing is  the  common  mode  of  operating ; the 
hydrocele  is  to  be  tapped  with  a trocar  at  its 
anterior  and  inferior  part,  and,  when  the 
whole  of  the  fluid  is  evacuated,  the  cavity  of 
the  tunica  vaginalis  is  to  be  distended  to  its 
former  dimensions  with  the  above  injection. 
Thfs  is  to  be  allowed  to  remain  in  the  part 
about  five  minutes,  upon  the  average,  after 
which  it  is  to  be  discharged  through  the  can- 
nula. The  patient  usually  feels  some  pain 
in  the  groin,  and  about  the  kidneys,  on  the 
injection  being  introduced : which  symptoms 
are  rather  desirable,  as  they  evince  that  the 
stimulus  of  the  fluid  is  likely  to  have  the 
wished-for  effect  of  exciting  the  necessary 
degree  of  inflammation.  This  plan,  which 
was  brought  to  a high  pitch  of  perfection  by 
the  late  Sir  James  Earle,  may  be  deemed 
almost  an  infallible  means  of  obtaining-  a 
permanent  cure;  and  being,  at  the  same  time, 
mild,  is  mostly  preferred  in  England,  France, 
and  Germany. 

The  treatment  after  the  operation  is  exactly 
like  that  of  the  common  swelled  testicle, 
(see  Hernia  Humoralis,)  consisting  of  the 
use  of  fermentations,  poultices,  leeches, 
saline  purges,  and,  above  all,  of  a bag  truss 
for  keeping  up  the  scrotum. 

There  is  a particular  case,  that  has  been 
called  the  congenital  hydrocele,  by  which  is 
implied  a collection  of  water  in  the  tunica 
vaginalis,  w ith  a communication  between  the 
cavity  of  this  membrane  and  that  of  the  peri- 
tonaeum. Desault  used  to  cure  this  disease, 
by  a red  wine  injection.  After  the  protruded 
viscera  had  been  returned  into  the  belly,  and 


wfhile  the  opening  between  that  and  the  in-' 
side  of  the  tunica  vaginalis  was  carefully 
compressed  and  closed1  by  a trusty  assistant, 
Desault,  after  letting  out  the  water  in  the 
common  way,  used  to  throw  in  the  injection. 
The  method,  it  is  said,  succeeded  without 
causing  the  perilous  consequence,  one  might 
a priori  expect,  viz.  inflammation  of  the 
peritonaeum. 

This  kind  of  hydrocele  has  not  been  des- 
cribed by  many  writers.  The  case  is  easily 
distinguished  by  the  fluid  being  capable  of 
being  pushed  into  the  belly.  According  to 
Desault,  this  disease  admits  of  a cure  by  in- 
jections, care  being  first  taken  to  press  the 
upper  part  of  the  cord,  so  as  to  keep  the  in- 
jection from  coming  into  contact  with  the 
peritonaeum.  A successful  instance  of  this 
practice  is  related,  by  which  a boy  was 
cured  both  of  a congenital  hydrocele  and 
hernia.  The  patient  was  nine  years  old, 
and  had  in  his  scrotum,  ever  since  he  wa3 
born,  a fluctuating  semi-transparent  tumour, 
which  was  free  from  pain,  of  the  size  of  a 
large  egg,  and  disappeared  when  compressed^ 
and  in  a horizontal  posture.  (See  (Euvres 
Chir  dc  Desault,  T 2, /v.  442.) 

This  subject  of  congenital  hydrocele  has 
been  more  particularly  considered  in  my 
other  work. 

One  caution  it  is  necessary  to  offer,  before 
taking  our  leave  of  this  subject ; it  has  some- 
times happened,  duringthe  operation, thatthe 
cannula  has  slipped  out  of  the  tunica  vaginalis, 
and  its  inner  mouth  become  situated  in  the 
substance  of  the  scrotum,  in  which  event 
the  operator,  if  he  persists  in  propelling  in 
the  injection,  will  fill  the  cellular  texture  of 
the  part  with  a stimulating  fluid,  which  may 
cause  sloughing,  and  other  unpleasant  symp- 
toms, wdtbout  entering  the  cavity  of  the  tu- 
nica vaginalis,  or  producing  a radical  cure 
of  the  hydrocele,  which,  however,  I have 
known  happen  from  this  cause,  as  I have 
elsewhere  related.  (See  First  Lines  of  Sur- 
gery, Hoi.  2.)  When  such  an  accident  hap- 
pens, it  is  better  to  defer  the  operation,  till  a 
sufficient  quantity  of  ffuid  has  collected 
again.  Hydroceles  have  been  cured  by  ap- 
plying to  the  scrotum  a solution  of  muriate 
of  ammonia  in  vinegar  and  water  (Kcate.) 
But,  the  application  frequently  creates. a 
good  deal  of  pain  and  irritation,  and  does  not 
often  succeed,  to  say  the  best  of  it.  (Earle.) 

Distending  the  tunica  vaginalis  with  air, 
cold  water,  or  even  the  fluid  discharged,  has 
sometimes  effected  a radical  cure.  (See 
Supplement  to  Ploucquct,  Tub.  1S14,  p.  103.) 

For  many  other  important  remarks,  con- 
cerning hydroceles,  I am  obliged  to  refer  to 
the  2d  vol.  of  the  last  edition  of  the  First 
Lines  of  the  Practice  of  Surgery,  1S20.  Monro 
on  the  Tumours  of  the  Scrotum  in  the  Ediab. 
Med.  Essays,  Vol.  5.  John  Douglas.  .1.  Trea- 
tise on  Hydrocele,  8vo  Loud.  1755;  and 
Answer  to  Remarks  on  that  Work , 8vo.  Loud. 
1758.  Pott  on  the  Hydrocele  ; Else  on  the 
on  the  Hydrocele,  8vo.  Land  1770;  and  the 
Works  of  Joseph  Else,  8vo.  Loud.  J782.  W. 
Dense , on  the  Different  kinds  of  Hydrocele, 
8 vo.  London.  1798.  Kcate ; B.  Bell,  on  Hy'- 


HYDROPHOBIA 


31 


i i/occlc , Sarcocele,  fyc.  8 vo.  Edinb.  1704.  Sir 
James  Earle,  Treatise  on  llie  Hydrocele , 2 d 
Ed.  Si’o.  Land.  1803.  Schreger  Chirurgisches 
Versuchc,  B.  1,  8 vo.  JYumberg,  1811  , a cure 
effected  by  the  injection  of  air,  p.  30G.  Ber 
trandi.  in  Mem.  de  l' Acad.  de  Chir.  T.  3;  and 
in  Traitato  delle  Operazioni  di  Chirurgia, 
Nizaa,  1763.  Desault , Remarques,  fyc.  sur 
diverses  especes  d'  Hydrocele.  (Euvres.  Chir. 
T.  2.  S.  Sharp's  Treatise  on  the  Operations, 
and  his  Critical  Inquiry.  J.  Howard , Obs. 
on  the  Method  of  Curing  the  Hydrocele  by 
Means  of  a Seton,  Svo.  Loud.  1783.  Sabatier , 
Mldecine  Optraloire , T.  1,  Ed.  2.  Scarpa, 
Traili  des  Hernies,  p.  64,  fyc.  Larrey , Me- 
moir es  de  Chir.  Militaire,  T.  3,  p.  400,  4'C. 
T.  Ramsden , Practical  Observations  on  the 
Sclerocele,  §'C.  Svo.  Lond.  1811.  IV  IVadd, 
Cases  of  Diseased  Bladder  and  Testicle,  4to. 
Lond.  1815.  Kinder  Wood,  some  Observations 
on.  the  Cure  of  the  Hydrocele  of  the  Tunica 
Vaginalis,  without  procuring  an  Obliteration 
of  the.  Sac , in  Med.  Chir.  Trans.  Vol.  0.  p 38, 
Svo.  Lond.  1818. 

* H YD R O P H 0 B 1 A . (from  vJcep,  water,  and 
poSoj,  fear.  A dread  of  water.)  This  being, 
for  the  most  part,  a striking  symptom  of  the 
fatal  indisposition  which  results  from  the  bite 
of  a mad  dog,  and  some  other  animals  af- 
fected in  the  same  way,  the  disease  itself 
lias  been  named  Hydrophobia.  Some  have 
used  the  more  general  term,  hygrophnbia, 
from  vygpv,  liquid.  But  strong  objection  has 
been  made  to  both  these  terms,  because  de- 
rived from  a symptom,  which  does  not  ex- 
clusively belong  to  the  disease,  nor  constant- 
ly exist  in  it. 

The  old  writers,  as  we  learn  from  Caelius 
Aureliapus,  used  the  terms  acrophobia,  or  a 
dread  of  air,  and  pantephobia,  or  a fear  of 
all  things.  Since  the  impression  of  cold 
air  sometimes  excites  terror,  and  the  disor- 
der is  marked  by  a singular  degree  of  gene- 
ral timidity  qnd  distrust.  Others  called  it 
phobodipson  (S'i^W)  signifying  thirst,)  because 
the  patient  is  thirsty,  yet  fears  to  drink.  Se- 
veral modern  authors,  however,  objecting  to 
any  appellation  expressive  only  of  one  symp- 
tom, denominate  the  disease  rabies,  and 
rabies  catiina,  or  canine  madness.  The  French 
call  it  la  rage. 

With  respect  to  hydrophobia,  orthe  dread- 
ful mdisposjtion  produced  by  the  bite  of  a 
dog,  or  other  animal,  affected  with  rabies,  or 
by  the  application  of  some  of  the  secretions 
of  such  animal  to  a part  of  the  body,  the 
first  allusion  to  it  to  be  found  in  authors,  is 
that  made  by  Aristotle,  (Hist.  Animal,  lib. 
7,  cap.  22  ;)  but  he  could  have  had  but  very 
erroneous  notions  upon  the  subject,  since  he 
sets  down  man  as  incapable  of  receiving  the 
distemper  from  the  bite  of  a rabid  dog. 

With  respect  to  a name  for  the  disorder, 
as  the  patient  does  not  commonly  betray  any 
tendency  to  fury,  While  the  dread  of  water 
is  really  a customary  attendant  on  the  com- 
plaint, the  terms  rabies  and  la  rage  seem 
strictly  even  more  exceptionable  than  the 
word  hydrophobia.  At  the  same  time,  in 
Order  not  to  imbibe  confused  notions,  what- 
ever name  be  thought  fittest  for  the  illness 
Vol.  If  ~ 11 


arising  in  (he  human  subject  from  the  bite 
of  a mad  dog,  and  some  other  animals  simi- 
larly affected,  it  is  necessary  to  understand 
well,  that  hydrophobia,  in  the  sense  of  a 
horror  of  water,  or  other  liquids,  is  an  occa- 
sional symptom  of  many  diseases,  and  nei- 
ther exclusively  confined  to  the  indisposi- 
tion caused  by  the  bite  of  a rabid  dog,  or 
certain  other  animals,  nor  even  constantly 
attendant  upon  it.  And,  with  the  same 
view  of  avoiding  perplexity,  all  hydrophobic 
complaints  may  be  arranged  in  two  general 
divisions: 

1.  The  first,  comprising,  all  cases  not 
ascribable  to  the  bite  of  a rabid  animal,  or 
the  application  of  some  of  its  secretions  to 
a part  of  the  body. 

2.  The  second,  comprehending  the  ex- 
amples preceded  by  one  of  those  occurren 
ces. 

The  eases  included  in  the  first  of  these 
divisions  are  subdivided  into  the  symptomatic 
and  idiopathic,  or  spontaneous.  By  symptom- 
atic hydrophobia  is  understood  an  aversion 
or  dread  of  liquids,  presenting  itself  as  an 
occasional  symptom  of  various  diseases,  as 
of  certain  inflammatory,  febrile,  and  nervous 
disorders,  hysteria,  epilepsy,  injuries  of  the 
brain,  (Trecourt,  in  Recueil  Periodique , tyc. 
T.  6 ; Acta  Nalurce  Curios.  Vol.  2,  Obs.  205,)  ■ 
the  operation  of  particular  poisons;  (Filler- 
may,  Traite  des  Mai.  JYer reuses,  T.  1,  p.  90  ; 
Harles  i/ber  die  Hundiswuth,  Frankf.  1809; 
Schmiedel,  Diss.de  Hydrophobia  exusufruc- 
tuum  fagi,  Erlang.  1762,  fee.)  gastritis, 
pneumonia,  hepatitis,  angina,  fcc.  &c.  In 
many  of  the  instances  of  symptomatic 
hydrophobia,  the  aversion,  or  dread  of  fluids, 
occurs  on  the  same  day  as  the  cause  upon 
which  it  depends,  or  a few  days  afterward  ; 
and,  for  the  most  part,  may  be  cured  with 
the  disease  which  has  given  rise  to  it,  or 
eVtn  independently  of  it.  On  the  contrary, 
the  hydrophobia  from  the  bite,  or  infection 
of  a rabid  animal,  does  not  come  on  till  a 
long  time  after  the  occurrence  of  the  cause, 
and,  when  once  formed,  has  hitherto  proved, 
incurable,  or  very  nearly  so.  Whatever 
analogy,  therefore,  may  be  imagined  to  exist 
between  symptomatic  hydrophobia  and  ra- 
bies, they  differ  essentially  in  their  causes, 
progress,  degree  of  curability,  and  also  in 
the  treatment  required.  (See  Did.  des 
Sciences  Med . T.  4,  p.  3S.J 

Spontaneous,  or  idiopathic  hydrophobia, 
denotes  the  questionable  form  of  the  com- 
plaint, sometimes  supposed  to  be  induced  by 
violent  mental  commotion,  anger,  fright, 
6ic.  uupreceded  by  any  other  primary  dis- 
ease, to  which  it  can  be  referred  as  a symp- 
tom. 

Numerous  facts  upon  record  leave  no 
doubt  concerning  the  reality  of  symptomatic 
hydrophobia ; but,  perhaps,  none  of  the 
cases  adduced  by  Raymond  (Mem.  de  la  Sor , 
Royale  de  Med.  T.  2,  p.  457,)  Roupe  (JYova 
Ada  Physico-Med.  T.  4.)  or  Pouteau  ( Essai 
sur  la  Rage,  Lyons,  1763,)  in  proof  of  the 
possibility  of  a spontaneous  idiopathic  form 
of  the  disease  in  the  human  subject,  aro 
sufficiently  unequivocal  to  remove  all  susfi' 


HYDROPHOBIA. 


82 


cion,  that  the  complaint  either  had  been 
preceded  by  another  primary  disease  {Did. 
des  Sciences  Med.  T.  22,  p.  333,)  or  had  been 
the  result  of  an  unobserved,  or  forgotten 
occasion,  on  which  the  infection  wasi  re- 
ceived from  handling  a dog,  or  cat,  never 
suspected  at  the  time  to  be  affected  with 
rabies.  Here  a wrong  conclusion  is  the 
more  apt  to  be  drawn,  in  consequence  of 
the  disease  being  communicable  without 
any  bite  to  fix  the  patient’s  attention,  and 
not  commencing  sometimes  for  months 
after  the  unnoticed  receipt  of  the  infection. 
Thus,  Francis  Stannier  died,  in  Nov  1787, 
with  symptoms  of  hydrophobia,  though  it 
was  not  known  that  he  had  ever  been  bitten 
by  a mad  dog,  ( Loud . Med.  Journ.  Vol.  9,p. 
256 3)  yet,  what  safe  inference  can  be  drawn 
from  this  case,  when  the  above-mentioned 
circumstances  are  recollected,  and  it  is 
known  that  the  man  was  often  drunk,  and 
in  the  streets  at  night  ? These  and  other 
considerations  even  throw7  a doubt  upon  a 
part  of  the  cases,  recorded  as  instances  of 
symptomatic  tetanus,  and  they  lead  the 
generality  of  the  modern  writers  ta  incline 
to  the  sentiment  of  Dr.  .1.  Hunter,  that  a 
disease,  similar  in  its  nature  to  what  is  pro- 
duced by  the  bite  of  a mad  dog,  never  arises 
spontaneously  in  the  human  subject.  (See 
Trans,  of  a Soc.for  the  improvement  of  Med. 
and  Chir.  Knowledge , Vol.\,p.  299 — 303.) 
Many  of  the  symptomatic  cases,  however, 
or  those  in  which  more  or  less  aversion,  or 
dread  of  liquids,  is  evinced  as  an  effect  of 
another  disease,  are  too  well  authenticated 
to  admit  of  doubt.  In  the  Did.  des  Sciences 
Mid.  T.  22,  art.  Hydrophobie,  may  be  found 
a great  deal  of  information  likely  to  interest 
such  readers  as  wish  to  follow  up  the  subject 
of  the  symptomatic  forms  of  the  disease. 
However,  in  looking  over  some  of  the  cases 
there  detailed,  a suspicion  wdll  sometimes 
arise  in  an  intelligent  mind,  that  the  disorder 
was  mistaken  ; for  it  will  be  noticed,  that 
sometimes  pain  shooting  up  the  limbs  prece- 
ded the  general  indisposition,  while  the 
rapidity  of  the  disease,  arid  the  appearances 
found  on  dissection,  corresponded  precisely 
to  what  is  usually  remarked  in  hydrophobia. 
In  particular,  one  patient  is  described  as  a 
man  habituated  to  drinking,  and,  as  a sports- 
man, to  dogs  also ; he  died  on  the  third  day, 
and,  on  dissection,  the  stomach  and  intes- 
tines were  found  inflamed,  and  even  gan- 
grenous in  several  places,  the  (Esophagus 
and  lungs  also  participating  in  the  inflam- 
mation. ( Commerc . Litter.  JVoremb.  1743, 
Hebd.  5.) 

Animals  of  the  dog  kind,  including  the 
wolf  and  the  fox,  are  most  frequently  the 
subject  of  rabies  ; and  certain  writers  have 
maintained,  that,  although  it  may  be  recei- 
ved and  propagated  by  other  animals,  yet  it 
always  originates  in  some  of  the  canine  race. 
{Hillary  on  Diseases  of  Barbadoes,  p.  246.) 
However,  it  is  asserted,  that  the  disease 
sometimes  originates  spontaneously  in  cats, 
that  is  to  say,  without  their  having  been 
previously  bitten  by  another  rabid  animal  ; 
but  the  moderns  do  not  incline  to  the  belief. 


that  it  ever  has  been  known  to  commence 
in  this  manner  in  other  animals,  though  such 
an  assertion  is  made  by  Ccelius  Aurelianus, 
Porphyrius,  Avicenna,  Valeriola,  Stafpart- 
vandei  Wiel,  he.  not  only  with  respect  to 
man,  but  horses,  asses,  camels,  hogs,  bul- 
locks, bears,  monkeys,  and  even  poultry. 
(See  Diet,  des  Sciences  Mid.  T.  47,  p.  45.) 

It  is  interesting  to  inquire,  what  animals 
are  capable  of  communicating  rabies,  and 
what  animals  of  receiving  it  ? As  far  as  our 
knowledge  yet  extends,  it  appears  that  ani- 
mals of  the  canine  species,  with  perhaps 
those  of  the  feline  race,  are  the  only  ones 
in  which  this  disorder  ever  arises  spontane- 
ously, and  they  may  transmit  it  to  animals 
of  their  own  kind,  to  other  quadrupeds,  and 
to  man.  The  experiments  made  by  Dr. 
Zincke,  tend  to  prove  also  that  birds,  at 
least  the  common  fowl,  may  have  the  dis- 
ease communicated  to  them.  (Neue  Jin - 
dchten  der  Hundswuth , fyc.  8 vo,  Jena,  1804.) 

But,  though  it  be  w ell  known,  that  animals 
of  the  dog  and  cat  kinds  can  propagate  the 
disorder,  it  is  not  settled  whether  it  can  be 
communicated  by  other  animals.  In  a me- 
moir read  to  the  French  Institute,  M.  Hu- 
zard  explained  that  herbivorous  quadrupeds, 
affected  with  rabies,  are  incapable  of  trans- 
mitting the  disease  ; a position  subsequently 
confirmed  by  additional  experiments  and 
observations  made  in  the  veterinary  school 
at  Alfort.  Professor  Dupuy  could  never 
communicate  the  distemper  to  cows  and 
sheep,  by  rubbing  their  wounds  with  a 
sponge,  which  animals  of  the  same  class, 
already  labouring  under  the  disease,  had 
had  in  their  mouths ; though  the  same  ex- 
periment, made  with  a sponge,  Avhich  had 
been  bitten  by  a rabid  dog,  propagated  ra- 
bies by  a kind  of  inoculation.  Dupuy  has 
likewise  seen,  among  several  flocks,  sheep 
affected  with  rabies,  yet  the  distemper  was 
never  communicated  by  them  to  other  sheep, 
notw  ithstanding  the  latter  were  bit  in  parts 
stripped  of  wool.  Dr.  Gillman  inoculated 
two  rabbits  with  the  saliva  of  a rabid  pig  ; 
but  the  disease  W'as  not  communicated  to 
them.  (On  the  Bite  of  a Rabid  Animal,  p. 
38.)  On  the  other  hand,  Mr.  King,  of  Clifton, 
is  stated  to  have  communicated  rabies  to  a 
fowl,  by  inoculating  it  with  the  saliva  of  an 
ox,  which  had  just  fallen  a victim  to  the 
disease.  (J.  Ashburner , Diss.  de  Hydrophobia , 
p.  29  ) The  author  of  the  article  Rnge  (Did. 
des  Sciences  Mid.)  observes,  respecting  this 
singular  case,  that,  as  it  is  accompanied  with 
no  details,  doubts  must  remain,  whether  the 
fowl  actually  died  of  rabies. 

As  for  some  extraordinary  cases,  in  which 
the  disease  is  alleged  to  have  been  com- 
municated to  the  human  subject  by  the 
bites  of  birds,  or  injuries  done  with  the  claws 
of  animals,  they  are  generally  dismissed  by 
modern  writers,  with  the  inference,  that 
the  complaint  thus  transmitted  was  not  true 
hydrophobia  or  rabies.  This  conclusion  is 
made,  with  respect  to  the  cases  of  this  kind, 
reported  by  Ccelius  Aurelianus  and  Bader, 
and  the  notorious  example  mentioned  by  A 
Baccius  of  a gardener,  who  died  of  the  bite 


HYDROPHOBIA. 


of  a cock,  which,  according  to  some,  was 
rabid,  according  to  others,  merely  enraged. 
Hildanus  also  details  an  instance,  in  which 
a young  man  was  scratched  on  the  great 
toe  by  a cat:  and,  some  months  afterward, 
was  attacked  with  hydrophobia  ( Obs  Chir . 
Cent.  1,  Obs.  16;)  but,  as  a modern  writer 
observes,  if  the  patient  were  really  affected 
with  rabies,  it  is  conceivable  that  the  cat’s 
claw,  with  which  the  scratch  was  made, 
might  have  been  wet  with  the  animal’s 
saliva.  (Did.  des  Sciences  Med.  T.  47,  p.  47.) 

Another  question  of  considerable  import- 
ance is,  whether  hydrophobia,  that  is  to  say 
rabies,  can  be  communicated  from  one  hu- 
man being  to  another  ? — or  whether,  in  man, 
the  disease  is  infectious  or  contagious  ? 
Many  attempts  have  been  made,  in  vain,  to 
communicate  the  distemper  to  several  kinds 
of  animals,  by  inoculating  them  with  the 
saliva  of  patients  who  had  perished  of  the 
disease.  These  experiments  were  made  in 
this  country  by  Gauthier,  Vaughan,  Babing- 
ton,  &c.;  but  no  infection  was  the  conse- 
quence. In  France,  Giraud  inoculated 
several  dogs  with  the  saliva  of  a man  in  the 
convulsed  stage  of  hydrophobia,  but  none 
of  them  afterward  took  the  distemper. 
( Bosquillon , Mim.  sur  Its  Causes  de  l'  Hydro- 
phobie,  in  Mini  de  la  Soc.  d’ Emulation,  5 me 
annie.)  M.  Girard,  of  Lyons,  collected  some 
of  the  frothy  saliva  the  instant  it  was  dis- 
charged from  a patient’s  mouth,  and  he  in- 
serted some  of  it  into  eight  punctures,  made 
on  the  inside  of  a dog’s  four  legs  ; yet,  six 
months  after  this  inoculation,  the  animal 
had  not  suffered  the  slightest  inconvenience  . 
(Essai  sur  le  Tetanos  Rabiens,  p.  29.)  A 
similar  experiment  was  made  on  three  dogs 
by  M.  Paroisse,  who  kept  the  animals  be- 
tween three  and  four  months  afterward, 
during  all  which  time  they  continued  quite 
unaffected.  ( Bibl . Med.  T 43.) 

Dr.  Bezard  published  the  following  ex- 
periments : — Pieces  of  the  flesh  of  a person 
who  had  died  of  hydrophobia,  were  smeared 
with  his  saliva,  and  given  to  a dog  ; another 
dog  was  suffered  to  eat  the  salivary  glands  ; 
and  a third,  the  sides  of  a wound.  In  three 
other  dogs,  incisions  were  made,  the  cut 
parts  were  then  inoculated,  and  sewed  up. 
Not  one  of  these  six  animals  became  affected 
with  rabies.  (See  Mim.  et  Obs.  lus  b la  Soc. 
Mid.  Philanthropique,  premiere  annie , 1807, 
V • IV.) 

The  preceding  experiments  only  furnish 
negative  results  : but  one,  to  which  we  shall 
now  advert,  tends  to  establish  a contrary 
opinion.  On  the  19th  June,  1813,  in  the 
Hotel-Dieu,  at  Paris,  Magendie  and  Brescht  t 
took  some  of  the  saliva  of  a man,  who 
died  a few  minutes  afterward  of  hydropho 
bia,  and,  by  means  of  a bit  of  rag,  they 
conveyed  this  saliva  to  the  short  distance  of 
twenty  paces  from  the  patient’s  bed,  and  in- 
oculated with  it  two  healthy  dogs.  One  of 
the  dogs  became  rabid  on  the  27th  of  July, 
an  ' rat  two  others,  one  of  which  was  attack- 
ed with  complete  rabies  on  the  26th  of 
August.  (C.  Burnout;  see  Collect,  des  Theses, 
in  4 to.  de  la  Faculty  de  Paris , 1814.)  It  is 


83 

remarked,  in  the  work,  from  which  I have 
collected  these  particulars,  that  the  foregoing 
is  one  of  the  best  authenticated  experiments 
on  the  subject ; for,  in  addition  to  the  con- 
sideration of  the  talents  and  characters  of 
the  experimeners  themselves,  the  facts 
were  witnessed  by  numerous  medical  stu- 
dents. And,  notwithstanding  the  objections 
which  have  been  urged  against  the  account, 
(see  Journ.  Gen.  de  Mid.  T.  52,  p.  13 ) the 
main  points  are  declared  to  be  entitled  to 
credit.  (See  Did.  des  Sciences  Mid.  T.  47, 
p.  4-h 

With  these  relations,  it  is  proper  to  notice 
certain  cases,  too  credulously  promulgated 
as  proofs  of  the  possibility  of  the  disease  be- 
ing communicated  from  one  human  being 
to  another.  Neither  the  instance  of  the 
maid-servant,  who  died  merely  from  seeing 
her  mistress  vomit,  while  labouring  under 
hydrophobia  (Mich.  Ettmuller,  Op.  Med.  T. 
2 ;)  the  case  of  the  peasant’s  children,  which, 
all  died  on  the  seventh  day , as  is  alleged  from 
embracing  their  dying  father;  the  example 
of  a woman  contracting  hydrophobia  from 
her  husband,  as  detailed  by  Mangor  (Acta 
Soc.  Reg.  Hafniens.  V.  2,  Obs  32,  p.  40S ;) 
nor  other  cases  of  a similar  tenor ; are  now 
regarded  as  proving  any  thing  more  than 
that  the  patients,  supposed  to  have  caught 
the  disease  by  contagion,  fell  victims  either 
to  violent  affections  of  the  mind  and  nervous 
system,  or  illnesses  accidentally  taking  place 
soon  after  the  death  of  a near  relation  or 
mistress.  It  is  clear  enough  also,  that  some 
of  the  cases  were,  at  most,  only  instances 
of  symptomatic  hydrophobia. 

With  regard  to  another  opinion,  that  the 
bite  of  a man,  or  other  animal,  when  merely 
enraged,  may  bring  on  hydrophobia,  it  is 
now  entirely  discarded  as  erroneous.  The 
cases  in  support  of  it,  recorded  by  Cl.  Pou- 
teau,  Mangetus,  Malpighi,  Zuinger,  Le  Cat, 
&c.  when  critically  examined,  only  prove 
that  the  patients  were  affected  with  tetanus, 
or  symptomatic  hydrophobia,  not  arising 
from  any  infection;  for  neither  the  mode 
of  attack,  nor  the  progress  of  the  symptoms, 
in  any  of  the  examples  which  are  related 
with  sufficient  minuteness,  lead  to  the  infe- 
rence, that  the  patients  actually  died  of 
rabies.  (See  Did.  des  Sciences,  Mid.  T.  47, 
p.  49.) 

Wrong  notions  of  a very  dangerous  ten- 
dency, have  been  generally  entertained,  in 
regard  to  the  diseasb,  as  it  appears  in  the 
canine  race.  The  writer  of  the  article  Dog , 
in  Dr.  Rees’s  Cyclopasdia,  appears  to  have 
had  extensive  opportunities  of  observing  the 
disorder  in  dogs,  having  paid  attention  to 
more  than  two  hundred  cases.  From  his 
remarks,  I have  collected  the  following  in- 
formation. 

The  peculiar  symptom  which  character- 
izes the  complaint  in  the  human  subject,  has 
been  applied  to  the  disease  in  the  dog,  end 
has  occasioned  it  to  be  called  by  the  same 
name,  hydrophobia.  This  is  a palpable  mis- 
nomer; for,  in  no  instance,  does  there  ever 
exist  any  dread  of  water;  on  the  contrary,, 
dogs  are  in  general  very  greedy  after  it. 


84 


HYDROPHOBIA. 


Such  unfounded  supposition  has  often  con- 
duced to  a very  fatal  error : for,  it  being 
the  received  opinion,  that  no  dog  is  mad 
who  can  lap  water,  many  persons  have  been 
lulled  into  a dangerous  security.  Anotner 
equally  false  and  fatal  idea  has  prevailed, 
that  every  mad  dog  must  be  wild  and  furi- 
ous ; but  this  is  so  far  from  being  true,  that, 
in  the  greater  number  of  instances,  there  is 
very  little  of  that  wild  savage  fury  that  is 
expected  by  the  generality  of  persons. 
H Hence,”  says  this  author,  u as  it  is  evi- 
dent that  the  term  hydrophobia,  characteri- 
zing the  affection  in  the  dog,  is  a misnomer, 
so  it  is  evident  that  the  term  madness  is 
equally  so.  In  no  instance  have  1 ever  ob- 
served a total  alienation  of  the  mind  ; in 
very  few  have  the  mental  faculties  been 
disturbed.  The  disposition  to  do  mischief 
is  rather  an  increased  irritability  than  ab- 
sence of  sense;  for,  in  most  instances,  even 
those  that  are  furious,  they  acknowledge  the 
master’s  voice,  and  are  obedient.”  The 
symptom,  which  is  most  frequently  first  ob- 
servable in  a rabid  dog,  is  a certain  peculia- 
rity in  his  manner;  some  strange  departure 
from  his  usual  habits.  In  a very  great  num- 
ber of  instances,  the  peculiarity  consists  in 
a disposition  to  pick  up  straws,  bits  of  paper, 
rags,  threads,  or  the  smallest  objects,  which 
may  happen  to  be  on  the  iloor.  This  is  said 
to  be  particularly  common  in  small  dogs. 
ti  Others  again  show  an  early  peculiarity  by 
licking  the  parts  of  another  dog.  In  one 
instance,  the  approach  of  the  disease  was 
foretold  by  our  observing  a very  uncommon 
attachment  in  a pug-puppy  towards  a kitten, 
which  he  was  constantly  licking  ; and  like- 
wise the  cold  nose  of  a healthy  pug  that  was 
With  him.  An  attachment  to  the  sensation 
of  cold  appears  in  many  cases,  it  being  very 
common  to  observe  them  (the  dogs)  licking 
the  cold  iron,  cold  stones, &.c.  Some  dogs, 
early  in  the  disease,  will  eat  their  own  ex- 
crement, and  lap  their  own  urine.  An  early 
antipathy  to  strange  dogs  and  cats  is  very 
commonly  observed,  but  particularly  to  cats. 
As  the  disease  advances,  the  affected  dogs 
bite  those  with  which  they  are  domesticated, 
and,  lastly,  the  persons  around  ; but,  except 
in  a moment  of  irritability,  they  seldom 
attack  the  human  subject.  The  irritability 
that  induces  them  to  bite  is  very  strong,  but 
is  devoid  of  wildness.  It  is  more  like  pee- 
vishness than  fury.  A stick  held  up  at  them 
always  excites  their  anger  in  a violeni  de- 
gree, and  throughout  the  disease  there  is 
generally  a wonderful  impatience  of  control, 
and  the  animals  are  with  great  difficulty 
frightened.  (See  art.  Dog,  in  Reefs  Cyclopes  - 
dia.) 

To  this  passage  the  following  remarks  may 
be  added : — Dr.  John  Hunter  calculated, 
that  out  of  every  dozen  of  rabid  dogs,  about 
one  evinces  no  particular  tendency  to  bile. 
That  these  animals,  and  wolves  also,  have 
no  particular  dread  of  fluid,  is  proved  by 
facts.  Thus,  a rabid  wolf,  at  Frejus,  swam 
across  several  rivers.  ( Dariuc , Recucil  Pe- 
riod. d'Obs.  Vol.  d.)  Duboueix  has  seen 
tnad  dogs  drink  without  difficulty,  and  plen- 


tifully. ( Hist,  de  la  Roc.  de  Med.  an.  1783.) 
Rabid  animals  will  sometimes  eat  as  well  as 
drink.  Thus  the  wolf  which  bit  so  many 
persons  at  Meyne,  in  1718,  was  found  in  the 
morning  devouring  a shepherd’s  dog.  And 
Dr.  Gilman  speaks  of  a dog,  which  was  not 
deemed  rabid, because  it  eat  and  drauk  well ; 
but,  as  it  seemed  indisposed,  it  was  kilted, 
though  not  before  it  had  bit  a man,  who  fell 
a victim  to  hydrophobia.  (On  Ike  Bile  of  a 
Babid  Animal,  p.  15.) 

When  a dog  bites  a person,  it  should  not 
be  immediately  killed,  but  merely  chained 
up,  because,  by  destroying  it  at  once,  the 
possibility  of  ascertaining  whether  it  was 
rabid  is  prevented,  and  great  alarm  is  thus 
kept  up  in  the  mind  of  the  wounded  person 
and  his  friends.  If  the  animal  be  affected 
with  rabies,  it  will  perish  in  a few  days.  At 
the  veterinary  school  at  Alfort,  when  a dag 
has  been  bit,  it  is  usual  to  chain  the  animal 
up,  for  at  least  fifty  days,  before  it  is  resto- 
red to  its  master,  about  six  weeks  being 
considered  the  period  when  a dog  generally 
becomes  rabid  after  being  bitten. 

For  additional  details,  relating  to  the  dis- 
ease as  it  appears  in  the  dog,  I must  refer 
to  the  above-mentioned  paper.  Enough,  I 
hope,  has  been  said  to  make  the  reader 
aware,  that  mad  dogs  are  not  particularly 
characterized  by  an  inability  to  lap  water, 
or  any  degree  of  fury.  These  animals,  when 
actually  affected  with  rabies,  from  their 
quiet  manner,  have  even  not  been  suspected 
of  having  the  disorder,  and  have  been  allow- 
ed to  run  about,  been  fondled,  and  even 
slept  with.  (See  Mem  oj  Swedish  Acad , 
3777.) 

The  causes  of  this  peculiar  distemper  in 
dogs  are  at  present  unknown,  and  little 
more  than  conjecture  prevails  upon  the  sub- 
ject. It  is  not  positively  known  whether 
rabies  sometimes  originate  spontaneously  in 
these  animals,  though  1 believe  this  opinion 
is  at  present  gaining  ground;  or  whether, 
like  small-pox  in  the  human  species,  it  is 
propagated  only  by  contagion.  That  the 
disease  is  frequently  imparted  in  conse- 
quence of  one  dog  biting  another,  every 
body  well  knows.  Yet  there  are  many  in- 
stances in  which  this  mode  of  propagation 
cannot  be  suspected.  Several  facts  render 
it  probable,  that,  among  dogs,  the  disease  is 
often  communicated  by  contagion  It  is 
observed,  that,  in  insular  situations,  dogs 
are  seldom  affected,  and  this  circumstance 
is  ascribed  to  such  animals  being  in  a kind 
of  quarantine.  The  celebrated  sportsman, 
Mr.  Meynell,  secured  his  dogs  from  the  ma- 
lady by  making  every  new  hound  perform 
a quarantine  before  lie  was  suffered  to  join 
tht  j:ack.  (See  Trans. for  the  Improvement 
of  ed.  and  Chir.  Knowledge,  Vol.  I .art.  17,.) 
Great -heat  was  very  commonly  supposed  to 
be  an  exciting  cause  of  the  disease  in  dogs  ; 
but  without  much  foundation.  “ A very  Dot 
climate,  or  one  exposed  to  the  extremes  ol 
heat  and  cold  ; a very  hot  and  dry  season  ; 
feeding  upon  putrid,  stinking,  anu  magotty 
flesh;  want  of  water;  worms  in  the  kid- 
neys, intestines,  brain,  or  cavities  of  the 


HYDROPHOBIA. 


tod 


nose,”  are  set  down  by  Boerhaave  as  causes 
of  the  disease.  {Aphorism,  1134.)  We 
learn  from  Dr.  J.  Hunter,  that,  in  the  hot 
islund  of  Jamaica,  where  dogs  are  exceed- 
ingly numerous,  not  one  was  known  to  go 
mad  during  forty  years.  ( Trans,  for  the  Im- 
provement of  Med.  Knowledge,  loc.  cit.)  Cold 
weather  has  also  been  set  down  as  condu- 
cive to  rabies  among  the  canine  race,  as  is 
suggested,  because  the  ponds  being  frozen, 
these  animals  cannot  quench  their  thirst. 
(Le  Roux.)  That  neither  of  these  senti- 
ments about  heat  and  cold  being  the  cause 
of  the  origin  of  the  disease  in  dogs  is  cor- 
rect, will  be  manifest  enough  to  any  body 
who  has  patience  to  look  over  the  volume 
of  the  Mem.  de  la  Soc.  Royale  de  Med.  devo- 
ted entirely  to  the  consideration  of  rabies  $ 
and,  from  the  investigations  of  M.  Andry, 
(Rechcrches  sur  la  Rage , 8 vo.  Paris,  1780,)  it 
appears  that  January,  the  coldest  month  in 
the  year,  and  August,  the  hottest,  are  those 
which  furnish  the  fewest  instances  of  hydro- 
phobia. On  the  contrary,  the  greatest  num- 
ber of  rabid  wolves  is  in  March  and  April  ; 
and  that  of  dogs,  affected  with  spontaneous 
rabies,  in  May  and  September. 

According  to  Savarv,  dogs  never  go  mad 
in  the  Island  of  Cyprus,  nor  in  that  part  of 
Syria  which  is  near  the  sea  ; and  Volney 
assures  us  that  these  animals  enjoy  the 
same  fortunate  exemption  both  in  the  latter 
country  and  in  Egypt.  ( Voyage  in  Syrie,  T. 
1.)  The  traveller  Brown  also  declares,  that, 
in  Egypt,  they  are  never,  or  very  rarely, 
attacked  with  rabies. 

“ Although  (says  Baron  Larrey)  hydro- 
phobia is  more  frequent  in  warm  than  tem  - 
perate climates,  it  is  not  observed  in  Egypt, 
and  the  natives  assured  us,  that  they  knew 
of  no  instance  in  which  this  disease  had 
manifested  itself,  either  in  man  or  animals. 
No  doubt  this  is  owing  to  the  species  and 
character  of  the  dogs  of  this  country,  and 
their  manner  of  living. 

“ It  is  remarked,  that  the  Egyptian  dogs 
are  almost  continually  in  a state  of  inaction; 
during  the  day,  they  lie  down  in  the  shade, 
near  vessels  full  of  fresh  water  prepared  by 
the  natives.  They  only  run  about  in  the 
nighttime  ; they  evince  the  signs  and  effects 
of  their  love  but  once  a year,  and  only  for 
a few  instants.  They  are  seldom  seen  cou- 
pled. On  our  arrival,  there  was  a vast  num- 
ber of  these  animals  in  Egypt,  because  they 
were  held,  like  many  others,  in  great  vene- 
ration, and  were  never  put  to  death.  They 
do  not  go  into  the  houses;  in  the  day  time 
they  remain  at  the  sides  of  the  streets,  and 
they  only  wander  into  the  country  at  night, 
in  orderto  find  any  dead  animals  which  hap- 
pen to  be  unburied.  Their  disposition  is 
meek  and  peaceable,  and  fhey  rarely  fight 
with  each  other.  Possibly  all  these  causes 
may  exempt  them  from  rabies.”  (Larrey 
in  Mim.  de  Chir.  Militaire,  T.  2 ,p.  226.) 

This  observation,  about  the  exemption  of 
the  Egyptian  dogs  from  rabies,  is  a very 
ancient  one,  having  been  made  by  Prosper 
Alpinus,  (Rer.  JEgypliarum,  lib.  4,  cap.  8.) 
According  to  Barrow,  (he  dogs  in  the  vici- 


nity of  the  Cape  of  Good  Hope,  and  in  Caf- 
fraria,  very  rarely  go  mad.  (Travels  into 
the  Interior  of  Africa.)  Several  authors  assert, 
that  rabies  never  occurs  in  South  America. 
{Bill.  Raisounte,  1750.  Van  Swieten  Com- 
ment iiAphor.  1129,  Portal  fyc.)  L.  Va- 
lentin declares,  that  it  is  exceedingly  rare  in 
the  warm  regions  of  America,  but  common 
in  the  northern  part  of  that  continent. 
( Journ . Gen.  de  Med.  T.  20.)  Dr.  Thomas, 
who  resided  a good  while  in  the  West 
Indies,  never  saw  nor  heard  of  a case  of 
rabies  there,  (Practice  of  Physic ;)  and  Dr. 
B.4 Moseley  states  that  the  disorder  was  not 
known  in  those  islands,  down  to  1783.  On 
the  other  hand,  the  disease  sometimes  hap- 
pens in  the  East  Indies,  though  not  with 
such  frequency  as  at  all  to  justify  the  doc- 
trine about  heat  being  the  cause  of  its  pro- 
duction. The  silence  of  Hippocrates  proves, 
that  in  his  days  hydrophobia  must  have  been 
very  rare  in  Greece  ; and,  as  the  disorder  is 
not  mentioned  in  tht  Scrip  ores,  an  inference 
may  be  made,  that  it  could  not  be  so  com- 
mon in  the  hot  tracts  of  the  globe,  inhabit- 
ed by  the  Hebrews,  as  in  the  temperate  cli- 
mates of  Europe  and  A merica. 

Neither  can  the  sentiment  be  received  as 
correct,  that  rabies  is  more  frequent  in  the 
north  than-  in  the  temperate  parts  of  Europe ; 
for  De  la  Fontaine  particularly  notices  how 
extremely  rare  it  is  in  Poland.  (Chif.  Med. 
Abhandl.  Breslau , 1792.)  The  disease  is 
reported  to  be  very  common  in  Prussian 
Lithuania ; but  mad  dogs  are  seldom  or 
never  heard  of  at  Archangel,  Tobolsk,  or  in 
the  country  north  of  St.  Petersburg. 

In  Mr.  Meynell’s  account,  which  was 
communicated  to  him  by  a physician,  it  is 
asserted,  that  the  complaint  never  arises 
from  hot  weather,  nor  putrid  provisions, 
nor  from  any  cause  except  the  bite  ; for, 
however  dogs  have  been  confined,  however 
fed,  or  whatever  may  have  been  the  heat  of 
the  season,  the  disorder  never  commenced, 
without  a possibility  of  tracing  it  to  the 
preceding  cause,  nor  was  it  ever  introduced 
into  the  kennel,  except  by  the  bite  of  a mad 
dog.  (See  art.  Dog,  in  Rees's  Cyclopedia.) 

Dr.  Gillman  endeavours  to  prove,  that 
the  disease  in  dogs  is  probably  excited  inde  - 
pendently of  particular  climates,  of  putrid 
aliment,  of  deficiency  of  water,  of  want  of 
perspiration,  or,  of  the  worm  under  the 
tongue,  to  which  causes  it  has  been  at 
different  times  ascribed,  and  he  expresses 
his  belief,  that  it  originates  somewhat  like 
typhus  in  the  human  subject,  and  is  not 
always  produced  by  inoculation,  or  by 
means  of  a bite.  He  thinks  that  it  maybe 
occasionally  brought  on  by  the  confinement 
of  dogs,  without  exercise,  in  close  and  filthy 
kennels  ; and  that  the  success  of  Mr.  Treval- 
yan,  as  related  by  Dr.  Bardsley,  in  clearing 
his  kennel  of  the  disease,  by  changing  even 
the  pavement,  after  other  means  of  purifica- 
tion had  failed,  affords  presumptive  evidence 
in  favour  of  the  opinion;  and,  consequently, 
this  author  thinks,  that  the  method  of  qua- 
rantine, adopted  by  Mr.  Meynell,  and  recom- 
mended by  Dr.  Bardsley,  on  the  supposition, 


86 


HYDROPHOBIA. 


that  the  disease  originates  exclusively  from 
contagion,  will  not  be  a sufficient  prevent- 
ive alone  ; and  he  infers,  from  some  facts, 
reported  by  Mr.  Daniel,  that  the  poison 
sometimes  lies  dormant  in  dogs  fpur,  five, 
and  six  months  ; and,  consequently,  that 
the  period  of  two  months  is  not  a sufficient 
quarantine.  (See  Gillmari’s  Diss.  bn  the 
Bite  of  a Rabid  Animal.) 

In  opposition,  however,  to  some  of  the 
sentiments  contained  in  the  foregoing  pas- 
sage, it  should  be  known,  that  Dupuytren, 
Magendie,  and  Breschet,  have  purposely 
kept  many  dogs  for  a long  time  in  the  most 
disgusting  state  of  uncleanliness,  let  them 
even  die  in  this  condition  for  want  of  food 
and  water,  or  even  devour  each  other,  yet 
without  exciting  rabies  (Did.  des  Sciences 
Mid.  T.  47,  p.  53  ) Yet  Professor  Rossi,  of 
Turin,  is  said  to  have  produced  this,  or  seme 
similar  disease  in  cats,  by  keeping  them 
shut  up  in  a room.  (Mem.  de  I'Acad.  Imp. 
de  Turin , 1805,  A 1808,  p.  93,  de  la  JYolice 
des  Travaux.)  On  the  whole,  I consider  it 
well  proved,  that  neither  long  thirst,  hun- 
ger, eating  putrid  flesh,  nor  filth,  will  occa- 
sion the  disease  in  the  canine  race.  At 
Aleppo,  where  these  animals  perish  in  great 
numbers  from  want  of  food  and  water,  and 
the  heat  of  the  climate,  the  distemper 
is  said  to  be  unknown.  Nor  is  rabies  found 
to  attack  dogs  and  cats,  with  particular  fre- 
quency during  the  copulating  season,  and 
therefore,  the  oestrus  veneris  cannot  be  ad- 
mitted to  have  any  share  in  its  production, 
as  some  writers  have  been  disposed  to  be- 
lieve. (See  Did.  des  Sciences  Mid.  T.  47, 
V-  55.) 

Although  most  writers  believe  in  the  reali- 
ty of  a poison,  or  specific  infectious  princi- 
ple, in  cases  of  rabies,  the  fact  has  been 
questioned,  or  absolutely  rejected  by  others. 
Bosquillon  considered  the  disease  always  as 
the  effect  of  fear,  or  an  impression  upon  the 
imagination.  This  view  of  the  matter  is  far 
from  being  new,  and  has  been  ably  refuted 
by  many  authors,  and  especially  by  M.  De 
sault,  of  Bordeaux,  who  remarks,  that 
horses,  asses,  and  mules,  quibus  non  est  in- 
tellects, had  died  rabid  the  very  year  in 
which  he  wrote  ; and,  it  is  observed  by  Dr. 
J.  Vaughan,  that  an  infant  in  the  cradle  is 
som  times  attacked,  while  many  timorous 
children  escape. 

Another  notion  has  partially  prevailed, 
that  rabies  does  not  depend  upon  any  virus, 
but  upon  the  continuance  of  an  irritation 
in  the  bitten  parts,  affecting  the  whole  ner- 
vous system.  (Percival;  J.  Mease  ; Girard; 
^c.)  But,  this  doctrine  confounds  rabies 
and  tetanus  together,  and  can  only  apply 
to  the  symptomatic  non-infectious  hydro- 
phobia from  an  ordinary  wound,  or  lacera- 
tion. 

The  facts,  in  proof  of  the  reality  of  a pe- 
culiar infectious  principle  in  cases  of  rabies, 
are  too  numerous  to  leave  any  doubt  upon 
th-  subject.  Twenty -three  individuals  were 
bit  or, e morning  by  a female  wolf,  of  whom 
thirteen  died  in  the  course  of  a few  months, 
besides  several  cows,  which  had  been  inju- 


red by  the  same  animal.  How  could  all 
these  unfortunate  persons  have  had  similar 
symptoms,  and  especially  a horror  of  fluids, 
had  they  not  been  all  under  the  influence 
of  some  cause,  besides  the  bites  ? The  pa- 
tients who  died,  were  bit  on  the  naked 
skin  ; while  in  the  others,  who  escaped  in- 
fection, the  bites  happened  through  their 
clothes,  which  no  doubt  intercepted  the  sa- 
liva, the  vehicle  of  the  virus.  In  the  Essay 
by  Le  Roux,  mention  is  made  of  three  per- 
sons, bit  by  a rabid  wolf  near  Autun,  in  July, 
1781,  and,  notw  ithstanding  mercurial  fric- 
tions, they  all  died  of  hydrophobia.  Of  ten 
other  individuals  bit  by  a wolf,  nine  died 
rabid.  (Rey,  Mim.  de  la  Soc.  Royale  de  Mid. 
p 147.)  Twenty-four  persons  were  injured 
in  the  same  manner  near  Rochelle,  and 
eighteen  of  them  perished.  ( Andry , Ri- 

cherches  sur  la  Rage,  Ed.  3,  p.  196.)  On  the 
27th  January,  1780,  fifteen  individuals  were 
bit  by  a mad  dog,  and  attended  at  Senlis  by 
the  commissioners  of  the  French  Royal  So- 
ciety of  Physic  ; ten  had  received  the  bites 
on  the  naked  flesh,  and  five  through  their 
clothes.  Of  the  first  ten,  only  five  lost  their 
lives,  three  of  them  dying  of  decided  rabies 
between  the  27th  of  February,  and  the  3d 
of  April ; and  the  other  two  between  the 
29th  of  February,  and  the  18th  of  March. 
Unless  the  opinion  be  adopted,  that  the  dis- 
ease is  caused  by  an  infectious  principle,  a 
sort  of  inoculation,  it  would  be  impossible 
rationally  to  explain  the  cause  of  so  many 
deaths  from  the  bites  of  rabid  animals.  If 
the  idea,  that  rabies  originates  from  fear 
or  nervous  irritation  were  true,  how  could 
we  account  for  there  being  such  a differ- 
ence between  the  usual  consequences  of 
the  bite  of  a healthy  dog,  and  those  of  the 
bite  of  one  affected  with  rabies  ? Healthy 
dogs  are  incessantly  quarrelling,  and  biting 
each  other  in  the  streets,  yet  their  wounds 
are  not  followed  by  rabies  ; and  as  a mo- 
dern author  remarks,  if  hydrophobia  were 
referrible  to  nervous  irritation  derived  from 
the  wounded  part,  how  does  it  happen,  that 
among  the  thousands  of  wounded  after  a 
great  battle,  hydrophobia  is  not  seen  in- 
stead of  tetanus.  (Did.  des  Sciences  Mid. 
T.  47,  p.  61.)  But,  if  it  were  yet  possible 
to  entertain  a doubt  of  an  infectious  princi- 
ple in  hydrophobia,  this  possibility  would  be 
removed  by  the  reflection,  that  the  disease 
may  be  communicated  to  healthy  animals 
by  inoculating  them  with  the  saliva  of  cer- 
tain other  rabid  animals.  In  fact,  as  I have 
stated,  the  bites  of  such  animals  are  in  every 
point  of  view  only  an  inoculation  ; and  the 
same  remark  may  be  extended  to  the  nu- 
merous instances  on  record,  in  which  the 
disease  arose  in  the  human  subject,  as  a 
consequence  of  a rabiJ  dog,  or  cat,  (not 
suspected  to  be  in  this  state  at  the  time)  ha- 
ving been  played  with,  fondled,  or  suffered 
to  lick  the  naked  skin,  in  which  there  was 
at  the  moment  some  slight  scratch,  entirely 
overlooked. 

Many  of  the  ancient  writers  not  only  be-  ‘ 
lieved  in  the  hydrophobic  virus,  or  infec- 
tious principle,  but  even  in  its  diffusion 


HYDROPHOBIA 


87 


through  the  blood,  flesh,  and  secretions  in 
general  ; and  this  hypothesis  was  professed 
by  Boerhaave,  Van  Swiet  n,  Sauvages,  F. 
Hoffman,  &c.  but,  in  proportion  as  the  hu- 
moral pathology  lost  ground,  the  foregoing 
idea  was  abandoned,  and  the  opinion  adopt- 
ed, that  the  infection  is  confined  to  the  sa- 
liva, and  wounded  part,  in  which  it  has 
been  inserted. 

The  tales  of  some  old  authors  would  lead 
one  to  think,  that  hydrophobia  may  be 
communicated  by  eating  the  flesh  of  a rabid 
animal.  ( Fernelius , De  Obs.  Rer.  Caus.  et 

Morb.  Epidem.  lib.  2,  cap.  14;  Schenckius ; 
Mangetus , fyc.)  But,  respecting  these  ac- 
counts, it  is  remarked,  that  they  are  not  en- 
titled to  much  confidence  ; for,  it  is  certain, 
that  rabies  never  begins  as  is  stated,  with 
regard  to  some  of  the  cases  in  question,  a 
few  hours  after  the  application  of  its  cause, 
and  its  early  stage  is  never  characterized  by 
any  fury,  or  disposition  to  bite.  And,  be- 
sides, how  can  such  relations  be  reconciled 
with  the  practice  of  the  ancients,  who,  ac- 
cording to  Pliny,  employed  the  liver  of  the 
mad  dog  or  wolf,  as  a remedy  ? Palmarius 
also  fed  his  patients  for  three  days  with  the 
dried  blood  of  the  rahid  animal.  (Mim.  de 
la  Soc.de  Mid.  p.  136,  et  le  No.  178.)  The 
fie^h  of  a bullock,  which  had  been  bit  by  a 
mad  dog,  and  afterward  died  rabid,  was 
sold  to  the  inhabitants  of  Medola  near  Man- 
tua, yet  none  of  them  were  attacked  with 
hydrophobia.  ( Andry , Richerches  sur  la 

Rage,  fyc.  p.  30.)  Dr.  Le  Camus  informed 
Lorry,  that  he  had  eaten  the  flesh  of  animals 
which  died  rabid,  but  he  suffered  no  incon- 
venience from  the  experiment.  And,  it  is 
stated  in  the  letter  of  Dr.  L.  Valentin,  that 
the  negroes  in  the  United  States  of  Ameri- 
ca had  no  illness  from  eating  the  flesh  of 
pigs,  which  had  died  of  rabies.  ( Journ 
Gen.  de  Mid.  T.  3,  p.  417.)  As  for  the  ques- 
tion, whether  the  blood  is  infected  ? It  is 
generally  considered  to  be  settled  in  the 
negative,  notwithstanding  the  account  given 
by  I^mery  of  a dog,  which  was  attacked 
with  rabies,  as  is  said,  from  lapping  the 
blood  of  a hydrophobic  patient,  who  had 
been  bled.  (Hist,  de  ’Head.  Royale  des 
Sciences , 1707, p.  25.)  Dupuytren,  Breschet, 
and  Magendie,  wrere  never  able  to  commu- 
nicate rabies  by  rubbing  wounds  with  blood 
taken  from  mad  dogs  ; and  they  even  seve- 
ral times  injected  such  blood  into  the  veins 
of  other  healthy  dogs,  yet  none  of  these 
latter  animals  were  attacked  with  rabies, 
though  they  w^ere  kept  for  a sufficient  length 
of  time  to  leave  no  doubt  upon  the  subject. 
(See  Did.  des  Sciences  Med.  T 47,  p.  63.) 

A point  of  greater  practical  interest  than 
the  former,  is,  whether  the  drinking  of  the 
milk  of  an  animal,  labouring  under  rabies,  is 
attended  with  any  risk  of  communicating 
the  disease  P It  is  asserted  by  Timaeus,  that 
a peasant,  his  wife,  children,  and  several 
other  persons,  were  seized  with  hydropho- 
bia, in  consequence  of  drinking  the  milk  of 
a rabid  cow  ; and  that  the  husband  and  el- 
dest child  were  saved  by  medical  treat- 
ment : but,  that  the  wife  and  four  of  the 


children  died.  It  is  further  stated,  that 
three  or  four  months  afterward,  the  maid 
and  a neighbour,  who  had  partaken  of 
the  milk  of  the  same  cow,  also  died  of  hy- 
drophobia. (Cons.  7,  Obs.  33.)  In  opposi- 
tion to  this  account,  however,  several  facts, 
reported  by  othm  writers  of  greater  credit, 
tend  to  prove,  that  hydrophobia  cannot  be 
communicated  by  the  milk  of  a rabid  ani- 
mal. ( Nova  Ada  Nat.  Cur.  Vol  1,  Obs.  55  ; 
Baudot,  in  Mem.  de  la  Soc.  Royale  de  Med. 
an  1782  et  83,  T.  2 ,p.  91. ) 

The  cases  reported  by  F.  Hoffman  and 
Cbahert,  with  the  view  of  proving  the  pos- 
sibility of  infection,  through  the  medium  of 
the  sernen,  are  of  no  weight,  because,  on  a 
critical  examination  of  them,  it  will  be 
found,  that  the  infection  of  the  women  is 
stated  to  have  taken  place  very  soon  after 
their  husbands  had  been  bit,  which  is  quite 
at  variance  with  the  established  character 
of  the  disease,  as  it  never  commences,  and 
of  course  cannot  be  propagated  in  any  man- 
ner, soon  after  the  receipt  of  the  bite.  Be- 
sides, these  histories  are  refuted  by  others  of 
greater  accuracy.  (See  Baudot  in  Mem.  dr, 
la  Soc.  Royale  de  Med.  an  1782,  fyc.,  p.  92; 
Ricallier,  Vol.  cit.p.  136  \ p.  211  ; Bouteille, 
p.  237  ; Boissiere,  in  Journ.  Gin.  de  Mid.  T. 
IT,  p.  296.) 

Neither  can  hydrophobia  be  imparted  by 
the  breath,  notwithstanding  the  statements 
of  Caelius,  Aurelianus,  and  some  other  old 
writers.  A nurse,  mentioned  by  Dr.  J. 
Vaughan,  repeatedly  kissed  a hydrophobic 
infant,  which  she  had  suckled,  a,c^l  exposed 
herself  incessantly  to  its  breath,  but  with- 
out the  least  ill  effects.  The  fear  which  has 
also  been  entertained  of  the  disorder  being 
receivable  from  the  application  of  the  pa- 
tient’s perspiration  to  the  skin,  is  not  found- 
ed  upon  any  authentic  facts. 

Does  the  infectious  principle  of  rabies  re- 
side in  the  salivary  secretion,  or  in  the  mu- 
cus of  the  trachea  and  bronchiae  ? The 
common  belief  is,  that  in  hydrophobia,  the 
salivary  glands  are  considerably  affected. 
But,  it  has  been  remarked  by  a modern  wri- 
ter, that  if  these  glands  exhibit  no  morbid 
alteration  during  the  whole  course  of  the 
disorder;  if  they  are  found  healthy  after 
death  ; if  the  air-passages  are  the  seat  of 
inflammation  ; if  the  saliva  does  not  con- 
stitute the  frothy  slaver  about  the  lips ; and 
if  such  slaver,  wherewith  the  disease  may 
be  communicated  by  inoculation,  is  derived 
from  the  inflamed  windpipe  and  bronchiae, 
and  consists  of  mucus  converted  into  a kind 
of  foam  by  the  convulsive  manner  in 
wrhich  the  patient  breathes,  there  is  some 
reason  for  questioning,  whether  the  saliva, 
strictly  so  called,  undergoes  the  alteration 
generally  supposed  ? (See  Diet,  des  Sciences 
Mid.  T.  47,  p.  66.)  However,  this  writer 
is  not  exactly  correct,  w'hen  he  describes 
the  frothy  secretion  about  the  mouth,  as  be- 
ing altogether  composed  of  mucus  from  the 
trachea,  since  a great  part  of  it  is  unques- 
tionably true  saliva  and  mucus  secreted  in 
the  fauces  and  mouth.  In  the  stomachs  of 
dogs,  which  died  rabid,  Dr.  Gillman  con 


S8 


HYDROPHOBIA 


slantly  observed  traces  of  inflammation,  and 
he  once  tried  to  communicate  the  disease  to 
two  rabbits,  by  inoculating  them  with  matter 
taken  from  pustules,  found  in  the  stomach  of 
a rabid  do^  • but  no  infection  took  place. 
{On  the  Bile  of  a Rabid  Animal,  p.  32.) 

According  to  Professor  Rossi,  of  Turin,  the 
nerves,  “ before  they  grew  cold,  participated 
with  the  saliva  in  the  property  of  communi- 
cating rabies  ” He  asserts,  that  he  once  im- 
parted the  disease  by  inserting  in  n wound  a 
toil  of  the  sciatic  nerve,  immediately  after 
it  had  been  taken  from  a living  rabid  cat. 
(See  M6m.  de  I'Acad  Imp.  de  Turin , Sciences , 
Phys.  el  Mathem.  de  1805  a 1808,  part.  93.  de 
la  Notice  des  Travaux.) 

After  all  which  has  been  stated,  concerning 
the  hypothesis  of  the  infectious  principle  of 
hydrophobia  being  more  or  less  diffused 
through  the  solids  and  fluids  of  a rabid  ani- 
mal, and  not  being  restricted  to  the  saliva, 
perhaps,  the  safest  conclusion  to  be  made  is, 
not  to  reject  the  opinion  altogether,  but  to 
consider  it  as  at  present  requiring  further 
proof.  And  from  observations  of  what  hap- 
pens in  the  human  subject,  the  same  infer- 
ences should  not  always  be  drawn,  as  from 
experiments  on  animals,  which  are  liable  to 
be  attacked  with  spontaneous  rabies  of  \ de- 
cidedly infectious  character.  (S ec  Diet.  des 
Sciences  Mid.  T 47,  p.  67.) 

Although  many  casts  are  to  be  met  with 
in  the  records  of  medicine  and  surgery, 
tending  to  convey  an  idea,  that  the  mere  ap- 
plication of  the  saliva  of  a rabid  animal  to 
the  sound  entire  skin  of  tiie  human  subject, 
may  give  rise  to  hydrophobia,  t he  assertion  is 
contrary  to  general  experience,  and  liable  to 
a reflection  which  must  overturn  the  hypo- 
thesis ; viz.  the  slightest  prick  scratch,  abra- 
sion, or  broken  pimple  on  1 he  surface  of  the 
body,  such  as  would  not  be  likely  in  many 
instances  to  excite  notice,  may  render  the 
application  of  the  saliva  to  the  part  a posi- 
tive inoculation. 

Instances  are  also  reported,  the  tenor  of 
which  is  to  prove,  that  the  hydrophobic  virus 
may  take  effect  through  a sound  mucous 
membrane.  ( Palmarius , de  Morbis  Ccnlag. ; 
Portal , Obs.  sur  la  Rage,p.  131  , Mallhieuin 
Mem.  de  la  Soc.  Royale  de  M6d.  p 310,  fyc.) 
But  that  this  does  not  happen  ir,  the  human 
subject  is  tolerably  well  proved  by  the  con- 
sideration, that  formerly  a class  of  men  made 
it  their  business  to  suck  the  wounds,  caused 
by  the  bites  of  rabid  animais;  yet  none  of 
them  contracted  hydrophobia  from  this  bold 
employment.  {Bosqnillon,  Mem.  d6  la  Soc 
d' Emulation , T.5, //.  1.)  The  example  of  die 
nurse,  who  repeatedly  kissed  a child  without 
the  least. ill  effect,  while  it  was  dying  of  ra- 
bies, as  recorded  by  Dr.  J.  Vaughan,  has 
been  already  noticed.  However,  if  hydro- 
phobia were  apparently  to  arise  in  any  rare 
instance  from  the  application  of  the  slaver  of 
a rabid  animal  to  the  inside  of  the  lips,  no 
positive  inference  could  be  drawn  from  the 
fact,  unless  the  means  were  also  possessed  of 
ascertaining,  that  there  were  no  slight  abra- 
sion about  the  gums,  or  within  the  mouth, 
previously  to  such  application. 


For  the  hydrophobic  virus  to  take  effect, 
therefore,  it  is  generally,  if  not  always  ne- 
cessary, that  the  infectious  saliva  be  either 
applied  to  an  abraded,  wounded,  or  ulcera- 
ted surface.  In  the  case  of  a bite,  the  teeth 
are  (he  envenomed  weapons,  which  a*  once 
cause  the  solution  of  continuity,  and  deposit 
the  infection  in  the  part.  But  the  mere  abra- 
sion of  the  cuticle,  and  the  application  of  the 
infectious  saliva  to  the  denuded  cutis,  will  of- 
ten suffice  for  the  future  production  of  the 
disease.  As  the  mode  of  communication, 
therefore,  is  a true  inoculation,  it  follows, 
that  the  danger  must  depend  very  much 
upon  the  quantity  of  infectious  matter  con- 
veyed into,  or  applied  to  the  part,  the  effec- 
tual manner,  in  which  the  saliva  is  lodged  in 
the  flesh,  the  extent  and  number  of  the 
wounds,  and  particularly  the  circumstance  of 
the  teeth  of  the  rabid  animal  having  passed 
through  no  clothes,  by  which  the  saliva 
might  possibly  be  effectually  prevented  from 
entering  the  wound  at  all.  Hence,  bites  on 
the  hands  and  face  are  well  known  to  be  of 
the  most  dangerous  description,  especially 
those  on  the  face,  the  hands  being  sometimes 
protected  with  gloves. 

From  what  has  been  observed,  however, 
it  is  not  to  be  concluded,  that  the  disease  al- 
ways follows,  even  when  the  animal,  which 
inflicts  the  bite,  is  decidedly  rabid,  and  some 
of  its  saliva  is  actually  applied  to  the  wound- 
ed or  abraded  parts.  On  the  contrary,  ex- 
perience fuHv  proves,  that  out  of  the  great 
number  of  individuals  often  bit  by  the  same 
mad  dog,  and  to  whom  no  effectual  prophy- 
lactic measure  is  extended,  only  a greater  or 
lesser  number  are  afterward  attacked  with 
hydrophobia.  When  this  difference  in  the 
fate  of  the  individual  cannot  be  explained 
by  the  intervention  of  their  clothes,  the  thick- 
ness of  the  cuticle  at  the  injured  part,  the 
small  size  and  superficial  nature  of  the  bite, 
the  ablution  of  the  part,  or  some  other  mode 
in  which  any  actual  inoculation  may  have 
been  rendered  ineffectual,  it  can  only  be  re- 
ferred to  some  unknown  peculiarities,  or  dif- 
ferences in  the  constitutions  of  the  several 
individuals.  The  latter  conjecture  seems 
more  probable,  when  the  fact  is  recollected, 
that  some  animals  are  more  susceptible  of 
rabies  than  others,  and  some  appear  to  resist 
the  infection  altogether. 

Dogs  are  more  susceptible  of  the  infection 
than  the  human  species.  Four  men  and 
twelve  dogs  were  bit  by  the  same  mad  dog, 
and  every  one  of  the  dogs  died  of  the  dis- 
ease, w hile  all  the  four  men  escaped,  though 
they  used  no  other  in'  an*  of  prevention  but 
such  as  we  see  every  d:w  fail.  There  is  also 
an  instance  of  twenty  persons  being  bit  by 
the  same  mad  dog,  of  whom  only  one  had 
the  disease. 

Dr.  Heysham  has  defined  hydrophobia  to 
be  an  aversion  arid  horror  at  liquids,  exciting 
a painful  convulsion  of  the  pharynx,  and  oc- 
curring at  an  indeterminate  period  after  the 
canine  virus  has  been  received  into  the  sys- 
tem. Dr.  Culb  n places  it  in  the  class  ncuro - 
ses,  and  order  spatyni}  and  defines  it  a loath 
irig  and  great  dread  of  drinking  any  liquids- 


HYDROPHOBIA. 


89 


from  their  creating  a painful  convulsion  of 
the  pharynx,  occasioned  most  commonly  by 
the  bite  of  a mad  animal.  Olliers  have  sug- 
gested the  following  definition,  as  more  com- 
plete : melancholy,  dread  of  cold  air,  of  any 
thing  shining,  and  particularly  of  water  ; 
often  arising  from  the  bite  of  a mad  animal. 
( Parr's  Med.  Diet.)  However,  the  latter  de- 
finition is,  perhaps,  equally  objectionable,  be- 
cause there  is  not  invariably  a dread  of 
shining  bodies.  (See  Dr-  Powel/.  s Case , p. 
S.)  While  some  authors  represent  it  as  a 
nervous  disorder,  others,  among  whom  is 
Boerhanve,  consider  it  as  one  of  an  inflam 
matory  nature.  In  many  systems  of  sur- 
gery, hydrophobia  is  treated  of  with  poison- 
ed wounds,  of  one  species  of  which  it  is 
strict  ly  the  effect. 

With  regard  to  the  symptoms  of  hydro- 
phobia, they  are  generally  tardy  in  making 
their  appearance,  a considerable,  but  a very 
variable  space  of  time  usually  elapsing  be- 
tween their  commencement  .nd  the  receipt 
of  the  bite.  Out  of  a table  of  131  ca'es, 
none  of  the  patients  became  ill  before  the 
eleventh  day  after  the  bite,  and  only  three 
before  the  eighteenth.  It  is  pretended  by 
Fouteau,  that  one  patient  was  bit  by  a dog 
in  she  morning,  and  was  attacked  with  hy- 
drophobia at  three  o’clock  in  the  afternoon. 
But  as  this  account  was  communicated  to  the 
author  a long  time  after  the  ■occurrence,  and 
not  by  a medical  man,  it  deserves  little  con- 
fidence. Another  case,  adverted  (o  by  Mead, 
is  deprived  of  all  its  importance  by  the  same 
consideration.  These  examples,  as  well  as 
another  reported  by  Astrnc,  in  u hich  the 
patient  is  said  to  iiave  had  hydrophobia  in  less 
than  three  days  after  being  wounded  on  the 
temples,  can  at  most  be  regarded  only  as 
specimens  of  symptomatic  hydrophobia. 
(Diet,  des  Sciences  Med.  T.  47,  p.  74.)  There 
appears  to  be  no  determinate  period,  at  which 
the  disorder  makes  its  attack  after  the  bite  ; 
but  it  is  calculated,  that  the  symptoms  most 
frequently  commence  between  the  30lb  and 
40th  day,  and  that  after  (his  time  the  chances 
of  escape  increase.  Of  15  patients,  whose 
cases  Trolliet  was  acquainted  with,  seven 
were  attacked  between  the  14th  and  30th 
days;  five  between  the  30th  and  40tii ; two 
a little  beyond  the  iattel-  period  ; and  one 
after  14  weeks,  in  May,  1784,  17  persons 
were  bii  by  a rabid  wolf,  near  Brive,  of 
whom  10  were  afterward  attacked  with  hy- 
drophobia; viz.  one  on  the  15th  day  after 
the  bite  ; one  o i the  18th  ; one  on  the  19th  ; 
one  on  the  28th  ; one  on  the  30th  ; one  on 
the33d  ; one  on  the 35th  ; one  on  the  44th;  one 
on  the  52d  ; and  the  last  on  the6Sthday.  (Hist. 
delaSoc.  RoyaledeM6d.p.2 09.)  Fothergilland 
Mo-,  iy  mention  cases,  in  vv h i < b the  disease 
began  four  months  alter  ihe  bile;  and  M 
Matthey.  ot  Geneva,  details  an  instance,  in 
which  the  interval  was  117  days.  (Journ. 
Gen.  T-  54,  p.  275)  , Haguenot  knew  ot  a 
case,  in  which  the  interval  between  the  bite 
and  the  commencement  of  the  illness  was 
five  months.  (Portal,  p.  183.)  Dr.  J.  Vaugh- 
an mentions  an  interval  of  nine  months; 
Mead,  of  11;  Galen,  Bauhin,  and  Boissiere, 
Vol.  IF  12 


of  a year;  Noursc,  of  19  months;  and  R. 
Lentilius,  of  three  years. 

Dr.  Bardsb  y,  of  Manchester,  has  recorded 
a case,  in  which  the  rno-t  careful  inquiries 
tended  to  prove,  that  the  patient  had  never 
suffered  the  least  injury  from  any  animal,  ex- 
cept the  bite,  inflicted  twelve  y*-ars  previous- 
ly to  the  commencement  of  hydrophobia,  by 
a dog  apparent ! v mad.  (Mem.  of  Liter,  and 
Phil  Society  of  Manchester,  Pol.  4,  Part  2, 
p.  431.) 

A merchant  of  Montpellier  is  also  stated 
to  have  been  attacked  with  hydrophobia  ten 
years  after  the  bite  of  a rabid  dog,  which 
also  bit  the  patient’s  brother,  who  died  hy- 
drophobic on  the  40th  day  after  the  accident. 
(See  Diet,  des  Sciences  Med.  T.  47,  p.  75.) 
Here  may  also  be  found  references  to  cases, 
i t which  the  interval  is  alleged  to  have  been 
IS,  20,  and  even  30  years.  It  is  certainly 
difficult  to  attach  any  credit  to  these  very 
late  periods  of  attack.  Dr.  J.  Hunter  consi- 
ders 17  months,  and  Dr.  Hamilton  19, 
the  longest  interval  deserving  belief.  (On 
Hydrophobia,  Vol.  1 ,p.  113.)  Exposure  to 
the  heat  of  the  sun,  violent  emotions  of  the 
mind,  and  tear,  are  believed  to  have  consi- 
derable influence  in  accelerating  the  com- 
mencement ot  the  symptoms.  That  mental 
alarm  is  also  of  itscif  sometimes  capable  of 
bringing  on  a simple  hydrophobia,  totally 
unconnected  with  infection,  is  incontestable  ; 
a case,  which  has  not  always  been  duly  dis- 
criminated. A most  convincing  proof  of 
this  fact  i-  recorded  by  Barbantini,  in  the 
Italian  Journ.  of  Physic,  Ciiymistry,  &c.  for 
January  ami  February,  1817.  A young  man 
was  bit  by  a dog,  which  he  iancied  was  mad, 
arid  on  the  5 tit  day  he  evinced  symptoms  of 
hydrophobia,  ot  which  he  was  nearly  dying, 
when  the  dog  which  had  bit  him,  was  shown 
to  him  perfectly  well,  atid  the  intelligence 
tranquillized  him  so  effectually,  that  he  was 
quite  well  four  days  afterward.  Mr.  John 
Hunter  is  said  to  have  mentioned  in  his  Lec- 
tures a very  similar  case,  in  which  he  believ- 
ed the  patient  would  certainly  have  died,  if 
the  dog  which  inflicted  the  bite  had  not  been 
found,  and  shown  to  the  patient  perfectly 
well.  (See  Journ.  Gen.  de  Med.  T.  4J,  p. 
215.)  It  is  to  the  effects  of  terror,  that  seve- 
ral modern  writers  are  disposed  to  refer  the 
instances  of  very  late  attacks  of  hydropho- 
bic symptoms  after  the  period  when  the  pa- 
tients were  bitten  ; though,  unless  the  intel- 
lects be  changed  in  the  mean  time'  by  other 
causes,  it  is  difficult  to  conceive,  why  Ihe 
alarm  should  not  have  the  greatest  effect 
earlier,  while  the  impression  of  the  danger 
is  undiminished  by  time.  The  idea,  that  the 
symptoms  begin  sooner  after  the  bite  of  a 
wolf,  than  that  of  a dog,  is  not  adopted  by  a 
writer  who  has  taken  great  pains  to  collect 
information  on  the  present  interesting  dis- 
order. (8ee  Diet,  des  Sciences  Mid.  T.  47,  p. 
77.) 

Cullen  has  divided  the  disease  into  two 
stages,  the  hydrophobia  simplex  and  rabiosa  ; 
or  the  melancholy  and  raving  stages  of  some 
other  writers.  But  as  the  early  stage  is  fre- 
quently unattended  with  any  thing  like  me- 


hydrophobia. 


00 


lancholy,  it  is  best  merely  to  adopt  the  dis- 
tinction of  the  first  and  second  stages ; one 
comprehending  t he  effects  of  the  disorder 
previously  to  the  occurrence  of  a dread,  or 
decided  aversion  of  liquids;  the  other,  the 
subsequent  changes.  The  wound,  if  treated 
by  common  methods,  usually  heals  up  at 
first  in  a favourable  manner.  At  some  inde- 
finite period,  and  occasionally,  long  after  the 
bitten  part  seems  quite  well,  a slight  pain 
begins  to  be  felt  in  if,  or  the  neighbouring 
parts,  now  and  then  attended  with  itching,  but 
generally  resembling  a rheumatic  pain.  If 
the  bite  took  place  on  the  linger,  the  pain 
successively  extends  from  the  hand  to  the  lore 
arm,  arm,  and  shoulder,  without  any  redness 
or  swelling  in  these  parts,  or  any  increase  of 
suffering  from  pressure  or  motion  of  the 
limb.  In  a great  number  of  instances  the 
trapezius  muscle,  and  the  neck,  on  the  same 
side  as  the  bite,  are  the  points  to  which  the 
pain  principally  shoots.  The  cicatrix,  in 
the  mean  while,  begins  to  swell,  inflames, 
and  often  festers  and  discharges  an  ichorous 
matter.  These  uneasy  painful  sensations  re- 
cur from  time  to  time,  and  usually  precede 
any  dread  of  water  several  days ; and  they 
are  a just  reason  for  apprehension.  Some 
times  pains  of  a more  flying,  convulsive  kind, 
are  felt  in  various  parts  of  the  body.  As  the 
disease  advances,  the  patient  complains  of 
the  pain  shooting,  from  the  situation  of  the 
bite,  towards  the  region  of  the  heart.  Some- 
times instead  of  pain,  there  is  rather  a feel- 
ing of  heat,  a kind  of  tingling,  or  even  a sen- 
sation of  cold,  extending  up  to  the  chest  and 
throat.  Occasionally  no  local  symptoms  take 
place  : thus  Sabatier,  in  giving  account  of  se- 
veral cases,  remarks  it  as  worthy  of  notice, 
that  the  bitten  parts  did  not  become  painful 
previously  to  the  accession  of  the  fatal  symp- 
toms ; nor  did  any  swelling,  or  festering 
occur.  (See  Mdm.  de  I'lnstilut.  National , T. 
2,  p.  249.  <^c.) 

Dr.  Marcet  particularly  observed,  that  the 
pain  follows  tiie  course  of  the  nerves,  rather 
than  that  of  the  absorbents.  In  the  case 
which  he  has  related,  as  well  as  in  one  of  the 
cases  detailed  by  Dr.  Babington,  there  was 
pain  in  the  arm  and  shoulder,  but  without  any 
affection  of  the  axillary  glands  ; and  in  ano- 
ther case,  (See  Medical  Communications,  Vol. 
2,)  the  pain,  occasioned  by  a bite  in  the  leg, 
was  referred  to  the  hip  and  loins,  without 
any  affection  of  the  inguinal  absorbents. 
( Medico-Chir . Trans.  Vol.  1 p.  156.)  Of  the 
accuracy  of  the  foregoing  statement,  by  Dr. 
Marcet,  there  is  no  doubt : the  observation, 
however, in  regard  to  the  irritation  not  affect- 
ing the  absorbents,  was  long  ago  anticipated 
by  several  authors,  who  urged  the  freedom 
of  the  lymphatic  glands  from  disease,  as  an 
argument  that  the  disorder  did  not  depend 
upon  the  absorption  of  any  virus.  It  is  also 
noticed  by  others,  who  inclined  to  the  belief, 
in  the  absorption  of  the  infectious  principle. 
“ Resorptiouem  virus  ope  syslematis  lympha- 
tic! fieri  verisimiliirnum  videtur  ; neque  ta- 
rnen  nee  vasa  lymphatics,  necglandulae  vici- 
nae  stimulo  morboso,  vel  tumore  adfici 
videntur ; quod  in  aliis  resorptionibus  virulen- 


tis  fieri  sole?.  ; ( CaUisen  Sijsl.  Ch/irurgite 

Hodiernal,  Vol.  1 ,p.  595,  Hafnice,  1798.) 

Pain  and  heaviness  are  felt  in  the  head. 
Sometimes,  the  headach  is  at  first  very  se- 
vere : sometimes  but  slight ; but,  in  the  latter 
case,  it  often  becomes  intense,  general,  and 
accompanied  with  a sense  of  pressure  upon 
the  temples.  In  certain  instances,  the  pa- 
tient’s sleep  lasts  a good  while,  though  dis- 
turbed by  dreams;  while,  in  other  more 
frequent  examples,  he  is  continually  restless. 
The  intellectual  functions  generally  seem  in- 
creased; the  memory  stronger;  the  concep- 
tion more  ready  ; the  imagination  more  fer- 
tile ; and  the  conversation  more  animated. 
However,  some  patients  are  silent  and  de- 
jected, and,  when  questions  are  put  to  them, 
the  answers  are  short  and  peevish.  But  the 
greater  number  are  active,  lively,  and  talka- 
tive. At  the  same  time,  the  organs  of  sense 
betray  signs  of  increased  sensibility ; and 
the  eyes,  which  are  very  open  and  bright, 
avoid  a strong  light.  Sometimes,  the  pupil  is 
found  to  be  considerably  dilated.  Extraor- 
dinary pains  are  felt  about  the  neck,  trunk, 
and  limbs.  It  is  not  uncommon  also  for  the 
patient  to  evince  great  anxiety,  or  to  fall  into 
a state  of  dull  despair  and  melancholy. 
These  last  symptoms,  of  which  great  notice 
is  taken  by  writers,  are  particularly  ascriba- 
ble  to  the  effect  of  fear.  The  disorder  of  the 
organs  of  digestion  is  sometimes  manifested 
in  various  ways,  though  it  is  far  from  being  so 
frequent  and  striking,  as  the  affections  of  the 
head,  which  precede  it.  The  disorder  refer- 
red to,  consists  at  first  in  loss  of  appetite; 
nausea;  vomiting;  and  afterward  constipa- 
tion, and  sometimes  colic.  In  the  first  stage 
of  the  disease,  the  pulse  is  generally  some- 
what more  frequent  and  strong  than  in  health, 
and  the  countenance  appears  more  animated. 

The  above  symptoms  precede  the  second 
stage,  or  that  of  decided  rabies,  only  by  a 
few  days,  usually  four  or  six,  though  some- 
times but  two  or  three.  (Diet,  des  Sciences 
Med.  T.  47, p.  78.) 

The  second  stage  of  hydrophobia  com- 
meuces  with  the  first  manifestation  of  the 
dread,  or  aversion  of  liquids.  The  ungovern- 
able agitation  and  distressing  sense  of  suffo- 
cation excited  by  the  sight  of  liquids,  the  at- 
tempt to  drink,  or  even  the  mere  idea  of 
drinking,  is  unquestionably  the  most  remark- 
able symptom  of  the  disorder.  The  patient 
is  also  frequently  attacked  with  the  same  kind 
of  commotion  and  suffering,  from  other 
causes,  such  as  the  least  agitation  of  the  air, 
or  exposure  to  a strong  light.  Indeed,  some 
patients  are  so  much  affected  by  a blast  of 
wind,  that  they  have  been  known  to  endea- 
vour to  elude  it  by  walking  with  I heir  backs 
towards  it ; (Hist,  de  la  Soc.  Roy.  de  Med.  p. 
157,)  while  others  scream  out  whenever  the 
window  or  door  of  their  room  is  opened. 
(Morgagni  De  Sed.  et  Cans.  Morb.  Epist.  8, 
No.  28,) 

Dr.  Marcet,  in  relating  the  case  of  the  pa- 
tient affected  with  hydrophobia,  observes, 
that  “on  our  proposing  to  him  to  drink,  he 
started  up,  and  recovered  his  breath  by  n 
deep  convulsive  inspiration  ; yet,  he  express- 


HYDROPHOBIA. 


91 


cd  much  regret,  that  he  could  not  drink,  as 
he  conceived  it  would  give  him  great  relief, 
his  mouth  being  extremely  parched  and  clarn- 
mv  On  being  urged  to  try,  however,  lie 
took  up  a cup  of  water  in  one  hand,  and  a 
tea-spoon  in  the  other.  The  thought  of  drink- 
ing out  of  the  cup  appeared  to  him  intolera- 
ble ; but,  he  seemed  determined  to  drink 
with  the  spoon.  With  an  expression  of  ter- 
ror, yet  with  great  resolution,  he  filled  the 
spoon.  and  proceeded  to  carry  it  to  li is  lips  ; 
but  before  it  reached  his  mouth,  his  courage 
forsook  him,  and  he  was  forced  to  desist. 
He  repeatedly  renewed  the  attempt  ; but, 
with  no  more  success.  His  arm  became  rigid 
and  immoveable,  whenever  he  tried  to  raise 
it  towards  his  mouth,  and  he  struggled  in 
vain  against  this  spasmodic  resistance.  At 
last,  shutting  his  eyes,  and,  with  a kind  of 
convulsive  effort,  he  suddenly  threw  into 
bis  month  a few  drops  of  the  fluid,  which 
he  actually  swallowed.  But,  at  the  same  in- 
stant, he  jumped  up  from  his  chair,  and  flaw 
to  the  end  of  the  room  panting  for  breath, 
and  in  a state  of  indescribable  terror.”  (See 
Med.  Chir.  Trans.  Vol.  l,p,  loS.)  Even  the 
splashing  or  running  of  any  liquid  causes  a 
great  deal  of  inconvenience.  As  the  system 
becomes  more  and  more  affected,  the  patient 
loses  his  sleep  entirely,  and  has  frequent  and 
violent  fits  of  anxiety  and  loud  screaming 
from  slight  causes.  The  woman,  whom  Dr. 
Powell  attended,  was  often  attacked  in  this 
way,  in  consequence  of  so  trivial  a circum- 
stance as  a fly  settling  on  her  face.  The  noise 
of  tea  cups,  or  the  mention  of  any  sort  of 
drink,  greatly  disturbed  het*1,  though  sbe  was 
not  at  all  agitated  by  the  sound  of  her  urine. 
The  currents  of  air  entering  her  room,  when- 
ever the  door  opened,  became  very  distress- 
ing to  tier,  and  ibis  more  and  more  so.  The 
pain  in  her  neck  became  so  great,  that  she 
could  scarcely  bear  it  to  be  touched  ; but  she 
made  use  of  a looking-glass  without  (he  in- 
convenience, which  hydrophobic  patients 
usually  suffer  from  the  sight  of  shining  bo- 
dies. Dr.  Powell  states,  that  the  paroxysms, 
which  this  poor  woman  suffered,  resembled 
those  of  hysteria,  and  increased  in  duration 
as  the  disorder  lasted.  “ She  described  their 
commencement  to  be  in  the  stomach,  with  a 
working  and  fulness  there,  and  that  a prick- 
ing substance  passed  up  into  her  throat  and 
choked  her;  she  screamed  suddenly,  and 
grasped  firmly  hold  of  her  attendants,  as 
if  voluntarily ; and  muscular  convulsions 
came  on,  which  were1  sometimes  more, 
sometimes  less  general  and  violent.  The 
causes  from  which  these  paroxysms  arose 
were  extremely  slight  ; the  passage  of  a fly 
near  her  face,  the  attempt  to  swallow  a pill, 
a stream  of  air,  the  sight  of  oil  or  wine, 
or  any  other  liquids,  even  the  sound  of  water, 
and  other  such  circumstances,  were  sufficient; 
she  now  also  complained  of  inconvenience 
from  light,  which  was  accordingly  modera- 
ted. The  effect  of  sounds  was  peculiar;  for 
though  in  the  subsequent  stages  their  influ- 
ence became  more  general,  at  this  period  the 
effect  was  rather  proportionate  to  the  ideas 
they  excited  in  her  mind,  than  to  their  vio- 


lence. Bells,  and  other  strong  noises,  did 
not  agitate  her,  hut  the  clatter  of  earthen- 
ware,  (he  noise  of  a distant  pump,  or  any 
thing  connected  with  liquids,  produced  the 
paroxysms  in  all  their  violence.”  She  could 
swallow  fresh  currants  with  less  resistance 
than  any  thing  else,  taking  care  that  they 
were  perfectly  dry.  Her  mind  had,  fill  now, 
been  quite  cairn  and  composed,  and  her  con- 
versation and  behaviour  proper,  during  the 
intervals  of  the  convulsive  attacks.  But  Dr. 
Powell  was  obliged  to  discontinue  the  pills  of 
argentum  nitratum,  in  consequence  of  the 
sufferings  which  the  attempt  to  swallow 
them  regularly  brought  ou.  Fifteen  grains  of 
this  substance  had  been  given  without  any 
sensible  effect-.  The  fits,  and  the  irritability  to 
external  objects,  increased.  The  pain  shot 
from  the  back  of  the  neck,  round  the  angles 
of  the  jaws,  the  chin,  and  throat.  At  length 
the  paroxysms  became  more  frequent,  and, 
indeed,  might  be  said  to  come  on  spontane- 
ously : seven  occurred  in  one  hour.  She 
looked  pale  and  exhausted,  anil  a tremor  and 
blueness  of  her  lips  and  fingers  were  obser- 
vable ; her  pulse  became  weaker  and  more 
rapid,  and  her  scalp  so  tender,  that  touching 
it  brought  on  convulsions.  She  had,  latterly, 
eructations  of  wind,  and  spit  up  some  thick 
viscid  saliva.  Her  urine  now  came  away  in- 
voluntarily, and  siie  was  ysore  and  more  irri- 
table and  uncontrollable*  indeed, she  passed 
two  hours  in  almost  constant  convulsions  ; 
became  extremely  irritable  and  impatient  of 
every  thing  about  her,  complained  of  failure 
of  her  sight ; wished  to  be  bled  to  death  ; 
her  words  were  fewer  and  interrupted  ; she 
struck,  and  threatened  to  bite,  her  attend- 
ants ; had  copious  eructations  of  air;  dis- 
charged an  increased  quantity  of  viscid  saliva 
with  much  convulsive  effort  ; said  the  affec- 
tion of  her  throat  and  stomach  had  quite  left 
her;  and  continued  in  a general  perspiration, 
with  a weak  pulse  from  140  to  150.  She  af- 
terward bit  some  of  the  attendants,  and  was 
therefore  confined  with  a waistcoat.  From 
(his  period,  she  had  lost  all  control  over  her 
mind,  and  continued  for  almost  four  hours  in 
a paroxysm  of  furious  insanity.  She  now 
swallowed,  with  an  effort,  near  half  a pint  of 
water : but  this  was,  in  a few  seconds,  vomit- 
ed up  with  some  mucus,  and  a greenish  fluid. 
In  this  violent  raving  state,  she  continued  till 
within  two  hours  of  her  death,  which  took 
place  forty-seven  hours  after  the  first  marked 
occurrence  of  hydrophobia.  In  the  course 
of  the  case{  she  swallowed,  once  or  twice,  a 
little  porter  ; and  also  some  cinnamon-water, 
with  tinct.  opii  : but  they  were  always  vomit- 
ed up.  (Dr.  Powell's  Case  of  Hydrophobia.) 

It  is  by  no  means  uncommon  tor  a period 
to  occur,  when  the  horror  of  liquids  undergut  s 
a considerable  diminution,  or  even  entirely 
ceases;  the  patient  quenching  his  thirst,  and 
this  sometimes  as  well  as  if  he  were  in  peifect 
health,  and  so  as  to  raise  doubts  of  the  exist- 
ence of  rabies.  But  after  a few  hours,  the 
dread  of  fluidscomes  on  again,  and  with  it  the 
convulsive  paroxysms, which  now  become  ge- 
neral. violent,  and  incessant.  Dr.  Cayol  at- 
tended a girl,  labouring  under  rabies,  who 


HYDROPHOBIA. 


92 

was  never  affected  with  any  very  great  dread 
of  liquids,  nor  an  absolute  inability  to  swal- 
low them,  though  she  certainly  disliked  them, 
and  swallowed  >hem  with  difficulty.  ( Journ . 
de  Med.  Chir.  tyc.  Avril.,  1811,  p.  241.)  IN  ay, 
patientsare  sometimes  seen,  ho  can  man  .ge 
to  swallow  red  wirie  and  broth,  though  their 
aversion  to  water  is  alread)  beyond  all  con- 
trol; and  other  patients  can  sometimes  look  tit 
a liquid  in  a black  put  without  inconvenience  ; 
though  any  fluid  ottered  to  them  in  a glass 
will  bring  on  a violent  paroxysm  of  spasm 
and  sense  of  suffocation.  The  sight  of  tears 
has  even  been  enough  to  bring  on  the  attack. 
(See  Diet.  des  Sciences  Med.  T.  47,  p.  79.) 

The  question  lias  sometimes  been  enter- 
tained, whether  rabies  can  ever  exis-t  quite 
unattended  throughout  its  course  with  a dread 
of  liquids  ? The  possibility  of  such  a case 
was  believed  by  Mead  and  others,  and  an  in- 
stance is  recorded  by  Migriot,  in  which  the 
patient  died,  without  having  manifested  any 
sign  of  hydrophobia.  (See  Hist  de  la  Soc. 
Roy.  de  Med.  an  1783,  2 me  Part.  p.  48.)  How- 
ever, it  is  asserted,  that  a careful  perusal  of 
this  case  must  produce  a conviction,  th.it  the 
disorder  was  not  raoies  ; and  it  is  added,  that 
when  the  histories  of  this  disease  on  record 
are  critically  investigated,  none  will  be  found 
complete,  which  do  not  make  mention  of  a 
more  or  less  decided  aversion  to  fluids.  It 
also  appears  from  the  facts  referred  to,  that 
the  dread  of  liquids  does  not  depend  upon  the 
pain,  which  the  patient  has  already  suffered 
from  his  attempts  to  drink,  as  it  sometimes 
occurs  before  any  such  attempt  has  been 
actually  made.  ( Vol . cit.p.  80) 

An  inclination  to  bite  has  been  noticed, 
as  happening  in  the  patient,  whose  case  is 
recorded  by  Dr.  Powell.  Yet,  this  disposi- 
tion is  far  from  being  usual  ; and  it  never 
presented  itself  in  any  of  the  cases  which 
fell  under  the  observation  of  the  author  of 
the  article  rage  in  the  foregoing  publication, 
or  P.  Desault,  Duchoisel,  Dr.  J Vaiighan, 
Sabatier,  Dupuytren.  &c.  And  even  when 
the  patient’s  imaginalion  is  so  disordered, 
that  he  cannot  help  biting,  he  commonly 
warns  the  bystanders  to  avoid  the  danger. 
The  frolhy  slaver,  which  is  voided  with 
considerable  and  repeated  efforts,  is  a symp- 
tom, which  is  said  not  to  commence  before 
the  respiration  begins  to  be  convulsive.  As 
the  disease  advances,  there  is  no  remission 
of  the  sputaiion,  necessary  to  clear  the 
throat  of  this  viscous  secretion  ; and  at  the 
approach  of  death,  when  it  cannot  be  ex- 
pelled, it  collects  in  the  mouth,  and  covers 
the  patient’s  lips. 

The  symptoms  of  what  is  termed  cerebral 
excitement  become  stronger  and  more 
marked  in  the  second  stage  of  the  disease. 
The  eyes,  the  brightness  of  which  is  still 
further  increased,  appear,  as  it  were,  infla- 
med-; the  patient  never  shuts  them  again  ; 
and  as  the  daylight  and  brilliant  colours  are 
offensive,  he  prefers  darkness.  The  hearing 
becomes  very  acute,  and  as  well  as  the 
sight,  is  troubled  with  hallucinations.  The 
touch  is  extremely  fine  ; the  speech  abrupt 
and  rapid  ; and  the  conversation  energetic, 


and  often  expressive  of  the  most  touching 
sentiments,  {Did.  des  Sciences  Med.  T.  47, 
V • 1 •) 

Dr.  Marshall  made  a very  just  distinction 
between  the  real  convulsions  which  came 
on  towards  the  termination  of  the  case  in 
death,  and  the  strong  sudden  action  of  the 
muscles,  excited  in  the  course  of  the  disor- 
der by  the  light,  the  sight  of  liquids,  and  the 
feel  of  the  air.  {The  Morbid  Anatomy  of  the 
Brain,  fyc.  p.  88.)  Convulsions  and  hic- 
cough, in  fact,  are  the  symptoms  of  disso- 
lution. 

Delirium  is  far  from  being  a constant 
symptom,  and  only  happens  the  last  day  of 
the  disorder.  ^Neither  is  it  always  without 
remissions  ; for  the  patients  affected  with  it 
sometimes  give  rational  replies.  Kvery  case 
upon  record,  where  delirium  is  described  as 
being  one  of  the  first  symptoms,  or  as  com- 
ing on  with  the  dread  of  liquids,  is  set  down 
on  good  authority,  not  as  true  rabies,  but 
a symptomatic  hydrophobia,  attended  with 
mania. 

The  dread  of  swallowing  liquids,  though 
the  most  singular  symptom  of  the  disease, 
constitutes  but  a small  part  of  it.  It  is  true, 
that  none,  or  very  few  recover,  who  have 
this  symptom,  yet  they  certainly  do  not  die 
in  consequence  of  the  difficulty  of  swallow- 
ing liquids  ; for  the  human  body  could  easily 
exist  double  the  time,  at  the  end  of  which 
the  disease  usually  proves  fatal,  without  food 
or  drink.  Besides,  the  sick  can  often  swallow 
substances  that  are  nourishing,  in  a pulpy 
state,  without,  however,  having  their  life 
thereby  at  all  prolonged.  It  is  not,  there- 
fore, the  difficulty,  or  impossibility  of  swal- 
lowing liquids  ; but  the  effects  of  the  poison 
upon  the  constitution  at  large,  which  occa- 
sion dea*h.  {Dr.  J.  Hunter  in  Trans,  for 
the  Improvement  of  Med.  Knowledge , Vol  1, 
p.  305.) 

The  extreme  sensibility  of  the  sick  to  all 
impressions,  appears  in  the  displeasure 
which  they  express  at  even  the  air  blowing 
upon  them  ; in  their  dislike  to  a strong 
light  ; in  their  aversion  to  new  faces,  or  even 
tiie  sight  of  their  friends  and  relations ; and 
in  the  terror  they  express  at  being  touched, 
which  almost  threatens  to  throw  them  into 
convulsions.  As  the  disease  advances,  the 
mind  is  more  and  more  filled  with  dreadful 
fears  and  apprehensions.  {Op.  cit.p.  307.) 

In  the  second  stage,  the  epigastrium,  as 
well  as  the  chest,  is  the  seat  of  considerable 
pain  ; the  patient  is  constipated,  but  the 
urine  is  plentiful  and  high  coloured.  Before 
a certain  period,  the  pulse  is  generally 
strong,  regular,  and  a little  accelerated  ; but 
towards  the  end  of  the  case,  it  becomes 
small,  irregular,  feeble,  and  rapid.  (See 
Did.  des  Sciences  M6d.  T.  47,  p.  83.) 

The  duration  of  life,  from  the  appearance 
of  hydrophobia  till  death,  varies  from  thirty- 
six  hours  to  four  or  five  days : the  most 
common  period  is  fr. • m tvyo  to  three  days. 
{Dr.J.  Hunter,  Op.  cit.p.  308.)  The  event  is 
said  to  be  directly  caused  by  asphyxia,  or 
the  cessation  of  respiration.  Of  ten  persons, 
who  were  bitten  by  the  same  animal,  nine 


HYDROPHOBIA. 


died  on  the  second  and  third  day,  from  the 
commencement  of  the  horror  of  fluids,  and 
only  one  on  the  fifth  day.  There  is  an  account 
of  a child  at  Senlis,  who  lived  nine  days, 
but  the  description  of  the  case,  and  the  cir- 
cumstance of  fourteen  worms  being  found 
in  the  intestines,  may  raise  doubts  about  the 
nature  of  the  disease.  (See  Hist,  de  la  Soc. 
Hoi/,  de  Med.  p.  209,  155.J 

Whatever  may  be  the  resemblance  found 
between  rabies  and  hydrophobia,  with  re- 
gard to  the  rapidity  of  their  course,  their 
causes,  and  some  of  /their  symptoms,  the 
following  considerations,  as  a modern  wri- 
ter observes,  will  always  serve  for  the  dis- 
crimination of  one  disorder  from  the  other: 
tetanus  attacks  the  muscles  of  the  jaw,  w hich 
remains  motionless,  w hile  in  rabies,  the  jaw 
is  not  only  moveable,  but  incessantly  mo- 
ving, in  consequence  of  the  efforts  unremit- 
tingly made  by  the  patient  to  free  bis  mouth 
from  the  thick  saliva  with  which  it  is  ob- 
structed. In  this  last  disorder,  the  muscles 
are  alternately  contracted  and  relaxed  ; but 
in  tetanus,  they  always  continue  rigid.  Te- 
tanus is  rarely  attended  with  any  aversion 
to  liquids,  and  the  patient  may  be  kept  for  a 
long  time  in  a bath  without  inconvenience  ; 
and  the  paroxysms  are  neither  excited,  nor 
increased  by  a vivid  light,  a noise,  the  pa- 
tient’s being  touched,  or  the  sight  of  water, 
or  shining  surfaces.  In  addition  to  these 
differences,  it  is  to  be  remembered,  that 
tetanus  is  most  frequent  in  warm  climates, 
and  that  it  mostly  comes  on  a few  days  after 
the  receipt  of  a local  injury,  and  may  occur 
as  a complication  of  any  kind  of  wound, 
even  that  which  is  made  in  a surgical  ope- 
ration. (See  Diet,  das  Sciences  Med.  T.  47, 

p.  86.) 

On  the  subject  of  prognosis,  with  respect 
to  the  bite  inflicted  by  a rabid  animal,  and 
its  effects,  as  evinced  in  the  decided  form 
of  rabies,  there  are  several  things  worthy  of 
attention.  According  to  some  writers,  small 
wounds  are  not  less  dangerous  than  others, 
and  an  attempt  is  made  to  account  for  the 
fact,  by  the  more  copious  hemorrhage  from 
larger  wounds,  and  the  frequent  neglect  of 
lesser  injuries.  Perhaps  another  reason  is, 
that  the  virus  is  more  likely  to  be  confined 
in  a wound  with  a small  orifice,  than  in  one 
which  is  ample,  and  admits  of  being  more 
effectually  washed.  The  more  numerous 
the  wounds  are,  the  greater  is  the  risk.  If 
it  be  inquired,  what  is  the  average  number 
of  persons  attacked  with  rabies  out  of  a 
given  number  w ho  have  received  bites  ? 
The  question  can  only  be  answered  by  r/  - 
ferring  to  the  extremes.  Thus,  Dr.  J.  Vaugh- 
an speaks  of  between  twenty  and  thirty 
individuals,  bit  by  a mad  dog,  ot  whom  only 
one  was  afterward  attacked  with  rabies  ; 
and  Dr.  J Hunter  teljs  us  of  an  instance, 
in  which  out  of  twenty-one  persons  bit,  only 
one  became  affected.  (See  also  Folhergill 
in  Med.  Obs.  and  Inq.  Vol.  5,  p.  195.)  On 
the  other  hand,  out  of  fifteen  persons  bit  by 
a mad  dog,  and  taken  care  of  at  Senlis,  three 
at  least  were  seized  with  the  disorder,  (Hist, 
de  la  Soc.  Roy.  de.  Med.p.  130  ;)  of  seventeen 


93 

others  bit  by  a wolf,  ten  were  attacked ; 
(ib.  p.  130;)  and  of  twenty-three,  bit  by  a 
she-wolf,  thirteen  died  of  rabies.  (L.  F. 
Trolliel,  Nouveau  Trait 6 de  la  Rage,  fyc. 
Obs.  Chirurgique,  fyc.  No.  25.) 

a wo  important  facts  should  always  be 
recollected  ; viz.  the  disease  may  often  be 
prevented  ; it  can  hardly  ever  be  cured. 
Experience  has  fully  proved  that  when  hy- 
drophobia once  begins,  it  generally  pursues 
its  dreadful  course  to  a fatal  termination, 
the  records  of  medicine  furnishing  very  few 
unequivocal  and  well-authenticated  cases 
to  the  contrary.  Hence,  the  imperious  ne- 
cessity of  using  every  possible  means  for  the 
prevention  of  the  disorder. 

Probably,  however,  many  things  which 
possess  the  character  of  being  preventive  of 
hydrophobia,  have  no  real  claim  to  such 
reputation.  I would  extend  this  observation 
to  all  internal  medicines,  mercurial  fric- 
tions, and  plunging  the  patient  for  a consi- 
derable time  under  water. 

The  instances,  in  which  a prevention  is 
inferred  to  have  taken  place,  by  different 
w riters,  in  consequence  of  such  means,  may 
all  be  very  rationally  ascribed  to  other  cir- 
cumstances. Facts  already  cited  sufficiently 
prove,  that  out  of  the  great  number  of  per- 
sons frequently  bitten  by  the  same  dog,  only 
a limited  proportion  is  commonly  affected . 
The  hydrophobic  poison  is  known  to  reside 
in  the  saliva  of  the  animal  ; consequently, 
the  chance  of  being  affected  must  greatly 
depend  upon  the  quantity  of  this  fluid  which 
is  insinuated  into  the  wound  ; and  if  the 
teeth  of  the  animal  should  have  previously 
pierced  a thick  boot,  or  other  clothing,  be- 
fore entering  the  skin,  the  danger  must  be 
obviously  much  diminished.  Many  patients 
wash  and  suck  the  wround,  immediately  after 
its  occurrence,  aqd  thus,  no  doubt,  very  often 
get  rid  of  the  poison.  Even  wdien  it  is  lodg- 
ed in  the  wound,  it  may  not  be  directly  ab- 
sorbed, but  be  thrown  off  with  the  discharge. 
All  prudent  patients  submit  to  excision  of 
the  bitten  part.  Now.  under  each  of  the 
above  circumstances, escapes  have  frequent- 
ly occurred,  while  internal  medicines,  half 
drowning  or  salivating  the  patients,  had  also 
not  been  neglected,  so  that  all  the  efficacy  of 
preventives  has  too  often  been  most  unjustly 
ascribed  to  means,  which  probably  never 
yet  had,  and  never  will  have,  any  beneficial 
effect  whatever.  What  confirms  the  truth  of 
the  preceding  statement  is  these  facts:  that 
persons  bitten  by  the  same  animal  have 
sometimes  been  treated  exactly  on  the  same 
plan  ; some  of  them  escaped  the  disease  ; 
others  had  it,  and  of  course  perished  : on 
other  occasions,  some  of  the  patients,  bit- 
ten by  the  same  animal,  have  been  treated 
in  a particular  way,  and  have  escaped  hy- 
drophobia; w hile  others  bitten  at  the  same 
time  by  the  animal,  also  never  had  any  con- 
stitutional effects,  although  they  took  no 
medicines,  nor  followed  any  other  particu- 
lar plan. 

If  to  these  reflections  be  added  the  con- 
sideration, that  it  is  frequently  doubtful, 
whether  the  bite  has  actually  been  inflicted 


94 


HYDROPHOBIA. 


by  a truly  rabid  animal,  and  that  the  men- 
tal alarm  will  sometimes  bring  on  a symp- 
tomatic hydrophobia,  it  is  easily  conceiva- 
ble, how  mistaken  a person  may  be,  who 
believes  that  he  has  prevented  the  disorder, 
and  how  unmerited  is  the  reputation  of  the 
means,  which  ho  has  employed  for  the  pur- 
pose. 

The  bite  of  a naturally  ferocious  beast 
has  often  been  thought  to  be  attended  with 
more  risk  than  that  of  an  animal  naturally 
f ame  ; and  hence  the  bite  of  a wolf  is  said 
to  be  more  frequently  followed  by  rabies, 
than  that  of  a dog.  This  proposition  is  ad- 
mitted to  be  true  ; but  the  explanation  is 
erroneous.  The  true  reason  of  the  differ- 
ence is,  that  a wolf  usually  seizes  the  face, 
and  inflicts  a deeper  bite;  while  a dog  only 
snaps  as  he  runs  along,  and  mostly  bites 
through  the  clothes.  (See  Dirt,  des  Sciences, 
Med.  T.  47,  p.  88.)  The  bite  of  a rabid  ani- 
mal may  be  rendered  much  more  dangerous 
by  being  situated  near  a part,  or  an  organ, 
which  increases  the  difficulty,  or  risk,  of 
adopting  an  effectual  mode  of  removing 
the  whole  of  the  flesh,  in  which  the  virus 
may  be  lodged.  Thus,  bites  near  the  large 
arteries,  the  eyes,  the  joints,  &c.  are  of  a 
more  serious  description  than  others.  Dr. 
J.  Hunter  rated  the  hazard  in  some  degree 
by  the  vascularity  of  the  bitten  parts.  The 
prognosis  will  always  he  more  unfavourable, 
when  no  proper  measures  have  been  applied 
to  the  bite  soon  after  its  infliction,  and  per- 
haps the  risk  may  be  increased  by  certain 
causes  not  having  been  duly  avoided,  which, 
as  already  stated,  are  thought  to  have  a ten- 
dency to  accelerate  the  attack  of  rabies.  The 
exact  time  after  a bite,  when  the  prevention 
of  rabies  is  no  longer  practicable,  is  quite  an 
undetermined  point  ; but  every  fact  known 
upon  the  subject,  evinces  in  an  urgent  man- 
ner the  necessity  of  adopt  big  preservative 
measures  without  the  lea^t  delay. 

In  almost  all  the  dissections  of  patients, 
who  have  died  of  rabies,  certain  indications 
of  inflammation  have  been  perceptible  *, 
mure  frequently,  in  some  part  of  the  space 
between  the  pharynx  and  the.  cardiac  orifice 
of  the  stomach,  in  the  stomach  itself,  in  the 
lungs,  the  choroid  plexus,  and  membranes  of 
the  brain.  (See Med.  Repository.  Vol.  3.  p.  51.) 
3V1.  Troliiet  opened  with  the  greatest  c ue  sis 
bodies  of  persons  destroyed  by  this  disease. 
The  mouth  and  fauces  in  each  subject  were 
first  examined,  and  found  of  a pale  grayish 
colour  scarcely  lubricated  with  mucus,  and 
quite  free  from  all  frothy  matter.  All  the 
salivary  glands  seemed  perfectly  healthy. 
When  the  larynx,  trachea,  and  bronchia; 
were  opened,  they  appeared  to  have  been  the 
seat  of  inflammation,  the  traces  of  which 
were  the  most  marked  low  down,  where  the 
mucous  membrane  was  of  the  colour  of 
wine-lees.  In  four  of  the  bodies,  frothy  mu- 
cus was  perceived  in  the  bronchia;,  larynx, 
and  trachea.  Troliiet  infers  from  these  ap- 
pearances, that  the  frothy  matter  seen  about 
the  mouths  and  lips  of  patients  affected  with 
rabies,  is  secreted  by  the  inflamed  mucous 
membrane  of  the  bronchia;,  arid  tlmt  it  is 


this  secretion,  and  riot  the  veal  saliva,  which- 
contains  the  hydrophobic  poison.  (Nouveau 
Trails  de  la  Rage,  4 c ) In  giving  an  ac- 
count of  a dissection,  Faure  also  long  ago 
remarked,  that  the  frothy  matter  was  only 
met  with  in  the  air-passages,  that  the  sali- 
vary organs  were  unaffected,  and  that  the 
saliva  itself  did  not  contribute  to  the  form- 
ation of  the  thick  slaver,  which  appeared 
to  have  issued  from  the  chest.  (Hist,  de  la 
Soc.  Roy.  de  M6d.  ann.  17S3,  p.  39.)  From 
the  preceding  observations,  and  those  of 
Mignot  de  Genety  (Vol.  cit.p.  54,)  Morgagni 
(De  Sedib.  et  Caus.  Morb.  Epist.  8,  art.  20, 
25,  30.)  Darlue  (Journ.  de  Med.  de  Vander- 
monde. T.  4,  p.  270  ;)  B.  Rush;  and  Dupsey 
(Obs.  InMites,  No.  138)  it  would  appear: 

1 That  the  mouth,  strictly  so  called, 
and  the  salivary  glands,  are  without  any  al- 
teration. 

2.  The  mucous  membrane  of  the  air-pas- 
sages is  affected  with  inflammation,  which 
in  its  highest  degree  extends  from  the  divi- 
sion of  the  bronchia;  to  the  pharynx.  .When 
the  inflammation  is  of  less  extent,  the  pha- 
rynx appears  sound  ; and  when  yet  more 
limited,  it  is  usually  not  to  be  traced  in  the 
larynx.  The  point  where  it  seems  to  com- 
mence and  is  most  strongly  marked,  is  at  the 
lower  part  of  the  trachea,  or  in  the  bron- 
chia;. Lastly,  when  none  of  these  parts  are 
found  inflamed,  the  lungs  themselves  present 
vestiges  of  inflammation. 

With  respect  to  the  theory  of  Troliiet, 
wherein  the  hydrophobic  poison  is  said  to 
be  contained  in  the  mucous  secretion  void- 
ed from  the  lungs,  and  to  be  the  product  of 
inflammation  of  the  membrane  of  the 
bronchia;,  and  not  derived  from  the  sali- 
vary glands;  the  question  requires  the- 
confirmation  of  experiment ; for,  though 
the  salivary  glands  are  not  the  seat  of  pain, 
swelling,  fcc.  it,  by  no  means  follows,  that 
their  secreting  process  may  not  have  been 
subject  to  some  peculiar  modification,  on 
which  the  production  of  the  hydrophobic 
virus  depended.  Thus,  severe  and  obstinate 
ptyalisras  often  occur,  and  yet  there  is  no 
manifest  change  in  the  state  of  the  salivary 
glands.  According  to  Van  Swieten  and 
Mead,  there  are  also  sometimes  no  morbid 
appearances  either  in  the  head,  fauces,  chest, 
or  stomach.  (Comment,  in  Bocrh.  T.  3 ,p. 
562.) 

In  three  cases,  out  of  six,  the  lungs  were 
found  emphysematous,  that  is  to  say,  their 
interlobular  substance  was  distended  with 
air,  and  the  pleura  pulmofialis  raised  into  a 
great  number  of  transparent  vesicles  on  the 
surface  of  the  lungs.  In  a fourth  instance, 
the  emphysema  was  not  observed  in  the 
lungs  themselves,  but  in  the  cellular  substance 
between  the  two  layers  of  the  mediastinum  ; 
and  under  the  muscles  of  the  neck.  Mor- 
gagni also  noticed  vesicles  of  air  on  the  sur- 
face of  the  lungs  of  a person,  that  die^  of 
hydrophobia.'  (DeSed.cl  Cans.  Morb.  Epist. 
8,  art.  30.)  M.  Troliiet  presumes,  that  this 
emphysema  is  occasioned  by  the  rupture  oi 
one  of  the  air-cells,  in  the  convulsive  efforts 
of  respiration,  as  sometimes  happens  when 


HYDROPHOBIA. 


95 


a foreign  body  is  lodged  in  the  larynx.  (See 
Cases  by  Louis  and  Lescure  in  Mem,  de  V Acad, 
de  Chir.  T.  4 ,p.  538  ; T.  5,  p.  527  ) 

The  lungs  were  of  a deep-red  colour  in 
all  the  six  subjects  dissected  by  Trolliet,  and 
they  were  observed  to  be  gorged  with  blood 
in  cases  reported  by  numerous  writers:  as 
Bonet  (See  Van  Swieten , T 3,  § 1 140  ;)  Bo- 
erhaave  (Op.  Omn.  p.  215  ;)  Morgagni  (De 
Sedibus  et  Cans.  Morb.  F.p.  S,  art.  23,  <^c.  ; ■ 
Mead,  Darlue  (Recueil  Period,  fyc.  T.  3.  and 
4 ;)  Faure  (Hist,  de  la  Soc.  Roy.  de  Med.  p. 
39 ;)  De  la  Caze  (ib.  p.  69 ;)  Portal,  Old- 
know,  Ballingall  (Edinb.  Med.  and  Surg. 
Journ. :)  Marshall  (Morbid  Anatomy  of  the 
Brain,  fyc.  p.  69  ;)  Gorey  (Journ.  de  Med. 
Chir.  T.  13,  p.  83  ;)  Ferriar  (Med.  Hist,  and 
t Reflections , §c.)  u Pnlmones  in  quinque 
* nigri  ex  toto,  aut  magn&  parte  (says  Morgag- 
ni,) in  quatuor  magna  item  ex  parte  sanguine 
pleni.”  With  respect  to  the  state  of  the  or- 
gans of  the  circulation,  in  three  of  the  cases 
dissected  by  Trolliet,  a good  deal  of  air 
escaped  from  the  heart  and  aorta.  Morgagni 
is  supposed  to  be  the  only  other  writer,  who 
has  noticed  a similar  occurrence  (Epid.  8, 
Mo  30,)  and  who  also  in  another  case  saw 
air  escape  from  beneath  the  dura  mater.  (Ib. 
No.  23.)  fn  two  of  Trolliet’s  cases,  some 
gelatinous  clots  were  found  in  the  heart  and 
large  vessels  ; but  the  great  mass  of  blood 
was  black,  and  very  fluid  in  the  heart,  arte- 
ries, and  veins,  as  in  subjects,  who  have  died 
of  asphyxia.  In  all  the  six  cases,  traces  of 
inflammation  were  noticed  in  the  brain,  or 
its  membranes.  The  sinuses  w ere  filled  with 
a dark-coloured  fluid  blood  ; and  the  pia 
mater  was  much  injected,  and  of  a brownish 
hue.  The  same  appearances  were  found 
above  the  cerebellum,  and  the  vessels  on  the 
investment  of  the  medulla  spinalis  wrere  con- 
siderably enlarged.  The  surface  of  the  ce- 
rebrum wras  also  studded  with  scarlet  spots, 
which  appeared  to  arise  from  blood  effused 
from  the  small  vessels  of  the  pia  mater  into 
its  cellular  substance.  In  two  subjects,  blood 
was  extra vasated  towrards  the  base  of  the  brain 
in  larger  quantity.  The  plexus  choroides  was 
gorged  with  blood,  and  of  a brown  colour. 
Besides  those  and  other  changes,  Trolhet  re- 
marked, in  two  of  the  cases,  a thickening  of 
the  pia  mater.  The  substance  of  the  brain 
was  generally  softer  than  usual ; but  the  fluid 
in  the  lateral  ventricles  was  not  in  large  quan- 
tity, though,  in  twro  cases, it  had  a bloody  tinge. 
Tiie  late  Dr.  Marshall  believed  that  in  rabies, 
the  brain  was  the  part  principally  affected. 
(Op.  cit.  p.  145.) 

Hufeland  conjectured,  that,  in  hydropho- 
bia, the  medulla  spinalis  is  the  part  originally 
affected,  whence  the  effects  of  the  disease 
are  propagated  to  the  nerves  of  the  trunk. 

(Bibl.  Med.  T.  55,  p.  395,  fyc.)  Dr.  R.  Reid 
believed,  that  an  alteration  of  the  spinal 
marrow  was  essentially  concerned  in  the 
disease.  (On  the  Nature,  fyc.  of  Tetanus  of 
Hydrophobia,  Svo.  Dublin , 1817.)  A caae 
was  also  published  by  M.  Matthey,  of  Gene- 
va, in  which  a quantity  of  serum  was  found 
within  the  spinal  canal.  (Journ.  Gen.  de 
Med.  T.  54,  p.  279  ) See  on  this  subject 


some  observations  by  Dr.  Abercrombie. 
(Edinb.  Med.  and  Surg.  Journ.  Vol.  14. 

p.  66.) 

According  to  Trolliet , the  traces  of  inflam- 
mation in  the  digestive  organs  are  not  so 
constant  as  in  the  lungs  and  brain.  In  none 
of  the  six  cases  dissected  by  him,  was  there 
any  appearance  of  inflammation  in  the  pha- 
rynx, though  some  parts  of  the  alimentary 
canal  were  atfected  in  this  manner.  The 
cases  recorded,  however,  in  which  the  diges- 
tive organs  presented  considerable  mor- 
bid appearances,  are  very  numerous.  Thus 
Joseph  de  Aromatarius,  Darlue  (Recueil  Pe- 
riod. T.  3 , p.  189,  et  T.  4 , p.  270.)  Sauvages 
(p.  107,)  Professor  Rossi,  M.  Gorci  (Journ. 
de  Med.  Chir. tye.  T 13.)  and  Dr.  Powel  (Case 
of  Hydrophobia,,)  found  inflammation  either 
in  the  pharynx,  or  oesophagus,  or  both  these 
tubes;  Dr.  Powell’s  words  are,  “ the  oesopha- 
gus was  rather  redder  than  natural,  and 
covered  with  a thin  layer  of  coagulable 
lymph.”  A similar  coat  of  lymph  was  also 
found  by  Oldknow  (Edinb.  Med.  and  Surg. 
Journ  Vol,.  5,  p.  280,)  Ballingall  (Op.  cit.  Vol. 
11,  p.  76.)  Dr.  Ferriar  (Med.  Hist.  S^c.  Vol. 
3 , p.  27.)  In  dogs.  Dr  Gillman  found  the 
pharynx  and  oesophagus  in  a stale  of  inflam- 
mation. (On  the  Bite  of  a Rabid  Animal ,p, 
13,  23,  26,  44.)  It  is  conjectured,  that 
in  many  of  these  instances,  the  inflam- 
mation extended  to  the  oesophagus  from 
the  trachea  and  bronchi*.  (Diet,  des  Sci- 
ences Med.  T.  47,  p.  98.)  Inflammation 
of  the  mucous  membrane  of  the  stomach 
and  small  intestines,  has  likewise  been 
very  generally  noticed,  as  may  be  seen 
by  referring  to  the  accounts  published 
by  Morgagni,  Powell,  Oldknow,  Ferriar, 
Ballingall,  Marshall,  &.c.  In  d ;gs,  the  same 
fact  was  remarked  by  Dr.  Gillman  (P.  13,  31, 
44;)  sometimes,  however,  according  to 
this  last  author,  no  vestiges  of  inflammation, 
nor  any  other  morbid  appearances,  are  dis- 
coverable in  the  examination  of  animals 
that  have  died  of  rabies.  (P  83.)  Dupuy- 
tren  is  stated  to  have  found  the  mucous 
membrane  of  the  stomach  and  bowels  in- 
flamed in  several  places,  and  even  almost 
gangrenous  (Diet  des  Sciences  Med.  T.  47,  p. 
98.) 

From  recent  investigations,  made  at  the 
veterinary  school  at  Abort,  by  Professor 
Dupuy,  the  following  are  tiie  usual  morbid 
appearances,  noticed  in  the  dissection  of 
dogs,  horses,  cows,  and  sheep,  destroyed  by 
rabies.  1 The  lungs  and  brain  universally 
gorged  w'ith  blood.  2.  Greater  or  lesser 
remarks  of  inflammation  in  the  mucous 
membrane  of  the  bronchi*,  trachea,  larynx, 
throat,  oesophagus,  stomach,  and  frequently 
even  in  that  of  the  bowels,  vagina,  ute  y, 
and  bladder.  3.  The  air-passages  filled  with 
frothy  mucus.  4.  - collection  of  serum  in 
the  ventricles  of  the  brain,  and  sometimes 
even  betweeh  the  membranes,  covering  the 
spinal  marrow.  5.  An  unusual  redness  of 
tiie  investment  of  the  pneumogastric  and 
trisplanchnic  nerves.  (See  Diet,  des  Sciences 
Med.  T.  47,  p.  99.) 

Happily,  surgery  possesses  one  tolerably 


HYDROPHOBIA. 


DO 

certain  means  of  preventing  hydrophobia, 
when  it  is  practised  in  time,  and  in  a com- 
plete manner  Every  reader  will  know, 
that  I he  excision  of  the  bitten  parts  is  the 
operation  to  which  I allude.  Indeed,  as  hy- 
drophobia is  often  several  months  before  it 
begins,  the  wounded  parts  should,  perhaps, 
always  be  cut  out,  e\ eu  though  they  are  heal- 
ed,and  some  weeks  have  elapsed  since  the  ac- 
cident, provided  no  symptoms  of  the  hydro- 
phobia have  actually  commenced.  The 
operation  should  be  done  completely;  for 
a timorous  surgeon,  afraid  of  cutting  deeply 
enough,  or  of  removing  a sufficient  quantity 
of  the  surrounding  flesh-  would  be  a most 
dangerous  one  for  the  patient.  All  hopes  of 
life  depend  on  the  prevention  of  the  disor- 
der ; for  in  the  present  state  of  medical 
knowledge,  none  can  rest  upon  the  efficacy 
of  any  plan,  except  the  extirpation  of  the 
part.  For  this  purpose,  caustics  have  some- 
times been  employed.  However,  as  their 
action  can  never  be  regulated  with  the 
same  precision  as  that  of  the  knife,  and  con- 
sequently, they  may  not  destroy  the  flesh  to 
a sufficient  depth,  excision  should  always 
be  preferred.  The  latter  method  is  also  the 
safest  for  another  important  reason,  viz.  tue 
part,  and  poison  lodged  in  it,  are  removed 
from  the  body  at  once;  but  when  the  cau- 
tery or  caustic  is  used,  the  slough  must  re- 
main a certain  time  undetached.  Some 
surgeons  are  not  content  with  cutting  out 
the  part:  but  after  the  operation,  till  the 
wound  with  the  liquor  ammoniae,  or  caute- 
rize its  surface,  for  the  sake  of  greater  secu- 
rity. How  late  excision  may  be  done  with 
any  prospect  of  utility  I am  not  prepared 
to  say  ; but,  there  are  practitioners,  who 
deem  excision  right,  even  when  heat,  irrita- 
tion, or  inflammation  is  observed  in  the  bit- 
ten part.  (See  Med.  Repository,  Vol.  3,  p. 
54.) 

Cases  present  themselves,  in  which  it  is 
even  preferable  to  amputate  the  limb,  than 
attempt  to  extirpate  either  with  the  knife, 
or  cautery  the  whole  of  tiie  bitten  parts  ; 
an  endeavour,  which  could  not  be  accom- 
plished with  any  degree  of  certainty.  Thus, 
as  Delpech  observes,  when  the  hand  or  foot 
has  been  deeply  bitten  in  several  places,  it 
is  obvious,  that  it  would  be  impossible  to 
make  caustic,  (or  the  cautery)  certainly 
reach  every  part,  which  the  saliva  of  the 
rabid  animal  may  have  touched.  Besides, 
the  mischief  resulting  both  from  the  injury, 
and  the  other  proceedings  together,  might 
be  such  as  to  afford  no  prospect  of  saving 
the  limb,  or  at  least,  of  preserving  it  in  an 
useful  state.  (See  Precis  Idem,  des  Mai. 
Cliir.  T.  2,  p.  133.)  I have  known  of  one  or 
two  cases,  in  which  the  patients  lost  their 
lives,  in  consequence  o.  the  excision,  or  de- 
struction of  the  bitten  parts  ,iot  having  been 
attempted,  on  account  of  the  surgeon’s  re- 
luctance to  cut  tendons,  or  wound  a large 
artery,  as  one  of  those  at  the  wrist.  In  such 
cases,  however,  the  fear  of  rendering  a 
muscle  useless,  or  of  wounding  an  artery, 
is  no  justification  of  leaving  the  patient  ex- 
posed to  a danger,  so  surely  fatal,  as  that  of 


the  hydrophobic  virus,  if  it  once  affect  the 
constitution.  The  artery  should  be  exposed 
for  a sufficient  length,  and  secured  with  two 
ligatures,  when  the  requisite  extirpation 
of  the  parts  between  them  may  be  safely 
performed. 

When  once  the  hydrophobic  symptoms 
have  commenced,  there  is  little  or  no  hope 
of  -aving  the  pa'ient,  the  disease  having 
almost  invariably  baffled  every  plan  of 
treatment,  which  the  united  talents  of  nu- 
merous medical  generations  have  suggested. 
All  the  most  powerful  medicines  of  every 
class  have  been  tried  again  and  again  ; 
mercury;  opium;  musk;  camphor;  arse- 
nic; the  nitrate  of  silver;  cantharides ; 
belladonna;  ammonia;  plunging  the  pa- 
tient in  the  sea  ; bleeding  ; be.  &c. 

The  inefficacy  of  opium  is  now  generally 
acknowledged  ; in  the  space  of  fourteen 
hours,  Dr.  J.  Vaughan  gave  one  patient 
fifty -seven  grains  of  opium,  and  also  half  an 
ounce  of  laudanum  in  a clyster,  but  the  fa- 
tal termination  of  the  disease  was  not  pre- 
vented. Dr.  Babington  even  prescribed  the 
enormous  quantity  of  180  grains  in  eleven 
hours,  without  the  least  amendment,  or 
even  any  narcotic  effect.  (Med.  Records 
and  Researches,  p.  121.)  On  the  very  first 
day,  that  rabies  decidedly  showed  itself  in 
a man,  who  had  been  bit  by  a mad  dog, 
Dupuytren  injected  into  the  vena  saphena, 
by  means  of  Anel’s  syringe,  two  grains  of 
the  extract  of  opium  dissolved  in  distilled 
water,  and  as  a degree  of  calm  appeared  to 
be  the  result,  four  grains  mure  were  thrown 
into  the  cephalic  vein.  The  patient  re- 
mained perfectly  tranquil  three  hours  longer; 
but  the  symptoms  afterward  recurred  with 
increased  violence.  The  next  morning, 
about  six  or  eight  grains  more  were  dissol- 
ved, and  thrown  into  the  circulation  ; but, 
all  was  in  vain,  as  the  patient  died  in  three 
quarters  of  an  hour  after  the  last  injection, 
(see  Diet,  des  Sciences  Med.  T.41,p.  131.) 

As  for  belladonna,  its  employment  for  the 
prevention  and  cure  of  hydrophobia  is  very 
ancient,  its  external  use  for  this  purpose  ha- 
ving been  mentioned  by  Pliny,  and  its  inter- 
nal exhibition,  w ith  the  same  view, by  Theod. 
Turquetus  in  a posthumous  work  published 
in  1696.  (See  Pmxeos  Medicce  Syntagma, 
^•c.)  In  1763,  belladonna  was  recommended 
by  Schmid  as  a remedy  for  hydrophobia,  , 
and  in  1779  by  J.  H.  Munch.  (See  Richter's 
Chir.  Bibl.)  At  present,  this  medicine,  has 
entirely  lost  its  character  of  possessing  any 
power  against  hydrophobia. 

01  late  years,  the  public  hope  has  been 
raised  by  {he  accounts  given  of  the  virtue  of 
hydro-chlorine,  or  oxymuriatic  acid.  Wen- 
delstadt  even  published  the  story  of  an  Eng- 
lishman, who  allowed  himself  to  he  bit  seve- 
ral times  by  a mad  dog,  and  then  saved  him- 
self by  washing  the  bites  with  this  acid. 
And,  still  more  recently  Professor  Brugna- 
ttjlli,  in  the  Italian  Journ  of  Physic,  Chymis- 
try,  be.  ( T . 9,  p.  3.4,)  has  published  some 
observations,  lending  to  prove  the  efficacy 
of  the  external  and  internal  employment  of 
the  medicine  for  the  prevention  of  rabies. 


HYDROPHOBIA. 


97 


The  biles  are  washed  with  it,  and  then  co- 
vered with  chappie  wet  with  it.  And,  when 
the  symptoms  commence,  if  it  could  not  he 
swallowed  in  a fluid  form,  Brugnatelli  gives 
bread  pills  imbued  with  it.  For  a child  eight 
years  old,  the  dose  is  3ij  four  or  five  times 
a day,  but  gradually  increased.  According 
to  Orfila,  hvdro-chlorine  was  long  since  re- 
commended by  Cluzel,  as  an  internal  remedy 
for  hydrophobia.  ( S&cours  a dormer  auxper- 
sonnes  empois niees,  fyc.  Svo  Paris,  1818,  p. 
158.)  With  regard  to  Brugnatelii’s  cases, 
they  are  said  to  be  so  destitute  of  precision 
and  certainty,  that  no  inference  can  be  drawn 
from  them.  ( Diet,  dcs  Sciences  Med.  T.  47,  p. 
119.)  In  order  to  ive  hydro-chlorine  a fair 
trial,  it  was  used  internally  and  externally 
on  seven  patients  in  the  Hotel-Dieu  at  Lyons 
in  1817.  The  bites  were  washed  and  bathed 
with  it,  and  some  of  them  also  cauterized  ; 
and  each  patient  took  daily  a dram  of  the 
acid,  made  into  an  agreeable  sweetened 
drink.  All  these  unfortunate  individuals 
afterward  died  of  rabies,  though  the  treat- 
ment was  begun  the  day  after  the  receipt  of 
the  wounds.  ( L . F.  Trolliel , Nouveau  Troil6 
de  la  Rage,  tyc.)  The  excision  of  the  bites  70 
lion rs  after  their  infliction,  and  washing  the 
wound  with  oxymuriatic  acid,  did  not  in  Dr. 
Johnson’s  case  prevent  the  disease.  (See 
Edinb.  Med.  and  Snrg.  Journ.  Vo!.  15,  p.  212.) 
In  America,  the  plant  scuteilaria  lateriflora 
has  been  lately  extolled,  as  a certain  specific 
for  hydrophobia.  (See  A History  of  the  In- 
troduction and  Use  of  Scutellaria  Lateriflora , 
as  a remedy  for  preventing  and  curing  Hydro- 
phobia, by  Lyman  Spalding,  M.  D.  New-  York, 
1819.)  I'he  prussic,  or  hydrocyanic  acid 
has  likewise  been  proposed,  on  account  of 
its  reputed  antispasmodic  properties;  but, 
some  experiments,  made  with  it  on  dogs  by 
Dupuytren,  iVIagendie,  and  Breschet,  furnish 
co  results  in  favour  of  its  being  likely  to 
prove  useful  in  the  present  disorder.  (See 
Diet,  des  Sciences  Med.  T.  47.  p.  133.)  By 
Dr.  Rossi,  of  Turin,  the  trial  of  galvanism 
was  suggested.  (Alibert,  Nouveaux  Elemens 
de  Therapeutique , T.  2 ,p.  436,  Ld.  4 ;)  yet, 
the  only  fact  brought  forward,  as  an  en- 
couragement to  persevere  with  the  last 
means,  appears  to  a modern  author,  from  its 
symptoms  and  progress,  not  to  have  been  a 
case  of  rabies.  ( Dirt  cit  T.41,p.  126.)  The 
rapid  and  powerful  effects  of  t.he  bite  of  a 
viper  on  the  whole  :-yslem,  and  perhaps  the 
idea,  that  the  operation  of  this  animal’s 
venom  might  counteract  that  of  the  hydro- 
phobic virus,  led  some  experimenters  to  try 
what  would  be  the  result  of  subjecting  pa- 
tients, affected  with  rabies,  to  the  bite  of  that 
kind  of  snake.  Tiie  project,  however,  was 
attended  with  no  success  Three  cases  of 
this  description  were  communicated  to  the 
Royal  Society  of  Medicine,  (Hist.  p.  201  ;) 
two  additional  ones  were  recorded  by  Dr. 
Gilibert,  physician  to  the  HOtel-Dieu  at  Lyons, 
{ Advers . Med.  Pract.  p.  257;)  and  Viricel, 
surgeon  of  the  same  hospital,  repeated  the 
experiment  on  a child,  which  yet  fell  a vic- 
tim to  hydrophobia.  Other  trials  are  also 
said  to  have  been  made  in  France  and  Ger- 
Voj,.  H 13  * 


many  with  no  better  success.  Dr.  de  Mathiis, 
in  the  year  1783,  let  a viper  bite  a rabid  dog 
on  the  throat.  '1  he  dog's  head  was  attacked 
with  considerable  swelling,  the  hydrophobia 
ceased,  and,  according  to  some  accounts, 
the  animal  perfectly  recovered  ; but,  accord- 
ing to  other  statements,  though  it  drank 
freely  as  soon  as  its  head  had  swelled,  it 
only  survived  the  experiment  a few  hours. 
(See  Diet,  des  Sciences  Med  T.  47,  p.  126.) 

Some  facts  which  occurred  a few  years 
ago  in  the  East  Indies,  tended  for  a time  to 
raise  an  expectation,  that  a copious  abstrac- 
tion of  blood  might  be  the  means  of  pre- 
serving patients  actually  attacked  with  this 
fatal  disorder.  Mr.  Tyrnon, assistant  surgeon 
of  the  22d  Light  Dragoons,  tried  successfully 
tiie  method  of  taking  away  at  once  an  im- 
mense quantity  of  blood  from  the  patient, 
“ I began  by  bleeding  him  (,says  Mr.  Tymon) 
until  scarcely  a pulsation  could  be  felt  in  either 
arm.”  Opium  was  afterward  given,  and 
the  patient  salivated  with  mercury.  (See 
Madras  Gazette  of  Nov  23,  1811.) 

Although  in  the  observations,  annexed  to 
this  case  by  Dr.  Berry,  there  are  some  cir- 
cumstances. which  render  it  probable,  that 
the  case  was  really  hydrophobia  ; yet,  as  the 
successful  termination  of  it  is  an  event  so 
extraordinary,  I much  regret,  that  some  de- 
sirable information  is  omitted.  For  instance, 
we  have  no  account  of  any  pain,  or  changes, 
in  the  bitten  part,  or  limb,  at  the  first 
coming  on  of  the  indisposition.  The  early 
constitutional  symptoms  are  not  described, 
and  the  violent  spasms,  screaming,  fcc.  are 
the  first  things  mentioned.  Some  particu- 
lars of  the  dog  would  also  have  been  inter- 
esting. 

Such  information,  indeed,  becomes  still 
more  essential,  when  we  find  it  stated,  that 
another  man,  Serjeant  Jackson,  was  also 
bitten  by  the  same  doi:,  and  had  hydrophobia 
in  a mild  form,  from  which  lie  recovered 
under  the  use  of  mercury,  blisters  to  the 
head,  and  cathartic  injections,  without  any 
recourse  to  bleeding  at  all.  This  last  case  is 
even  more  contrary  than  the  former,  to  what 
general  experience  teaches;  because  mer- 
cury, blisters,  and  injections,  have  been  tried 
a thousand  times  unavailing!}'  ; while,  per- 
haps, blood-letting,  in  the  manner  practised 
by  Mr.  Tymon , is  a new  treatment.  Dr. 
Schoolbred,  of  Calcutta,  published  a second 
case  of  hydrophobia  cured  by  bleeding  ad 
deliquium  aniroi,  and  afterward  exhibiting 
calomel  and  opium.  The  patient,  being 
threatened  with  a relapse,  was  largely  bled 
again.  The  whole  of  tiie  success  is  imputed 
by  Dr.  Schoolbred  to  the  venesection.  But 
this  gentleman  is  not  so  sanguine  as  to  be- 
lieve. that,  bleeding  will  cure  every  case  of 
hydrophobia.  It  is  probable,  that  there  is  a 
period,  beyond  which  its  curative  effect} 
cannot  extend,  and,  therefore,  it  is  uponihw, 
firstappearance  of  unequivocal.symptomsof 
the  disease,  that  he  thinks  copious SBleed mg 
affords  a prospect  of  success, , -while  . t lie 
delay  of  only  a few  hours  may  proven  fatal. 
He  observes,  that  the  medical  profession,, 
taught  by  numerous  disappointments,  admit 


HYDROPHOBIA. 


9S 


very  cautiously  the  claims  of  any  new  prac- 
tice to  general  adoption.  If  several  patients 
in  hydrophobia,  therefore,  should  happen  to 
be  bled  in  an  advanced  stage  of  (he  disease, 
and  die,  (as  they  inevitably  would  do,  whe- 
ther they  had  been  bled  or  not,)  such  cases 
would  be  quoted  against  die  new  practice,  as 
failures  But  Dr.  Schoolbred  rightly  con- 
tends, that  numerous  failures  in  an  advanced 
sta::e  of  the  disease  can  form  no  just  ground 
for  the  rejection  of  a remedy,  which  has  in- 
contestably effected  a cure  in  an  earlier 
stage  of  the  disorder.  He  insists  upon  the 
necessity  of  making  a large  orifice  in  the 
vein,  so  as  to  evacuate  the  blood  quickly, 
which  must  be  allowed  to  fiovv,  without  re- 
gard to  quantity,  ad  deliquium  animi. 

Dr.  Schoolbred  was  well  aware,  that  bleed- 
ing in  cases  of  hydrophobia  had  often  been 
tried.  But,  says  he,  owing  probably  to  the 
evacuation  not  having  been  pushed  far 
enough,  when  used  in  the  early  stage  of  the 
disease  ; or  to  the  period  for  its  beneficial 
employment  having  elapsed  ; the  cases,  in 
which  it  was  tried,  afforded  little  or  no  en- 
couragement to  the  continuance  of  the  prac- 
tice. 

Since  the  preceding  cases,  the  effect  of 
bleeding  has  had  the  fairest  trials  made  of  it, 
and  some  of  the  reports  are  in  favour  of  its 
occasional  utility.  (See  Particulars  of  the 
successful  Treatment  of  a case  of  Hydropho- 
bia, by  R.  Wynne , 8 vo.  Shrewsbury , 1813; 
Also  Edmonstone  in  Lond.  Med.  Repository, 
Vol.  3,  p.  93.)  In  almost  every  instance, 
however,  it  fails  in  hindering  the  usual 
melancholy  event.  (See  Kirrison's  Case  and 
Obs.  in  Med.  Repository,  Vol.  2 ,p.  197.)  This 
unpleasant  truth,  I think,  receives  confirma- 
tion from  the  fact,  that  the  practice  is  far 
from  being  new. 

Dr.  Mead,  who  was  very  confident  that  he 
had  found  an  infallible  preventive  of  the  dis- 
ease in  a little  liverwort  and  alack  pepper, 
aided  by  bleeding  and  cold  bathing  before 
the  commencement  of  the  course  of  medi- 
cine, says,  ‘as  to  all  other  ways  of  curing 
the  hydrophobia,  I own  I have  not  been  so 
happy  as  to  find  any  success  from  the  many 
I have  tried.  Bathing  at  this  time  is  ineffec 
tual.  I have  taken  many  large  quantities  of 
blood;  have  given  opiates,  volatile  salts,  fee. 
All  has  been  in  vain,  because  too  late.”  Not- 
withstanding his  disappointment,  he  con- 
cludes, “ if  any  relief  could  be  expected  in 
this  desperate  state,  I think  it  would  be  from 
bleeding,  even  ad  animi  deliquium,”  tyc. 

The  doctrines  of  Boerhaave  also  led  him 
and  his  pupils  to  recommend  and  practise 
bleeding  in  hydrophobia.  “ The  distemper 
(says  he)  is  to  be  treated  asone  highly  inflam- 
matory, upon  the  first  appearance  of  the 
signs  which  denote  its  invasion,  by  blood- 
letting from  a large  orifice,  continued  till  the 
patient  faints  away ; and  soon  after  by 
euemata  of  warm  water  and  vinegar,  be.. 
and  lie  adds.  “ that  this  practice  is  supported 
by  some  small  number  of  trials.”  But  the 
particulars  of  this  successful  practice,  arc 
not  given. 

Dr.  Schoolbred  finds,  that  a trial  of  it  was 


made  at  Edinburgh,  more  than  sixty  years 
ago,  by  Dr.  Rutherford  who  took  away 
gradually  sixty  ounces  of  blood  from  a pa- 
tient, who  had  already  been  bled  the  same 
morning.  As  the  patient  lived  forty-eight 
hours  after  the  large  bleeding,  the  method 
was  probably  tried  somewhat  early  in  the 
disease;  and  the  case  may  therefore  be  set 
down  as  a fair  instance  of  a failure  of  the 
practice.  The  trials,  which  have  been  made 
in  this  country  of  the  practice  of  bleeding, 
in  cases  of  hydrophobia,  since  the  receipt  of 
the  above  reports  from  India,  I am  sorry  to 
say,  have  not  confirmed  its  efficacy,  as  a 
means  which  can  be  much  depended  upon 
for  saving  the  patients. 

Bleeding  was  also  recommended  in  cases 
of  hydrophobia,  by  Poupari.  (See  Hist.de 
I'Acad.  Royale  des  Sciences,  pour  I'annee 
1699,  /?.48.)  The  practice  is  likewise  men- 
tioned in  the  Medical  Essays  of  Edinburgh, 
Vol.  5,  part  2,  § 5;  and  in  the  writings  of  Dr. 
Rush  See  also  Dr.  Burton's  Case,  Phil. 
Mag.  August,  1805. 

After  all  that  has  been  said,  and  the  little 
confidence  assigned  to  any  practice  but  that 
of  the  early  excision,  or  amputation  of 
the  bitten  par's,  it  is  necessary,  (hat  some- 
thing should  be  done  after  the  actual  com- 
mencement of  rabies,  and  that  every  practi- 
tioner should  be  prepared  for  the  adoption  of 
some  mode  of  treatment,  or  another.  As 
however,  my  own  mind  is  not  made  up  upon 
the  subject,  I prefer  offering  a conclusion  or 
two,  made  by  a modern  critical  writer:  “ That 
experience  authorizes  the  placing  confidence 
in  bleeding  ad  deliquium;  on  vomiting;  and 
perhaps  on  use  of  atropa  belladonna  ; and, 
on  tobacco  exhibited  as  a glyster.  That  it  is 
probable,  advantage  would  result  from  the 
combined  employment  of  bleeding,  vomit- 
ing (see  Dr.  Sattery's  Obs.  in  Medical  Trans. 
Vol.  4,)  and  purging  in  the  early  stage  of  the 
disease.  That  analogy  recommends  the 
trial  of  spirit  of  turpentine  in  the  comvulsivo 
stage  of  the  disease.”  ( Med . Repository,  Vol. 
3 ,p.  54.)  Jos.  de  Aromatarius , De  Rabie  Con- 
tagiosa, 4 to.  Francof  1626.  Sauvages  sur  la 
Rage , 12mo.  Paris , 1771.  James  on  Canine 
Madness,  8r o.  Lond.  1780.  Mead  on  the  Bile 
of  a Mad  Dog.  Jos.  S Dolby,  The  Virtues 
of  Cinnabar  and  Musk,  against  the  Bite  of  a 
Mad  Dog,  41  o.  Birmingh  1764.  J.  Hey  sham, 
De  Rabie  Lanina,  Edinb.  1777.  B.  F.  Munch. 
De  Belladonna,  efficace  in  Rabie  Canina  re- 
medio,  Frank.  Del.  op.  1 . D.P.  Layard?  Essay 
on  the  Bite  of  a Mad  Dog,  2 d Ed.  1763.  R. 
Hamilton,  Remarks  on  Hydrophobia,  2 Ed  2 
Vols.  8 vo.  Lond  1798.  Medical  Museum, 
Vol.  2.  Lond  Med.  Trans.  Vol.  2 and  4,  Ed.  2. 
Med.  Obs.  and  Inq.  Vol  3;  and  Fothergill  in 
Vol.  5 of  the  same  work.  C.  Nugent , Essay  on 
Hydrophobia  ; to  which  is  prefixed,  the  Case  of 
a Person  cured , 8 vo.  Lond.  1753.  Le  Roux , 
sur  la  Rage,  8 vo.  Dijon,  1780.  Idem.  Traite- 
menl  local  de  la  Rage,  8vo.  Paris,  1783.  Edinb. 
Med.  Comment  Vol.  5,  p.  42.  J Vaughan's 
Cases  and  Obs.  on  Hydrophobia,  8r o.  Lond. 
1778.  Dr.  Powell's  Case  of  Hydrophobia. 
Latta's  System  of  Surgery,  Vol.  3.  Cullen's 
First  Lines , Vol.  4.  Enaux  el  Chaussier,  Me- 


HYDRO  PH  THAT.MFA. 


fhodc  dt  traltc.r  lea  Morsure a des  Animaux  en- 
rages., fyc.  12mo.  Dijon , 1780.  Memoirs  oj  the 
Med.  Society  of  London , Vol.  1,  p 248. 
Medical.  Communications , Col.  1.  J.  Mease, 
An  Essay  on  the  Disease  produced  by  the  Cite 
of  a Mad  Dog,  with  a Preface , fyc.  by  J.  C. 
Lettsom,  Svo.  Philadelphia,  1793.  Mem.  de  la 
Societe  Royale  dr  Mcdecine  de  Paris,  pour 
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Observations,  and  his  Med.  Histories,  fyc  ‘Id 
Ed.  Svo.  Loud.  1810.  Callisen's  Sy sterna  Chi- 
rurgiir.  Hodiernts,  T.  1,  p.  593,  Hafnice,  1798. 
Marcel,  in  Med.  Chir.  Trans.  Vol.  1,  p.  132, 
«^-e.  Jesse  Foote,  An  Essay  on  the  Rite  of  a 
Mad  Dog,  8 vo.  Lond.  1788.  Lassus,  Patholo- 
gic t hir.  T.  2,  p.  239.  fyc  Ed.  1809.  A 
valuable  Paper  by  Dr.  J.  Hunter  in  Trans,  of 
a Society  for  the  Improvement  of  Med  and 
Chir.  Knowledge,  Vol.  1,  art.  17.  James  Gid- 
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mal, Svo.  Lond.  1812.  Leveille,  Aouvelle 
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in  Memoirs  of  the  Literary  and  Philosophical 
Society  of  Manchester,  Vol.  4,  part  2.  Medi- 
cal Reports,  4'C.  ; to  which  are  added  the  In- 
quiry into  the  origin  of  Canine  Madness,  and 
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from  the  British  Isles,  8 vo.  Lond.  1807.  Ba- 
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of  an  Inflammatory  Diathesis  in  Hydrophobia 
considered,  Birmingh.  1798.  Art.  Hy  drop  ho 
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establishing  the  Efficacy  of  the  Opiate  Fraction 
in  Spasmodic  and  Febrile  Diseases ; also  an  at- 
tempt to  Investigate  the  Nature,  Causes,  and 
Method  of  Cure  of  hydrophobia  and  Tetanus, 
Svo.  Manchester,  1809.  Richter's  Anfangs. 
grunde  der  IVundarzneykunsl  ■ B.  1,  p.  252, 
<^c  Gott  1799.  Cases  and  Cures  of  Hydro- 
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Hydrophobia , Svo.  Lond.  1808.  B.  Moseley, 
on  Hydrophobia,  its  Prevention  and  Cure, 
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la  Rage,  Svo.  Paris,  1812.  A Portal,  M6mo ires 
sur  la  Nature , fyc.  des  plusieures,  Maladies, 
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la  Ftvre  en  gdndral,  dt  la  Rage,  tyc.  8 vo. 
Metz.  1800.  Bosquilhn  M6m.  sur  les  Causes 
de  T Hydrophobie,  Svo.  Paris,  1808.  S.  N. 
Sauter,  Esperienze  Medicht  inlorna  la  Cura 
dele  Idrophobia,  ossia  della  Malattia  proveni- 
ence dal  Morso  del  Cane  Rabbioso,  Svo.  Bolog- 
na, 1806.  Dr.  Berry's  Obs.  and  Mr.  Tymon's 
Case  cured,  by  large  blood-letting,  as  detailed 
in  the  Madras  Gazette  of  November  23,  1818  ; 
and  Dr.  Schoolbred's  Case  sucessfully  treated 
by  copious  bleeding , as  related  in  one  of  the 
Asiatic  Mirrors  for  May,  1812.  O'Donnel's 
Cases  of  Hydrophobia,  i S 13.  T.  Arnold,  Case 
of  Hydrophobia  successfully  treated,  Svo.  Lond. 
1793.  R.  Wynne,  Particulars  of  the  success 
ful  Treatment  of  a Case  of  Hydrophobia,  Svo. 
Shrews,  1808.  Boyer,  fraite  des  Mai  Chir. 
T \,p.  435,  fyc.  Paris,  1814  C.  IT.  Parry, 
Cases  of  Tetanus  and  Rabies  Contagiosa,  or 
Canine  Hydrophobia.  Svo.  Lond.  1814  A 
Marshall,  The  Morbid  Anatomy  of  the  Brain 
in  Mania  and  Hydrophobia,  with  the  Pathology 
of  these  two  Diseases,  fyc.  Svo.  Land.  1815. 


l(.  htid  on  the  Nature  and  Treatment  of  Te- 
tanus and  Hydrophobic  Svo.  Dublin , 1817. 
Aulenrieth , Hiss,  de  hactenus  preetervisa  nervo- 
rum lu  dratione  in  sectionibus  hydrophoborum, 
4lo.  Tub.  1802  Gottfr.  Zinke,  Neue  Ansichten 
der  Hunsdwuth  Svo.  Jena,  1804.  Did.  des 
Sciences  Med.  T.  22,  art.  Hydrophobie,  et  T. 
17,  art.  Raze.  G.  Lipscombe  Cautions  and 
Reflexions  on  Canine  Madness , 8ro.  Lond. 
1807.  C.  Gilber , Pract  Abhandl.  tteber  die 
Vorbeugung , <^-c  der  Hundswuth,  Svo.  Wien. 
1818  ; This  author  has  confidence  in  the  pow- 
der of  meloe  maialis.  C.  F.  Har'es , neber  die 
Behandlung  der  Hundswuth.  4to.  Frank f. 
1809  Stramonium  recommended. 

HYDROPH  1 HALAl  I A.  (fro.,  water, 

and  the  eye.)  Dropsy  of  the  Eye. 

Hydrophthalmus  : Hydrophthalrnos.  Also 
Bupthalmos,  or  Ox-eye.  As  in  other  organs, 
dropsy  of  the  eye  arises  from  a dispropor- 
tion taking  place  between  the  action  of  the 
secerning  arteries,  by  which  the  tluid  is  de- 
posited in  the  part,  and  the  action  of  the 
absorbent  vessels,  by  which  it  is  taken  up 
and  returned  to  the  circulation  ; and,  ac- 
cording to  this  principle,  the  disease  may- 
be supposed  to  depend,  either  upon  secre- 
tion being  made  too  rapidly,  or  absorption 
being  slower  than  is  proportionate  to  the 
natural  activity  of  the  vessels  by  which  the 
secretion  of  the  humours  of  the  eye  is 
effected. 

According  to  Beer,  dropsy  of  the  eye  is 
seldom  entirely  a local  disease,  but  at  least 
is  generally  combined  with  an  unhealthy 
constitution,  or  is  a mere  symptomatic  » 
effect  of  some  other  dropsical  affection, 
anasarca,  hydrocephalus,  Kc.  Sometimes 
it  appears  as  a symptom  of  chlorosis.  Beer 
adds,  that  the  disease  may  originate  either 
from  a preternatural  accumulation  of  the 
aqueous  humour  ; from  that  of  the  vitreous 
humour  ; or  from  an  immoderate  accumula- 
tion of  both  these  humours  together.  ( Lehre 
von  den  Augenkr.  B.  2.  p.  616,  Wien.  117.) 
When  the  vitreous  humour  collects  in  this 
manner,  it  usually  loses  its  natural  consist- 
ence, and  becomes  thinner  and  more  wa- 
tery. ( Richter  Anfmgsgr.  B.  3,  p.  392.) 

Professor  Beer  states,  that  in  the  case 
proceeding  from  a morbid  quantity  of  the 
aqueous  humour,  the  first  indication  of  the 
disease  is  an  increase  in  the  dimensions  of 
the  cornea,  attended  with  a manifest  enlarge- 
ment of  the  anterior  chamber.  The  cornea 
may  become  in  this  manner  two,  three,  or 
even  four  times  wider  than  natural,  without 
bursting  or  losing  its  transparency ; for, 
though  a turbid  appearance  is  discernible, 
this  depends  rather  upon  the  stale  of  the 
aqueous  humour  itself.  The  iris,  which,  in 
the  very  commencement  of  the  disease, 
begins  to  lose  its  mobility,  soon  becomes 
completely  motionless,  and  acquires  a duller 
colour;  the  pupil  always  remaining  in  the 
mid-state  between  contraction  and  dilata- 
tion. In  the  eyeball,  an  annoying  sense  of 
pressure,  tension,  and  heaviness  is  teit, 
rather  than  actual  pain.  Lithe  beginning 
of  the  disease,  there  is  a considerable  degree 
of  farsightedness,  or  praesbvopia,  which 


HYDROPHTHALMIA. 


1«0 

soon  changes  into  a true  amaurotic  weak- 
ness of  sight,  but  never  terminates  in  perfect 
amaurosis  The  free  motions  of  the  eyeball 
are  more  and  more  interrupted,  in  propor- 
tion as  the  organ  grows  larger,  and  it  has 
invariably  a hard  feel,  while  the  sclerotica, 
to  tiie  distance  of  two  lines  from  the  mar- 
gin of  the  cornea,  is  as  bluish  as  it  is  in  the 
newborn  infant. 

Respecting  the  precise  cause  of  the  accu- 
mulation of  the  aqueous  humour,  Beer 
offers  no  observation  worthy  of  repetition, 
excepting  perhaps  that  in  which  he  reminds 
us,  that  a similar  collection  happens  appa- 
rently as  an  effect  of  the  conical  staphylo- 
ma of  the  whole  cornea  (See  also  War- 
drop's  Essays  on  the  Morbid  Anatomy  of  the 
Eye,  Vol  2,  p.  19.)  indeed,  as  far  as  onr 
knowledge  yet  extends,  it  is  impossible  to 
say  whether  the  changes  of  the  cornea  are, 
in  the  present  disease,  to  be  regarded  as  the 
cause  or  the  effect  of  the  increased  quantity 
of  the  aqueous  humour,  or  whether,  as  seems 
to  me  most  probable,  both  phenomena  are 
only  effects  of  one  and  the  same  cause. 
The  examples,  somewhat  repugnant  to  this 
idea,  are  those  referred  to  by  Beer,  as  symp- 
tomatic of  other  dropsical  affections.  On 
the  other  hand,  Mr.  Wardrop  has  never  seen 
a preternatural  collection  of  <be  aqueous 
humour,  without' its  being  accompanied  with 
disease  of  the  coats  of  the  eye.  (Vol.  cit.p. 
20.) 

In  hydrophthalmia,  the  prognosis  is  gene 
rally  unfavourable,  and,  when  the  sight  is 
nearly  or  quite  lost  scarcely  any  hope  can 
he  entertained,  either  of  restoring  vision  or 
preserving  the  shape  of  the  eye.  Yet,  ac- 
cording to  Beer,  things  are  not  always  quite 
so  unpromising  in  the  preceding  form  of  the 
disease,  especially  when  the  surgeon  is  con- 
sulted in  time,  and  the  patient’s  constitution 
is  not  exceedingly  impaired.  The  same 
experienced  author  has  never  seen  any  in- 
stance in  which  the  eye  spontaneously  burst ; 
on  the  contrary,  when  the  habit  was  deci- 
dedly bad,  anti  the  treatment  ineffectual, 
the  disease  became  gradually  conjoined 
with  the  second  species  of  dropsy  of  the 
eye,  and  terminated  in  a frightful  disfigure- 
ment of  the  whole  organ,  and  death  On 
dissection,  the  innermost  textures  of  the 
part  were  found  spoiled  and  disorganized, 
and  sometimes  even  the  orbit  itself  carious. 
(Vol.  cit.p.  619.)  \Vith  respect  to  the  treat- 
ment, Beer  thinks,  that  this  must  depend 
very  much  upon  the  nature  of  the  primary 
disease,  to  which  the  dropsical  affection  is 
ascribable  as  an  effect.  He  has  known 
great  benefit  sometimes  produced  by  the 
submuriate  of  mercury,  combined  with  di- 
gitalis, and  a drink  containing  supertartrate 
of  potassa,  and  borax.  When  the  disease 
has  been  preceded  by  the  sudden  cure  of 
any  cutaneous  disease,  he  has  faith  in  the 
method  of  attempting  to  restore  the  affection 
of  the  skin  by  inoculation,  or,  if  that  be  im- 
practicable, by  stimulating  its  surface  with 
antimonial  ointment,  or  making  an  issue. 
This  plan  is  to  be  aided  with  internal  altera- 
tive medicines,  such  as  camphor,  the  sul- 


phur auratuin  antimonii,  and  flowers  of  sul- 
phur. The  local  applications,  which  he 
prefers  in  the  early  stage,  are  warm  dry 
bags  filled  with  aromatic  herbs,  and  rubbing 
the  parts  about  the  eyebrow,  sometimes  with 
mercurial  ointment,  sometimes  with  a mix- 
ture of  ajther  and  liquor  ammoniae.  But, 
when  the  disease  has  made  considerable 
progress,  and  vision  is  either  weak  or  nearly 
lost,  while  the  sclerotica,  near  the  cornea  is 
not  much  discoloured,  and  there  are  no 
appearances  of  a varicose  affection  of  the 
blood-vessels  of  the  organ,  Beer  recommends 
making  a puncture  with  a small  lancet  in 
the  lowest  part  of  the  cornea,  half  a line 
from  the  sclerotica,  so  as  to  discharge  the 
aqueous  humour.  The  anterior  chamber  is 
then  to  be  kept  empty  for  several  days  or 
weeks,  if  possible,  by  reopening  the  small 
wound  every  day  with  the  point  of  the  lan- 
cet. (See  also  Richter's  Anfavgsgr.  B.  3,  p. 
4(;3  ) After  the  operation,  the  eye  is  to  be 
dressed  in  the  same  way  as  after  the  extrac- 
tion of  a ataract.  (See  Cataract.)  Previ- 
ously to  the  paracentesis,  Beer  has  often 
seen  every  general  arid  focal  means  perfectly 
useless,  but  highly  beneficial,  as  soon  as  that 
operation  had  been  practised.  Kven  when, 
the  paracentesis  fails  in  bringing  about  a 
permanent  cure,  it  may  still  be  resorted  to 
a a palliative  with  real  advantage,  and  be 
often  beneficially  repeated,  if  care  be  taken 
not  to  make  the  puncture  too  large  How- 
ever, when  the  blood-vessels  are  generally 
varicose,  and  the  constitution  very  bad,  such 
operation  is  apt  to  excite  vioh  nt  inflamma- 
tion, suppuration,  and  even  sloughing  of 
the  organ,  attended  with  imminent  danger 
to  the  patient’s  life.  ( Beer , vol.  cit.  p.  620, 
622.) 

With  regard  to  the  second  species  ol  hy- 
drophthalmia or  that  depending  upon  a pre- 
ternatural accumulation  of  the  vitreous  hu- 
mour, Beer  states,  that,  in  this  case,  it  is 
chiefly  the  posterior  part  of  the  eyeball  which 
is  enlarged,  so  that  the  whole  organ  ac- 
quires a conical  shape,  in  which  the  cornea 
very  much  participates  The  latter  mem- 
brane remains  unaltered  in  regard  to  its 
diameter  ; but  it  is  more  convex  than  natu- 
ral, and  its  transparency  is  perlect.  It  is 
observed  by  Mr.  Wardrop,  (on  Morbid  Ana- 
tomy of  the  Eye,  Vol.  2,  p.  126,)  that  an  in- 
crease in  the  quantity  of  the  vitreous  hu- 
mour happens  not  unfrequently  in  staphy- 
loma, in  which  disease,  he  says,  the  enlarge- 
ment of  the  eyeball  will  generally  be  found 
to  arise  more  from  an  increase  in  the  quan- 
tity of  the  vitreous  than  of  the  aqueous  hu- 
mour, and  he  then  expresses  his  belief,  that 
the  case,  adduced  by  Scarpa  to  illustrate 
the  pathology  of  hydrophthalmia,  and  cited 
in  the  ensuing  part  of  this  article,  was  an 
example  of  staphyloma.  B»*  this  as  it  may, 
one  character  constant  in  staphyloma,  is 
olten  absent  in  hydrophthalmia  ; 1 mean 
opacity  of  the  cornea.  In  tin-  case,  which 
consists  in  an  immoderate  collection  of  the 
aqueous  humour,  the  anterior  chamber  is 
always  enlarged : on  the  contrary,  in  the 
present  form  of  the  disease,  that  cavity  is 


HTDTtOPHTH  ALMIA. 


101 


manifestly  lessened,  for  the  motionless  iris 
is  gradually  forced  so  much  towards  the 
cornea,  that  at  length  the  chamber  in  ques- 
tion imost  completely  disappears.  Howe- 
ver, the  colour  of  the  iris  undergoes  no 
change,  and  the  pupil  is  always  rather  dimi- 
nutive. Around  the  cornea,  the  sclerotica 
is  rendered  bluish  by  distention,  with  a 
somewhat  smutty  tinge.  In  the  early  stage, 
the  patient  is  affected  with  shortsightedness, 
myopia  ; but  his  power  of  vision  is  always 
seriously  diminished,  and,  at  last,  is  so  totally 
destroved,that  not  a ray  of  light  can  be  per- 
ceived. The  motions  of  the  globe  of  the 
eye  ar.d  eyelids  are  lessened  or  impeded  at 
a still  earlier  period  than  in  the  first  species 
of  hydrophtiialmia,  an.i  o the  touch  the 
organ  seems  like  an  egg-shaped  ston-e.  The 
very  commencement  of  the  disease  is  attend- 
ed with  pain,  which  daily  becomes  more 
and  more  severe,  and,  at  length,  is  not  con- 
fined to  the  eye  and  its  vicinity,  but  affects 
all  the  side  of  the  head,  the  teeth,  and  neck, 
being  sometimes  so  violent  as  almost  to 
bereave  the  patient  of  his  senses,  who 
urgently  begs  the  surgeon  to  puncture  the 
eye.  or  even  is  driven  by  desperation  to  do 
it  himself,  as  Beer  once  knew  happen.  Even 
while  the  pain  is  less  affliefing,  the  patient 
is  deprived  of  his  sleep  and  appetite.  {Beer, 
vol.  cit.p.  623.)  Though  an  increase  in  the 
quantity  of  the  vitreous  or  aqueous  humour 
lias  generally  been  treated  of  as  a distinct 
disease,  and  denominated  hydrophtiialmia, 
Mr.  Wardrop  has  never  seen  a dropsy  of 
the  eye  without  an  accompanying  disease  of 
the  sclerotic  coat,  or  cornea.  {On  the  Mor- 
bid Anatomy  of  the  Eye,  Vol  2,  p.  126.) 
Beer  offers  no  valuable  remark  on  the  causes 
of  the  preceding  form  of  hydrophthalmia,  his 
account  of  the  connexion  with  scrofula  and 
syphilis  being  mere  con  jecture,  though  deli- 
vered as  a positive  matter  of  fact  Howe- 
ver, another  position  offered  in  the  para- 
graph, concerning  the  prognosis,  seems 
more  correct : viz.  that  as  the  disease  is 
almost  always  conjoined  with  an  unhealthy 
constitution,  there  can  be  scarcely  any  hope 
of  a radical  cure.  Beer’s  opinion  also  is, 
that,  hen  the  disease  has  made  such  pro- 
gress that  not  a ray  can  be  discerned,  and 
the  pain  in  the  eye  and  head  is  so  violent, 
by  day  and  night,  that  the  sleep,  appetite, 
and  even  the  senses  are  lost ; it  is  fortunate 
if  only  the  most  perilous  symptoms  can  be 
obviated  by  palliative  treatment;  for  the 
preservation  of  a good-shaped  eye  is  then 
quite  out  of  the  question.  And  even  in  the 
most  favourable  cases,  the  utmost  which 
can  be  expected,  is  to  stop  the  further 
advance  of  the  disease,  a perfect  cure  being 
extremely  rare. 

According  to  Beer,  the  first  indication  is 
to  improve  the  state  of  the  health  by  medi- 
cines and  regimen  ; for,  unless  this  object 
be  effected,  no  expectation  of  curing  the 
dropsical  affection  of  the  eye  can  be  enter- 
tained. For  this  purpose  a long  time  will 
be  requisite,  and  as  for  local  treatment  in 
this  case,  little  or  nothing  can  be  accom- 
plished by  it.  Hence,  the  disease  often  con- 


tinues to  grow  worse  and  worse,  and,  when 
the  pain  becomes  violent,  the  best  thing 
which  the  surgeon  can  do,  both  with  the 
view  to  the  functions  of  the  organ  and  its 
form,  is  to  let  out  the  aqueous  humour.  But 
Beer  reprobates,  in  the  strongest  terms,  the 
plan  sometimes  recommended,  of  plunging 
a trocar  through  the  sclerotica  into  the  vitre- 
ous humour  and  keeping  the  tube  introdu- 
ced until  a certain  quantity  of  that  humour 
is  discharged.  According  to  Beer’s  experi- 
ence, the  usual  result  of  such  practice  is  a 
carcinomatous  disease  of  the  eye,  termina- 
ting in  death,  which  the  removal  of  the  part 
will  not  prevent.  The  method  preferred  by 
Beer  is  that  which  is  mentioned  by  Richter, 
{Anfangsgr.  B.  3,  p.  400,)  and  consists  in 
opening  the  cornea  and  capsule  of  the  lens* 
as  in  the  extraction  of  the  cataract,  dischar- 
ging the  lens  and  vitreous  humour,  and  let- 
ting the  coats  of  the  eye  collapse  ; but,  in 
order  to  prevent  any  reaccumulation  of 
fluid,  he  afterward  cuts  away  a little  bit  of 
the  flap  of  the  cornea.  The  eye  is  then  to 
be  dressed  in  the  same  manner,  as  after 
the  extraction  of  the  cataract.  (See  Cata- 
ract.) The  third  species  of  hydrophthalmia, 
or  that  produced  by  an  accumulation  both 
of  the  aqueous  and  vitreous  humours  toge- 
ther, is  excellently  described  by  Scarpa. 
He  observes,  that  in  every  case  on  which 
he  has  performed  the  operation,  and  in  other 
examinations  of  the  different  stages  of  the 
disease,  made  on  the  dead  subject,  he  has 
constantly  found  the  vitreous  humour  more 
or  less  altered  in  its  organization,  liquefied., 
and  converted  into  water,  according  as  the 
disease  was  ancient  or  ''©cent.  In  some 
instances  he  could  not  distinguish  whether 
the  increased  quantity  of  the  vitreous,  or 
aqueous  humour,  had  most  share  in  the 
formation  of  the  disease. 

Scarpa  also  dissected  a dropsical  eye, 
taken  from  the  body  of  a child  three  years 
and  a half  old,  who  died  of  marasmus.  The 
vitreous  humour  was  not  only  wanting  in 
this  eye,  and  the  cavity  destined  for  its 
reception  filled  with  water,  but  the  vitreous 
tunic  was  converted  into  a subtauce,  partly 
of  a spongy,  partly  of  a fatty  nature.  This 
dropsical  eye  was  one-third  larger  than  na- 
tural. The  sclerotica  was  not  thinner  than 
that  of  the  other  eye  ; but,  in  consequence 
of  being  yielding,  flaccid,  and  separated 
from  the  choroides,  it  had  lost  its  plumpness, 
and  globular  shape.  The  cornea  formed  a 
disk,  one-third  larger  than  that  of  this  mem- 
brane in  a sound  state;  it  did  not  retain  its 
natural  pulpy  structure,  and  was  obviously 
thinner  than  the  cornea  of  the  healthy  eye. 
There  was  a considerable  quantity  of  an 
aqueous,  reddish  fluid,  between  the  cornea 
and  iris.  The  crystalline  lens,  with  its  opaque 
capsule,  had  been  pushed  forward  a lit- 
tle way  into  the  anterior  chamber,  but 
could  not  advance  further  on  account  of  a 
firm  adhesion  which  the  capsule  had  con- 
tracted with  the  iris  around  the  edge  of  the 
pupil.  As  soon  as  the  capsule  was  opened, 
the  lens  issued  from  it  half  dissolved,  tin- 
rest  exceedingly  soft.  It  was  impossible  to 


102 


HYDROPHTHALMl*. 


detach  the  whole  of  the  posterior  layer  of  the 
capsule  from  a hard  substance,  which  seem- 
ed to  be  the  altered  membrane  of  the  vitre- 
ous humour.  Scarpa,  therefore,  slit  open 
the  choroides,  from  the  cihary  ligament  to 
the  bottom  of  the  eye,  when  a considerable 
quantity  of  a reddish  aqueous  fluid  gushed 
out,  without,  however,  one  particle  of  ihe 
vitreous  humour.  In  lieu  of  the  latter  body, 
there  was  found  a small  cylinder  of  a sub- 
stance, partly  of  a fungous,  partly  of  a fatty 
nature,  surrounded  wilh  a good  deal  of  wa 
ter,  which  was  effused  in  the  longitudinal 
axis  of  the  eye,  from  the  entrance  of  the 
optic  nerve,  as  far  as  the  ciliary  ligament, 
or  that  hard  substance  to  which  the  posterior 
layer  of  the  capsule  firmly  adhered..  This 
little  cylinder  was  covered  for  the  extent  of 
two  lines  and  a half  forwards  from  the  en- 
trance of  the  optic  nerve,  by  a stratum  of 
wh.tish  matter,  reflected  on  itself,  like  the 
epiploon,  when  raised  towards  the  fundus  of 
the  stomach.  Scarpa  conceived  th;  t this 
stratum  of  whitish  matter  was  the  relics  of 
the  unorganized  retina ; for,  on  pouring 
rectified  spirits  of  wine  on  the  whole  inner 
surface  of  the  choroides,  and  the  little  cy- 
lindrical body,  he  found  no  vestiges  of  the 
retina  on  this  membrane,  and  that  the  whi- 
tish substance,  which  was  reflected  on  itself, 
became  very  firm,  just  as  the  retina  does 
when  immersed  in  spirits  of  wine.  Both 
the  cylinder  and  the  indurated  substance, 
occupying  the  place  of  the  ciliary  body, 
were  manifestly  only  the  membrane  of  the 
vitreous  humour,  destitute  of  water,  and 
converted,  as  was  described,  into  a sub- 
stance partly  of  a spongy,  partly  of  an  adi- 
pose nature.  It  is  not  easy  to  determine 
whether  this  altered  state  of  the  vitreous 
tunic  had  preceded,  or  was  a consequence 
of  the  dropsy  of  the  eye.  However,  it  may 
be  this  fact,  in  conjunction  with  several 
other  similar  ones,  that  Scarpa  has  met  with, 
in  wdiieh  he  found  no  vitreous  humour  in 
the  posterior  cavity  of  the  eye,  b t only 
water,  ora  bloody  lymph,  tends  very  much 
to  establish  the  fact,  that  this  disease  princi- 
pally consists  of  a morbific  secretion  of  the 
vitreous  humour,  and  occasionally,  also,  of 
a strange  degeneration  of  the  alveolary 
membrane,  by  which  this  humour  is  formed. 
Scarpa  refers  to  a similar  case.  (See  Med. 
Obs.  and  Inquiries , Vol.  3,  art.  14.) 

The  augmentation  in  the  secretion  of  the 
aqueous  fluid,  both  in  the  cells  of  the  vitre- 
ous humour  and  out  of  them,  after  they  have 
been  ruptured  from  excessive  distention, 
together  with  a debilitated  action  of  the 
absorbent  system  of  the  eye  affected  ; Scarpa 
regards  as  the  probable  cause  of  the  morbi 
fic  accumulation  of  humours  in  the  eye. 
From  such  a lodgment,  and  successive  in- 
crease of  the  vitreous  and  aqueous  humours, 
the  eyeball  at  first  necessarily  assumes  an 
oval  shape,  ending  at  the  point  of  the  cor- 
nea; the  organ  enlarges  in  all  dimensions  ; 
and  in  the  end,  it  projects  from  the  orbit  in 
a manner  that  it  cannot  be  covered  by 
•he  eyelids,  di -figuring  the  patient’s  face  as 


much  as  if  an  ox's  eye  were  placed  in  the 
orbit. 

This  disease  (says  Scarpa)  is  sometimes 
preceded  by  blows  on  the  eye,  or  adjoining 
temple  ; sometimes  bv  an  obstinate  internal 
ophthalmy.  In  other  instances  it  is  prece- 
ded by  no  inconvenience,  except  an  uneasy 
sensation  of  tumefaction  and  distention  in 
the  orbit,  a difficulty  of  moving  the  eyeball, 
and  a < onsiderable  impairment  of  sight. 
Lastly,  it  is  sometimes  preceded  by  none  of 
these  causes,  or  no  other  obvious  one  what- 
ever, especially  when  the  complaint  occurs 
in  children  of  very  tender  age,  from  w hom 
no  information  can  be  obtained.  As  soon 
as  the  eye  has  assumed  an  oval  form,  and 
the  anterior  chamber  has  become  preterna- 
turaily  capacious,  the  iris  seems  situated 
further  backward  than  usual,  and  tremulates 
in  a very  singular  way  on  the  slightest  mo- 
tion of  the  eyeball.  1 he  pupil  remains  di- 
lated in  every  degree  of  light,  wfhile  the 
crystalline  is  sometimes  brownish  from  the 
very  beginning  of  the  disease;  and  some- 
times it  does  not  become  cloudy  till  the 
affection  has  arrived  at  its  highest  pitch. 
The  complaint  then  becomes  stationary ; 
and  as  the  crystalline  is  not  deeply  opaque, 
the  patient  can  distinguish  light  from  dark- 
ness, and,  in  some  degree,  the  contour  of 
objects,  and  brilliant  colours.  But  when 
the  eye  has  acquired  a larger  volume,  and 
the  whole  crystalline  has  become  opaque, 
the  retina  at  last  remains  in  a state  of  com- 
plete paralysis. 

In  the  last  stage  of  the  disease,  to  which 
the  term  bupthalmos,  or  ox-eye,  is  properly 
applicable,  when  the  dropsical  teye  projects 
from  the  orbit,  so  as  not  to  admit  of  being 
covered  by  the  eyelids  with  the  inconveni- 
ences already  enumerated,  says  Scarpa, 
others  associate  themselves,  arising  from  the 
friction  of  the  cilia?,  the  secretion  of  gum, 
the  flux  of  tears,  the  ulceration  of  the  lower 
eyelid,  on  which  the  eye  rests,  and  the  ex- 
coriation of  the  eye  itself.  Hence  the  drop- 
sical eye  is  gradually  attacked  with  violent 
ophthalmies,  attended  with  intolerable  pains 
in  the  part  affected,  and  the  whole  head. 
The  ulceration,  also,  does  not  always  con- 
fine itself  within  certain  limits;  but  conti- 
nues to  spread,  first  depriving  the  cornea  of 
ils  transparency,  next  consuming  the  sclero- 
tica, and  lastly,  destroying  progressively  the 
other  component  parts  of  the  eyeball. 

At  the  first  appearance  of  dropsy  of  the 
eye,  many  surgeons  recommend  mercurials, 
the  extract  of  cicuta,  and  of  pulsatilla  nigri- 
cans ; and  astringent’and  corroborant  colly- 
ria,  a seton  in  the  nape  of  the  neck,  and 
compression  of  the  projecting  eye.  Howe- 
ver, Scarpa  has  never  yet  met  with  a single 
well-detailed  history  of  a dropsy  of  the  eye, 
cured  by  means  of  the  above-mentioned 
internal  medicines.  With  regard  to  exter- 
nals he  has  learnt,  from  his  own  experience, 
that  when  the  disorder  is  manifest,  astrin- 
gent and  corroborant  collyria,  as  well  as 
compression  of  the  protuberant  eye,  are 
highly  prejudicial.  In  such  circumstances. 


HYDROPHTHALMIA. 


Ku 


landing  a seton  in  the  nape  of  tlie  neck, 
frequently  bathing  the  eye  in  a lotion  of 
mallows,  and  applying  to  it  a poultice  com- 
posed of  the  same  plant,  have  enabled  him 
to  calm,  for  a time,  that  disagreeable  sense 
of  distention  in  the  orbit,  and  over  the  fore- 
head and  temple  of  the  same  side,  of  which 
patients  in  this  state  make  so  much  com- 
plaint, especially  when  they  are  affected 
with  a recurrence  of  ophihalmy.  But  as 
soon  as  the  eyeball  begins  to  protrude  from 
the  orbit,  and  project  beyond  the  eyelids, 
he  thinjcs  there  is  no  means  of  opposing  the 
very  grievous  dangers  which  the  dropsy  of 
the  eye  threatens,  except  an  operation  which 
consists  in  evacuating,  by  an  incision,  the 
superabundant  humours,  then  exciting  gen- 
tle inflammation  of  the  membranes,  and 
suppuration  within  this  organ,  so  as  to  make 
it  contract,  and  shrink  into  the  bottom  of  the 
orbit.  To  defer  the  operation  any  longer, 
would  be  abandoning  the  patient  to  the  con- 
stant inconvenience  of  an  habitual  ophthal- 
my,  the  danger  of  an  ulceration  of  the  eye- 
ball and  subjacent  eyelid,  and  what  is  worse, 
of  carcinoma  of  the  whole  eye,  with  great 
peril  to  the  patient. 

Beer’s  prognosis  in  the  third  species  of 
hydrophthalmia  is  at  least  as  discouraging  as 
that  made  by  Scarpa  ; for  the  rapidity  of 
the  disease  is  said  to  be  such  as  leaves 
scarcely  a possibility  of  benefit  being  effect- 
ed by  any  mode  of  treatment,  and  the  case 
usually  terminates  in  a carcinomatous  ex- 
ophthalmia, and  death.  These  melancholy 
events  are  said,  by  Beer,  to  be  accelerated 
by  paracentesis  of  the  eye,  however  execu- 
ted ; and  he  thinks  that  the  sole  chance  of 
stopping  the  progress  of  the  disease  depends 
upon  an  endeavour  being  made  in  its  very 
commencement  to  improve  the  general 
health,  though  he  owns  that  success  is  to  be 
regarded  as  a very  rare  and  fortunateoccur- 
rence.  The  same  author  has  no  faith  in 
any  local  treatment,  and,  when  the  disease 
is  advanced,  he  considers  the  extirpation  of 
the  eye  the  only  rational  expedient,  though 
verv  precarious  in  its  result.  ( Lehre  von  den 
Augenkr.  R.  2,  p.  628,  629.) 

The  main  point,  on  which  Scarpa  differs 
from  Beer,  is  that  respecting  the  effects  of 
discharging  the  humours  of  the  eye  ; a prac- 
tice, which  the  former  represents  as  useful, 
even  in  cases  where  the  hydrophthalmia  com- 
bines an  accumulation  both  of  the  aqueous 
and  vitreous  humours.  In  former  times,  says 
Scarpa,  paracentesis  of  the  eye-hall  was 
greatly  extolled.  Nuck  one  of  the  promoters 
of  this  operation,  punctured  the  eye  with  a 
trocar,  exactly  in  the  centre  of  the  cornea. 
(De  Duct.  Ocul.  Aquos,  p.  120.)  It  has  since 
been  thought  better  to  puncture  the  sclerotica 
about  two  linps  from  the  junction  of  this 
membrane  with  the  cornea,  that  such  a small 
quantity  of  the  vitreous  humour  may  be  more 
easily  discharged  at  the  same  time  with  the 
aqueous,  as  may  be  deemed  adequate  to  ef 
feet  a diminution  in  the  morbific  enlargement 
of  the  eye-ball. 

According  to  Scarpa,  paracentesis  of  the 
eye,  done  so  as  merely  to  discharge  the  hu- 


mours, can  never  be  a means  of  curing  drop- 
sy of  the  eye,  unless  the  puncture,  made  with 
the  trocar,  excite  inflammation  and  suppura- 
tion, and  afterward  a concretion  of  the 
membranes  composing  the  eye  ball.  Indeed 
Nuck  relates,  that  in  a young  man  at  Breda, 
hp  was  obliged  to  puncture  the  eye  five  seve- 
ral times  ; that,  on  the  fifth  time  of  doing 
this,  it  was  necessary  to  suck  through  the  can- 
nulnr  of  the  trocar,  in  order  to  evacuate  the 
greatest  possible  quantity  of  the  vitreous 
humour  ; and  lastly,  that  it  seemed  proper  to 
introduce  a plate  of  lead  between  the  eyelids 
arid  eye-ball,  for  the  purpose  of  making  con- 
tinual pressure  on  the  pye,  in  its  empty  shri- 
velled state.  In  a woman  at  the  Hague,  be 
twice  punctured  the  eye  in  vain  ; and  she 
submitted,  two  or  three  times  afterward,  to 
the  same  operation,  but  with  what  degree  of 
success  is  not  specified.  Scarpa  has  no  diffi- 
culty in  believing,  that  a radical  cure  of  the 
dropsy  has  sometimes  bpen  accomplished  by 
means  of  the  puncture,  after  the  trocar,  and 
other  similar  hard  substances,  have  been  re- 
peatedly introduced  into  the  eye,  through  'he 
cannula  of  that  instrument  ; but  this  success 
can  never  be  attributed  to  the  mere  evacua- 
tion of  the  superabundance  of  the  vitreous 
and  aqueous  humour ; though  it  may  be  re- 
ferred to  that  circumstance,  conjoined  with 
the  irritation  produced  bvthe  cannula,  or  the 
tents  with  which  Muuchart  kept  open  the 
wound. 

Scarpa  condemns  the  plan  of  making  a 
circular  incision  through  the  sclerotica,  s 
disadvantageous,  and  even  dangerous.  In 
fact,  this  circular  recision.  is  constantly  fol- 
lowed by  the  most  aggravated  symptoms, 
particularly  frequent  hemorrhages,  an  accu- 
mulation of  grumous  blood  at  the  bottom  of  the 
eve-ball,  vehement  inflammation  of  the  eye, 
eyelids,  and  head,  obstinate  vomitings,  con- 
vulsions, delirium,  and  the  most  imminent 
danger  <o  the  patient’s  life.  Such  modern 
surgeons,  as  have  faithfullv  published  the 
results  of  their  practice  on  this  point,  among 
whom,  after  M Louis,- (Mim.  de  VAcad.  de 
Chir.  T 13  p.  289,  290  ) Marchan,  (Journal 
de  Med.  de  Paris , Janvier , 1770  : Sur  deux 
Exophthalmies , ou  grosseurs  contre  nature  du 
Globe  deV (TAl ;)  and  Terras,  (Ibidem,  Mars, 
1776;  Sur  V Hydrophthafmie,)  having  ingenu- 
ously declared  that,  after  performing  the  cir- 
cular recision  of  dropsical  eyes  in  the  scle- 
rotica, they  had  the  greatest  motives  for  re- 
penting of  what  they  had  done.  Scarpa  pre- 
fers making  a circular  section,  about  three  lines 
in  breadth,  at  the  summit  or  centre  of  the 
cornea  of  the  dropsical  eye,  as  directed  by 
Celsus,  in  cases  of  staphyloma. 

Whether  the  cornea  be  transparent  or  not, 
as  sight  is  irrevocably  lost,  the  surgeon  must 
introduce  a small  bistoury  across  the  apex,  or 
middle  of  the  cornea,  at  one  line  and  a half 
Irom  its  central  poini  ; and  then  by  pushing 
the  instrument  from  one  towards  the  other 
canthus  of  the  eye,  he  will  cut  the  lower  part 
of  the  cornea  in  a semicircular  manner.  The 
segment  of  the  cornea  being  next  elevated 
with  the  forceps,  the  operator  is  to  turn  the 
edge  of  the  knife  upward,  and  complete  the 


104 


HYD 


HYP 


work  fev  a circular  removal  of  as  much  of  the 
centre  of  the  cornea  as  is  -qual  to  three  li  ies 
in  diameter,  fhrough  t his  circular  opening, 
made  in  the  centre  of  the  cornea,  the  -urgeon 
may,  by  mean--  of  gentle  pressure,  di-  barge 
as  much  of  t tie  -upehab  ntdanl  Ini  no  irs  in 
the  eye,  as  i->  requisite  to  make  the  eye-hall 
diminish,  and  return  into  the  orbit,  so  a-  to 
be  covered  by  the  eyelids.  A-  f,»r  the  rest  of 
the  Honour  lodged  in  the  eve,  i;  will  gradn 
ally  escape  of  -self.  through  'he  cncular 
opening  in  tli  • cornea,  w thout  any  more 
pressure  bei;s.:  tn  -da. 

Until  tb^  appe  trance  of  th“  inflamm  lion, 
that  is,  until  the  third  or  fif  h e after  the 
operation,  the  dressings  re  to  consist  <u  the 
application  ot  a compress  of  dry  lit  sup- 
ported by  a bandage.  As  soon  as  the  • ;«m- 

mation  and  mm -faction  invade  the  eye  ope- 
rated on,  and  t c eyelids,  the  surgeon  is  to 
employ  such  internal  remedies  as  are  calcu- 
lated to  moderate,  the  progress  of  inflamma- 
tion ; and  he  is  to  e iver  the  eyelids  • ith  a 
bread  and  milk  poultice,  which  must  be  i-e- 
nevved  at  lea-,  once  every  two  hours.  It  is  a 
very  frequent  result,  both  in  the  staphyloma 
and  drop  y of  the  eve,  that,  on  the  first  ap- 
pearance of  intla  -I mat  ion,  the  eye-ball,  on 
which  the  operation  has  been  done,  augments 
and  protrudes  again  from  the  eyelids  in  th  j 
came  way  as  before  the  operation.  fri  t--is 
circumstance.  Scarpa  directs  the  projecting 
part  of  the  eye-ball  to  be.  covered  well  apiece 
ot  fine  linen,  smeared  with  a liniment  of  oil 
and  wax,  or  the  yelk  of  an  egg  and  oleum 
hy perici  ; the  apple  lion  of  the  b a.J  and 
milk  poultice  being  continued  over  this  other 
dressing.  Scarpa  next  sta'es,  that  when  the 
interior  ot  the  f-ye  begi  -$  o suppurate,  he 
swelling  of  the  eye-lids  decreases,  and  the 
eye-ball  diminishes  in  -ize,  and  returns  gra- 
dually into  the  orbit.  This  stale  of  suppura- 
tion may  be  known  by  observing,  that  the 
dressings  are  smeared  with  a viscid  lymph, 
blended  with  a portion  of  h humours  of  the 
eye,  which  incessantly  issue  from  the  centre 
of  the  cornea  ; and  by  noth  ing  the  appear- 
ance of  the  margin  of  the  reci-ion,  wbic.li  is 
changed  into  a circle  of  a, whitish  sub, lance, 
resembling  the  rind  of  bacon,  which  is  after- 
ward detached,  like  a -lough,  so  as  to  leave 
a small  ulcer,  of  a very  healthy  colour,  ib  is 
ulcer,  as  well  as  the  whole  eye-ball,  con- 
tracts, and  becomes  mihrely  cic  a iiz«  d.  lea- 
ving every  opportunity  for  the  placing  of  an 
artificial  eye  between  the  eyelids  and  the 
Stump  of  the  eyeball. 

If  a mild  inflammation  and  suppuratio  in 
the  interior  of  the  eye  should  not  take  place 
on  hue  fifth  day,  Scarpa  exposes  tue  eye  to  the 
air,  or  removes  a circular  portion  of  the  cor- 
nea, half  a line  in  breadtn,  or  little  more,  by 
met-ns  of  the  forceps  and  curved  scissor--. 
The  foregoing  practice  is  certainly  p efera- 
bie  to  that  advised  by  R-cttier.  who,  when  the 
eyesight  is  lost,  and  the  object  is  merely  to 
discharge  the  humours,  and  let  the  eye  col- 
lapse, sometimes  makes  a crucial  division  of 
the  cornea,  and  removes  the  four  flaps  or  an- 
gles, or  even  cuts  away  1;>e  whole  of  the 
anterior  part  of  the  eye-ball  through  the 


sclrrotica.  {Anfangsgr.  B.  3,  p.  404A  It* 
order  'o  lessen  the  -mlk  of  the  eye,  the  late 
VI r.  Ford,  in  one  instance,  passed  a seton 
through  the  front  of  the  organ  with  apparent 
success.  (See  Med.  Communications , Vol  1.) 
Consult  Maucharl.  Dt  Parac'entesi  Oculi , Tub. 
17  44.  Conradi,  Handbucfi  der  Pathol.  Anat. 
p.  523.  Fieliz,  in  Huf eland’s  Journ.  4 B.  p. 
208.  Flajani , Cullesione  d Ossenazioni , T.  1, 
Obs.  43  Gendron.  Mai.  d s Yeux.  T.  2. 
Loins,  in  M6m.de  I’Acad.  dt  Chir.  T.  5,4 to. 
Marchun  in  Jo  m.  de  Med  T.  32,  p.  65, 
Terras,  op.  cit.  Vol.  45.  p.  237.  Scarpa , Salle 
principali  Mnlattie  degli  Occhi , Cm  . 13  C. 
P.  Begcr , Dr’  Hydrophthnlmia  Haller  Disp . 
C/nr.  i 575.  A.  Sanvey , />e  Paracentid 
Ce  di  in  i 7 y dr ophthalmia  et  Amblyopia  Se- 
nu . - ; H llcr,  Disp.  hir.  15-  7,  Tub.  1744. 
Benedict,  de  Mo.  bis  Hum  oris  Vitrei.  Luke , 
Diss.de  Hydropethalnna,  Jen.  1803.  Rich- 
ter. Anfangsgr.  B.  3,  p.  392,  fyc.  67;/.  1795. 
Beer Lthrev  n den  iugenkr.  B. 2,  Wien.  1817. 
J W.rd  op,  Essays  on  the  Morbid  Anatomy 
of  the  II  man  Eye,  Chap.  18  and  40,  Vol  2; 
8vo.  Load.  18i».  B.  Travers.  Synoj  is  of  the 
Diseases  of  the  Eye,  p.  195,  p.1 200,  8ro, 

Load  1820. 

HV'DiiOPS.  (from  ieJa)g,  uer.)  A drop- 
sy, o morbid  accumulation  of  w a' or.  For 
hydrops  articuli , refer  to  Joints , diseases  of;  for 
hydrops  oculi,  see  the  foregoin  _ article.  With 
re  - i i hydrops  pectoris , hydrothorax,  or 
dropsy  of  Ihe  chest , as  it  is  altogether  a medi- 
cal case,  an  account  of  its  symptoms  and 
tree. - merit  w ll  hardly  be  required  in  this 
Dictionary.  Tue  only  concern,  o itich  a sur- 
geon has  ivitlj  the  disease,  is  being  oceasion- 
al'y  required  to  make  an  opening  for  the 
discharge  of  the  water.  (See  Paracentesis 
Thoracis) 

HYDROS  ARC OCtfLE.  (from  wfyg,  water  ; 
<r* igf,  flesh  ; and  a tumour.)  A surcocele 
a -d  with  a collection  of  fluid  in  the 
tuni • va  inalis 

HYMEN  IMPERFORATE.  The  incon- 
veniences brought  on  by  such  a cause,  and 
t tie  mode  of  relief,  are  explained  in  the  arti- 
cle Vagina. 

A continuation  of  the  hymen  over  a part 
of  the  orifice  of  the  meatus  urinarius  may 
produce  great  pain  and  difficulty  in  making 
water,  and  symptoms,’  w liicli  may  give  rise 
to  suspicion  of  there  being  a stone  in  the 
bladder.  Foi  a case  illustrating  the  truth  of 
this  observation,  see  Warner's  Cases  in  ■'sur- 
gery, p.  276,  Edit.  4. 

HYPOPIUM,  or  HYPOPYON.  (from 
vvo , under  ; arid  <sruty,  pas.) 

Bs  bypopium  (sa\s  Scarpa)  limply  with 
al  surgeons,  that  accumulaiioroof  « glutinous, 
yeiiowi  h fluid,  like  pus,  which  takes  place 
in  - lie  anterior  chamber  of  aqueous  humour, 
and.  fr«  quently,  aiso  in  the  posterior  one,  in 
conseqti'  re  oj  severe,  acute  opht'ndmy.  par- 
ticularly the  internal  species.  Though  sel 
vere,  a«  u e ophtualmy  mostly  affects  par- 
ticularly the  external  parts  of  the  eye  ; yet,  it 
occasionally  invades,  with  equal  violence, 
both  the  external  and  internal  coats  of  this 
organ,  especially  the  choriodes  and  uvea. 
If  such  inflammation  be  not  promptly  check- 


HYPOPIUM. 


'10# 


«<1,  by  chlrurgicnl  means, coagulating  lymph  is 
extravasated  from  tin-  highly  inflamed  choroi- 
des  and  uvea, and  gradually, as  it  is  effused  into 
the  cavity  of  the  eye,  it  passes  through  the  pu- 
pil into  the  chambers  of  the  aqueous  humour, 
and  descends  to  the  bottom  of  the  anterior 
one,  so  as  to  fill  sometimes  one-third, 
sometimes  one-half  of  this  space  ; and  occa- 
sionally, to  occupy  it  to  such  a height,  as  to- 
tally to  conceal  the  iris  and  pupil. 

This  viscid  matter  of  hypopium,  though 
commonly  called  pus,  Scarpa  regards  as 
coagulating  lymph.  The  symptoms,  por- 
tending an  extravasation  of  coagulating 
lymph  in  the  eye,  or  an  hypopium,  are  the 
same  as  those  which  occur  in  the  highest 
stage  of  violent  acute  ophthalmy:  viz.  pro- 
digious tumefaction  of  the  eyelids  ; the  same 
redness  and  swelling  ot  the  conjunctiva,  as 
in  chemosis  ; burning  heat  and  [tain  in  the 
eye  ; pains  in  the  eyebrow  and  nape  of  the 
neck  ; fever,  restlessness,  aversion  to  the 
faintest  light,  and  a contracted  state  of  the 
pupil. 

As  soon  as  the  hypopium  begins  to  form, 
(say?  Scarpa)  a yellowish  semi-lunar  streak 
makes  its  appearance  at  the  bottom  of  the 
anterior  chamber,  and,  regularly,  as  the  glu- 
tinous fluid  is  secreted  from  the  inflamed 
internal  membranes  of  the  eye,  so  as  to  pass 
through  the  pupil,  and  fall  into  the  aqueous 
humour,  it  increases  in  all  dimensions,  and 
gradually  obscures  the  iris,  first  at  its  inferior 
part,  next  where  it  forms  the  pupil,  and  lastly 
the  whole  circumference  of  this  membrane. 
As  long  as  the  inflammatory  stage  of  violent 
ophthalmy  lasts,  the  hypopium  never  fails 
to  enlarge  ; but,  immediately  this  stage 
ceases,  and  the  opbthalmy  enters  its  second 
period,  or  that  dependent  on  local  weakness, 
the  quantity  of  coagulating  lymph,  forming 
the  hypopium,  leaves  !>ff  increasing,  and, 
from  that  moment,  is  disposed  to  diminish. 

This  fact  sufficiently  evinces  (continues 
this  eminent  Professors  how  important  it  is, 
in  order  to  check  the  progress  of  the  hypo- 
.pium,  to  employ,  with  the  utmost  care,  the 
most  effectual  means  for  checking  the  attack 
of  violent  ophthalmy  in  its  first  stage. 
Copious  evacuations  of  blood, both  generally 
and  topically,  ought  to  be  speedily  pul  in 
practice  ; and  when  chemosis  exists,  the 
conjunctiva  should  be  divided  ; mild  aperi- 
ents given,  blisters  applied  to  the  nape  of 
the  neck,  little  bags  of  emollient  herbs  to 
the  eye,  and  other  measures  employed.  It 
Avill  be  known  that  they  have  fulfilled  the 
indication,  by  noticing  that,  some  days  after 
the  adoption  of  such  treatment,  though 
there  may  still  be  redness  of  the  conjunctiva 
and  eyelids,  the  lancinating  pains  in  the  eye 
abate,  the  heat  considerably  diminishes,  the 
fever  subsides,  quietude  and  sleep  are  resto- 
red, the  motion  of  the  eye  becomes  free, 
and,  lastly  the  collection  of  viscid  matter 
forming  the  hypopium,  becomes  stationary. 
It  is  not  unfrequent  to  see,  especially  among 
the  lower  orders  of  the  people,  persons 
affected  with  the  second  stage  of  severe 
acute  ophthalmy,  bearing  this  collection  of 
coagulating  lymph,  in  the  chambers  of  the 
Vol.  11  14 


aqueous  humour,  with  the  greatest  indiffer- 
ence, and  without  complaining  of  any  of 
those  symptoms  which  characterize  the 
acute  stage  of  ophthalmy.  It  is  only  at 
this  crisis,  or  at  the  termination  of  the  acute 
stage  of  violent  inflammation  of  the  eye, 
that  the  enlargement  of  the  hypopium 
ceases,  and  the  coagulating  lymph  begins  t® 
be  absorbed,  provided  this  salutary  opera- 
tion of  nature  be  not  impeded,  nor  retarded, 
by  any  injudicious  regitnen.  However,  if 
Scarpa  had  also  been  aware  of  the  great 
efficacy  of  mercury,  in  arresting  the  effusion 
of  lymph,  I can  hardly  doubt,  that  he  would 
have  modified  some  of  the  preceding  obser- 
vations, as  well  as  his  practice  ; a subject  t® 
which  I shall  presently  advert  again. 

Scarpa  states,  that  persons,  little  versed 
in  the  treatment  of  diseases  of  the  eyes, 
would  fancy  that  the  most  expeditious  and 
efficacious  mode  of  curing  an  hypopium, 
after  it  has  become  stationary  in  the  seeond 
stage  of  severe  acute  ophthalmy,  would  be 
that  of  opening  the  cornea  at  its  most  de- 
pending part,  in  order  to  procure  a speedy 
exit  for  the  matter  collected  in  the  chambers 
of  the  aqueous  humour;  especially  as.  this 
was  once  the  common  doctrine.  But  ex- 
perience shows,  that  dividing  the  cornea,  in 
such  circumstances,  is  seldom  successful, 
and  most  frequently  gives  rise  to  evils,  w'orse 
than  t lie  hypopium  itseif,  notwithstanding 
the  modification  suggested  by  Richter,  ( Obs . 
Chir.  Fasc.  1,  Chap  12,)  not  to  evacuate  the 
whole  of  ihe  matter  at  once,  nor  to  promote 
its  discharge  by  repeated  pressure  and  in- 
jections, but  to  allow  it  to  flow  slowly  out 
of  itself.  The  wound  made  at  the  lower 
part  of  the  cornea,  for  evacuating  the  matter 
of  the  hypopium,  small  as  tbe  incision  may 
be,  most  commonly  reproduces  severe  acute 
ophthalmy,  and  a greater  effusion  of  coagu- 
lating lymph  into  the  chambers  of  the  aque- 
ous humour.  Besides,  after  opening  the 
cornea,  if  the  matter  of  the  hypopium  w’ere 
allowed  to  escape  gradually  of  itself,  it 
would  be  several  days  in  being  completely 
discharged,  on  account  of  its  viscidity. 
During  this  time,  the  glutinous  lymph  would 
keep  the  edges  of  the  wound  of  the  cornea 
dilated,  and  make  them  suppurate.  Thus, 
the  incision  would  be  converted  into  an 
ulcer,  through  which  the  aqueous  humour 
wrould  escape,  and  even  a fold  of  the  iris. 
Opening  the  cornea,  therefore,  only  converts 
the  hypopium  into  an  ulcer  of  that  mem- 
brane, attended  with  a prolapsus  of  the  iris, 
and  occasionally  of  the  crystalline  itself. 
Nor  can  any  inference  be  drawn,  in  favour 
of  making  an  artificial  opening,  during  the 
stationary  state  of  an  hypopium  in  the 
second  stage  of  severe  acute  ophthalmy, 
from  the  matter  of  the  hypopium  having 
sometimes  made  its  way  spontaneously 
through  a narrow  aperture  in  the  cornea, 
with  a successful  result.  For,  there  is  a 
wide  difference,  betw'een  the  effects  of  a 
spontaneous  opening  in  a natural,  or  preter- 
natural cavity  of  the  animal  body,  or  of 
one  made  with  caustic, and  the  consequences 
of  an  opening,  made  with  a cutting  iastru- 


10  6 


HYPOPIUM. 


ment.  In  the  two  first  methods,  the  subse- 
quent symptoms  are  constantly  milder  than 
in  the  last.  Besides,  even  in  the  instance  in 
which  a spontaneous  discharge  of  the  hy- 
popium  takes  place  through  the  cornea,  an 
escape  of  the  aqueous  humour,  and  a pro- 
lapsus of  the  iris,  not  unfrequently  ensues ; 
consequently,  the  spontaneous  evacuation 
of  the  hypopium  cannot  justly  form  a rule 
for  the  treatment  of  the  disease.  There  is 
only  one  case,  in  which  dividing  the  cornea, 
in  order  to  discharge  an  hypopium,  is  not 
only  useful,  but  indispensable  ; this  is,  when 
there  is  such  an  immense  quantity  of  coagu- 
lating lymph  extravasatea  in  the  eye,  that 
the  excessive  distention,  which  it  produces 
of  all  the  coats  of  this  organ  occasions 
symptoms  so  vehement,  as  not  only  threaten 
the  entire  destruction  of  the  eye,  but  even 
endanger  the  life  of  the  patient.  But  this 
particular  case  cannot  serve  (says  Scarpa) 
as  a model  for  the  treatment  of  ordinary 
cases. 

The  dispersion  of  the  hypopium,  by  means 
of  absorption,  forms  the  primary  indication, 
at  which  the  surgeon  should  aim.  In  order 
to  stop  its  progress,  the  most  efficacious 
method  is  to  subdue  the  first  violence  of  the 
inflammation,  and  to  shorten  its  acute  stage, 
by  the  free  employment  of  antiphlogistic 
treatment,  and  the  use  of  mild  emollient, 
topical  remedies.  And,  in  conjunction  with 
these  means,  there  can  now  be  no  doubt, 
that  the  practice  of  BrUel,  published  in  1809, 
as  will  be  mentioned  at  the  close  of  this 
article,  ought  to  be  followed  : 1 mean,  the 
quick  exhibition  of  the  submuriate  of 
mercury,  which  has  been  also  found  at  the 
London  Eye  Infirmary  the  most  powerful 
means  of  checking  the  effusion  of  lymph  in 
the  eye.  (See  Saunders's  fVork  on  the  Eye, 
Ed.  2,  and  a Synopsis  of  the  Diseases  of  the 
Eye , by  B.  Travers,  p.  135.) 

If  this  treatment  answer,  the  incipient 
collection  of  coagulating  lymph,  at  the 
bottom  of  the  anterior  chamber  of  the 
aqueous  humour,  not  only  ceasestoaugment, 
but,  also,  in  proportion  as  the  severe 
ophthalmy  disappears,  the  absorbent  system 
takes  up  the  heterogeneous  fluid  extravasa- 
ted  in  the  eye,  and  the  white,. or  yellow 
speck,  shaped  like  a crescent,  situated  at  the 
bottom  of  the  anterior  chamber,  gradually 
diminishes,  and  is  at  last  entirely  dispersed. 
Janin  considered  an  infusion  of  the  flowers 
of  mallows,  applied  to  the  eye  that  is  infla- 
med apd  affected  with  this  disease,  as  a 
specific  resolvent  in  these  circumstances, 
(M6m.  et  Obs.  surVCEil,  p.  405,)  but  it  is  now 
known,  that  every  topical  emollient  applica- 
tion, provided  it  be  conjoined  with  such 
internal  antiphlogistic  treatment,  as  is  the 
most  proper  for  repelling  the  acute  stage  of 
the  severe  ophthalmy,  produces  quite  as 
good  an  effect  as  this  infusion.  Simple 
warm  water  produces  the  same  benefit. 

A young  girl  (says  Naenoni)  was  struck 
in  the  eye  by  an  ear  of  corn.  An  inflamma- 
tion was  the  consequence,  which  produced 
a white  pus  of  a semi-lunar  shape,  apparent- 
ly behind  the  cornea,  without  a possibility 


of  judging  whether  the  matter  was  actually- 
situated  between  the  laminae  of  that  mem- 
brane, or  in  the  anterior  chamber.  Hence, 

I was  asked,  whether  it  might  not  be  evacu- 
ated by  an  incision,  particularly  as  the 
patient  complained  of  great  pain  in  the  eye, 
and  eyebrow.  She  was  in  the  hospital ; 
and  in  the  presence  of  Dr.  Lulli,  and  several 
students  in  surgery,  I said  that  the  pain  of 
which  the  patient  complained,  was  not  occa- 
sioned by  the  pus  itself,  but  tbe  cause  which 
produced  it.  This  cause  was  inflammation, 
which  probably  would  be  increased  by 
making  a larger  opening  for  the  external 
air,  than  wbat  it  has  to  the  internal  parts, 
while  the  external  ones  remain  entire.  By 
fomenting  the  eye  and  forehead  with  warm 
■water,  the  inflammation  subsided,  and  the 
pus  disappeared.  We  have  so  often  witness- 
ed tbe  fact  subsequently,  that  we  can  also 
extol  the  simplicity  of  the  treatment.” 
Such,  in  short,  is  the  successful  termination 
of  an  hypopium,  whenever  the  disease  is 
properly  treated  at  its  commencement,  and 
the  acute  stage  of  severe  ophthalmy  is 
promptly  checked  by  internal  antiphlogistic 
means,  and  emollient  applications.  But,  in 
consequence  of  the  inflammatory  period  of 
the  severe  ophthalmy  having  resisted,  in  an 
uncommon  manner,  the  best  means,  or 
because  such  means  have  been  employed 
too  late,  it  sometimes  happens,  that  the 
coagulating  lymph,  collected  in  the  anterior 
chamber,  is  so  abundant,  even  after  the 
acute  stage  of  ophthalmy,  that  it  continues 
for  a long  time  to  cloud  the  eye,  and  inter- 
cept vision.  Scarpa  has  often  seen  patients, 
especially  paupers,  who,  from  indolence, 
negligence,  or  ill  treatment,  remained  a 
long  time  after  the  cessation  of  the  inflam- 
matory stage  of  ophthalmy,  with  the  anterior 
chamber  almost  entirely  filled  with  the 
glutinous  matter  of  hypopium.  When  the 
inflammation  had  ceased,  these  unhappy 
persons  wandered  about  tbe  streets  almost 
quite  indifferent,  and  without  complaining 
of  pain,  or  any  other  inconvenience,  than 
the  difficulty  of  seeing  with  the  eye  affected. 
In  this  second  stage  of  the  ophthalmy,  the 
resolution  of  hypopium  obviously  cannot  be 
accomplished  by  the  same  means,  nor  with 
equal  celerity,  as  in  the  first.  At  this  crisis, 
the  great  quantity  and  density  of  the  gluti- 
nous matter  extravasated,  and  the  atony  of 
the  vascular  system  of  the  eye,  make  it 
necessary  to  give  nature  sufficient  time  to 
dissipate  the  thick,  tenacious  matter,  and,  at 
length,  to  dispose  it  to  be  insensibly  absorbed 
with  the  aqueous  humour  which  is  continu- 
ally undergoing  a renovation.  Hence  it  is 
right,  (says  Scarpa)  to  adopt  those  means, 
which  are  best  calculated  to  iavigorate  the 
vascular  system  of  the  eye,  more  especially 
the  lymphatics.  This  requires  more  or  less 
time,  according  as  the  patient  is  advanced  in 
years,  of  a relaxed  fibre  and  weak  ; or  a 
young  man  of  good  constitution. 

However,  according  to  Scarpa,  in  the 
second  stage  of  violent  acute  ophthalmy, 
complicated  with  hypopium,  the  surgeon 
should  limit  his  efforts  to  the  rernovnl  ot 


HtPOPIUM. 


107 


every  thing,  which  may  irritate  the  eye,  or 
be  likely  to  renew  the  inflammation  ; and 
he  should  only  employ  such  means,  as  are 
conducive  to  the  resolution  of  the  second 
inflammatory  stage,  depending  on  relaxation 
of  the  conjunctiva  and  its  vessels,  and  such 
remedies  as  tend,  at  the  same  time,  to  invigo- 
rate the  action  of  the  absorbents.  There- 
fore. i , this  state,  he  ought  first  to  examine 
carefully  the  degree  of  irritability  in  the  eye. 
affected  with  the  hypopium,  by  introducing, 
between  the  eye  and  eyelids,  a few  drops  of 
vitriolic  collyrium,  containing  the  mucilage 
of  quince  seeds.  Should  the  eye  seem  too 
strongly  stimulated  by  this  application,  it 
must  not  be  used,  and  little  bags  of  warm 
mallows  with  a feu  grains  of  camphor  are 
to  be  substituted  for  it.  In  the  intervals,  the 
vapours  of  the  liquor  ammon.  comp,  may 
be  applied,  and  recourse  had  again  to  a 
blister  on  the  nape  of  the  neck.  When  the 
extreme  sensibility  of  the  eye  is  overcome, 
the  zinc  collyrium  must  be  used  again,  after- 
ward strengthened  with  a few  drops  of 
camphorated  spirit.  Under  such  treatment, 
proceeds  Scarpa,  the  surgeon  may  observe, 
that,  in  proportion  as  the  chronic  ophthahny 
disappears,  and  the  action  of  the  absorbents 
is  re-excited,  the)  tenacious  matter  of  the 
hypopium  divides  first  into  several  small 
masses  ; then  dissolves  still  further  ; and, 
afterward,  decreases  in  quantity  : descend- 
ing towards  the  inferior  segment  of  the 
cornea  ; and,  finally,  vanishing  altogether. 
But  Scarpa  accurately  observes,  tfiat  the 
surgeon  cannot  always  expect  to  be  equally 
successful,  whether  the  disease  occur  during 
the  first,  or  second  stage  of  violent  acute 
opbthalmy,  if  the  tenacious  lymph,  suddenly 
extravasated  in  the  interior  of  the  eye, 
prevail  in  such  quantity,  as  not  only  to  fill, 
but  strongly  distend,  the  two  chambers  of 
the  aqueous  humour,  and  the  cornea  in 
particular.  In  this  state,  notwithstanding 
the  most  skilful  treatment,  the  unpleasant 
complication  is  often  followed  by  another 
inconvenience,  still  worse  than  the  hypopi- 
um itself;  viz.  ulceration,  opacity,  and  burst- 
ing of  the  cornea. 

The  ulceration  of  the  cornea  ordinarily 
takes  place  tvith  such  celerity,  that  the  sur- 
geon seldom  has  time  to  prevent  it.  As 
soon  as  an  aperture  has  formed,  the  exces- 
sive abundance  of  coagulating  lymph,  con- 
tained in  the  eye,  (sometimes  named  em- 
pyema oculi)  begins  to  escape  through  it, 
and  a degree  of  relief  is  experienced.  But, 
this  melioration  is  not  of  long  continuance  ; 
for.  scarcely  is  the  glutinous  fluid  evacuated, 
that  distended  the.  whole  eye,  and  especially 
the  cornea,  when  it  is  followed  by  a portion 
of  the  iris,  which  glides  through  the  ulcera- 
ted aperture,  protrudes  externally,  and  con- 
stitutes the  disease  termed  prolapsus  of  the 
iris.  (See  Iris,  Prolapsus  of.)  But,  if  in 
such  an  emergency,  the  cornea  already 
ulcerated,  opaque,  and  greatly  deranged  in 
its  organization,  should  not  immediately 
burst,  the  surgeon  is  then  constrained  by  the 
violence  of  the  symptoms,  depending  on  the 
prodigious  distention  of  the  eyeball,  to 


make  an  opening  in  this  membrane,  in  order 
to  relieve  the  immense  constriction,  and 
even  the  danger  in  which  life  is  placed. 

Were  there  the  least  chance  of  restoring, 
in  any  degree,  the  transparency  of  the  cor- 
nea, and  the  functions  of  the  organs  of  vision, 
after  opening  the  cornea,  Scarpa  acknowled- 
ges that  it  would  certainly  be  more  prudent 
to  make  the  opening  at  the  lower  part  of 
this  membrane.  But  in  the  case  of  empye- 
ma of  the  eye,  now  considered,  in  which  the 
cornea  is  universally  menaced  with  ulcera- 
tion and  opacity,  and  seems  ready  to  slough, 
there  can  be  no  hope  of  its  resuming  its 
transparency  at  any  point,  and  he  therefore 
decrns  it  the  best  and  most  expeditious  me- 
thod of  relief  to  divide  its  centre  with  a 
small  bistoury  to  the  extent  of  a line  and  a 
half;  and  then  to  raise  with  a pair  of  for- 
eeps  the  little  flap,  and  cut  it  away  all  round 
with  one  stroke  of  the  scissors,  so  as  to  let 
the  humours  escape  without  any  pressure. 

The  eye  is  to  he  covered  with  a bread  and 
milk  poultice,  which  is  to  be  renewed  every 
two  hours,  the  use  of  such  general  remedies, 
as  are  calculated  to  check  the  progress  of 
acute  inflammation,  and  to  quiet  the  nervous 
system,  not  being  omitted.  In  proportion  as 
the  interior  of  the  eye  suppurates,  the  eye- 
ball gradually  diminishes,  shrinks  into  the 
orbit,  and  at  length  cicatrizes,  leaving  things 
in  a favourable  state  for  the  application  of 
an  artificial  eye. 

When  Scarpa  delivers  his  opinion,  that  in 
the  above  aggravated  form  of  hypopium, 
there  can  be  no  chance  of  the  cornea  resu- 
ming its  transparency  at  any  point,  I think  his 
assertion  rather  imprudent.  Nor.  admitting 
its  general  truth,  does  it  follow  as  a matter  of 
course,  that  it  is  necessary  and  right  to  cut 
away  a piece  of  the  centre  of  the  cornea, 
and  absolutely  destroy  whatever  little  chance 
may  yet  be  left  of  saving  the  eye.  In  sup- 
port of  this  remark,  let  me  contrast  what 
Mr.  Travers  has  said  with  the  advise  of  Scar- 
ps “ When  the  hypopium  is  so  large  as  lo 
rise  towards  the  pupil,  and  the  ulceration  of 
the  cornea  is  extending,  I think  its  discharge 
by  section  near  its  margin  adviseable.  If  not 
too  long  delayed,  the  ulcerative  process  is 
checked  by  it,  which  would  otherwise  rrin 
into  sloughing,  and  Ike  cornea  recover  with 
only  partial  opacity  and  disfigurement."  (Sy- 
nopsis of  the  Diseases  of  the  Eye,  p 2S0.) 

Mau chart  de  Hypopyo.  Tubingw,  1742.  C. 
P.  Leporin,  de  Hypopyo.  ilo.  Goett.  1778. 
Gotldlin,  Diss.  de  Hypopyo.  Erlang.  1810. 
IV nit  her  Merkwiirdige  Iieilung  eines  Eiter- 
auges,  fyc..  8t'o.  Landsh.nl,  1819.  I observe , 
that  in  Hufelahd  and  Himley's  Journal  for 
Oclob.  1809,  p.  93,  there  is  an  account  of  the 
treatment  of  an  hypopium,  or  case  of  effused 
lymph  in  the  chambers  of  the  eye,  by  exhibit- 
ing from  12  to  18  grains  of  the  submuriate  of 
mercury,  in  the  space  of  12  hours , and  then 
giving  bark,  while  as  an  external  application 
the  tinct.  opii  crocat.  teas  employed.  Thus  ue 
spe  that  the  efficacy  of  mercury  in  checking  the 
effusion  of  lymph  in  the  eye , and  promoting 
an  absorption , has  been  known  many  years  in 


Germany.  A.  Scarpa  Saggio  di  Osservazioni  Anatomy  of  the  Human  Eye,  Chap.  6. 
c d'Esperitnze,  suite  Principali  Malaltie  Edinb.  1S08. 

degli  Occhi;  Venezia , 1802.  Richter  An-  HYSTEROTOMIA.  (from  vo-ree,*.,  Ihe 
Jdngsgriinde  der  Wundarzneykunst , B.  3.  womb,  and  rifj.vu>,  to  cut.)  See  Ccesartan 
1705.  ,/.  Wardrop,  Essays  bn  the  morbid  Operation. 


I. 


I VI PERFORATE  HYMEN.  (See  Va- 
gina.) 

1 NCARCEKAT10N.  This  term  is  usually 
applied  to  cases  oi  hernia  in  the  same  sense 
as  strangulation.  When  the  viscera  are  press- 
ed upon  either  by  the  opening  through 
which  they  protrude,  or  by  the  parts  them- 
selves within  the  hernial  sac,  in  such  a de- 
gree, that  the  course  of  the  intestinal  matter 
to  the  anus  is  obstructed,  and  n usea,  sickness, 
pain,  and  tension  of  the  swelling  and  abdo- 
men, &lc.  are  occasioned,  the  rupture  is  said 
to  be  in  a slate  of  incarceration  or  strangula- 
tion. 

Accordingto  Professor  Scarpa,  however,  an 
incarcerated , and  a strangulated  hernia,  do  not 
imply  exactly  the  same. thing.  Inthefirst  case, 
says  he,  the  course  of  the  intestinal  matter  is 
interrupted,  without  any  considerable  impair- 
ment of  the  texture,  or  vitality  of  the  bowel. 
On  the  contrary,  in  the  strangulated  hernia, 
besides  the  obstruction  to  (he  course  of  die 
fecal  matter,  there  is  organic  injury  of  the 
coats  of  the  intestine,  with  loss  of  its  vitality. 
The  bowel  that  is  merely  incarcerated,  re- 
sumes its  functions  immediately  it  is  replaced 
in  the  abdomen  ; while  that  which  is  truly 
strangulated  never  returns  to  its  natural 
state.  ( Traite  dcs  Remits,  p.  251.) 

This  distinction,  however,  is  by  no  means 
generally  adopted. 

INCONTINENCE  OF  URINE.  (See 
Urine,  Incontinence  of.) 

INFLAMMATION,  (from  inflammo,  to 
burn.)  By  the  term,  inflammation,  is  gene- 
rally understood  the  state  ot  apart  in  which 
it  is  painful,  hotter,  redder,  and  somewhat 
more  turgid  than  it  naturally  is  ; which  topical 
symptoms,  when  present  in  any  considerable 
degree,  or  when  they  atfect  very  sensible 
parts,  are  attended  with  lever,  or  a general 
disturbance  of  the  system.  (Burns.) 

The  susceptibility  of  the  body  for  in- 
flammation is  of  two  kinds  ; the  one  origi- 
nal, constituting  a part  of  the  animal  econo- 
my, and  beyond  the  reach  of  human  investi- 
gation ; the  other  acquired  from  the  influence 
of  climate,  habits  ot  life,  and  state  of  the 
mind  over  the  constitution.  (Hunter.)  The 
lirst  kind  of  susceptibility  being  innate,  can- 
not be  diminished  by  art ; the  second  may  be 
lessened  by  the  mere  avoidance  of  the  par- 
ticular causes  upon  which  it  depends. 

Inflammation  may,  with  great  propriety, be 
divided  into  healthy  and  unhealthy.  Of  the 
first,  there  can  only  be  one  kind,  though  di- 
visible into  different  stages  ; of  the  second, 
there  must  be  an  infinite  number  of  species, 
according  to  the  peculiarities  of  different 
GOn$tftutions,  and  the  nature  of  diseases 


which  are  numberless.  (Hunter.)  Another 
general  division  is  into  common  and  specific 
inflammation,  the  latter  lurm  implying,  that 
the  affection  has  some  strongly  marked  par- 
ticularity about  it,  rendering  it  in  some  de- 
gree independent  of  such  circumstances  as 
would  control  and  regulate  the  progress  of 
common  inflammation.  Such  are  venereal , 
variolous,  vaccine,  erysipelatous,  gouty , and 
rheumatic  inflammation^,  &. c.  Inflammation 
may  ;»lv>  be  divided  into  the  acute  and  chro- 
nic. This  division  of  the  subject  is  one  of 
the  most  ancient,  and  seems  to  have  obtain- 
ed the.  sanction  of  all  the  best  surgical  wri- 
ters. Healthy  inflammation  is  invariably 
quick  in  its  progress,  for  which  reason,  it 
must  always  rank  as  an  acute  species  of  the 
affection.  However,  there  are  numerous  in- 
flammation-, controlled  by  a diseased  princi- 
ple, which  are  quick  in  their  progress,  and 
are,  therefore,  to  be  considered  as  acute. 
Chronic  inflammation,  which  will  be  treated 
of  when  1 come  to  the  subject  of  tumours , 
is  always  accompanied  with  diseased  action. 

My  friend,  Mr.  James  of  Exeter,  justly 
impressed  with  the  utility  which  would  re- 
sult from  a good  nosological  arrangement  of 
inflammation,  has  lately  attempted  to  .supply 
what  must  generally  be  allowed  to  be  a great 
desideratum.  To  the  division  of  inflamma- 
tion into  the  acute,  subacute , or  chfonic,  be 
o jeets,  that  in  many  instances,  these  are 
merely  different  stages  of  the  same  disease. 
The  arrangement  into  the  adhesive,  suppura- 
tive, ulcerative,  or  gangrenous  inflammation, 
be  does  not  altogether  approve,  because  it  is 
merely  founded  on  the  modes  in  which 
either  different,  or  in  some  instances,  the 
same  kinds  of  inflammation  terminate.  Un- 
der the  heads  of  phlegmonous,  erysipelatous , 
and  gangrenous  inflammation,  he  argues,  that 
diseases  of  the  most  opposite  nature  have 
been  indiscriminately  brought  together.  The 
disposition  to  terminate  in  gangrene,  he  ad- 
mits, will  afford  a basis  for  subdivision,  but 
not  for  primary  separation.  Mr.  Janies 
makes  some  judicious  observations  on  the 
arrangement  of  the  kinds  of  inflammation, 
according  to  the  elementary  tissue  in  which 
they  occur,  as  proposed  by  Dr.  Carmichael 
Smith,  JPinel,  and  Bichat."  The  tissues  in 
question  are  five,  and  ihe  doctrine  supposes, 
that  the  inflammation  of  each  is  essentially 
different.  The  first  is  phlegmonous  inflamma- 
tion, which  affects  the  cellular  membrane, 
including  the  parenchyma  of  the  several  vis- 
cera. The  second  is  inflammation  of  serous 
membranes.  The  third,  of  mucous  mem- 
branes. The  fourth,  which  is  named  erysi- 
pelatous, is  of  the  skin.  And  the  fifth,  term- 


INFLAMMATION. 


109 


cd  rheumatic,  belongs  to  fibrous  structure. 
That  in  Summations  differ  materially  from 
tfie  circumstance  of  their  affecting  one  of 
these  elementary  tissues,  rather  than  another, 
Mr.  James  freely  admits:  but  the  following 
objections  appear  to  him  fatal  to  this  system, 
if  they  are  tru<‘.  1.  Different  kinds  o i in- 
flammation are  liable  to  occur  in  the  same 
tissue.  2.  The  same  kind  of  inflammation 
is  often  met  aith  iti  different  tissues.  3. 
The  same  inflammation  may  be  transferred 
from  one  to  another;  an  argument,  however, 
on  which  he  lays  less  stress,  as  being  difficult 
of  direct  proof.  (S  e Obs.  on  the  different 
Species  of  Inflammation,  p.  3 — 7 8 vo.  Lond. 
1821.)  At  though  difference  of  structure  un- 
questionably accounts  for  some  of  the  varie- 
ties in  the  appearance  and  character  of  in- 
flammation, it  will  not  sufficiently  explain 
the  principal  diversities  of  this  affection  to 
be  taken  s the  foundation  of  a nosological 
arrangement,  not  only  for  the  reasons  pointed 
out  by  Mr.  James,  r>u;  because  the  common 
distinctions  of  inflammation  at  present  in 
vogue,  arid  some  of  which  at  least  are  ob- 
vious and  striking,  cannot  be  at  all  solved  by 
any  reference  merely  to  texture.  N >r  did 
this  theory  satisfy  Mr.  Hunter,  who  observed, 
that  if  it  were  true,  “ we  should  soon  be 
made  acquainted  with  all  the  different  in- 
flammations in  the  same  person  at  be  same 
time,  and  even  in  the  same  wound.  For  in- 
stance, in  an  arnpui  *tion  of  a leg,  where  we 
cut  through  the  -kin,  cellular  membrane, 
muscle,  tendon,  periosteum,  bone,  and  mar- 
row, the  skin  should  ;ive  us  inflammation  of 
its  kind,  the  cellular  membrane  of  its  kind  ; 
the  muscles  of  theirs,  h &c.  but  we  find  it 
is  the  same  i iflammation  in  them  all.  How- 
ever, though  Mr.  Hunter  did  not  ad. nil  the 
possibility  >t  referring  the  different  kinds  of 
inflammation  to  peculiarities  of  texture,  his 
doctrines  assign  to  this  cause  considerable 
influence  over  every  form  of  the  disorder,  as 
will  be  presently  explained. 

The  mode  of  reasoning  adopted  by  Mr. 
James,  leads  him  to  propose  ; 1-t.  The  divi- 
sion of  inflammations  into  two  great  classes, 
according  to  their  disposition  either  to  be  li- 
mited by  the  effusion  of  organizable  coagu- 
lable  lymph,  or  to  spread.  2<ily.  The  orders 
are  established  on  the  principle  of  die  de- 
gree of  connexion  of  the  organ  with  the  vital 
functions  of  the  animal;  another  cause,  which 
exerts  a predominant  influence  over  the  cha- 
racter of  the  inflammation  ; acts  invariably, 
and  cwteris  paribus,  in  the  same  degree  ; the 
constitutional  sympathy  being  in  proportion 
to  the  danger,  the  difficulty  of  resisting  that 
danger,  and  of  repairing  the  mischief  done. 
3Jiy.  The  genera  are  founded  on  the  original 
disposition  of  inflammations  to  have  particu- 
lar modes  of  terminal  ion:  thus,  says  Mr. 
James,  in  boil  and  whitlow,  it  is  to  suppurate  ; 
in  carbuncle,  to  slough  ; and  in  mumps  to 
resolve  : and  this  disposition  is  so  strong, 
that  it  is  very  difficult  to  procure  any  other 
termination.  It  may  happen,  however,  that 
there  shall  be  more  than  one  mode,  in  which 
it  (the  inflammation)  is  disposed  to  terminate, 
as  in  either  resolution,  or  suppuration,  in 


sphacelus,  or  ulceration,  &c.  (Op.  cit.  p.  13 
— 16.)  Mr.  James  conceives,  “that  these 
general  principles  will  perhaps  afford  a suffi- 
cient basis  for  sueli  an  arrangement,  as  shall 
be  both  natural  and  useful  in  its  application 
to  all  kinds  of  common  inflammation;  gout, 
rheumatism,  and  scrotula  having  peculiarities 
which  require  them  to  be  separated.”  Also 
with  respect  to  inflammations  arising  from 
external  injurie-,  as  tin  y are  more  simple  in 
their  nature,  may  take  place  in  sound  consti- 
tutions, and  are  accompanied  with  disorgani- 
zations, which  do  not  exist  in  other  cases, 
Mr.  James  considers  them  as  materially  dif- 
ferent. ! his  author  purposely  excludes  from 
his  classification  inflammations  of  ihe  organs 
of  sense,  and  of  he  bones,  the  peculiarities 
in  their  structure  and  functions  rendering 
them  fit  subjects  foi  separate  description. 
With  respect  to  Mr.  James’s  nosological  ta- 
ble of  inflammation,  I consider  it  very  inge- 
nious, and  well  deserving  of  the  attention  of 
the  profession  : 1 may  say  this  without  at  all 
involving  inyself  in  the  hypothesis,  that  the 
limitation,  or  spreading  of  the  generality  of 
inflammations,  is  a circumstance  entirely  de- 
pendent upon  their  di- position  or  indisposi- 
tion to  effuse  organizable  lymph.  Mr.  Hun- 
ter was  well  acquainted  with  the  frequent 
usefulness  of  the  adhesfve  inflammation  in 
setting  limits  to  disease,  yet  be  did  not  ven- 
ture lo  refer  the  circumscription  of  every  in- 
flammation to  this  cause,  or  the  spreading  of 
the  disorder  entirely  to  its  absence.  Nor, 
indeed,  does  it  seem  essential  to  Mr.  James’s 
classification,  that  any  canse  should  be  as- 
signed for  tlie  disposition  of  one  class  of 
inflammations  to  be  limited,  and  of  another 
to  spread  ; the  two  facts  themselves  being 
sufficient  for  the  basis  of  the  division. 

There  is  much  foundation  for  believing 
that  healthy  inflammation  is  invariably  an 
homogeneous  process,  obedient  to  ordained 
principles,  and,  in  similar  structures,  similar 
situations,  and  in  constitutions  of  equal 
strength,  uniformly  assuming  the' same  fea- 
tures. If  experience  reveals  to  us,  that  here 
it  is  commonly  productive  of  certain  effects, 
and  there  it  ordinarily  produces  different 
ones,  the  same  unbounded  source  of  wis- 
dom communicates  lo  the  mind  a know- 
ledge, that  there  is  some  difference  in  the' 
tone  of  the  constitution,  or  in  the  structure 
or  situation  of  the  parts  affected,  assignable 
as  the  cause  of  this  variety.  A modem 
author  (Dr.  Smith , in  Med.  Communications , 
Vol.  2.)  makes  the  nature  of  the  exciting 
cause  one  principal  ground  of  the  specific 
distinctions  in  inflammation,  and  with  good 
reason,  when  he  takes  into  the  account  the 
action  of  morbid  poisons,  and  the  qualities 
of  disease  in  general. 

The  doctrine  also  receives  confirmation 
from  what  is  observed  in  cases  of  burns,  and 
chilblains,  where  the  inflammation  is  un- 
questionably attended  with  great  peculiari- 
ty, requiring  different  treatment  from  that 
of  common  inflammation  in  general.  But, 
when  the  exciting  cause  is  strictly  mechani- 
cal, its  violence  and  extent  may  cause  dif 
ferences  in  the  degree  and  quantity  of  in ! 


INFLAMMATION". 


no 


flammation  ; but,  with  respect  to  its  quality, 
this  must  be  accounted  for  by  constitution, 
or  other  circumstances. 

The  attentive  observation  of  experience, 
the  only  solid  basis  of  all  medical,  as  well 
as  other  knowledge,  has  informed  the 
practitioner,  that  parts,  which  from  their 
vicinity  to  the  source  of  the  circulation, 
enjoy  a vigorous  circulation  of  blood  through 
them,  undergo  inflammation  more  favour- 
ably, and  resist  disease  bet  er  than  other 
parts,  of  similar  structure,  more  remote 
from  the  heart.  The  lower  extremities  are 
more  prone  to  inflammation,  and  disease  in 
general,  than  parts  about  the  chest  ; when 
inflamed,  they  are  longer  in  getting  well  ; 
a ad  the  circumstance  of  their  being  de- 
pending parts,  which  retards  the  return  of 
blood  through  the  veins,  must  also  increase 
the  backwardness  of  such  parts  in  any  salu- 
tary process.  (Hunter.)  Healthy  inflam- 
mation is  of  a pale  red  , w hen  less  health)', 
it  is  of  a darker  colour  ; but,  in  every  con- 
stitution, the  inflamed  parts  will  partake 
more  of  the  healthy  red.  the  nearer  they 
are  to  the  source  of  the  circulation.  (Hun- 
ter.) 

Inflammation,  when  situated  in  highly  or- 
ganized and  very  vascular  parts,  is  generally 
more  disposed  to  take  a prosperous  course, 
and  is  more  governable  by  art,  than  in  parts 
of  an  opposile  texture.  The  nearer  also 
such  vascular  parts  are  to  the  heart.,  the 
greater  will  be  their  tendency  to  do  well  in 
inflammation.  (Hunter..  Hence,  inflarn 
mation  of  the  sk  n,  cellular  substance,  mus- 
cles, &c  more  frequently  ends  favourably, 
tin  the  same  affection  of  bones,  tendons, 
fascia?,  ligaments,  he.  It  is  also  more  ma- 
nageable by  surgery  ; for  those  parts  of  the 
bod  > , which  are  not  what  anatomists  verm 
vascular , seem  to  enjoy  only  inferior  pow- 
ers of  life,  and,  consequently,  when  excited 
in  a preternatural  degree,  frequently  mor- 
tify. 

But,  inflammation  of  vital  parts,  though 
they  may  be  exceedingly  vascular,  cannot 
go  on  so  favourably,  as  in  other  parts  of  re- 
sembling structure,  but,  of  different  func- 
tions ; because,  the  natural  operations  of 
universal  health  depend  so  much  upon  the 
sound  condition  of  such  organs.  (Hunter.) 
The  truth  of  this  observation  is  illustrated 
in  cases  of  gastritis,  peripneumony,  he. 

All  new-formed  parts  not  originally  en- 
tering into  the  fabric  of  the  body,  such  as 
tumours,  both  of  the  encysted  and  sarcoma- 
tous kinds,  excrescences,  he.  cannot  en- 
dure the  disturbance  of  inflammation  long, 
ror  in  a great  degree.  The  vital  powers  of 
such  parts  are  weak,  and  when  irritated  by 
the  presence  of  inflammation,  these  adven- 
titious substances  are  sometimes  removed 
by  the  lymphatics,  but  more  commonly 
slough  This  remark  applies  also  to  sub- 
stances generated  as  substitutes  for  the  ori- 
ginal matter  of  the  body  ; for  instance, 
granulations  and  callus  The  knowledge 
of  this  fact,  leads  us  to  a rational  principle 
of  cure  in  the  treatment  of  several  surgical 
diseases.  Do  we  not  here  perceive  the 


cause,  why  very  large-wens  are  occasion- 
ally dispersed  by  the  application  of  urine, 
brine,  and  similar  things,  which  are  now  in 
great  repute,  on  this  account,  with  almost 
every  one  out  of  the  profession  ? How 
many  verruca?,  wrongly  suspected  to  origi- 
nate from  a syphilitic  cause,  are  diminished 
and  cured  by  a course  of  mercury  ! It  is  the 
stimulus  of  this  mineral  upon  the  whole 
system,  that  accomplishes  the  destruction 
of  these  adventitious  substances — not  its 
antivenereal  quality.  Topical  stimulants 
vouid  fulfil  the  same  object',  not  only  with 
greater  expedition,  but  with  no  injury  to 
the  general  health. 

Inflammation,  cceleris  paribus , always  pro- 
ceeds more  favourably  in  strong,  than  in 
weak  constitutions;  for,  when  there  is 
much  strength, there, is  little  irritability.  In 
weak  constitutions,  the  operations  of  in- 
flammation are  backward,  notwithstanding 
the  part  in  which  it  is  seated  may,  compa- 
ratively speaking,  possess  considerable  or- 
ganization, and  powers  of  life.  (Hunter.) 

Healthy  inflammation,  wherever  situated, 
is  always  most  violent  on  that  side  of  the 
point  of  inflammation,  which  is  next  to  the 
external  surface  of  the  body.  When  in- 
flammation attacks  the  socket  of  a tooth,  it 
does  not  take  place  on  the  inside  of  the  al- 
veolary  process,  but  towards  the  cheek. 
When  inflammation  attacks  the  cellular  sub- 
stance, surrounding  Ihe  rectum,  near  the 
anus,  the  affection  usually  extends  itself  t® 
the  skin  of  the  buttock,  leaving  the  intes- 
tine perfectly  sound,  though  in  contact  with 
the  inflamed  part.  (Hunter.) 

We  may  observe  the  influence  of  this 
law  in  the  diseases  of  the  lachrymal  sac  and 
duct,  in  those  of  the  frontal  sinus  and 
antrum,  and  particularly  in-gunshot  wounds. 
Suppose  a ball  were  to  pass  into  the  thigh, 
to  within  an  inch  of  the  opposite  side  of  the 
iimb  we  should  not  find,  that  inflammation 
would  be  excited  along  the  track  of  the 
ball,  but,  on  the  side  next  ihe  skin  which 
had  not  been  hurt.  If  a ball  were  to  pass  quite 
through  a limb,  and  carry  into  the  wound  a 
piece  of  cloth,  which  lodged  in  the  middle, 
equidistant  from  the  two  orifices,  the  skin, 
immediately  over  the  extraneous  body, 
would  inflame,  if  the  passage  of  the  ball 
were  superficial. — (Hunter)  Mr.  Hunter 
compared  this  law  with  the  principle,  by 
which  vegetables  approach  ihe  surface  of 
the  earth  ; but,  t ee  solution  ot  it  was  too 
arduous  even  for  his  strong  genius  and  pene- 
tration. 

We  see  three  very  remarkable  effects 
follow  the  prevalence  of  inflammation  ; 
viz.  adhesions  of  parts  of  the  body  to  each 
other;  the  formation  of  pus,  or  suppura- 
tion ; and  ulceration,  a process,  in  which 
the  lymphatics  are  more  concerned,  than 
the  blood-vessels.  Hence,  Mr.  Hunter 
termed  the  different,  stages  of  inflammation, 
the  adhesive,  the  suppurative,  and  the  ulcer- 
ative. 

All  parts  of  the  body  are  not  equally  lia- 
ble to  each  of  the  preceding  consequences, 
(Hunter.) 


INFLAMMATION’. 


Ill 


In  the  cellular  membrane,  and  in  the  cir- 
cumscribed cavities,  the  adhesive  stage 
takes  place  more  readily  than  the  others  ; 
suppuration  may  he  said  to  follow  next  in 
order  of  frequency  ; and  lastly  ulceration. 

In  internal  canals,  on  the  inner  surfaces 
of  the  eyelids,  nose,  mouth,  and  trachea,  in 
the  air-cells  of  the  lungs,  in  ihe  oesophagus 
stomach,  intestines,  pelvis  of  the  kidney, 
ureters,  bladder,  urethra,  and  in  all  the  ducts 
and  outlets  of  the  organs  of  secretion,  being 
what  are  termed  mucous  membranes , the  sup- 
purative inflammation  comes  on  more  rea- 
dily, than  either  the  adhesive,  or  the  ulcer- 
ative stage.  Adhesions,  which  originate 
from  the  slightest  degree  ot  inflammation  in 
other  situations  and  structures,  can  only  be 
produced  by  a violent  kind  in  the  above- 
mentioned  parts.  Ulceration  is  more  fre- 
quently met  with  upon  mucous  surfaces, 
than  adhesions.  (Hunter.)  The  cellular 
membrane  appears  to  be  much  more  sus- 
ceptible of  the  adhesive  inflammation,  than 
the  adipose,  and  much  more  readily  passes 
into  the  suppurative.  (Hunter  ) Thus  we 
see  the  cellular  substance,  connecting  the 
muscles  together,  and  the  adipose  mem- 
brane to  the  muscles,  inflaming,  suppurating 
and  the  matter  separating  the  muscles,  from 
their  lateral  connexions,  and  even  the  fat 
from  the  muscles,  while  the  latter  substance 
and  the  skin  are  only  highly  inflamed. 
(Hunter.)  But,  it  must  be  allowed,  that  in 
situations  where  fat  abounds,  we  very  fre 
quently  meet  with  abscesses.  This  is  so 
much  the  case,  that  fat  has  been  accounted 
a more  frequent  nidus  for  collections  of 
matter,  than  the  cellular  substance.  (Brom- 
Jield.)  Abscesses  are  particularly  liable  to 
form  in  the  neighbourhood  of  the  anus, 
mamma,  &c.  With  respect  to  the  fat  being 
highly  inflamed,  however,  the  expression  is 
not  strictly  true.  Fat  has  no  vessels,  princi- 
ple of  life  nor  action  of  its  own  ; conse- 
quently, we  cannot  suppose  that  it  can  itself 
either  inflame,  or  suppurate.  We  know', 
that  it  is  itself  a secretion,  and  when  an  ab- 
scess forms  in  it,  vve  understand,  that  the 
mode  of  action  in  the  vessels,  naturally  des- 
tined to  deposit  fat,  has  been  altered  to  that 
adapted  to  the  formation  of  pus.  When 
therefore  the  fat  is  said  to  be  inflamed,  it  is 
only  meant,  that  the  membranous  cells,  in 
which  it  is  contained,  and  by  which  it  is  se- 
creted, are  thus  affected. 

The  deeply-situated  parts  of  the  body, 
more  especially  the  vital  ones,  very  readily 
admit  of  the  adhesive  stage  of  inflammation 
The  circumstance  of  deeply-seated  parts 
not  so  readily  taking  on  the  suppurative 
stage  of  inflammation,  as  the  superficial 
ones  do,  is  strikingly  illustrated  in  cases  of 
extraneous  bodies,  which,  if  deeply  lodged, 
only  produce  the  adhesive  inflammation. 
By  this  process,  a cyst  is  formed,  in  which 
they  lie  without  much  inconvenience,  and 
they  may  even  gradually  change  their  situa 
tion,  without  disturbing  the  parts,  through 
which  they  pass.  But, "no  sooner  do  these 
same  bodies  approach  the  skin,  than  absces- 
ses immediately  arise.  (Hunter.) 


All  inflammations,  attended  with  disease, 
partake  of  some  specific  quality,  from  which 
simple  inflammation  is  entirely  free.  When 
the  constitution  allows  the  true  adhesive 
and  suppurative  stages  to  occur,  it  is  to  be 
regarded  as  the  most  healthy.  Were  it  in 
an  opposite  state,  vve  should  see  the  very 
same  irritation  excite  some  other  kind  of 
inflammation,  such  as  the  erysipelatous, 
scrofulous,  &c.  (Hunter.) 

In  specific  inflammations,  the  position, 
structure,  and  distance  of  the  part  affected 
from  the  source  of  the  circulation,  as  well 
as  from  t lie  surface  of  the  body,  seem  also 
to  have  as  much  influence  as  in  cases  of 
common  inflammation.  Upon  this  point,  I 
feel  conscious  of  being  a lit'le  at  variance 
with  what  Mr.  Hunter  has  stated  ; but,  the 
undecided  manner  in  which  he  expresses 
himself,  not  less  than  the  following  reflec- 
tions, encourages  me  not  to  desert  my  own 
ideas.  We  see,  that  venereal  eruptions 
sooner  make  their  appearance  upon  the 
chest  and  face,  than  upon  the  extremities. 
No  organized  part  can  be  deemed  exempt 
from  the  attack  of  common  inflammation  ; 
many  appear  to  be  totally  insusceptible  of 
the  venereal.  We  know,  that  scrofulous  dis- 
eases of  tiie  superior  extremities  take  a more 
favourable  course,  require  amputation  less 
frequently,  and  get  well  oftener  than  when 
situated  in  the  inferior  limbs.  (Ford.)  The 
venereal  disease  makes  more  rapid  advan- 
ces in  the  skin  and  throat,  than  in  the  bones 
and  tendons  ; we  often  see  it  producing  a 
specific  inflammation,  and  an  enlargement 
of  the  superficial  parts  of  the  tibia,  ulna, 
clavicle,  cranium,  &,c.  while  other  bones, 
covered  by  a considerable  quantity  of  flesh, 
are  very  rarely  affected.  Gouty  inflamma- 
tion is  prone  to  invade  the  small  joints  ,j 
rheumatic,  the  large. 

SYMPTOMS,  NATURE,  AND  CAUSES  OF  INFLAM- 
MATION. 

Redness,  swelling,  heat,  and  pain,  the  four 
principal  symptoms  of  phlegmonous  inflam- 
mation, have  been  accurately  noticed  by 
Celsus  : Notce  vero  injlammationis  surd  qua- 
tuor,  rubor,  et.  tumor,  eum  calore  et  dolore , lib. 
3,  cap.  10.  If  we  refer  to  any  writer  on  this 
interesting  part  of  surgery,  we  shall  find  the 
above  symptoms  enumerated  as  characteri- 
zing phlegmon.  In  short,  this  term  is  usu- 
ally applied  to  a circumscribed  tumour,  at- 
tended with  heat,  redness,  tension,  and  a 
throbbing  pain.  These  are  ihe  first  appear- 
ances observed  in  every  case  of  phlegmon  ; 
and  when  they  are  slight,  and  the  part  af- 
fected is  of  no  great  extent,  they  have  com- 
monly very  little,  and  sometimes  no  appa- 
rent, influence  on  the  general  system.  But 
when  they  are  more  considerable,  a id  the 
inflammation  becomes  extensive,  a full, 
quick,  and  generally  a hard  pulse  takes 
place,  and  the  patient,  at  the  same  time, 
complains  of  universal  heat,  thirst,  and  other 
symptoms  of  fever.  While  the  inflamed  part 
becomes  red,  painful,  and  swelled,  its  func- 
tions are  also  impaired.  The  same  degree 


112 


INFLAMMATION. 


of  inflammation  is  said  to  produce  more 
swelling  in  sol.  parts,  and  less  in  those  of  a 
harder  structure.  {Burns.) 

Though  the  redness,  swelling,  throbbing, 
tension,  and  other  symptoms  of  phlegmo- 
nous inflammation,  are  less  manifest,  when 
the  affection  is  deeply  situated,  yet  their  ex 
isterice  is  undoubted.  When  persons  die  of 
peripneumony,  or  inflammation  of  the  lungs, 
the  air-cells  of  these  organs  are  found 
crowded  with  a larger  number  of  turgid 
blood-vessels  than  in  the  healthy  state,  and 
of  course  the  parts  must  appear  preternatu- 
rallv  red.  Coagulating  lymph,  and  even 
blood,  are  extrav.  sated  in  the  substauce  of 
these  viscera,  which  become  heavier,  and 
feel  more  solid.  ( Bnillie .) 

The  extravasation  of  coagulating  lymph, 
which  is  one  of  the  chief  causes  of  the  swell- 
ing, is  also  one  of  the  most  characteristic 
signs  of  phlegmonous  inflammation. 

Some  writers  (Smith,  in  Med.  Commun. 
Vol.  2.)  have  confined  the  seat  of  phlegmon 
to  the  cellular  membrane  ;•  but  this  idea  is 
erroneous.  Had  such  authors  duly  discrimi- 
nated the  nature  of  common  inflammation, 
they  would  have  allowed  that  this  affection 
existed,  wherever  the  capillaries  appeared 
to  be  more  numerous  and  enlarged  '.nan  in 
the  natural  state,  accompanied  with  an  effu- 
sion of  coagulating  lymph,  whether  upon 
the  surface  of  a membrane,  or  a bone,  or 
into  the  interstices  of  the  cellular  substance, 
and  attended  with  acute  pain,  and  a throb- 
bing pulsation  in  the  part. 

As  Dr.  Thomson  has  observed,  the  epithet 
remote  as  applied  to  the  causes  of  inflamma- 
tion. does  not  appear  to  be  happily  chosen  ; 
for  under  this  term  are  comprehended  all 
those  agents,  evtents,  and  states,  which  con- 
tribute "immediately,  as  well  as  remotely, 
directly  as  well  as  indirectly,  to  the  produc- 
tion of  the  affection.  ( Lectures  on  Inflam- 
mation, p.  50.) 

The  remote  causes  of  inflammation  are 
infinite  in  number,  but  very  easy  of  com- 
prehension, because  orny  divisible  into  two 
general  classes.  The  first  includes  all  such 
agents  as  operate  by  their  stimulant  or 
chyrnfcal  qualities;  for  instance,  canthari- 
des,  heat,  the  action  of  concentrated  acids, 
alkalies,  metallic  oxides,  and  metallic  salts, 
acrid  vapours,  such  as  ammoniaeal  gas,  the 
nitrous,  sulphureous,  muriatic,  oxygenated 
muriatic  gases,  &vc.  alcohol,  aether,  and  all 
acrid  vegetable  essential  oils,  animal  poi- 
sons,and  the  whole  of  that  class  of  substances 
known  by  the  name  of  rubefacients.  ( Thom- 
son on  Inflammation,  p.  55.)  The  second  class 
of  causes  are  those  which  act  mechanically, 
such  as  bruises,  wounds,  pressure,  friction, 
fcc. 

Fevers  often  seem  to  become  the  remote 
causes  of  local  inflammation,  in  other  in- 
stances, inflammation  appears  to  arise  spon- 
taneously, or,  as  I should  rather  say,  without 
any  perceptible  exciting  cause. 

The  principle  on  which  the  application 
of  cold  to  a part  becomes  the  remote  cause 
of  inflammation,  is  not  decidedly  known. 
“ No  sublet  (says  a distinguished  professor) 


is  more  deserving  of  your  study,  than  the 
effects  which  are  produced  in  the  human 
body  by  the  operation  of  cold  applied  to  its 
surface  ;but  the  subject  is,  at  the  same  time, 
exceedingly  extensive,  complicated,  and  dif- 
ficult. .These  effects  differ  according  to  the 
degree  in  which  the  cold  is  applied,  the 
state  of  the  system,  the  part  of  the  body  to 
which  it  is  applied,  and  the  mode  of  its  ap- 
plication. So  diversified,  indeed,  are  these 
effects,  that  it  requires  no  mean  confidence 
in  theoretical  reasoning  to  believe,  that  the 
operation  of  cold  in  producing  them  is  ex- 
plicable upon  any  single  general  principle.’' 
(See  Thomson  on  Inflammation,  p.  58.)  And 
in  the  preceding  page,  he  observes:  “The 
operation  of  cold  upon  the  human  body  af- 
fords the  best  example  which  1 can  suggest 
to  you.  of  the  production  of  inflammation 
from  the  operation  of  a power  acting  upon 
a part  at  a distance  from  that  in  which  the 
inflammation  takes  place.  The  instances 
formerly  mentioned  of  inflammation  of  the 
throat,  chest,  or  belly,  from  the  application 
of  cold  to  the  feet,  are  daily  occurrences  in 
these  climates,  of  which  it  is  impossible  for 
us,  in  the  present  stale  of  o ir  knowledge  of 
the  animal  economy,  to  give  any  thing  like 
a satisfactory  explanation. 

“ In  some  instances,  cold,  or  a diminution 
of  temperature,  seems  to  act  more  directly 
upon  the  parts,  with  which  it  comes  into 
contact.  We  have  examples  of  this  in  the 
inflammation  of  the  mucous  membranes  of 
the  nose,  fauces,  trachea  and  bronchia?, 
from  the  inhalation  of  cold  air;  and  in  the 
production  of  rheumatic  inflammation  from 
the  accidental  exposure  of  some  part  or 
other  of  the  body  to  cold.  The  application 
of  cold,  in  the  instances  I have  mentioned, 
seems  to  have  somewhat  of  a directly  exci- 
ting effect ; and  perhaps  the  same  remark  is 
still  more  applicable  to  the  local  effects  of 
cold  in  the  production  of  the  inflammation 
accompanying  the  state,  which  is  usually 
denominated  fast-bite.  Touching  a solid 
body,  as  a piece  of  metal,  the  temperature 
of  which  has  been  greatly  reduced,  produces 
a sensation  like  that  of  burning,  and  maybe 
folhmed,  like  the  application  of  fire,  with  a 
blister.”  (Op.  cil.) 

Numerous  opinions  have  been  entertain- 
ed respecting  die  proximate  cause  of  Inflam- 
mation ; but  almost  every  theory  has  been 
built  upon  the  supposition  of  there  being 
some  kind  of  obstruction  in  the  inflamed 
part. 

While  the  circulation  of  the  blood  was 
unknown,  and  the  hypothetical  notions  of 
the  power  of  the  liver,  in  preparing  and 
sending  forth  this  fluid,  continued  to  prevail, 
physicians  were  so  fully  persuaded  of  the 
existence  and  influence  of  different  humours 
and  spirits,  and  so  little  did  they  know  of 
the  regular  and  constant  motion  of  the 
blood,  that  they  believed  in  the  possibility 
of  depositions  and  congestions  of  the  blood, 
the  bile,  or  lymph  ; and  acknowledged  these 
as  the  cause  of  inflammation.  I heir  anato- 
mists taught  them,  and  their  professors  <*1 
physic  supported  the  opinion,  that  the  liver 


INFLAMMATION.  113 


was  the  centre  of  the  vascular  system,  from 
which  the  blood  went  forth  by  day  to  the 
extremities,  and  returned  again  by  night.  If 
then  any  peccant  matter  irritated  the  liver, 
the  blood  was  sent  out  more  forcibly  ; and 
if,  at  the  same  time,  any  part  of  the  body 
were  weakened,  or  otherwise  disposed  to 
receive  a greater  quantity  of  fluid  than  the 
rest,  then  a swelling  was  produced  by  ihe 
flow  of  humosrs  to  this  place.  Fluxions,  or 
flows  of  humour  to  a place,  might  happen 
cither  from  weakness  of  the  part  which  al- 
lowed the  humours  to  enter  more  abun- 
dantly, or  from  the  place  attracting  the  hu- 
mours, in  consequence  of  the  application  of 
heat  or  other  agents.  The  peculiar  nature 
of  the  swelling  w as  supposed  to  depend  upon 
the  kind  of  humour.  Blood  produced  the 
true  phlegmon  ; bile,  erysipelas  ; &c.  An 
idea  was  also  entertained,  that  the  blood 
and  humours  might  slowly  stagnate  in  a 
part,  from  a want  of  expulsive  power,  and 
this  affection  w as  termed  a congestion,  w hile 
the  expression  fluxion  or  defluxion  was  used 
to  denote  any  swelling  arising  from  the  sud- 
den flow  of  humours  from  a distant  part. 
(J.  Burns , Dissertations  on  Inflammation.) 

From  the  theories  of  fluxion  and  conges- 
tion, which  were  quite  incompatible  with 
the  laws  of  the  circulation  of  the  blood, 
we  turn  our  attention  to  the  doctrine  of  ob- 
struction. 

Boerhaave  inculcated,  (Jlph.  375  el  seq.) 
that  inflammation  w as  caused  by  an  obstruc- 
tion to  the  free  circulation  of  the  blood  in 
the  minute  vessels,  and  this  obstruction,  he 
supposed,  might  be  caused  by  heat,  diar- 
rhoea, too  copious  flow  of  urine,  and  sweat, 
or  whatever  could  dissipate  the  thinner  parts 
of  the  blood,  and  produce  a thickness  or 
viscidity  of  that  fluid.  When  the  lentor  did 
not  exist  before  the  production  of  inflamma- 
tion, he  imagined  that  the  larger  globules 
of  the  blood  passed  into  the  small  vessels, 
and  thus  plugged  them  up.  This  circum- 
stance was  termed  an  error  loci.  The  ob- 
struction, whether  caused  by  viscidity  or  an 
error  loci,  was  imagined  to  occasion  a resist- 
ance to  the  circulation  in  the  part  affected  ; 
and  hence,  an  increase  of  the  flow  of  the 
blood  in  the  other  vessels,  an  irritation  of 
the  heart,  and  augmentation  of  the  force,  or 
attraction  of  the  blood  in  that  part  of  the 
vessel  which  was  behind  the  obstruction. 
This  caused  heat  and  pain,  while  the  accu- 
mulation of  blood  produces  redness.  Bo- 
erhaave also  brought  into  the  account  an 
acrimonious  stale  of  the  fluids,  which  render- 
ed resolution  out  of  the  question,  and  gan- 
grene likely  to  follow.  (Jlph.  388.) 

The  viscidity  of  the  blood  cannot  be  ad- 
mitted as  the  proximate  cause  of  inflamma- 
tion ; because  we  have  no  proof  that  this 
state  ever  exists  ; or,  granting  that  it  did,  it 
would  not  explain  the  phenomena.  Were 
a viscidity  to  occur,  it  would  exist  in  the 
whole  mass  of  blood,  would  affect  every 
part  of  the  body  alike,  and  could  not  be  sup- 
posed to  produce  only  a local  disorder. 
How  also  could  such  a lentor  be  produced 
by  causes  which  bring  on  inflammation  sud- 
Vot..  TT  15 


denly,  without  there  being  time  for  changes 
of  the  fluids  to  take  place  ? 

With  regard  to  the  doctrine  of  error  loci , 
or  of  red  globules  going  into  vessels  which 
did  not  formerly  transmit  them,  the  fact 
must  be  admitted,  at  the  same  time,  that  the 
conclusion  is  denied.  When  the  eye  be- 
comes inflamed,  the  tunica  conjunctiva  is 
seen  with  its  vessels  full  of  red  blood,  which 
in  health  is  not  the  case;  but  this  redness 
never  appears  until  the  inflammation  has 
commenced,  and  must  therefore  be  consi- 
dered as  an  effect,  not  a cause.  Nor  can 
this  error  loci  occasion  any  obstruction  in 
these  vessels  ; for  if  they  be  divided,  the 
blood  flows  freely,  which  shows  that  they 
are  large  enough  to  allow  an  easy  circula- 
tion. (J.  Burns.) 

Boerhaave’s  theory  of  obstruction  was  too 
circumscribed,  and  too  mechanical  ; it  re- 
duced all  inflammations  to  one  species:  the 
only  distinctions  which  could  have  arisen, 
must  have  proceeded  from  the  nature  of  the 
obstruction  itself ; and  it  was  a doctrine  that 
never  could  account  for  the  action  of  many 
specific  diseases  and  morbid  poisons.  (Hun- 
ter.) 

As  for  the  supposition  of  the  co-operation 
of  an  acrimony  of  the  fluids,  the  proportion 
of  the  saline  matter  of  the  blood  has  never 
been  proved  to  be  greater  in  this,  than  in. 
any  other  state  of  the  body.  (Burns.)  Even 
were  a general  disorder  of  this  kind  to  be 
admitted,  no  rational  explanation  of  the 
proximate  cause  of  local  inflammation  could 
be  deduced  from  it. 

The  decided  impossibility  of  giving  a ra- 
tional explanation  of  the  immediate  cause 
of  inflammation  by  any  supposed  state  of 
the  blood  alone,  led  pathologists  to  investi- 
gate how  far  a change  in  the  blood-vessels 
themselves  might  account  for  the  process. 
It  belongs  more  properly  to  a physiological 
than  a surgical  work,  to  explain  the  various 
facts  and  experiments  in  support  of  the  opi- 
nion, that  the  arterial  tubes,  and  especially 
the  capillaries,  possess  a high  degree  of  vital 
contractility,  whereby  the  motion  of  the 
fluids  in  them,  the  process  of  secretion,  and 
other  local  phenomena  may  be  importantly 
affected,  in  a manner  not  at  all  explicable, 
by  reference  only  to  the  action  and  power 
of  the  heart.  For  such  information,!  would 
particularly  advise  the  x-eader  to  consult  the 
publications  of  Dr.  Wilson  Philip,  and  Dr. 
Hastings.  Accoi’ding  to  the  latter  gentle- 
man, the  actual  agency  of  the  capillaiy  ves- 
sels, “ is  not  only  supported  by  such  ex- 
periments as  those  related,  it  is  also  coun- 
tenanced by  an  extensive  series  of  pheno- 
mena presented  during  disease  in  the  hu- 
man subject.  Of  these  may  be  mentioned, 
irregular  determinations  of  blood,  the  growth 
of  tumours,  increased  pulsation  of  arteries 
leading  to  inflamed  parts,  of  which  the  fol- 
lowing is  a well-marked  example,  the  accu- 
racy of  which  may  be  entirely  relied  upon. 
The  carotids,  when  the  person  alluded  to 
is  in  health,  beat  equally  as  to  strength  and 
frequency;  but  when  he  is  attacked  with 
inflammation  in  the  right  tonsil,  to  which 


114 


INFLAMMATION. 


he  is  particularly  subject,  and  which  pro- 
ceeds sometimes  so  far  as  nearly  to  prevent 
deglutition,  each  pulsation  of  the  artery 
gives  a throbbing  sensation  on  the  right 
side  of  the  head.  On  the  application  of  the 
hand  at  this  time  to  each  carotid,  the  right 
is  found  to  beat  much  stronger  and  fuller 
than  the  left.  This  diversity  of  action  in 
these  two  arteries  cannot  arise  from  any 
impulse  given  by  the  blood  to  the  heart : it 
must  be  derived  from  some  modification 
of  the  contractile  power  of  the  artery.”  And 
Dr.  Hastings  expresses  his  belief  in  this  ex- 
planation, notwithstanding  Dr.  C.H.  Parry 
wishes  to  attribute  to  the  remote  influence 
of  the  heart  some  of  the  phenomena  of  local 
congestion  and  motion,  and  to  show,  that 
the  different  states  of  vascular  dilatation  are 
still  more  conspicuously  connected  with  the 
different  degrees  of  action  of  the  heart,  and 
the  consequent  momentum  of  the  blood, 
than  with  local  circumstances ; and  that 
the  proneness  to  local  dilatation,  or,  as  it  is 
called,  action,  is  a consequence  of  slowly 
succeeding,  but  continued  impulse 

The  blood-vessels,  through  every  part  of 
the  system,  possess  a considerable  share  of 
irritability,  by  which  they  contract,  and  pro- 
pel forward  their  contents.  Hence,  the 
blood,  by  the  action  of  the  vessels,  receives 
a new  impulse  in  the  most  minute  tubes, 
and  a well-regulated  momentum  is  preser- 
ved in  every  part  of  its  course.  But  of  all 
parts  of  the  sanguiferous  system,  the  capil- 
laries seem  most  eminently  endowed  with 
this  faculty,  and  are  least  indebted  to  the 
presiding  influence  of  the  heart.  Yet  even 
in  these  vessels,  the  action  of  the  heart  is  of 
high  importance  in  sustaining  the  healthy 
circulation,  inasmuch  as  it  gives  the  first 
impulse  to  the  blood,  and  preserves  the  har- 
jnony  of  the  sanguiferous  system. 

The  vessels  are  endowed  with  this  vital 
property,  in  order  that  each  organ  in  the 
body  may  receive  such  a supply  of  blood 
as  will  enable  it  duly  to  exercise  its  func- 
tions. Hence,  a healthy  state  of  this  pro- 
perty is  absolutely  necessary  for  the  preser- 
vation of  the  animal  functions ; for,  if  the 
vital  contraction*  of  the  blood-vessels  be 
either  increased  or  diminished,  irregular 
distribution  of  the  blood  inevitably  follows, 
and  from  this  source  numerous  diseases 
arise,  and  none  more  frequently  than  in- 
flammation. However,  though  these  senti- 
ments, delivered  by  Dr.  Hastings,  may  be 
generally  correct,  1 am  not  prepared  to  join 
in  the  opinion,  that  inflammation  is  ever 
produced  simply  by  an  inequality  in  the 
distribution  of  the  blood ; a statement 
which  this  gentleman  probably  does  nut 
mean  to  make  himself,  as  he  confesses  that 
some  of  the  phenomena  of  this  disease  de- 
pend upon  sympathy  between  the  sanguife- 
rous and  nervous  systems.  (See  Hastings 
on  Inflammation  of  the  Mucous  Membrane  of 
the  Lungs,  p.  32,  64,  65,  8 vo.  Lond.  1820; 
and  C.  H Parry,  Additional  Experiments  on 
the  Arteries , fyc.p.  112,  114  ; Also  Why 1 1 on 
the  Motion  of  the  Fluids  in  the  small  Vessels ; 
Yerscfiuir  dr.  Arteriarvm  et  Venarum  vi  irri • 


tabiti ; Zimmermann  de  irritabilitatc,  p.  24  j 
Hunter  on  the  Blood , «^c.) 

Dr.  Cullen  attributed  the  proximate  cause 
of  inflammation  to  a “ spasm  of  the  extreme 
arteries  supporting  an  increased  action  in 
the  course. of  them.”  This  theory  only  dif- 
fers from  that  of  Boerhaave  in  the  cause 
which  is  assigned  for  the  obstruction,  Dr. 
Cullen  conceived,  however,  that  some 
causes  of  inequality  in  the  distribution  of 
the  blood  might  throw  an  unusual  quantity 
of  it  into  particular  vessels,  to  which  it  must 
necessarily  prove  a stimulus  ; and  that,  in 
order  to  relieve  the  congestion,  the  vis  me- 
dicatrix  naturae  increases  still  more  the 
action  of  the  vessels  ; which,  as  in  all  other 
febrile  diseases,  it  affects  by  the  formation 
of  a spasm  on  their  extremities.”  “ A spasm 
of  the  extreme  arteries,  supporting  an  in- 
creased action  in  the  course  of  them,  may, 
therefore  be  considered  as  the  proximate 
cause  of  inflammation  ; at  least,  in  all  cases 
not  arising  from  direct  stimuli  applied  ; and 
even  in  this  case  the  stimuli  may  be  suppo- 
sed to  produce  a spasm  of  the  extreme 
vessels”  (Cullen.) 

The  inconsistencies  in  Cullen’s  theory  are 
very  glaring.  The  congestion  or  accumula- 
tion of  blood,  which  is  only  an  effect  or  con- 
sequence of  inflammation,  is  set  down  as 
the  cause  of  the  spasm  of  the  vessels  to 
which  spasmodic  constriction  Cullen, 
strangely  enough,  assigns  the  name  of  proxi- 
mate cause.  The  spasmodic  contraction  of 
the  extremities  of  the  vessels,  instead  oi 
propelling  the  accumulated  quantity  ot 
blood,  would  render  Ihe  passage  of  the 
blood  from  the  arterial  into  the  venous  sys- 
tem still  more  difficult.  (Burns.) 

We  shall  now  notice  the  celebrated  and 
very  original  opinions  promulgated  on  this 
subject  by  John  Hunter.  According  to  him, 
inflammation  is  to  be  considered  only  as  a 
disturbed  state  of  parts,  which  requires  a 
new  but  salutary  mode  of  action  to  restore 
them  to  that  state  wherein  a natural  mode 
of  action  alone  is  necessary.  From  such  a 
view  of  the  subject,  therefore,  inflammation 
in  itself  is  not  to  tie  considered  as  a disease, 
but  as  a salutary  operation,  consequent 
either  to  some  violence  or  some  disease. 
F.lsewhere  the  author  remarks,  the  act  of  in- 
flammation is  to  be  considered  as  an  increa- 
sed action  of  the  vessels,  which , at  first,  consists 
simply  in  an  increase  or  distention  beyond 
their  natural  size  This  increase  seems  to  de- 

pend upon  a diminution  of  the  muscular 
power  of  the  vessels,  at* the  same  time  lhat 
the  elastic  power  of  the  artery  must  be  di- 
lated in  the  same  proportion.  This  is, 
therefore,  something  more  than  simply  a com- 
mon relaxation : we  must  suppose  it  an 
action  in  the  parts  to  produce  an  increase 
of  size  for  particular  purposes,  and  this  Mr. 
Hunter  would  call  an  act  of  dilatation.  The 
whole  is  to  be  considered  as  a necessary 
operation  of  nature.  Owing  to  this  dilata- 
tion, there  is  a greater  quantity  of  blood  cir- 
culating in  ihe  part,  which  is  according  to 
the  common  rules  of  the  animal  economy  ; 
for,  whenever  a part  has  more  to  do  thfpi 


INFLAMMATION1. 


115 


Simply  to  support  itself,  the  blood  is  there 
collected  in  larger  quantity.  The  swelling 
is  produced  by  an  extravasation  of  coagula- 
ble  lymph,  with  some  serum  : but  this 

lymph  differs  from  the  common  lymph,  in 
consequence  of  passing  through  inflamed 
vessels.  It  is  this  lymph  which  becomes 
the  uniting  medium  of  inflamed  parts ; ves- 
sels shoot  into  it ; and  it  has  even  the  power 
of  becoming  vascular  itself.  The  pain  pro- 
ceeds from  spasm.  The  redness  is  produ- 
ced either  by  the  arteries  being  more  dila- 
ted than  the  veins,  or  because  the  blood  is 
not  changed  in  the  veins.  “ As  the  vessels 
become  larger,  and  the  part  becomes  more 
of  the  colour  of  blood,  it  is  to  be  supposed 
there  is  more  blood  in  the  part ; and  as  the 
true  inflammatory  colour  is  scarlet,  or  that 
colour  which  the  blood  has  when  in  the 
arteries,  one  would  from  hence  conclude 
either  that  the  arteries  were  principally  di- 
lated, or,  at  least,  if  the  veins  are  equally 
distended,  that  the  blood  undergoes  no 
change  in  such  inflammation  in  its  passage 
from  the  arteries  into  the  veins,  which  I 
think  (says  Mr.  Hunter)  most  probably  the 
case  ; and  this  may  arise  from  the  quickness 
of  its  passage  through  those  vessels .”  When 
a part  cannot  be  restored  to  health,  after 
injury,  by  inflammation  alone,  or  by  adhe- 
sion, then  suppuration,  as  a preparatory 
step  to  the  formation  of  granulations,  and 
the  consequent  restoration  of  the  part,  takes 
place.  The  vessels  are  nearly  in  the  same 
state  as  in  inflammation  ; but  they  are  more 
quiescent,  and  have  acquired  a new  mode 
of  action.  (Hunter.) 

With  respect  to  Mr.  Hunter’s  theory, 
which  has  deservedly  had  vast  influence  in 
regulating  the  judgment  of  professional 
men  in  this  country,  on  the  nature  of  the 
process  called  inflammation,  it  cannot  be 
received  in  the  present  state  of  knowledge 
without  some  limitation.  The  hypothesis, 
that  the  blood-vessels  possess  an  active 
power  of  dilatation,  independently  of  their 
elasticity,  as  Dr.  Hastings  observes,  must  as 
yet  be  regarded  as  devoid  of  proof,  and 
therefore  should  not  be  assumed  as  a basis 
on  which  any  theory  of  inflammation  is 
founded.  (On  Inflammation  of  the  Mucous 
Membrane  of  the  Lungs,  fyc  p.  70. ) And,  as 
another  intelligent  writer  remarks,  how  dif- 
ferent would  have  been  Mr.  Hunter’s  infer- 
ences, if,  instead  of  trusting  to  the  unassisted 
eye,  he  had  viewed  the  inflamed  vessels 
through  the  microscope.  He  would  then 
have  seen  the  blood  moving,  and  found, 
that,  “ instead  of  its  passage  being  quickened 
in  the  inflamed  vessels , it  is  uniformly  render- 
ed s ower  in  proportion  to  the  degree  of  in- 
flammation. and,  in  the  most  inflamed  parts, 
stands  still  altogether .”  (On  the  Vital  Func- 
tions, p.  288,  Ed.  2.)  And.  in  another  part 
of  his  writings,  Dr.  Philip  has  endeavoured 
to  prove,  from  several  facts  respecting  the 
colour  of  the  blood,  that  within  certain 
limits , the  accumulation  of  this  fluid  in  the 
debilitated  vessels  of  the  inflamed  part  neces- 
sarily causes  the  blood  to  retain  the  florid, 
colour.  (On  Fevers,  Part  2,  Introd .) 


In  modern  times,  the  vague,  but  conve- 
nient expression,  increased  action  of  the  ves- 
sels. has  been  very  generally  used  as  an 
adequate  explanation  of  the  proximate  cause 
of  inflammation.  The  doctrine,  it  is  said, 
derives  support  from  a review  of  the  several 
exciting  causes  of  the  affection,  which,  be- 
ing in  general  of  an  irritating  nature,  must, 
when  applied  to  any  living  or  sensible  parts, 
occasion  such  increased  action  of  the  ves- 
sels ; while  the  method  of  cure  also  tends  to 
confirm  the  opinion.  But,  before  one  can 
judge  whether  this  doctrine  is  correct,  and 
supported  by  facts  and  observation,  it  is 
necessary  to  understand  precisely  what  is 
implied  by  increased  action  of  vessels;  for 
it  is  not  every  affection  of  the  vessels,  capa- 
ble of  being  thus  denominated,  which  will 
of  itself  constitute  inflammation.  In  gesta- 
tion, the  arteries  of  the  womb  are  enlarged, 
and  a greater  quantity  of  blood  is  sent  into 
them;  yet  this  organ  is  not  inflamed.  The 
carotids  are  in  a similar  state  during,  the 
growth  of  the  stag’s  horn  ; but  no  inflam- 
mation exists,  if  then  the  proximate  cause 
of  inflammation  is  to  be  called  an  increased 
action  of  the  vessels,  we  must  first  be  in- 
formed not  only  what  is  meant  by  the  term, 
but  what  particular  vessels  are  spoken  of, 
whether  the  arterial  trunks,  bio  chc's,  or 
capillaries  ? Because,  if  the  phrase  is  intend- 
ed to  signify  increased  alternate  expansions 
and  contractions  of  all  the  arteries  of  the 
inflamed  part,  it  is  an  hypothesis  entirely 
destitute  of  foundation.  If  it  be  meant  to 
denote  an  increased  velocity  of  the  mo- 
tion of  the  blood  in  the  part  affected,  the 
doctrine  is  rather  contradicted  than  con- 
firmed by  the  latest  and  most  carefully  insti- 
tuted microscopical  experiments.  But  if 
the  expression  onlyrefers  to  the  dilated  state 
of  the  capillaries,  the  throbbing  of  the  arte- 
ries leading  to  the  seat  of  inflammation,  the 
effusion  of  lymph,  &c.  less  fault  can  be  found 
with  the  language,  though  yet  requiring 
much  further  explanation  ere  it  can  com- 
municate any  very  precise  information. 

“ There  are  (says  a learned  professor) 
two  hypotheses,  which  at  present  divide  the 
opinions  of  pathologists  respecting  the  state 
of  the  capillary  vessels  affected  with  in- 
flammation. According  to  the  first  of  these 
hypotheses,  the  inflamed  vessels  are  in  at 
state  of  increased  action  ; according  to  the 
second,  they  act  with  less  force  than  the 
trunks  from  which  they  are  derived.”  (See 
Thomson  on  Inflammation,  p.  64.) 

The  first  of  these  opinions,  according  to 
Dr.  Thomson,  was  suggested  by  the  views 
which  Stahl  took  of  the  animal  economy, 
and  his  ideas  respecting  the  tonic  or  vital 
action  of  the  capillary  vessels.  The  doc- 
trine, however,  was  more  particularly  insist- 
ed upon  by  his  disciples  and  followers, 
especially  Dr.  Gorter,  who  in  one  place 
expressly  states,  u that  the  proximate  cause 
of  inflammation  consists  in  an  increased 
vital  action  of  some  particular  artery  or 
arteries,  by  which  the  blood  is  propelled 
with  greater  fofce  than  usual  into  the  com- 
mimic  ating  lymphatic  and  colourless  vete 


INFLAMMATION. 


lit) 


sels.”  (See  his  Compendium  Medicines  and 
Chirurgia  Repurgala  ) 

The  doctrine  which  supposes  the  action 
of  the  inflamed  vessels  to  be  diminished,  or 
to  be  proportionably  less  than  that  of  the 
trunk  or  trunks  from  which  they  are  deri- 
ved, was,  as  far  as  Dr.  Thomson  can  learn, 
first  stated  by  Vacca,  an  Italian  physician, 
in  a small  treatise  on  inflammation,  publish- 
ed at  Florence  in  1765,  entitled  “ Liber  de 
Inflammat ionis  Mo/bosce,  quae  in  humano  car- 
port fit  natur&y  causis,  effedibus , el  curatione .” 

For  an  account  of  the  arguments  with 
which  Vacca  supports  his  hypothesis,  my 
limits  oblige  me  to  refer  to  the  work  of 
Dr.  Thomson.  (P.  68.  <^c.) 

As  this  gentleman  has  observed,  there  are 
certain  points  in  which  the  two  doctrines 
agree,  as  well  as  in  which  they  differ. 

“ The  advocates  for  each  hypothesis  agree 
in  admitting,  1st,  that  inflammation  has  its 
seat  in  the  capillary  vessels  ; and  2dly,  that 
the  redness  in  inflammation  is  owing  to  an 
unusual  quantity  of  blood  in  the  vessels  of 
the  inflamed  part,  and  consequently  that 
the  capillary  arteries  are  much  dilated  du- 
ring the  state  of  inflammation.  The  con- 
tractions of  these  vessels,  indeed,  it  has 
been  said,  are  increased  also  in  a ratio  pro- 
portional to  the  dilatations  ; but,  this  is  an 
assertion  which  has  not  yet  been  proved, 
either  in  the  way  of  experiment  or  of  ob- 
servation. 

“ The  sense  of  throbbing,  which  the  advo- 
cates for  the  hypothesis  of  increased  capilla- 
ry action  regard  as  the  strongest  proof  of 
that  action,  Mr.  Allen  is  disposed  to  attribute 
to  the  difficulty,  which  the  blood  meets  with 
in  passing  from  the  trunk  into  the  capillary 
branches.  This  sensation  of  throbbing,  and 
appearance  of  increased  action,  may  be 
produced  in  an  instant,  by  applying  a liga- 
ture to  an  uninflamed  finger,  so  as  to  ob- 
struct the  motion  of  the  blood  through  its 
point.  Besides,  this  throbbing,  or  pulsatory 
motion,  can  afford  us  no  criterion,  by  which 
to  judge  of  (he  force,  with  which  the  artery 
contracts,  for,  it  is  produced  in  the  dilatation 
of  the  artery,  and  by  a power  foreign  to  the 
artery  itself.”  ( Thomson  on  Inflammation , 
P-  73.) 

Dr.  Wilson  Philip,  many  years  ago,  en- 
deavoured to  ascertain,  by  means  of  the 
microscope,  the  state  of  the  vessels  in  the 
various  stages  of  inflammation,  both  in  the 
Warm  and  cold  blooded  animal.  I have  put 
the  epithet  warm  in  Italics,  because  it  has 
been  very  recently  observed  by  my  friend 
Mr  James,  that  “ analogies  between  the 
higher  and  lower  orders  of  animals,  the 
chief  subjects  of  these  experiments,  cannot 
be  deemed  conclusive.”  (On  some  of  the 
General  Principles  of  Inflammation,  p.  29, 

8 vo.  Lond.  1821)  as  if  it  had  escaped  atten- 
tion, that  many  of  the  experiments  were 
really  made  on  the  more  perfect  animals. 
From  the  valuable  observations,  to  which 
1 here  allude,  (See  Philip  on  Febrile  Diseases , 
Part  2,  Inlrod.)  it  appears,  that  the  state  of 
the  smaller  vessels  in  an  inflamed  part  is 
that  of  preternatural  distention  and  debility. 


As  for  the  larger  vessels,  whose  state  rnay  be 
ascertained,  without  the  aid  of  the  micro- 
scope, “they  do  not  undergo  a similar  dis- 
tention, and  the  increased  pulsation  of  the 
arteries  sufficiently  evinces  their  increased 
action.  In  inflammatory  affections  of  the 
jaw  and  the  head,  for  example,  a greatly  in- 
creased action  of  the  maxillary  and  temporal 
arteries  is  readily  perceived  by  the  finger. 
It  is  to  be  observed,  however,  that,  although 
inflammation,  as  was  evident  from  the  fore- 
going experiments,  begins  in  the  capillaries, 
if  it  continues,  the  circulation  in  the  smallest 
vessels  becoming  very  languid,  those  imme- 
diately preceding  them  in  the  course  of  the 
circulation  begin  to  be  distended,  and  conse- 
quently debilitated.”  Dr.  Philip  adds,  that 
such  distention  and  debility  of  the  vessels, 
which  immediately  precede  the  capillaries, 
cannot  go  far,  because  when  the  former  lose 
their  power,  the  circulation  in  the  latter  is 
not  supported,  and  gangrene  soon  ensues. 
“ In  short,  (says  Dr.  Philip)  inflammation 
seems  to  consist  in  the  debility  of  the  capillaries , 
followed  by  a i increased  action  of  the  larger 
arteries ,”  and  is  terminated  by  resolution, 
when  the  capillaries  sere  so  far  excited,  and 
the  larger  arteries  so  far  weakened,  by  the 
preternatural  action  of  the  latter,  that  the 
power  of  the  capillaries  is  again  in  due 
proportion  to  the  vis  a tergo. 

“ Thus  far,  (says  Dr.  Philip)  I cannot  help 
thinking  the  nature  of  inflammation  appears 
sufficiently  evident.  The  motion  of  the 
blood  is  retarded  in  the  capillaries,  in  conse- 
quence of  the  debility  induced  in  them  ; an 
unusual  obstacle  is  thus  opposed  to  its  motion 
in  the  arteries  preceding  them  in  the  course 
of  the  circulation  ; which  are  thus  excited 
to  increased  action.  Several  difficulties, 
however,  remain,  on  which  the  experiments 
just  related  throw  no  light.  Why  does  a 
failure  of  power,  of  small  extent  in  the  ca- 
pillaries of  a vital  part,  strongly  excite,  not 
only  the  larger  arteries  of  the  part  affected, 
bur  those  of  the  whole  system ; while  a 
more  extensive  debility  of  the  capillaries  of 
an  external  part  excites  less  increased  action 
in  the  larger  arteries  of  that  part,  and  often 
none  at  all  in  those  of  the  system  in  general  ? 
Why  does  inflammation  often  move  sudden- 
ly from  one  part  to  another,  when  we  see 
no  cause,  either  increasing  the  action  of  the 
capillaries  of  the  inflamed  part,  or  weaken- 
ing those  of  the  part  now  affected  ? Why 
does  inflammation  often  arise  in  parts  only 
sympathetically  affected,  and  consequently 
far  removed  from  the  offending  cause  ? 
Why  is  inflammation  often  as  apt  to  spread 
to  neighbouring  parts,  between  which  and 
the  part  first  affected,  there  is  no  direct 
communication  of  vessels,  as  to  parts  in 
continuation  with  that  part? 

“ These  phenomena,  it  is  evident,  (says 
Dr.  Philip)  are  referrible  to  the  agency  of 
the  nervous  system,  and  seem  readily  ex- 
plained by  the  experiments,  vhich  prove, 
that  the  effects  of  both  stimuli  and  sedatives, 
acting  through  this  system,  are  felt  by  the 
vessels,  and  that  independently  of  the  inter- 
vention of  any  effect  produced  on  the  heart 


INFLAMMATION. 


(Exp.  27,  28.)  Thus,  the  irritation  of  the 
nerves  of  the  inflamed  part  may  excite  the 
larger  arteries  of  this  part,  or  of  distant  parts, 
•r  of  the  whole  sanguiferous  system.  It 
will  of  course  be  most  apt  to  do  so,  where 
the  irritation  excit^l  by  the  inflammation  is 
greatest  and,  consequently  in  the  more  im- 
portant vital  parts.  It  cannot  appear  surpri- 
sing, that  inflammation  should  suddenly 
cease  in  one  part  and  attack  another,  when 
we  know,  that  the  nerves  are  capable  of 
exciting  to  due  action  the  capillaries  of  the 
one  part,  and  in  the  other  of  impairing  the 
vigour  of  those,  which  have  not  suffered. 
In  the  same  way,  we  account  for  parts  only 
sympathetically  affected  becoming  inflamed, 
and  for  inflammation  readily  spreading  to 
neighbouring  parts,  which  always  sympa- 
thize, although  there  is  no  direct  communi- 
cation between  them,  either  of  vessels  or 
nerves.-’  (On  the  Vital  Functions,  p.  279, 
fyc.  Ed.  2.) 

Respecting  the  inference,  made  by  Dr. 
Philip  from  his  experiments,  that  the  circu- 
lation is  slower  in  inflamed,  than  uninflamed 
arteries,  Dr.  J.  Thompson  conceives,  that 
its  truth  “ is  not  necessary  to  the  establish- 
ment of  Mr.  Allen’s  hypothesis  ; and  from 
a number  of  experiments  which  I have  at 
different  times  made  upon  frogs,  I am  incli- 
ned to  believe,  that  a diminished  velocity  of 
the  blood,  in  the  capillary  branches,  is  by  no 
means  a necessary , constant,  nor  even  the  most 
common  effect  of  incipient  and  moderate 
degrees  of  inflammation .”  (P.  75.) 

In  order  to  reconcile  this  difference  in  the 
statements  made  by  the  only  two  writers, 
who  have  examined  this  subject  by  experi- 
ment, Dr.  Hastings  repeated  their  mode  of 
investigation  with  the  aid  of  the  microscope. 
His  conclusions  are,  “ that  certain  stimuli, 
applied  to  living  parts,  produce  an  increased 
velocity  of  the  blood’s  motion,  and  a con- 
traction of  the  blood-vessels.  During  this 
state  of  excitement,  the  part  affected  is  so 
far  from  giving  any  thing,  like  the  appear- 
ances of  inflammation,  that  the  size  of  the 
vessels  is  diminished,  and  the  part  paler. 
But,  if  the  stimulus  be  long  continued,  or 
increased  in  power,  the  small  vessels,  which 
in  the  natural  state  admit  only  of  one 
series  of  globules,  become  so  dilated,  as  to 
allow  an  accumulation  of  a much  less  fluid 
and  redder  blood  in  them,  which  loses  its 
globular  appearance,  and  moves  much  more 
slowly,  than  that  which  previously  passed 
through  the  vessels.  The  part  now  appears 
inflamed.  If  the  stimulus  be  removed,  the 
vessels  do  not  soon  regain  their  original 
state  ; time  is  necessary  to  allow  them  to 
recover  their  contractile  power,  so  as  to 
prevent  the  impetus,  with  which  the  blood 
is  propelled  by  the  hear!  and  larger  arteries 
from  keeping  up  the  dilated  state  of  the  ca- 
pillaries. Here  then  we  are  obliged  to  ad- 
mit, with  Boerhaave,  that  there  is  an  error 
loci  ; for,  a denser  and  redder  blood  passes 
into  small  vessels,  which  before  carried  much 
more  fluid  contents  ; but  the  error  loci  does 
not  cause  the  inflammation,  but  results  from 
the  previously  weakened  state  of  the  capilla- 


ries. In  this  manner,  the  blood  may  occa- 
sionally be  extravasated  in  inflammation, 
without  any  actual  rupture  of  a vessel,  for 
the  exhalants  may  be  so  weakened,  ami 
dilated,  as  to  allow  globules  to  pass  through 
them. 

“ If  the  stimulus,  which  produces  the  in- 
flammation, be  of  a very  acrid  nature,  de- 
bility of  the  vessels  is  frequently  induced 
without  any  previous  excitement.  The  blood 
in  all  the  smaller  vessels  becomes  very  red, 
circulates  very  slowly,  and  in  some  vessels 
stagnates. 

u The  application  of  a stimulus,  different 
from  that  which  produced  inflammation, 
w ill  sometimes  bring  on  resolution.  When 
(his  occurs,  the  dilated  vessels  contract; 
they  no  longer  contain  a red,  dense  homo- 
geneous fluid,  but  again  receive  blood,  con- 
sisting of  small,  nearly  colourless  globules, 
which  float  in  a colourless  fluid  ; and  the 
motion  of  these  globules  at  length  becomes 
as  quick  as  before  the  inflammation  took 
place.  If,  however,  the  inflammation  pro- 
ceed, the  blood  becomes  nearly  stagnant  ; 
it  continues  very  red,  and  the  vessels  are 
much  dilated. 

£‘  When  this  high  degree  of  inflammation 
is  not  relieved,  sphacelus  ensues.  The  part 
then  feels  softer  to  the  finger,  and  gives  way 
with  less  force.  The  vessels  are  much  dila- 
ted, the  blood  does  not  move,  it  loses  its  red 
colour,  and  becomes  of  a yellowdsh  brown 
hue.  The  separation  of  the  dead  from  the 
living  part  takes  place  soon  after  this  change 
in  the  colour  of  the  blood. 

“ While  the  ulceration,  produced  by  this 
separation  of  the  dead  from  the  living  part  of 
the  web  is  healing,  the  capillary  vessels, 
distributed  on  the  ulcerated  surface,  and  the 
contiguous  parts,  are  much  distended  with 
arterial  red  blood,  which  is  moved  very 
slowly.  When  the  ulceration  is  healed,  the 
vessels  become  contracted,  and  circulate  the 
fluid,  with  the  same  degree  of  velocity  as 
before  the  inflammation  was  excited. 

i£  With  respect  to  the  seat  of  inflammation, 
it  may  be  observed,  that  the  capillaries  are 
first  affected  ; but  even  the  small  arteries  of 
the  web  are  also  occasionally  distended.” 
( Hastings  on  Inflammation  of  the  Mucous 
Membrane  of  the  Lungs,  fyc.  p.  90 — 92.) 

With  respect  to  the  doctrine,  espoused  by 
some  pathologists,  that  the  smaller  branches 
of  veins  are  the  exclusive  seat  of  inflamma- 
tion, the  same  author  observes,  that  the 
microscope  shows  us,  that  the  most  minute 
arterial  branches,  though  far  less  numerous, 
are  equally  affected  with  weakness  and 
distention. 

In  the  course  of  Dr.  Hastings’s  inquiry,  it 
is  proved,  that  the  healthy  circulation  of  the 
blood  essentially  depends  upon  a due  degree 
of  action  in  the  vessels  throughout  the  sys- 
tem ; that  the  application  of  stimuli,  while 
it  increases  the  action  of  the  vessels,  produ- 
ces none  of  the  symptoms  of  inflammation. 
When,  however,  the  excessive  action  of 
these  stimuli  has  impaired  the  excitability  of 
the  small  vessels,  the  phenomena  of  inflam- 
mation are  fully  manifested  ; and  when  their 


118 


INFLAMMATION. 


excitability  is  restored,  the  inflnmmation 
subsides.  It  may  be  logically  inferred,  there- 
fore. says  this  writer,  that  inflammation  con- 
sists in  a weakened  action  of  the  capillaries , by 
which  the  equilibrium  between  the  larger  arid 
smaller  vessels  is  destroyed , and  the  latter  be- 
come distended.  And,  with  respect  to  the 
conclusion,  drawn  by  Dr.  Thomson  from  his 
experiments,  that  inflammation,  in  moderate 
degrees,  consists  in  an  increased  action  of 
the  vessels.  Dr.  Hastings  argues,  that  the 
writer’s  belief  in  the  excitement  of  the 
capillaries,  in  some  cases  of  inflammation, 
arises  from  his  having  denominated  that  a 
state  of  inflammation,  which  ought  not  to 
be  so  called.  “ The  application  of  the  salt, 
(says  Dr.  Thomson)  produced  an  increased 
velocity  in  the  dilated  larger  and  smaller 
arteries  and  capillary  vessels,  to  which  it  was 
more  immediately  applied.  In  nine  experi- 
ments, the  phenomena  of  which  I have 
minutely  recorded,  the  application  of  the 
salt  was  not  only  followed  by  a bright  red 
colour,  visible  to  the  naked  eye,  and  a sensi- 
ble enlargement  of  the  arterial  and  venous 
branches,  but  with  an  increased  rapidity  of 
circulation  in  the  capillary  vessels;  the  glo- 
bules becoming  less  distinct,  than  before  the 
application  of  the  salt,  and  obviously  less 
distinct,  from  the  rapidity  of  their  motion, 
than  the  globules  in  the  capillary  vessels  in 
the  uninflamed  part  of  the  web  in  the  same 
animal.  The  repeated  application,  however , 
of  the  salt  to  the  same  vessels,  was  always 
sooner  or  later  follo  wed  by  retarded  capillary 
circulation,  or  even  by  complete  stagnation.” 
(See  Thomson's  Lectures,  p.  68.)  The  results 
of  other  experiments,  made  by  this  gentle- 
man, and  which  coincide  with  the  sentiments 
of  Dr.  VV.  Philips  and  Dr.  Hastings,  need  riot 
here  be  cited. 

Now,  with  regard  to  those  experiments, 
which  seemed  to  Dr.  Thomson  to  justify  the 
inference,  that  moderate  degrees  of  inflam- 
mation may  be  attended  with  an  increased 
velocity  of  the ’blood  in  the  inflamed  vessels, 
Dr.  Hastings,  as  I have  already  said,  objects, 
that  the  appearances  seen,  while  such  velo- 
city of  the  circulation  presented  itself  in  the 
vessels  affected,  ought  not  to  have  been 
denominated  inflammation  ; because  “ it 
constantly  happened  in  hisown experiments, 
that  when  inflammation  commenced,  no 
. globules  could  be  seen  even  in  the  blood  of 
the  affected  vessels  It  was  universally  con 
verted  into  a bright  red  homogeneous  fluid. 
So  that  globules  could  never  be  seen  in  the 
capillaries  of  a really  inflame  d part,  much  less 
moving  with  great  velocity.  He  argues,  that 
the  state,  alluded  lo  by  Dr.  Thomson,  is  only 
that  temporary  excitement  of  the  capillaries, 
generally  preceding  their  debility,  which  is 
inseparable  from  inflammation.  (See  Hast- 
ings on  lnfla  mmnlon  fyc  p.  98,  1**1.) 

Of  course,  such  writers  as  believe,  that  the 
blood  in  the  capillaries  is  not  propelled  by 
these  vessels  themselves,  but  by  the  impulse 
received  from  the  heart,  cannot  assent  to  the 
foregoing  view,  in  which  the  proximate 
cause  of  the  inflammation  is  ascribed  to  de- 
bility of  those  vessels.  Dr.  Parry  argues, 


that  the  theory,  which  represents  this  pr<K 
cess  as  consisting  in  an  increased  momentum 
of  the  blood  in  the  part  affected,  is  not  inva- 
lidated, were  it  even  proved,  according  to 
the  opinion  of  Dr.  Philip,  that  the  velocity 
of  the  blood  in  th£  vessels  of  an  inflamed 
part  is  diminished,  unlefs  it  be  also  proved, 
that  the  velocity  is  diminished  in  a greater 
proportion,  than  the  quantity  is  increased. 
(Elements  of  Pathology,  Vol.],p.  84.)  As 
far,  however,  as  1 can  judge,  the  arguments 
are  in  favour  of  Dr.  Philip’s  view  of  the  sub- 
ject ; for,  with  respect  to  quantity  making 
up  for  loss  of  velocity,  if  the  supposition 
were  to  be  adopted,  surely  it  could  not  be 
retained  after  the  inflammation  has  arrived 
at  that  state,  in  which  the  fluid  in  the  capil- 
laries is  seen  with  the  microscope  to  b© 
nearly  or  quite  stagnant  It  must  be  con- 
fessed, at  the  same  time,  that  the  question 
about  the  proximate  cause  of  inflammation 
is  still  a topic  of  endless  controversy,  into 
which  I consider  it  perfectly  absurd  to  enter 
any  further  than  can  be  avoided,  without 
having  leisure  at  present  to  prosecute  the  in- 
quiry by  experiments.  In  one  sense,  both 
Dr.  Philip  and  Dr.  Hastings  admit,  that  an 
increased  action  of  the  vessels  may  exist  in 
inflammation  ; but  then  this  excitement  or 
i ■ creased  action  is  not  in  the  capillaries,  but 
the  larger  arteries;  and  Dr.  Philip  even  sug- 
gests, that  the  presence,  or  absence  of  such 
excitement  may  make  the  difference  be- 
tween acute  and  chronic  inflammation.  The 
considerations  in  support  of  the  side  of  the 
question,  to  which  1 do  not  myself  incline, 
may  be  found  in  the  writings  of  Dr.  Parry, 
Dr.  C.  H.  Parry,  and  Mr.  James  of  Exeter. 
From  this  remark,  I would  not  have  it  infer- 
red, that  I am  quite  convinced  of  the 
propriety  of  referring  the  proximate  cause  of 
inflammation  to  debility  of  the  capillaries, 
though  the  retarded  circulation  in  them,  like 
their  dilatation,  is  now  a fact  placed  out  of 
all  doubt  The  points,  however,  on  which  I 
should  not  assent  to  Dr.  Philip’s  doctrine, 
will  be  best  understood,  when  the  treatment 
is  considered.  In  the  work  of  Mr.  James 
may  be  perused  a very  good  summary  of 
Bichat’s  doctrine,  which  l would  willingly 
annex,  if  the  subject  were  intelligible,  with- 
out an  explanation  of  some  physiological 
opinions,  for  which  I have  not  room  in  this 
edition.  (See  J.  II  James,  Obs.  on  some  of 
the  general  Principles ■,  tyc.  of  Inflammation , p. 
38,  8vo.  Load.  1821.) 

Redness — This  is  manifestly  owing  to  the 
increased  quantity  of  blood  in  the  inflamed 
part.  More  blood  must  necessarily  be  con- 
tained there,  because  the  vessels,  which  pre- 
viously conveyed  this  fluid,  are  preternatu- 
rally  distended,  and  the  small  vessels,  which 
naturally  contained  only  lymph,  are  now  so 
enlarged  as  to  be  capable  of  receiving  red 
blood  “ I froze  (says  Mr.  Hunter)  the  ear 
of  a rabbit,  and  thawed  it  again  ; this  occa- 
sioned a considerable  inflammation,  an  in- 
creased heat,  and  thickening  of  the  part. 
This  rabbit  was  killed  when  the  ear  was  in 
the  height  of  inflammation,  and  the  head 
being  injected,  the  two  cars  were  removed 


INFLAMMATION 


119 


and  dried.  The  uninflamed  ear  dried  clear, 
and  transparent,  the  vessels  were  distinctly 
seen  ramifying  through  its  substance  ; but, 
the  inflamed  ear  dtied  thicker  and  more 
opaque,  and  its  arteries  were  considerably 
larger.-’ 

Many  have  supposed,  that  the  redness  of 
common  inflammation  is  partly  occasioned 
by  the  generation  of  new  vessels.  This 
doctrine,  however,  seems  very  questionable. 
When  coagulated  lymph  isextravasated  upon 
the  surface  of  a wound,  or  an  inflamed 
membrane,  unquestionably  it  often  becomes 
vascular,  in  other  words,  furnished  with  new 
vessels.  But,  in  the  extravasated  lymph  of  a 
phlegmonous  tumour,  we  have  no  evidence, 
that  there  is  any  formation  of  new  vessels. 
Were  the  lvmph  to  be  rendered  organized 
and  vascular,  the  swelling  and  redness  would 
probably  be  more  permanent,  and  at  least 
not  admit  so  easily  of  resolution.  When 
adhesions  form  between  two  inflamed  sur- 
faces, the  organized  substance  forming  the 
connexion,  lives  after  the  subsidence  of  the 
inflammation,  and  is  a permanent  effect  In 
the  experiments  detailed  by  Dr.  Hastings, 
when  the  inflammation  began  and  termina- 
ted, without  any  lesion  of  (he  part  affected, 
new  vessels  were  never  formed.  (On  In- 
flammation, fyc.p.  93.)  At  the  same  time,  it 
must  be  confessed,  that  great  obscurity  pre- 
vails in  this  very  difficult  part  of  the  subject ; 
for  when  suppuration  happens  in  a phleg- 
monous tumour,  the  cavity  is  lined  by  a 
kind  of  cyst,  or  membranous  layer  of  lymph, 
which  is  unquestionably  furnished  both  with 
secreting  vessels  and  absorbents  ; for,  other- 
wise, how  could  the  continued  secretion  of 
pus,  or  its  occasional  sudden  disappearance, 
be  at  all  explicable.  It  was  probably  the 
enlargement  of  the  small  vessels,  and  the 
circumstance  of  their  being  filled  with  red 
blood,  that  led  to  the  theory  of  new  vessels 
being  usually  formed  in  inflammation.  It 
has,  however,  been  justly  observed,  that  the 
supposition  easily  admits  of  refutation  : for 
heat,  and  many  other  causes  of  inflamma- 
tion, operate  so  quickly,  that  there  can  be 
no  time  for  the  formation  of  any  new  vessels ; 
and,  yet  the  redness  is  as  great,  and  the  in- 
flammation as  perfect  in  a minute  as  in  an  hour 
ora  day  after  the  application  of  the  exciting 
cause.  (Burns)  Mr.  Hunter,  it  is  well 
known,  believed,  that  a coagulutn  or  a layer 
of  lymph  might  produce  vessels  vvi'hin  it- 
self.— (On  the  Blood , p.  92.  fyc.)  Others, 
however,  distrust  this  hypothesis,  and  incline 
to  the  opinion,  which  refers  the  derivation 
of  vessels  for  the  organization  of  deposits 
to  parent  branches.  ( Travers , Synopsis  of 
Diseases  of  the  Eye,  p 113)  The  latter  sen- 
timent is  corroborated  by  the  appearances 
noticed  by  Dr.  Hastings,  in  his  experiments, 
who  describes  the  small  vessels  first  seen  in 
the  lymph,  upon  the  surface  of  a wound,  as 
even  then  communicating  with  the  inflamed 
capillaries.  (On  Inflammation , p.  94.)  Air- 
other  reason  assigned  for  the  redness  of  in- 
flammation, is  that  the  blood  after  it  has  be- 
come venous,  retains,  more  or  less,  its  bright 
scarlet  colour.  (Hunter.)  And,  in  some  late 


very  carefully  conducted  experiments,  it  was 
remarked,  that  the  weakened  action  of  tho 
smaller  vessels  was  always  accompanied 
with  an  alteration  in  the  appearance,  of  the 
blood.  In  the  natural  str.te  of  this  fluid, 
globules  can  be  distinctly  sec,  ; but,  after 
inflammation  has  commenced,  the  globular 
structure  disappears,  the  b!;Od  becomes 
redder,  and  the  most  minute  capillaries  are 
distended  with  it.  (Hastings  on  Inflamma- 
tion, fyc.  p.  95.) 

Swelling. — This  effect  arises  from  several 
causes:  1.  The  increased  quantity  of  blood 
in  the  vessels.  2.  The  effusion  of  coagu- 
lating lymph,  and  serum,  and  deposition  of 
new  matter.  3.  The  interruption  of  ab- 
sorption, particularly  noticed  by  Soemmer- 
ing. DeMorb.  Vas.  Absorb. 

Pain — This  is  observed  to  be  the  greatest 
during  the  diastole  of  the  arteries.  The  af- 
fection is  probably  owing  to  the  unnatural 
state  of  the  nerves,  and  not  to  mere  disten- 
tion, as  many  have  asserted.  Were  the 
latter  cause  a real  one,  the  pain  would 
always  be  proportioned  to  it. 

“ Parts,  which  in  the  sound  state  have 
little,  or  no  sensibility  (as  Dr.  Thomson  re- 
marks) become  exquisitely  sensible  in  the 
inflamed.  That  this  is  the  case  with  tendon, 
ligament,  cartilage,  bone,  and  membrane, 
seems  to  be  fully  established  by  Dr.  Wfaytt 
in  the  very  instructive  controversy  carried 
on  between  him  and  Haller,  respecting  the 
sensibility  and  irritability  of  the  different 
parts  of  man  and  other  animals.— -(Lectures 
on  Inflammation , p.  45.) 

Heat. — The  heat  or  real  increase  of  tem- 
perature in  an  inflamed  part,  when  judged  of 
by  the  thermometer,  is  generally  much  less, 
than  might  be  supposed  from  the  patient’s 
sensations.  It  is  said  never  to  exceed  the 
heat  of  the  blood  at  the  heart.  This  in  health 
is  usually  about  100°.  Fahrenheit’s  thermo- 
meter; but  sometimes  in  diseases  it  arises  to 
106°,  or  even  107°.  Mr.  Hunter  artificially 
excited  inflammation  in  the  chest  of  a dog, 
and  in  the  abdomen,  rectum,  and  vagina  of 
an  ass.  without  being  able  to  discover  any 
obvious  rise  of  temperature,  in  these  parts. 
In  a patient,  however,  on  whom  he  opera- 
ted for  hydrocele,  the  thermometer,  introdu- 
ced into  the  tunica  vaginalis,  and  kept  for 
some  time  close  to  the  side  of  the  testicle, 
was  only  92°  ; but  rose  the  following  day, 
when  inflammation  had  come  on  to  98°  3-4. 
As  Dr  Hastings  observes,  the  advocates  for 
excited  action  of  the  vessels  in  an  inflamed 
part  have  thought,  that  the  increase  of  tem- 
perature favours  their  hypothesis,  and  have 
called  to  their  aid  the  ingenious  calculations 
of  Dr.  Crawford.  They  have  even  gone  so 
far  as  to  sav,  what  state  of  the  arteries 
enables  the  blood  to  give  out  most  caloric. 
They  tell  us,  that,  in  consequence  of  excite- 
ment of  the  vessels,  more  blood  is  transmit- 
ted into  the  minute  arteries  ; the  capacity  of 
a greater  quantity  of  this  fluid  for  heat  is  of 
course  diminished,  and  more  caloric  is 
evolved  in  the  inflamed  part.  (Hastings,  on 
Inflammation , p.  il  .)  Yet,  this  theory,  be- 
sides involving  the  contradicted  hypothesis 


INFLAMMATION. 


i2e 


of  an  increased  and  accelerated  flow  of 
blood  through  the  vessels  of  the  inflamed 
part,  cannot  be  reconciled  to  various  other 
considerations.  11  Daily  experience  con- 
vinces us,  (says  the  above  writer,)  that  the 
temperature  is  not  always  proportional  to  the 
velocity  of  the  circulation.  In  fevers,  the 
author  has  several  times  ascertained,  with 
the  thermometer,  that  the  heat  was  101°, 
when  the  pulse  beat  only  45  times  in  a mi- 
nute. In  hydrocephalus,  with  a pulse  from 
60  to  70,  the  heat  is  often  above  the  degree 
it  reaches  in  health.  In  these  cases,  accord- 
ing to  the  theory  of  Dr.  Crawford,  the  heat 
should  rather  be  under,  than  above,  the  na- 
tural standard.”  (Op.  cit.  p.  112.)  And,  as 
another  judicious  writer  has  noticed,  al- 
though the  former  mode  of  explaining  the 
production  of  animal  heat  has  been  held 
adequate  to  account  for  the  phenomena  by 
such  philosophers  as  Black,  Crawford,  La- 
voisier, and  Place,  the  evidence  on  which  it 
rests,  is  not  so  clear  as  to  have  commanded 
universal  assent,  or  entirely  set  aside  objec- 
tions. It  has  indeed  been  generally  allow  ed, 
that  respiration  and  the  changes  it  produces 
in  the  air  and  animal  fluids,  are  essential  con- 
ditions of  the  evolution  of  caloric  in  ani- 
mals ; but,  it  has  been  thought,  that  there  are 
other  circumstances,  hitherto,  perhaps,  not 
well  understood,  which  influence  the  pheno- 
mena, In  external  appearance,  the  blood  is 
the  same  in  all  the  vessels  of  the  fcetus  : is 
this  any  proof,  that  its  temperature  is  owing 
to  the  conversion  of  oxygen  gas  into  carbo- 
nic acid  ? Is  the  uniformity  of  temperature 
in  the  higher  animals,  under  varying  states 
of  respiration  and  circulation,  and  the  con- 
sumption of  various  quantities  of  oxygen, 
whether  in  the  same,  or  different  individuals, 
consistent  with  the  theory  ? And  can  local 
variations  of  temperature  be  explained  by 
it  ? ( Rees's  i.yclopcedia,  art.  Respiration.) 
Doubts  must  also  spring  from  the  recollection 
of  the  discordance  of  the  experiments,  re- 
lated by  Dr.  Crawford,  Dr.  John  Davy,  De  la 
Roche,  and  Bernard.  In  fact,  the  determi- 
nations of  the  specific  heats  of  oxygen  gas 
and  carbonic  acid  by  the  tw'o  latter  experi- 
menters are  conceived  to  be  very  much 
against  the  probability  of  Dr.  Crawford’s 
theory.  Other  stronger  grounds  for  scepti- 
cism in  this  subject  are  the  results  of  Mr. 
Brodie’s  investigations.  Having  pithed,  or 
decapitated  animals,  he  kept  up  artificial 
respiration,  and  thus  maintained  their  t ircu- 
lation.  The  blood  continued  to  be  changed 
in  the  lungs  from  venous  to  arterial,  and 
from  arterial  to  venous,  in  the  general  cir- 
culation. The  respective  colours  of  the 
two  kinds  of  blood  could  not  be  distinguish- 
ed from  those,  which  they  exhibit  in  living 
and  healthy  animals.  Yet,  the  temperature 
of  an  animal,  thufe  heated,  sunk  faster,  than 
that  of  another  animal  simply  killed  and 
left  to  itself  ; and  the  former  w as  supposed 
to  be  more  quickly  cooled  by  the  air  con- 
veyed into  its  chest.  Other  experiments, 
detailed  by  Mr.  Brodie,  tend  to  prove,  that 
the  oyxgen  of  the  air  employed  in  arti- 
ficial respiration,  underwent  its  usual  con- 


version into  carbonic  acid.  A living  rabbit 
formed  50,  or  60  cubic  inches  of  carbonic 
acid  in  an  hour.  A decapitated  animal,  in 
whom  artificial  respiration  was  kept  up, 
emitted  40 — 48  inches  in  the  same  time.  The 
thermometer  krthe  rectum  of  the  latter  had 
fallen  from  97  to  90,  while,  in  another  rab- 
bit left  to  itself,  but  similarly  treated  in  all 
other  respects,  it  had  fallen  only  to  91.  In 
a rabbit,  poisoned  with  wmorara,  or  the  es- 
sential oil  of  bitter  almonds,  not  decapitated, 
and,  in  which  artificial  breathing  was  kept 
up,  51  cubic  inches  of  carbonic  acid  were 
emitted  in  an  hour.  The  thermometer  in 
the  rectum  had  sunk  to  91  in  30  minutes; 
while  it  stood  at  92  in  another  animal,  treat- 
ed exactly  in  the  same  way,  with  the  omis- 
sion of  the  artificial  breathing.  From  these 
experiments,  Mr.  Brodie  infers  “ that,  in  an 
animal  in  which  the  brain  has  ceased  to  ex- 
ercise its  functions,  although  respiration  con- 
tinues to  be  performed,  and  the  circulation 
of  the  blood  is  kept  up  to  the  natural  stand- 
ard, although  the  usual  changes  in  the  sen- 
sible qualities  of  the  blood  take  place  in  the 
two  capillary  systems,  and  the  same  quan- 
tity of  carbonic  acid  is  formed  as  under 
ordinary  circumstances  ; no  heat  is  genera- 
ted, and  (in  consequence  of  the  cold  air 
thrown  into  the  lungs.)  the  animal  cools 
more  rapidly,  than  one  which  is  actually 
dead.”  (See  Phil.  Trans,  for  1811,  p.  36; 
and  for  1812,  p.  378.)  It  appears  certain, 
therefore,  that  the  generation  of  animal  heat, 
either  in  an  inflamed,  or  an  uninflamed  part, 
can  never  be  satisfactorily  explained  by  any 
reference  merely  to  chymical  principles, 
and  that  the  process  is  essentially  connected 
with  and  influenced  by  the  state  of  the 
functions  of  the  brain  and  nervous  system, 
and  no  doubt  also  by  the  principle  of  life 
itself.  At  the  same  time,  I think,  that  any 
hypothesis,  suggested  without  due  reference 
to  the  connexion,  which  respiration  has 
with  this  curious  and  interesting  process, 
will  never  be  established.  Neither  wmuld  I 
venture  so  far  as  Dr.  Philip,  w ho  believes, 
that  animal  heat  is  evolved  by  the  same 
means,  by  which  the  formation  of  the  se- 
creted fluids  is  effected,  viz.  the  action  of 
nervous  influence  on  the  blood,  and  that  the 
production  of  such  heat  is  to  be  regarded  as 
a secretion.  (On  the  Vital  Functions, p.  169.) 
However,  the  influence  of  the  nervous  sys- 
tem over  this  process  must  be  allow  ed  to  be 
very  great,  and  may  afford  a more  probable 
explanation  of  the  cause  of  the  local  change 
of  temperature  in  inflammation,  than  Dr. 
Crawford’s  theory,  combined  with  the  doc- 
trine of  increased  action,  and  an  accelerated 
circulation  in  the  vessels  of  the  pari  aff  ected. 

Buffy  coat. — The  blood,  when  taken  out 
of  the  living  vessels,  spontaneously  separates 
into  two  distinct  parts,  the  serum  and  the 
crassamentum.  The  last  is  a compound 
substance,  consisting  chiefly  of  coagulating 
lymph,  and  red  globules,  the  most  heavy  in- 
gredients in  the  blood.  Blood,  taken  away 
from  persons  affected  with  inflammation,  is 
longer  in  coagulating,  and  coagulates  more 
firmly,  than  in  other  instances.  Hence,  the 


INFLAMMATION. 


led  globules,  not  being  so  soon  entangled 
in  the  lymph,  descend  by  ti.eir  gravity,  more 
deeply  Irom  its  surface  which  being  more 
or  less  divested  of  the  red  colouring  matter, 
is  from  its  appearance  termed  the  buffy  coat 
or  inflammatory  crust.  The  firmer  and  more 
compact  coagulation  of  the  lymph  compresses 
out  an  unusual  quantity  of  serum  from  it, 
and  the  surface  of  the  sizy  blood  is  often 
formed  into  a holjow,  the  edges  being  drau  n 
inward.  ( Hunter ) In  some  cases,  these 
changes  in  the  blood  are  deemed  more  in- 
fallible prool  of  the  existence  of  inflamma- 
tion, than  the  state  of  the  pulse  itself.  They 
are  however,  only  a criterion  of  some  un- 
usual operation  going  on  in  the  system  ; for, 
the  blood  taken  from  pregnant  women  is  al- 
ways found  10  present  the  same  phenomena. 
In  peritonaea!  inflammation,  the  patient 
sometimes  seems  to  be  in  the  most  feeble 
state,  and  the  pulse  abstractedly  considered, 
would  rather  induce  the  practitioner  to  em- 
ploy tonics,  and* stimulants,  than  evacua- 
tions ; but,  should  the  continuance  or  exas- 
peration of  the  disorder,  or  any  other  reason, 
lead  him  to  use  the  lancet,  then  the  buffy 
coat,  and  the  concave  surface  of  the  blood, 
materially  obviate  any  doubt  of  the  exist- 
ence of  inflammation.  Surgeons  should 
never  forget,  however,  that  in  a few  anoma- 
lous constitutions,  the  blood,  v\  hen  drawn, 
always  exhibits  the  above  peculiarities. 

Terminations. — Inflammation  is  said  to 
have  three  different  term  nations;  or,  in 
more  correct  language,  we  may  say,  that, 
after  this  process  has  continued  a certain 
time,  it  either  subsides  entirely,  induces  a 
disposition  in  the  vessels  to  form  pus,  orcom- 
pletely  destroys  the  vitality  of  the  part. 

When  the  inflammation  is  to  end  in  the 
first  manner,  which  is  the  most  favourable, 
the  pain  becomes  less,  the  swelling  subsides, 
the  fever, andevery other  symptom  gradually 
abate  till  at  last  the  part  is  wholly  restored  to 
its  natural  size  and  colour.  There  is  no  forma- 
tion of  pus,  nor  any  permanent  injury  of 
structure ; and  if  Dr.  Philip’stheory  of  inflam- 
mation be  correct,  the  debilitated  capillaries 
are  excited  to  due  action  by  the  increased  ac- 
tion of  the  larger  arteries.  (On  the  Vital  Func- 
tions, p.298.)  This  termination  of  inflamma- 
tion istermed  by  surgeons  resolution.  It  is  for- 
tunately the  most  common,  as  well  as  the 
most  desirable  manner,  in  which  the  affec- 
tion ends. 

If,  however,  notwithstanding  the  applica- 
tion of  the  usual  remedies,  the  several  symp- 
toms of  heat,  pain,  and  redness,  instead  of 
diminishing,  rather  increase  ; if  the  febrile 
symptoms  are  likewise  augmented,  and  the 
tumour  gradually  acquires  a larger  size, 
turns  soft,  somewhat  prominent  in  the  mid- 
dle, or  towards  its  most  depending  part;  if 
it  should  next  acquire  a clear  shining  appear- 
ance, and  become  less  painful,  the  different 
symptoms  of  fever  being  at  the  same  time 
diminished,  and  a fluctuation  perceptible  in 
the  tumour  ; the  inflammation  has  ended  in 
suppuration. 

The  worst,  but  happily,  the  least  frequent 
consequence  of  common  inflammation,  is 

vot..  n 


the  death,  or  mortification,  of  the  part  affect- 
ed. In  the  microscopical  experiment  ot  Dr. 
Hastings,  it  was  observed,  that,  on  the  ap- 
proach of  gangrene,  the  blood  entirely  loses 
its  red  colour,  and  acquires  a yellowish 
brown  tinge.  (On  I jlammaiion,p  ^l  ) 111(; 

part,  which  was  of  a bright  red,  becomes  ot 
a livid  hue;  small  vesicles,  filled  with  a thin 
fetid  serum,  arise  on  its  surface,  and  air  is 
plainly  felt  within  the  cellular  membrane. 
The  pain  is  indeed  diminished;  but  the 
pulse  sinks,  while  the  tumour  is  gradually 
changed  into  a black,  fibrous  mass. 

These  are  the  three  common  terminations 
of  inflammation.  In  books, scirrhus  is  some- 
times enumerated  asoneot  the  terminations 
of  inflammation.  The  best  modern  surgeons, 
however,  do  not  regard  scirrhus  as  one  ot 
the  usual  effects  of  ordinary  inflammation  , 
“ the  term  scirrhus,  as  used  by  the  older 
medical  writers,  is  extremely  indefinite, 
having  been  sometimes  used  to  expiess 
every  kind  of  induration,  which  remained 
after  an  attack  ot  inflammation,  as  well  as 
the  morbid  incipient  state  of  parts  about  to 
become  affected  with  cancer.  Surgeons 
now  usually  limit  the  use  of  the  term  to  the 
last  of  these  significations.”  (Thomson  on 
Inflammation , p.  126.) 

Common  inflammation,  particularly  when 
it  affects  glandular  parts,  is  often  followed 
by  induration,  which  afterward  continues 
for  a greater  or  lesser  time.  Thus,  when 
the  testis  has  been  inflamed,  a hardness  ot 
the  epididymis  frequently  remains  during 
life.  Such  induration,  however,  is  not 
at  all  malignant,  and,  consequently,  very 
different  from  what  is  implied  by  a real 
scirrhus. 

TREATMENT  OF  INFLAMMATION. 

One  principal  difficulty  in  believing  the 
fact  of  the  retardation  of  the  circulation  in 
the  capillaries  of  an  inflamed  part,  and  against 
the  supposition  of  their  being  in  a state  o 
debility,  is,  that  the  most  effectual  treatment 
ot  common  inflammation  consists  of  means,, 
which  are  generally  of  a debilitating  nature, 
as  bleeding,  purging,  he.  And  surgeons  are 
still  further  attached  to  the  theory  of  in- 
creased velocity  of  the  blood’s  motion,  in  the 
part  affected,  by  the  recollection  of  the  local 
augmentation  of  temperature,  the  throbbing, 
a d the  instantaneous  return  of  the  red  co- 
lour, after  the  discontinuance  of  any  pres- 
sure, by  whi-  h the  redness  has  been  mo- 
mentarily removed  at  some  point  of  Hie  in- 
flamed surface.  These  too  are  all  so  many 
facts,  which,  as  far  as  I can  judge,  are  ad- 
mitted by  the  generality  of  reasoners,  what- 
ever may  be  their  particular  theory.  At  the 
same  time,  it  appears  equally  well  pro  ed 
by  careful  microscopical  experiments,  that 
in  the  capillaries  of  the  part,  which  is  direct- 
ly the  seat  of  inflammation,  there  is  a retar- 
dation, and  sometimes  even  a stagnation,  of 
the  circulation.  But,  this  is  not  all,  it  is  fur- 
ther manifested,  that  the  capillaries  are  con- 
siderably dilated,  the  blood  in  them  materi- 
ally altered,  and  that  these  phenomena  are 
followed  by  an  increased  action  ot  the  lac 


122 


INFLAMMATION. 


ger  arteries  leading  to  the  part  affected. 
Now,  1 think,  if  we  remain  contented  with 
these  obvious  circumstances,  and  dismiss  the 
hypothesis  of  debility  of  the  capillaries,  not 
only  the  necessity  for  venturesome  conjec- 
tures may  be-avoided,  but  a more  rational 
account  delivered  of  the  principles  of  the 
efficacy  of  the  usual  mode  of  treatment. 
Thus,  I would  not  presume  to  offer  any  sup- 
position, why  the  capillaries  ar«j  dilated, 
and  why  the  m otion  of  the  fluid  in  them 
is  retarded,  but  would  he  satisfied  with  a 
knowledge  of  the  facts,  so  as  to  elude  a 
source  of  endless  controversy,  viz.  the  ques- 
tion, whether  these  changes  proceed  from 
debility  of  the  said  vessels,  or  other  causes  ? 
In  the  view7,  which  I take  of  the  nature  of 
phlegmonous  inflammation,  1 consider  the 
following  circumstances  proved:  1.  The 

dilated  state  of  the  capillaries  in  the  imme- 
diate seat  of  inflammation.  2.  The  retard- 
ation, or  even  stagnation  of  the  circulation 
in  them.  3.  The  increased  action,  or  ex- 
citement of  the  larger  arteries  leading  to  the 
inflamed  part.  All  these  three  main  points 
seem  to  me  to  be  fully  established  by  the 
investigations  and  experiments  both  of  Dr. 
Wilson  Philip  and  Dr.  Hastings  ; and  1 may 
make  the  observation,  though  aware,  that 
the  latter  gentleman  does  not  regard  increa- 
sed action  of  the  larger  arteries,  as  a consti- 
tuent and  necessary  part  of  inflammation, 
because  cases  occur,  in  which  no  such  ex- 
citement can  be  detected  . (On  Inflammation , 
p 104,)  for,  I here  put  out  of  consideration 
chronic  inflammation,  which  I believe  is 
entirely  a different  process,  bearing  no  re- 
semblance to  the  acute  forms  of  the  disor- 
der, either  in  the  state  of  the  capillaries,  or  of 
the  largerarteries.  Assuming  the  above  points 
as  proved,  it  is  to  be  inquired,  whether  other 
facts,  such  as  the  heat  and  throbbing  in  the 
inflamed  part,  the  instantaneous  return  of 
redness  to  the  spot,  which  has  been  touched, 
and  the  efficacy  ot  common  treatment,  are  re- 
concileable  with  them,  or  not.  1 am  dispo- 
sed to  think  they  are  ; for,  it  is  only  asserted, 
that  the  passage  of  the  blood  is  more  or  less 
obstructed  in  the  capillaries  in  the  seat  of 
fiie  inflammation  ; and  the  larger  arteries, 
leading  to  them,  are,  for  the  most  part,  ob- 
viously in  a state  of  increased  action,  where- 
by a greater  quantity  of  (flood  must  be  sup- 
posed to  be  determined  towards  the  part. 
Now,  as  this  augmented  quantity  of  blood 
cannot  pass  freely  through  the  smaller  vessels,' 
in  the  immediate  place  of  inflammation,  it 
must  be  thrown  into  such  arteries  in  the 
neighbourhood,  as  are  capable  of  receiving 
it,  so  that,  in  fact,  the  theory  of  obstruction 
of  the  capillaries  may  not  be  altogether  in- 
compatible both  with  increased  action,  and 
quickened  circulation,  in  the  arteries  directlv 
around  the  parts,  in  which  there  is  a retarded 
circulation  in  the  capillaries.  This  view  of 
the  subject,  I think,  is  not  liable  to  greater 
perplexity  in  the  explanation  of  the  heat, 
throbbing,  &.c.than  former  doctrines,  involv- 
ing the  contracted  notion  of  there  beingan  in- 
creased action,  and  an  augmented  velocity 
ot  the  blood’s  motion,  in  all  the  arteries  of 
the  part  affected. 


Resolution  being  the  most  favourable  ter- 
mination of  common  inflammation,  it  is  of 
course  the  object  at  which  the  surgeon 
generally  aims  in  the  treatment.  Dr.  Philip’s 
very  ingenious  view  of  inflammation  leads 
him  to  suppose  that  resolution  arises  from 
the  debilitated  capillaries  being  excited  to 
due  action  by  the  increased  action  o the 
larger  arteries.  {On  the  Vital  Functions , 
p.  298.)  Rut  I am  of ' opinion,  that  t lie 
doctrine  of  debility  of  the  capillaries,  and 
the  hypothesis  of  their  being  strengthen- 
ed by  the  excitement  or  increased  action 
oi  the  larger  vessels  are  by  no  means  satis- 
factory, and  p rhaps,  not  very  intelligi- 
ble. On  the  contrary,  if  the  capillaries  are 
already  so  weak  as  to  be  distended  by  the 
ordinary  impulse  of  the  blood,  how  are  they 
to  be  restored  to  their  natural  dimensions  and 
functions  by  any  increased  action  of  tne  lar- 
ger arteries  P the  effect  of  which  I should 
conceive,  w'ould  be  to  gorge  them  still  more 
with  blood,  and  produce  e^en  a greater  dila- 
tation of  them.  Were  the  above  reasoning 
correct,  it  would  follow7,  that  a principal  in- 
dication in  the  treatment  would  be  to  pro- 
mote the  increased  action  of  the  larger  ar- 
teries, wfliereby  so  much  supposed  benefit 
is  communicated  to  the  debilitated  capilla- 
ries. Yet,  such  practice  is  contrary  to  the 
dictates  of  experience, ’and  is  even  inconsist- 
ent with  the  principles,  on  which  Dr.  Philip 
himself  thinks  the  treatment  should  be  found- 
ed. Indeed,  the  following  directions  are 
such,  as  I imagine,  will  be  perfectly  appro- 
ved of  by  practitioners,  who,  farfrom  looking 
upon  the  increased  action  of  the  arteries, 
as  a means  of  relief,  are  accustomed  to  do 
every  thing  in  their  power  to  lessen  and  re- 
sist it.  “ All  the  local  means  (says  Dr. 
Philip)  are  calculated  either  to  lessen  the 
contents  of  the  morbidly  distended  vessels,  or 
to  excite  these  vessels  to  expel  them,  i he 
general  means  are  regulated  by  the  effects, 
produced  by  the  disease  on  the  more  distant 
vessels,  through  the  medium  of  the  nervous 
system  ; the  objects  of  this  part  of  the  treat- 
ment being,  neither  to  allow  the  action  of 
these  vessels  to  tall  so  low7,  that  it  is  incapa- 
ble of  supporting  any  degree  of  circulation 
in  the  debilitated  vessels,  nor  to  become  so 
powerful,  as  farther  to  distend  by  gorging 
them  with  blood.  Thus , when  the  symptoms 
of  active  inflammation  run  high,  we  lessen  the 
vis  a tergo  ; when  gangrene  is  threatened,  we 
increase  it.”  (fV.  Philip , mi  the  Vital  Func- 
tions, p.  285,  Ed.  2.)  In  short,  as  soon  as  the 
fact  is  established,  that  a string  flow  of  blood 
towards  an  inflamed  part  tends  to  aggravate 
the  disorder,  all  difficulty  ceases  in  reconci- 
ling the  usual  means  of  relief  to  that  theory 
of  inflammation,  which  takes  into  the  ac- 
count a retarded  state  of  the  circulation  in 
the  distended  capillaries. 

The  means  employed  for  the  relief  of  in- 
flammation have  been  cursorily  noticed  in  a 
preceding  article.  (See  Jin  lip  hi  ogisl  ics.)  We 
shall  how  devote  a few  more  pages  to  u more 
particular  consideration  of  them. 

Removal  of  exciting  causes — In  all  cases 
the  first  circumstance  to  be  attended  to  is, 
the  removal  of  alisuch  exciting  causes  as  may 


INFLAMMATION. 


123 


happen  to  present  themselves.  if  the  irrita- 
tion of  a splinter  were  to  excite  phlegmo- 
nous inflammation,  who  would  not  of  his 
own  accord  directly  takeaway  the  extraneous 
body  ? In  wounds,  foreign  substances  fre- 
quently excitt  inflammation,  and  ought  to  be 
taken  away  as  speedily  as  possible  ; splinter- 
ed pieces  of  bone  often  give  rise  to  the  affec- 
tion, and  require  removal  ; the  head  of  a 
bone,  being  out  of  its  place,  may  press  and 
inflame  the  part  on  which  it  lies;  and  who 
does  not  immediately  see  the  propriety  of 
putting  it  back  into  its  natural  situation?  These 
and  other  similar  exciting  causes  may  often 
be  detected  and  removed  at  once,  and  this  is 
doing  a great  de<»l  towards  the  cure  and  even 
the  prevention  of  inflammation.  However, 
many  of  the  exciting  causes  ot  this  affection 
are  only  of  monientaiy  application;  yet, 
though  they  no  longer  exis: , the  process  of 
inflammation  must  follow,  as  a kind  of  salu- 
tary operation,  without  which,  the  injured  or- 
ganization, and  lone  of  the  parts,  still  remain- 
ing, could  not  be  rectified  again.  Hence 
besides  taking  away  the  remote  cause, 
whenever  this  can  be  done,  it  is  proper  to 
moderate,  by  other  means,  the  increased 
action  of  the  larger  arteries,  and  lessen  the 
velocity  of  the  blood’s  motion  towards  the 
inflamed  part. 

Bleeding — As  there  is  reason  to  believe, 
that,  in  common  inflammation,  a greater 
quantity  of  blood  is  impelled  towards  the  in- 
flamed part,  than  in  the  natural  state,  and 
experience  proves,  that  nothing  has  a more 
powerful  effect  in  checking  tiie  disorder, 
than  diminishing  the.  determination  of  blood 
to  the  partj  bleeding  must  be  a principal 
means  of  relieving  inflammation  : it  lessens 
the  action  ot  the  w hole  sanguiferous  system, 
and,  of  course,  of  that  part  of  it,  which  is 
directly  concerned  in  regulating  the  quantity 
of  blood  transmitted  to  the  part  affected. 
On  ihe  principle  also  of  lessening  the  whole 
mass  of  blood  in  the  circulation,  it  must  have 
a similar  effect. 

Bleeding,  however,  is  often  misemployed, 
especially  when  regarded  as  the  only  remedy 
for  inflammation,  and  other  steps  are  ne- 
glected. The  general  obstinacy  and  vehe- 
mence. of  the  process  in  weak  constitutions 
prove,  that  bleeding  is  not  invariably  proper, 
arid  in  such  individuals  it  often  appears,  as  if 
their  general  irritability  and  the  difficulty  of 
curing  the  inflammation  ‘ were  in  a ratio  to 
their  weakness.  S'*  hen  inflammation  is  com- 
plicated with  disorder  of  the  chylopoietio, 
blood  should  be  taken  away  with  great  cir- 
cumspection. 

A great  deal  of  induration  with  little  pain 
and  heat  in  the  inflamed  part ; the  probability 
of  a long  and  copious  suppuration,  as  is  the 
case  in  many  compound  fractures  ; and  the 
connexion  of  ihe  inflammation,  with  a want 
of  tone  in  tiie  part  ; are  particular  instances, 
in  which  the  praelilionershould  he  sparing  of 
this  evacuation.  Bleeding  is  sometimes  quite 
unnecessary,  when  the  local  inflammation 
and  symptomatic  fever  are  trivial,  when  the 
patient  is  feeble  or  very  old,  and  when  the 


cause  of  the  afi'eclioa  can  be  entirely  remo- 
ved. (Richter.) 

On  the  other  hand,  bleeding  is  highly  be- 
neficial when  the  inflammation  is  uncompli- 
cated with  any  previously  existing  disorder 
of  the  gastric  system,  while  it  is  considerable 
in  extent  and  degree,  and  attended  with  a 
good  deal  of  febrile  disturbance.  The  same 
pruciice  is  also  strongly  indicated,  when  the 
part  affected  is  very  sensible,  ami  highly  im- 
portant, in  regard  to  its  office  in  the  system. 
Thus  the  lancet  must  he  trecly  employed  in 
acute  ophthalroy,  or  inflammation  ot  the  eye, 
which  is  a must  sensible  part  ; and  in  inflam- 
mation of  the  lungs,  brain,  or  stomach  ; 
organs,  the  sound  state  of  which  is  essential 
to  the  regular  continuance  ot  all  the  various 
operations  in  the  animal  machine  ; and  it  a 
successful  effort  be  not  promptly  made  to  .-(op 
such  inflammation  by  die  most  vigorous 
means,  death  itseit  will  be  the  result. 

Iu  general,  bleeding  may  be  said  to  be 
indicated,  when  the  patient  is  young,  robust, 
and  plethoric  ; when  the  cause  ot  the  disor- 
der can  neither  be  removed  nor  diminished  ; 
and  when  there  is  a very  strong  motive  for 
wishing  to  avoid  the  formation  ot  matter.  In- 
flammation of  the  eye  is  a case,  illustrative 
of  the  truth  of  the  last  observation  ; for,  if 
suppuration  lake  place  in  this  organ,  the 
com nion  consequence  is  so  serious  a destruc- 
tion ot  its  internal  structure  and  organization 
that  the  future  restoration  of  sight  is  totally 
impossible.  In  the  examples,  tailing  under 
the  conditions  specified  as  requiring  blood 
to  be  taken  away,  it  is  sometimes  necessary 
Irequeutly  to  repeat  the  evacuation. 

The  efficacy  of  bleeding  is  greater,  the 
sooner  it  is  practised,  and  the  more  suddenly 
the  blood  is  evacuated.  Bleeding  near  the 
part  affected  is  usually  mure  effectual,  than 
when  done  in  a remote  situation.  Hence,  in 
inflammation  of  the  eye,  or  brain,  it  is  often 
considered  most  advantageous  to  take  biood 
from  the  temporal  artesy. 

“ Iu  many  inflammations,  particularly  those 
of  the  parts  contained  iu  ihe  three  great 
cavities  of  the  head,  chest,  and  belly,  general 
blood-letting  (says  a judicious  writer)  if  not 
the  only,  is  the  principal  remedy,  to  which 
vre  can  trust  for  a cure.  The  quantity  of  blood, 
which  in  these  inflammations  it  is  necessary 
to  take  away,  varies  according  16  the  violence 
of  the  inflammation,  the  temperament,, 
strength,  and  habits  ot  the  patient,  and  ac- 
cording to  the  structure,  functions,  and  situa- 
tion of  the  organ  in  which  it  occurs.  From 
twelve  to  twenty  ounces,  or  even  more,  ought 
generally  to  be  drawn  every  time  we  have 
occasion  to  use  the  lancet  in  the  cure  of 
inflammation,  and  bleeding  to  this  extent  may 
be  repeated  two  or  three  times  in  the  course 
of  the  first  twenty-four  hours,  according  to 
t ie  effects  which  it  seems  to  produce,  as  w ell 
as  according  to  the  violence  and  urgency  of 
the  symptoms.  In  inflammation  ot  internal 
parts,  we  judge  of  the  effect  ot  bleeding,  and 
of  the  necessity  of  a repetition,  from  (he 
feeling  and  continuance  of  pain,  from  the 
state  of  the  pulse,  and  also  from  the  appear- 


124 


INFLAMMATION. 


anc«  of  (lie  blood,  which  has  been  last 
drawn 

u A partial,  and  in  some  instances,  an  al- 
most complete  cessation  ot  pain  takes  place 
even  during  the  operation  of  blood-letting. 
This  is  always  a favourable  symptom,  and 
indicates,  that  the  i fl  nunation  has  made  rio 
great,  nor  very  alarming  progress.  In  other 
instances,  the  relief  from  pain,  though  incon- 
siderable, at  the  time  of  bieedirg,  becomes 
afterward  more  sensible,  and  the  other 
symptoms  of  inflammation  abate  in  nearly 
the  same  proportion  ; while,  in  other  in- 
stances a^ain,  the  pain  i-  either  not  relieved 
by  the  bleeding,  or,  if  relieved,  the  relief  is 
but  of  short  duration.  These  last  are  cases, 
in  which  the  other  symptoms  ot  inflamma- 
tion continuing  unabated,  recourse  must  be 
had  again  to  the  use  of  the  lancet,  and  as 
much  blood  drawn,  as  can  be  done  with 
safety  to  the  patient. 

“The  changes,  which  take  place  in  the 
state  of  the  pulse,  either  with  regard  to  its  fre- 
quency, or  strength,  during,  or  soon  afterthe 
abstraction  of  blood,  though  they  attend  crite- 
ria, b\  which  we  may  judge  of  the  stale  of  the 
inflammation  nd  of  the  eff.  ctsof  the  bleed- 
ing, are  by  no  mean-  marks  so  sure  ol  the  ad- 
vantage, which  has  been  obtained,  as  that 
derived  from  the  cessation  of  pain. 

“In  some  inflammations  of  the  head,  for 
example,  the  pulse  is  slower  than  natural, 
though  it  beats  with  its  accustomed,  or  even 
with  an  increased  degree  of  strength.  In 
inflammations  also  of  the  peritonaeum,  and  of 
the  intestinal  ca.  al,  we  find  the  pulse  not 
much  quicker  than  natural,  small,  and  con- 
tracted. We  should  deceive  ourselves, 
therefore,  were  we  to  infer,  that  an  increase 
of  inflammation  had  taken  place,  because, 
in  the  first  instance,  the  pulse  had  become 
quicker,  and  in  the  second,  fuller  and  strong- 
er, during  or  soon  after  the  abstraction  of  a 
quantity  of  blood. 

“ The  pulse,  it  may  be  remarked,  has  often 
a contracted,  cord-like  feel  in  inflammation, 
and  it  may  always  be  regarded  as  a favour- 
able event,  when  it  becomes  softer,  fuller, 
and  slower,  during  or  soon  after  blood-let- 
ting.” (See  Thomson's  Lectures  on  Inflam- 
mation, p.  lt>»>,  It'S.) 

With  respect  to  I he  butty  coat  of  the  blood, 
Dr.  Thomson  stales,  that  it  is  not  by  the 
buffy  coat  alone,  hut  by  the  butty  coat,  in 
conjunction  with  the  quantity  and  firmness 
of  the  coagulum,  that  v\e  must  judge  of  the 
propriety  of  any  further  detraction.  When 
the  buffy  coat  has  a firm  and  tenacious  con- 
sistence, and  when  the  pain  continues  una- 
bated, we  may  conclude,  that  the  inflamma- 
tion is  not  subdued.  But,  when  the  c lagulum 
is  soft  and  easily  broken  and  when  the 
colour  of  the  buffy  coat  is  changed  from  a 
yellowish  to  a greenish  hu  ■,  Dr.  Thomson 
thinks,  that  little  or  no  benefit  can  be  derived 
from  bleeding.  Efut - as  already  mentioned, 
every  practitioner  should  remember,  that,  in 
particular  constitutions,  and  in  pregnancy, 
the  blood  lakeri  away  naturally  exhibits  a butty 
appearance,  independently  of  inflammation. 

The  preceding  remarks  chiefly  relate  to 


general  bleeding  ; for,  in  phlegmonous  inflam- 
mation. topical  bleeding  is  scarcely  ever 
improper.  It  is  always  a point  highly  worthy 
of  the  surgeon’s  consideration,  whether 
bleeding  in  or  near  the  part  will  answer  bet- 
ter, than  taking  the  blood  from  the  general 
habit ; for,  certainly  less  may  be  removed  in 
this  w ay,  so  as  to  have  equal  effect  upon  the 
part  inflamed,  and  probably,  upon  every 
other  disease  that  is  relieved  by  bleeding, 
with  less  injury  to  (he  constitution.  Although, 
in  many  case-.,  ihe  general  habit  is  relieved 
by  bleeding,  yet  it  is  the  part  affected  which 
most  requires  this  evacuation.  That  local 
bleeding  lias  very  considerable  effects  on  the 
inflamed  part,  is  proved  by  the  sudden  relief 
u hich  is  often  produced  by  the  application  of 
leeches  in  cases  of  gout  The  mere  use  of 
leeches,  without  other  measures,  will  also 
sometimes  remove  a tumour  in  the  breast, 
having  all  the  appearances  of  a scirrhus, 
which  cannot  be  considered  as  inflammatory, 
so  that  topical  bleeding  extends  its  power 
further,  than  the  mere  checking  of  inflam- 
mation. Some  part  of  its  effect  has  been 
imputed  to  sympathy.  (Hunter.)  There 
are  three  modes  of  performing  topical  bleed- 
ing : by  cupping;  by  leeches;  and  by  dividing 
or  scarifying  the  dilated  vesse|>  leading  to  the 
inflamed  part.  (See  Bleeding.)  Upon  the 
head  and  face,  leeches  are  commonly  em- 
ployed ; upon  the  chest,  either  leeches  or 
cupping;  upon  the  abdomen,  leeches;  and 
upon  the  joints,  either  cupping  or  leeches. 
When  the  eye  is  inflamed,  leeches  may  either 
be  applied  to  the  adjoini  g temple  ; or  the 
dilated  vessels  of  the  conjunctiva  may  be 
scarified  ; or  both  methods  may  be  adopt- 
ed. When  the  inflammation  extends  quite  to 
the  surface  of  the  body,  leeches  are  always 
most  eligible,  as  their  bites  cause  less  irritation 
in  inflamed  parts,  than  the  punctures  of  the 
scarificator,  or  the  pressure  of  cupping 
glasses. 

Purging.  The  exhibition  of  mild  laxative 
medicines,  and  saline  purgatives,  isa  principal 
means  of  diminishing  inflammation.  Purging 
does  not  produce  such  lasting  weakness  as  is 
the  consequence  of  bleeding,  and,  therefore, 
it  is  scarcely  ever  omitted,  even  when  the 
abstraction  of  blood  is  deeme  l improper. 
Saline  purges  must  lessen  the  quantity  of 
circulating  blood,  inasmuch  as  they  increase 
the  secretion  from  the  intestinal  arteries  ; and 
therefore,  t hey  probably  operate  beneficially 
in  the  cure  of  local  inflammation,  much  upon 
the  same  principle  as  bleeding.  Mr.  Hunter 
was  of  opinion,  that  purging  lowers  action, 
without  diminishing  strength,  by  which  we 
are  probably  to  understand,  without  produ- 
cing a very  lasting  or  permanent  loss  of 
strength.  With  respect  to  mild  laxative  me- 
dicines, none  are  superior  to  manna,  rhubarb, 
oleum  m ini,  and  the  like  ; and  of  the  saline 
purgatives,  the  best  are,  the  sulphate  of  soda, 
tartrate  of  potass,  phosphate  of  soda,  and 
sulphate  of  magnesia.  It  may  here  be  re- 
marked, that,  besides  the  benefit,  which  the 
local  i ii II  munition  derives  from  the  judicious 
administration  of  purgatives,  the  costiveness 
and  heat,  which  usually  attend  the  syropto- 


INFLAMMATION. 


123 


uiatic  fever,  sue  also  removed  by  the  same 
means. 

“ Purgatives  (says  Dr.  Thomson)  are  more 
or  less  required  in  almost  every  species  of 
inflammation  ; but  they  are  more  peculiar- 
ly necessary  in  those,  which  are  accompa- 
nied with  a high  degree  of  fever,  or  with 
derangement  of  the  digestive,  or  biliary  or- 
gans In  cases  of  inflammation,  which  have 
a tendency  to  spontaneous  resolution,  they 
are  almost  always  the  best,  and  often  the 
only  remedies  that  are  required.”  ( Lectures 
on  Inflammation,  p 171  ) 

Considering  the  general  approbation  of 
the  employment  of  mild  saline  purgatives  in 
cases  of  inflammation,  I confess  that  1 was 
not  a little  surprised  to  find  merely  the  fol- 
lowing short  unfavourable  notice  taken  of 
them  by  a celebrated  foreign  professor,  in 
his  account  of  the  treatment  of  inflamma- 
tion. “ As  for  purgatives,  they  must  be 
used  with  discretion.  There  are  none  of 
them  antiphlogistic,  as  has  been  pretended. 
They  always  produce  more  or  less  irritation, 
and  can  only  be  applicable,  when  the  cause 
of  the  inflammation  is  in  the  intestinal  ca- 
nal. In  the  beginning  of  the  complaint  we 
ought,  therefore,  in  general  to  abstai  from 
them,  and  confine  ourselves  to  emollient 
clysters  ” ( Boyer , Trail6  des  Maladies  Chi- 

rurgicales , T.  1,  p.  39.) 

Diaphoretic  and  nauseating  Medicines. 

Medicines,  which  have  the  power  of  pro- 
ducing sickness,  lessen,  fora  time,  the  ac- 
tion, and  even  the  general  powers  of  life. 
This  is  in  consequence  of  every  part  of  the 
body  sympathizing  with  the  stomach  ; and 
the  effect  may  be  very  quickly  excited 
Sickness  lowers  the  pulse,  makes  the  small 
vessels  contract,  and  rather  disposes  the  skin 
to  perspiration  But,  nothing  more  than 
nausea  should  be  caused ; for  vomiting 
"rather  rouses  than  depresses.  ( Hunter ) 
Nauseating  medicines,  employed  after 
bleeding  has  been  practised  once  or  twice, 
are  often  productive  of  considerable  bene- 
fit ; but  there  are  some  affections,  in  which 
they  cannot  be  used,  such  as  inflammation 
of  the  stomach  and  intestines.  In  all  super- 
ficial inflammations,  however,  they  may  be 
safely  and  advantageously  exhibited,  as 
well  as  in  most  inflammatory  affections  in- 
ternally situated.  In  inflammation  of  the 
dura  mater  and  brain,  and,  indeed,  iri  every 
instance,  in  whieh  there  is  an  urgent  reason 
for  putting  as  sudden  a check  as  possible  to 
the  continuance  of  the  affection,  the  em- 
ployment of  nauseating  doses  of  antimony 
is  most  strongly  indicated.  The  tarlrite  of 
antimony  (emetic  tartar)  is  the  medicine,  on 
WThich  practitioners  place  the  greatest  reli- 
ance, and  it  is  to  be  prescribed  for  the  pur- 
pose of  exciting  nausea,  as  follows: — 1^. 
Antimonii  tartarisati  grana  duo  ; Aquae  dis- 
tillatae  uncias  quatuor.  Misce  et  cola.  Do- 
sis,  Uneia  dimidia  sexta  quaque  hor<i. 

The  safest  diaphoretics  are  citrate  of  po- 
tass, acetate  of  ammonia,  and  tarlrite  of  an- 
timony, and  James’s  powder.  The  two 


latter, from  theip  effects  in  producing  nausea, 
and  weakening  the  pulse,  are  sometimes 
most  efficacious,  as  already  stated. 

“ The  warm  bath  seems  fo  act  (as  a mo- 
dern writer  says)  not  only  by  increasing  the 
tendency  to  perspiration,  but  also  by  occa- 
sioning a determination  of  blood  to  those 
parts  of  the  body  to  which  it  is  more  imme- 
diately applied.  It  is  in  this  w ay  that  bath- 
ing the  feet  seems  to  relieve  inflammatory 
affections  of  the  head  and  throat.  1 have 
not  seen  any  experiments,  nor  am  1 ac- 
quainted with  any,  which  have  been  made 
with  a view  to  ascertain  its  use  in  the  in- 
flammations of  the  chest ; but,  in  all  inflam- 
mations of  the  belly,  and  of  the  viscera  con- 
tained within  that  cavity,  there  are  no  other 
means  of  cure,  blood-letting  excepted, 
which  afford  such  sudden  and  permanent 
relief  as  that  which  is  obtained  from  hot  fo- 
mentations and  warm  bathing.”  (See  Thom- 
son on  Inflammation,  p.  173.) 

Opium.  The  majority  of  surgeons  enter- 
tain an  insuperable  objection  to  the  admi- 
nistration of  opiates  in  almost  all  cases  of  in- 
flammation, and  the  aversion  to  this  prac- 
tice is  for  the  most  part  deducible  from  the 
recollection  of  opium  being  a powerful  sti- 
mulant. The  plan,  however,  has  its  advo- 
cates. ( B . Bell ; Richter , <^c.)  One  of  its 
strongest  partisans  tells  us,  that  opium  parti- 
cularly lessens  the  disturbance  of  inflamma- 
tion, and  allays  pain,  which  is  at  once  a 
principal  symptom  of  the  process,  and  a 
cause  of  its  augmentation,  as  well  as  that  of 
the  fever.  Opium  also  quiets  the  inordinate 
action  of  the  solids,  the  mental  agitation 
and  restlessness  so  powerfully,  that  it  well 
deserves  the  name  of  the  grand  antiphlogis- 
tic remedy.  It  likewise  occasions  a mois- 
ture on  the  surface  of  the  body,  which  ex- 
perience shows  is  eminently  serviceable  in 
all  inflammations  affecting  the  skin.  When 
given  with  this  view,  it  is  usually  conjoined 
with  antimony,  camphor,  calomel,  or  ipe- 
cacuanha. The  administration  of  opium  is 
a general  practice  in  all  painful  inflamma- 
tions arising  from  external  causes,  and  it  is- 
attended  with  perfect  safety  when  evacuations 
from  the  bowels  and  bleeding  have  beenprevi- 
oo, sly  put  in  practice.  Care  must  be  taken 
to  give  it  in  sufficient  doses;  for  small  quan 
tities  not  only  fail  in  fulfilling  the  object, 
but  frequently  produce  quite  an  opposite 
effect.  During  its  employment,  the  bowels 
should  be  kept  open  with  glysters.  The 
efficacy  of  opium  chiefly  manifests  itself  in 
the  early  stage  of  the  affection  ; for,  as  soon 
as  the  inflammatory  fever  has  extended  it- 
self to  the  w7hoie  system,  it  loses  its  benefi- 
cial virtues.  Hence,  in  cases'  of  external 
injuries,  it  is  to  be  given  the  two  first  days, 
immediately  after  bleeding.  It  is  to  he 
given  as  soon  after  the  accident  as  possible, 
in  order  to  tranquillize  the  mental  alarm, 
and.  if  convenient,  towards  the  evening,  for 
the  sake  of  procuring  a quiet  night.  ( Rich- 
ter.) Evacuations  being  premised,  says  the 
other  advocate  for  this  medicine,  the  next 
object  of  importance  is  to  procure  ease  and 
quietness  to  the  patient,  w hich,  in  cases  of 


126 


INFLAMMATION. 


inflammation,  are  often  of  more  real  service, 
than  any  other  circumstance  whatever. 
The  most  effectual  remedy  for  this  purpose 
is  opium,  which,  when  the  pain  and  irrita 
tion  are  considerable,  as  very  frequently 
happens  in  extensive  inflammations,  should 
never  be  omitted.  In  large  wounds,  espe- 
cially after  amputations,  and  other  capital 
operations,  and  in  punctures  ot  all  kinds, 
lar.  e doses  of  opium  are  al  vays  attended 
with  remarkably  ood  effects  In  all  such 
cases,  however,  opium,  in  order  to  have  a 
proper  in  tuence,  should  he  administered  in 
very  la.  :e  doses  ; otherwise,  instead  of 
proving  serviceable,  it  sterns, rather  to  have 
the  contrary  effect.  This  circumstance  is, 
perhaps,  the  < iiief  reason  why  opiat  s in 
general  have  been  very  u.nj  stly  condemn- 
ed in  every  case  of  inflammation.  ( B . Bell.) 

Oil  the  contrary,  those  who  are  averse  to 
the  use  of  opium,  remark,  that  in  acute  in- 
flammation daily  experience  shows,  inde- 
pendently of  every  theory,  that  the  exhibi- 
tion of  this  medicine  increases  the  general 
fever,  and  aggravates  the  local  action.  Even 
given  as  a preventive  of  inflammation,  after 
operations  anodynes  are  almost  uniformly 
hurtful,  producing  restlessness,  heat,  thirst, 
and  afterward  headacb,  sickness  and  fre- 
quently troublesome,  vomiting.  (Burns.) 

According  to  Dr.  Thomson.  “ thos«-  dia 
phoretics,  into  the  composition  of  which 
opium  enters,  seem  to  be  better  adapted 
for  inflammation  attended  with  fever  of  a 
typhoid  character,  or  for  cases  where  the 
inflammation  has  existed  for  a considerable 
time  before  diaphoretics  are  employed. 
Given  at  an  early  period  in  acute  inflamma- 
tory diseases,  opium  never  tails  to  excite 
vascular  action,  and  to  aggravate  all  the 
symptoms  of  fever.  Opium,  therefore,  is 
not  to  be  used,  unless  to  allay  the  pain  and 
irritation  from  a surgical  operation,  or  from 
the  recent  infliction  of  an  external  injury. 
Indeed,  unless  when  the  patient  is  very 
nervous,  and  complains  much  of  pain,  its 
use,  even  after  chirurgical  operations,  had, 
I believe,  in  general,  better  be  abstained 
from,  as  it  almost  never  mils  to  add  to  the 
violence  of  the  symptomatic  fever,  which  is 
the  necessary  consequence  of  the  operation. 
Tts  effects  are  often  very  beneficial,  when 
the  period  of  this  fever  has  passed  over.” 
(See  Lectures  on  Inflammation,  p.  172.)  lip- 
on  the  whole,  candour  obliges  me  to  own, 
that  the  majority  of  surgeons  in  this  country 
are  decidedly  against  the  general  use  of 
opium  in  inflammation  ; but,  after  the  per- 
formance of  severe  operations,  and  in  all 
instances  attended  with  excessive  pain, 
truth,  I believe,  will  justify  my  saying,  that 
they  are  in  favour  of  the  exhibition  of  this 
remedy. 

Diet  and  Regimen. — In  all  cases,  the  sur- 
geon is  to  forbid  the  use  of  wine  and  spirits  ; 
and,  when  the  inflammation  is  at  all  consi- 
derable, the  same  prohibition  is  to  be  made 
in  regard  to  animal  food.  Watery,  cooling, 
mucilaginous  drinks  are  proper;  for  they 
keep  off  thirst  and  heat,  promote  perspira- 
tion. and  tend  to  sooth  the  increased  action 


of  the  whole  arterial  system.  For  this  pur- 
pose, whey,  buttermilk,  barley- water  de- 
coctions of  dried  fruits,  water-gruel,  &c. 

may  be  given. 

When  diluent  drinks  “ are  intended  to 
allay  thirst,  as  well  as  to  promote  perspira- 
tion, the  addition  of  some  vegetable  acid, 
such  as  lemon-juice,  or  cream  of  tartar,  ren- 
ders them  in  general  very  palatable  to  pa- 
tients In  the  earlier  stages  of  inflammation, 

and  where  the  object  is  to  induce  a mois- 
ture on  the  skin,  the  mineral  acids,  though 
t iey  might  serve  to  quench  thirst,  are  not 
to  be  employed, as  thevtend  rather  tocheck, 
than  promote  the  flow  of  sweat.”  (Thom- 
son on  Inflammation,  p.  172  ) . # 

The  chamber,  in  which  the  patient  lies, 
should  not  be  warmer  than  hi-,  comfort  re- 
quires ; for  heat  ten  is  powerfully  to  keep 
up  an  increased  action  of  tne  sanguiferous 
system.  For  the  same  reason,  the  patient 
should  not  be  covered  with  a superfluous 
quantity  of  bed-clothes. 

The  whole  bodv;  but  more  especially  the 
inflamed  part,  should  be  preserved  as 
complete  a state  of  rest  as  poi  ible.  '..very 
one  k ows,  that  all  motion,  exercise,  and 
muscular  exertion,  accelerate  the  circula- 
tion, and.  hence,  must  have  a pernicious 
effect  on  inflammation,  by  determining  a 
larrer  quantity  of  blood  to  the  part  affected. 

Applications.  With  the  exception  of  what 
has  been  stated,  concerning  topical  bleeding, 
all  the  foregoing  remarks  relate  to  the  ge- 
neral treatment  of  inflammation  : the  local 
means  remain  for  consideration. 

It  has  been  already  observed,  that  phleg- 
mon is  attended  with  an  increase  of  heat  in 
the  part  affected,  and  it  is  an  acknowledged 
and  well-known  fact,  that  the  action  of  the 
arteries,  as  well  as  every  other  operation  in 
the  animal  economy,  is  promoted  and  in- 
creased by  the  influence  of  heat,  for  this 
reason,  an  obvious  indication  arises,  viz.  to 
reduce  the  temperature  of  the  inflamed  part, 
by  the  topical  application  >f  cold,  and,  in 
particular,  bv  continually  abstracting  the 
heat  evolved  in  the  part,  by  keeping  up  a 
constant  evaporation  from  its  surface. 

« Of  the  local  remedies,  applied  directly 
to  inflamed  parts  (says  Dr.  Thomson)  cold 
is  undoubtedly  one  of  the  most  powerful. 
In  reducing  the  temperature,  cold  dimi- 
nishes the  morbid  sensibility  and  pain  ot  in- 
flamed parts;  and,  probably, in  consequence 
of  this,  the  action  also  of  the  vessels,  by 
which  the  inflamed  parts  are  supplied  with 
blood.  The  most  common  mode  ot  em- 
ploying cold  is  by  the  application  to  the 
part  inflamed  of  cloths,  which  have  been 
dipped  in  cold  water.  These  are  to  be  repeat- 
ed as  often  as  they  become  warm,  or  any 
relief  is  experienced  by  the  patient  from 
their  use.  When  the  inflammation  is  seat- 
ed on  the  remote  parts  of  either  the  upper 
or  lower  extremities  ot  the  body,  the  in- 
flamed part  itself  may  he  immersed  in  wa- 
ter. This  immersion,  as  I shall  afterward 
have  occasion  to  mention,  has  often  been 
found  useful  in  superficial  burns.  In  1)1  ”r.1 
to  increase  the  effect  produced  l»v  cold,  it 


IN-FLA  MM \TFQN, 


327 


lias  been  proposed  to  reduce  the  tempera- 
ture of  the  water  below  that  of  the  surround- 
ing atmosphere,  by  a proper  mixture  of  sa- 
line bodies,  as  some  of  these  are  known  to 
produce  cold  during  their  solution  in  water, 
or  even  in  very  urgent  cases  to  apply  ice  or 
snow.  The  ice,  however,  must  not  be  ap- 
plied too  long,  nor  in  too  large  a quantity  ; 
for,  it  very  quickly  reduces  the  temperature 
of  the  part  to  which  it  is  applied,  and,  in 
some  instances,  has  been  known  to  occa- 
sion gangrene,  &c.  (On  Inflammation,  p. 
180.) 

With  the  cold  water  applied  to  phlegmo- 
nous intiammation,  it  is  usual  to  blend  some 
remedies  which  are  astringent,  and  suppo- 
sed to  nave  also  a sedative  quality.  Theace- 
tite  of  h ad,  sulphate  of  zinc,  and  vinegar, 
seem  now,  indeed,  to  have  acquired  p>  rma- 
nent  celebrity  for  their  efficacy  in  resolving 
intiammation. 

Extensive  experience,  and  long-establish- 
ed trials,  have  now  fully  confirmed  the  vir- 
tue of  all  those  local  remedies,  in  which  the 
acetite  of  lead  is  the  active  ingredient.  M. 
Goulard,  and  other  French  surgeons,  found, 
that  the  objections  to  the  employment  of 
many  other  sedative  applications  in  the 
treatment  of  inflammation,  did  not  exist 
against  the  use  of  this  preparation  of  lead 
The  universal  assent  of  modern  practitioners 
proves,  indeed,  that  the  acetite  of  lead  as  a 
local  application  for  genuine  phlegmonous 
inflammation,  is  certainly  unsurpassed,  if 
not  unrivalled,  in  point  of  efficacy. 

The  preparations  of  lead  are  recommend- 
ed by  M.  Goulard,  as  almost  equally  applica- 
ble to  every  stage  of  inflammation.  When 
swellings  have  fully  suppurated,  the  employ- 
ment, of  what  he  calls,  the  extractum  Satur- 
ni,  will  almost  always  render  it  unnecessary 
to  open  them.  Even  in  gangrene,  the  solu- 
tion of  lead  is  represented  by  this  zealous 
writer,  as  a remedy  deserving  of  the  greatest 
confidence. 

But,  notwithstanding  the  above  exaggera- 
tion, every  man  of  experience  and  observa- 
tion will  allow,  that,  while  there  is  a chance 
of  accomplishing  resolution,  no  local  appli- 
cations to  phlegmonous  inflammation  are  in 
general  so  proper  as  cold  lotions,  containing 
the  acetite  of  lead. 

“ The  manner  in  which  it  operates  in 
curing  inflammation  (as  Dr.  Thomson  ob- 
serves) is  not  known  to  us,  nor  is  it  at  all 
times  easy  to  distinguish  between  the  share, 
which  the  lead  has  in  allaying  inflammation, 
and  that  which  is  to  be  attributed  to  the 
coldness  of  the  water  in  which  it  is  dissolved. 
No  one,  however,  will  doubt  of  the  efficacy 
of  this  remedy,  who  has  ever  felt  it  in  his 
own  body,  or  witnessed  in  others  the  sooth- 
ing and  agreeable  effects,  which  it  produces 
in  excoriations cf  the  skin,  or  in  inflamma- 
tion of  mucous  membranes.  Lead  is  a 
remedy,  which  is  often  highly  useful  in 
excoriations  from  friction,  in  punctured 
wounds  with  inflammation  of  absorbent 
vessels,  veins,  nerves,  &c.  in  slight  burns,  in 
cutaneous  heat,  eruptions  ot  the  face,  in  frac- 
tures and  dislocations,  in  the  inflammation 


attending  scirrhus  and  cancer,  syphilis  and 
gonorrhoea,  in  wounds  accompanied  w it'a 
excoriation  from  the  discharges  they  emit, 
and  in  wounds  attended  with  a burning 
sensation  of  pain.”  (P.  182.) 

F rom  the  poisonous  qualities  of  lead,  when 
taken  into  the  system,  and  from  the  possi- 
bility of  this  mineral  being  absorbed  from 
the  surface  of  the  body,  objections  have 
arisen  against  the  free  use  of  its  preparations, 
even  as  outv\ard  remedies  in  cases  of  inflam- 
mation. Certain  it  is,  however,  that  though 
the  possibility  of  such  absorption  is  proved 
by  the  occurrence  of  the  disorder  called  the 
colica  pictonum,  which  originates  in  painters 
from  the  white  lead  absorbed  into  the  sys- 
tem, yet,  any  ill  effects  from  the  use  of  lead, 
as  an  application  io  inflamed  parts,  are  so 
exceedingly  rare,  that  they  can  hardly  form 
a serious  objection  to  the  practice,  ft  is  a 
fact,  that,  in  inflamed  parts,  there  is  an  im- 
pediment to  absorption,  and  this  circum- 
stance may  tend  to  render  the  employ  ment 
of  lead  a matter  of  safety.  Mr.  B Bell  ob- 
serves, that  in  all  the  experience  which  he 
had  had  of  the  external  application  of  lead 
and  its  preparations,  and  in  many  cases,  par- 
ticularly of  burns,  where  he  had  known  the 
greatest  part  of  the  surface  of  the  body 
covered  with  applications  of  this  description 
for  days,  nay,  for  weeks  together,  he  did 
not  recollect  a single  instance  of  any  disa- 
greeable symptom  being  ever  produced  by 
them.  Nor  has  Dr.  Thomson  ever  seen  the 
colica  pictonum  follow  the  use  of  Goulard. 
(See  Lectures  on  Inflammation,  p . 183.) 

A lotion  composed  of  acetite  of  lead,  vine- 
gar, and  water,  is  very  commonly  employed. 

Plumbi  Acetatis  jjss.  Solve  in  Acet.  pur. 
j|iv.  Et  adde  Aq.  Fontanae  distill.  Ifoij.  The 
vinegar  makes  the  solution  more  complete. 
In  all  common  cases,  a teaspoonful  of  the 
liquor  plumbi  acetatis,  blended  with  a pint 
of  water,  will  be  found  an  eligible  lotion. 
Occasionally,  bread-crumb  is  moistened  in 
the  fluid,  and  applied  in  the  form  of  a poul- 
tice ; but  linen  dipped  in  the  lotion,  and 
kept  constantly  wet  with  it,  is  mostly  pre- 
ferred. Thus  a continual  evaporation  is 
maintained,  and  of  course  a regular  abitrac- 
tion  of  heat. 

When  the  surgeon  is  afraid  of  employing 
a solution  of  lead,  he  may  try  one  of  the 
sulphate  of  zinc.  One  dram  of  this  sub- 
stance is  to  be  dissolved  in  a pint  of  wa- 
ter, and  linen,  well  wet  with  the  lotion,  is 
to  be  applied  to  the  inflamed  part. 

Many  practitioners  impute  very  little  real 
efficacy  either  to  the  acetite  of  lead,  or  sul- 
phate of  zinc,  contained  in  the  above  ap- 
plications : and  they  attribute  all  the  good 
that  is  produced,  entirely  to  the  evaporation 
kept  up  from  the  surface  of  the  inflamed 
part,  and  to  the  cotdnessof  the  fluid  in  which 
the  metallic  salts  are  dissolved.  Surgeons, 
who  entertain  these  sentiments,  think  the 
application  of  simple  cold  water  quite  as 
efficacious  as  that  of  any  medicated  lotions. 

There  are  particular  cases  of  inflammation, 
in  which  the  extravasation  of  blood  and 
lymph,  in  the  interstices  of  the  inflamed 


INFLAMMATION. 


m 


part,  is  exceedingly  copious,  and  the  swell- 
ing considerable,  but  the  pain  and  redness 
not  particularly  great.  In  such  instances,  it 
is  an  indication  to  rouse  the  action  of  the  ab- 
sorbents, in  order  that  those  vessels  may  re- 
in >ve  the  extravasated  fluid,  and  with  this 
V;  mv,  a more  powerf  d discuiieut  lotion  may 
be  employed  than  in  other  cases,  and  some- 
times, it  is  even  better  to  use  embrocations 
and  linimen  s,  than  any  sort  of  lotion.  The 
following  discutient  lotions  are  often  em- 
ployed : Ammonite  Muriataj  ,^ss.  'ceti , 

Spiriths  Vini  rectificati  ; sing  ft>j.  M.  p*. 
Liq.  Ammon.  Acet.  Spir.  Vini  rectil.  ;•  Aq. 
Distillatai ; sing.  §iv.  M.  The  Liq.  Ammo-, 
nia?  Acet.  also  alone  answers  very  well. 

When  the  part  affect- d with  inflammation 
is  not  very  tender,  or  when  it  lies  deep,  ap- 
plications of  the  vegetable  acid  are  often 
had  recourse  to  with  considerable  advan- 
tage ; and  the  most  effectual  form  of  using 
it  seems  to  be  a poultice  made  with  vinegar 
and  crumb  of  bread.  In  such  cases,  it  lias 
been  thought,  that  an  alternate  use  of  this 
remedy,  and  the  saturnine  lo.  ion,  has  produ- 
ced more  beneficial  effects,  than  are  com- 
monly observed  from  a continued  use  of  one 
of  them.  (B.  Bell.)  However,  surgeons  of 
the  present  day  see  to  think,  that  vinegar 
can  be  as  advantageously  applied  in  the  form 
ot  a lotion,  as  in  that  of  a poultice,  and, 
certainly,  with  less  trouble. 

Alcohol  and  aither  Have  acquired  some 
celebrity  as  local  remedies  for  inflammation. 
No  doubt  one  great  reason  why  they  are  not 
more  extensively  used  for  this  purpose  is, 
the  expense  attending  such  treatment,  as 
these  fluids  evaporate  with  great  rapidity. 
Alcohol  may  possibly  prove  useful  from  its 
astringent  qualities  ; but  it  seems  uch 
more  rational  to  impute  both  its  virtue,  and 
that  aether,  to  the  powerful  manner,  in 
which  their  evaporation  deprives  the  infla- 
med nart  of  its  heat. 

Warm  Applications.  The  absurdity  of  at- 
tempting to  reconcile  every  usef-d  practice 
\vl  . a philosophical  theory,  is,  in  no  in- 
stance, morestri;  igly  exemplified,  than  in 
the  opposite  sorts  of  local  applications, 
which  are  of  service  in  inflammation.  The 
g «erality  of  cases  undoubtedly  receive  most 
l*  ief  from  the  use  of  cold  sedative  astringent 
lotions  : butthere  are  constitutionsaud  parts, 
which  derive  most  service  from  the  local 
employment  of  wa  rn  emollient  remedies. 

Were  1 to  endeavour  to  define  the  particu- 
lar instances,  in  which  the  latter  applications 
avail  most,  I should  take  upon  me  a task, 
which  has  baffle-!  all  the  most  able  surgical 
writers.  The  first  stage  of  the  acute  oph- 
thalmy,  and  the  hernia  humoralis,  or  infla- 
med testicle,  may  be  specified,  however,  as 
examples,  in  which,  generally  speaking, 
warm  emollient  applications  are  better  than 
cold  astringent  ones.  Yet,  even  with  res- 
pect to  inflammation  of  the  testis,  there  is 
some  difference  of  opinion  about  the  supe- 
riority of  cold  or  warm  applications.  Mr. 
James’s  sentiments  are  as  follows  : in  the 
treatment  it  is  of  importance  to  consider  the 
differences  of  the  cause  : thus,  in  mumps 


and  rheumatism,  the  constitution  is  chietp, 
to  be  attended  to,  and  cold  applications  are 
certainly  improper.  When  it  (the  inflamma- 
tion of  the  testis)  arises  from  a blow,  after 
leeches  have  been  freely  employed,  fomen- 
t tions  are  the  best  remedy  But  Mr.  James 
thinks,  that  this  is  not  the  rase,  in  many 
instances  of  hernia  humoralis  trom  gonor- 
rhoea, where  cold  applications  are  prefer- 
able ; but,  he  owns,  that  the  feelings  of  the 
patient  will  best  determine  the  point. 

( James  on  Inflammation,  p 164.) 

“ Fomentations,  or  embrocations  with 
warm  water,  (as  a j dicious  writer  has  re- 
marked! are  often  a very  powerful  means 
of  abating  internal  inflammation.  This  ef- 
fect is  ve,-y  apparent  in  some  of  the  deeper 
seated  inflammations,  as  in  the  inflammation 
of  the  urinary  bladder,  intestines,  or  other 
viscera  contained  within  the  cavity  of  the 
abdomen.  The  warmth,  in  this  case,  may 
be  applied  to  the  surface  of  the  abdomen,  by 
bath  or  fomentation,  or  in  the  way  of  injec- 
tion, by  the  anus,  &c.  In  some  inflamma- 
tions of  the  joints,  warmth  also  is  found  to 
be  very  useful.  These,  however,  are  in- 
flammations, which  have  a tendency  to  the 
chronic  state.  (See  Thomsonon  Inflammation, 
p . 188.) 

If  we  may  judge  by  the  feelings  of  certain 
patients,  there  are  undoubtedly  particular 
constitutions,  in  which  the  local  use  ot  warm 
remedies  produces  greate-  relief  than  that  of 
cold  ones  This  circumstance,  however, 
does  not  generally  happen  ; and,  as  warm 
emollient  applications,  of  ail  kinds,  have  the 
most  powerful  influence  in  promoting  sup- 
puration, a fact  admitted  by  every  experien- 
ced practitioner,  the  use  of  such  remedies, 
while  the  resolution  of  inflammation  is  prac- 
tical must  be  highly  censurable.  But,  I 
am  ready  to  grant,  that  in  all  cases  of 
inflammal:  o,  which  manifestly  cannot  be 
cured  without  suppuration,  the  emollient 
plan  of  treatment  ought  to  be  at  once  adopt- 
ed ; for  the  sooner  the  matter  is  formed, 

the  spoiler  the  inflammation  itself  is  stopped. 

The  inflammation  attending  contused  and 
gunshot  wounds,  and  that  accompanying 
bolls  and  carbuncles,  are  of  this  description. 
The  inflammation, originating  in  fevers,  com- 
monly ends  in  suppuration,  and,  in  such 
instances,  perhaps,  it  might  he  advantageous, 
also,  to  employ  at  once  the  emollient  treat- 
ment. 

Warmth  and  moisture  together,  in  other 
words  fomentations,  are  commonly  had  re- 
course to  in  cases  of  inflammation  ; but, 
when  the  warmth  is  as  much  as  the  sensitive 
principle  can  bear,  it  excites  action.  Whe- 
ther it  is  the  action  of  inflammation,  or  the 
action  of  the  contraction  of  the  vessels,  is 
unknown.  We  see  that  many  patients 
cannot  bear  warmth,  and,  therefore,  it 
might  he  supposed  to  increase  the  action  of 
dilatation,  and  do  harm.  But,  if  the  pain 
should  arise  from  the  contraction  of  the  in- 
flamed vessels,  benefit  would  he  the  result ; 
though  we  must  doubt  that  this  change  is 
produced,  as  making  the  vessels  contract 
would  probably  give  ease.  ( Hunter .) 


INFLAMMATION. 


From  the  preceding  observations,  we 
must  perceive  how  vain  it  is  to  theorize  on 
this  subject  which  even  puzzled  the  genius 
and  penetration  of  a Hunter.  In  addition 
to  what  has  been  already  observed,  I feel 
totally  incapable  of  giving  any  useful  practi- 
cal advice,  with  respect  to  those  cases,  in 
which  warm  emollient  applications  should 
be  used  in  preference  to  cold  astringent 
ones.  I can,  however,  with  confidence 
remark-  that  the  surgeon  who  consults  the 
feelings  and  comfort  of  the  patient  on  this 
point,  will  seldom  commit  any  serious  error. 
Hence,  in  all  cases,  in  which  the  first  kind 
of  topical  applications  seem  not  to  produce 
the  wonted  degree  of  relief,  let  the  second 
sort  be  tried.  From  the  opportunity  of  com- 
parison, a right  judgment  may  then  be  easily 
formed. 

The  poultice  made  of  the  powder  of  lin- 
seed is  so  easily  prepared,  that  the  old  bread 
and  milk  poultice  is  now  seldom  employed. 
As  much  hot  water  is  to  be  put  into  a basin, 
t'  as  the  size  of  the  poultice,  requires,  and  then 
i the  linseed  powrder  is  to  be  gradually  mixed 
‘ with  the  water,  till  the  mass  is  of  a proper 
! consistence.  Frequently,  a little  sweet  oil 
; is  also  added  to  keep  the  application  longer 
1 soft  and  moist. 

Fomentations  are  only  to  be  considered 
as  temporary  applications,  while  the  emol- 
lient poultices  are  the  permanent  ones.  The 
former  are,  at  most,  never  used  more  than 
three  times  a day,  for  the  space  of  about  half 
an  hour  each  time.  Two  cf  the  best  are  the 
- following: — -{J,.  Lini  contusi  ^j.  Chamae- 
meli  3jij.  Aq.  Distill,  ftjvj.  Paulisper  coque 
etcola.  Or.  Papaverisaibi  exsiccati  ^iv. 
Aq.  Purae  Jfevj  Coque  usque  remaneant 
}feij.  et  cola. 

Some  practitioners,  however,  are  incli- 
ned to  think  warm  w ater  alone  quite  as  effi- 
caciousas  the  decoctiousof  particular  herbs. 
Thus  Dr.  Thomson  observes,  “ herbs  are 
now  seldom  used  in  the  way  of  fomenta- 
tion, unless  in  compliance  with  ancient 
custom,  or  with  the  prejudices  of  particular 
individuals.  The  discutient  power  of  the 
warm  water  may  be  increased  by  the  addi- 
tion of  various  substances,  such  as  vinegar, 
spirits  of  wine;  saline  substances,  such  as 
common  salt,  acetite  and  muriate  of  ammo- 
nia. But,  these  warm  and  stimulating  em- 
brocations are  used  chiefly  in  the  passive, 
chronic,  or  more  indolent  species  of  inflam- 
mation/’ (See  Lectures  on  In jl0imaiiou.  p. 
189.) 

By  pursuing  the  treatment  recommended 
above,  the  resolution  of  the  inflammation 
will  in  general  begin  to  take  place,  either  in 
the  course  of  three  or  four  days,  or  in  a 
shorter  space  of  time.  At  all  events,  it  may 
usually  be  known  before  the  expiration  of 
this  period,  how  the  disorder  w^U  terminate. 
If  the  heat,  pain,  and  other  attending  symp- 
toms abate  ; and,  especially,  if  the  tumour 
begins  to  decrease,  without  the  occurrence 
of  any  gangrenous  appearances  ; we  may 
then  he  almost  certain,  that,  by  a continu- 
ance of  the  same  plan,  a total  resolution  will 
hi  time  he  effected 
Vor„  If 


12*> 

On  the  other  hand,  when  all  the  different 
symptoms  increase,  and  particularly  when 
the  tumour  becomes  larger,  and  softish,  at- 
tended with  a more  violent  throbbing  pain, 
we  may  conclude,  that  the  case  will  proceed 
to  suppuration.  Hence,  an  immediate 
change  of  treatment  is  indicated,  and  such 
applications,  as  were  proper  while  resolu- 
tion seemed  practicable,  are  to  he  left  off, 
and  others  substituted.  This  remark  relates 
to  the  employment  of  cold  astringent  reme- 
dies, which,  when  suppuration  is  inevitable, 
only  do  harm,  by  retarding  what  cannot  i e 
avoided,  and  affording  no  relief  of  the  pain 
and  other  symptoms.  If  the  inflammation, 
however,  should  already  be  treated  with 
emollients,  no  alteration  of  the  topical  ap- 
plications is  requisite,  in  consequence  of  the 
inevitability  of  the  formation  of  matter. 
Indeed,  emollient  poultices  and  fomenta- 
tions are  the  chief  local  means  both  of  pro- 
moting suppuration,  and  diminishing  the 
pain,  violent  throbbing,  & c.  which  always 
precede  this  termination  of  phlegmonous 
inflammation. 

But,  besides  the  substitution  of  warm 
emollient  applications  for  cold  astringent 
lotions,  practitioners  have  decided,  that  it 
is  also  prudent,  as  soon  as  the  certainty  is 
manifest,  to  relinquish  the  free  employment 
of  evacuations,  particularly  bloot-retting, 
and  to  allow  the  patient  a more  generous 
.diet.  When  tin*  system  is  too  much  redu- 
ced by  the  injudicious  continuance  of  rigo- 
rous antiphlogistic  treatment,  the  progiv  s 
of  the  ensuing  suppuration  is  always  retard- 
ed in  a disadvantageous  manner,  and  the 
patient  is  rendered  too  weak  to  support  ei- 
ther a Ion .. -tout iriued, or ajprofuse discharge, 
which  it  may  not  he  possible  to  avoid. 

I shall  conclude  this  article  with  briefly 
noticing  blisters,  rubefacients,  issues,  and 
synapisms,  as  means  often  employed  for  the 
relief  of  particular  cases  of  inflammation. 
“Blisters  (says  Dr.  Thomson)  are  never 
applied  to  a part  which  is  actually  inflamed. 
They  seem  to  he  chiefly  useful  by  exciting 
inflammation  in  a contiguous  part.  It  is 
from  this  tendency,  which  blisters  have  to 
produce  inflammation,  and  of  course  a cer- 
tain degree  of  fever,  that  they  are  seldom  to 
be  employed  in  acute  inflammatory  cases, 
till  the  constitutional  symptoms  are  by  other 
means  in  some  measure  subdued.” — (P. 
187.) 

“ Of  the  same  nature,  though  milder  in 
their  operation,  than  blisters,  are  the  whole 
class  of  rubefacients.  They  produce  a de- 
tennination"of  blood  to  the  parts  to  which 
they  are  applied,  and  in  a manner  not  yet 
well  understood,  occasion  a diminution  in 
the  action  of  the  vessels,  and  consequently 
in  the  quantity  of  blood  with  which  the  in; 
flamed  parts,  are  supplied.  This  influence 
is  exerted  more  or  less  directly  in  different 
instances.  The  extremities  of  the  intercos 
tal  arteries  may  open  both  on  the  pleura 
lining  the  chest,  and  on  the  surface  of  the 
skin  covering  it,  and  whatever  excites  au 
increased  flow  of  blood  into  one  of  these, 
textures,  may  be  conceived  to  be  attended 


17 


INF 


1N0 


13# 


with  a proportionally  diminished  flow  into 
the  other  texture,  B it,  blisters  are  found 
by  experience  to  be  efficacious  in  removing 
inflammation,  where  no  communication 
whatever  can  be  traced  between  the  blood- 
vessels of  t e inflamed  part,  and  that  to 
which  the  blister  is  applied.  We  have  ex- 
amples of  this  mode  of  action  in  the  bene- 
ficial effects  obtained  from  the  application 
of  blisters  in  inflammation  of  the  brain  and 
the  membranes  immediately  covering  it,  of 
the  lungs  and  intestines,  or  of  any  of  the 
viscera  contained  in  the  cavity  of  tiie  abdo- 
men. The  nearer  in  such  instances  the 
blister  or  rubefacient  can  be  applied  to  tiie 
part  inflamed,  the  greater  is  the  relief  ob- 
tained ; and  in  general,  l believe,  it  may  be 
laid  down  as  a rule,  that  the  relief,  which 
they  afford,  will  be  proportional  to  the  de- 
gree of  inflammation  which  they  excite.” 
(See  Thomson  on  Inflammation , p.  187,  189.) 

Synapisms,  blisters,  and  issues  are  in  ma- 
ny instances  applied  to  situations,  which  are 
so  remote  from  and  unconnected  by  v essels 
with  the  inflamed  parts,  that  it  is  impossible 
to  explain  their  mode  of  operation  except 
through  the  medium  of  the  nervous  system. 

11  The  irritation  of  a synapism  applied  to  the 
foot  (says  Dr.  Thomson)  may  relieve  an  at- 
tack of  gout  in  the  head,  or  stomach.  Bath- 
ing the  feet  and  legs  gives  relief  in  inflam- 
mation of  the  bowels  ; and  the  application 
of  a blister,  or  caustic  to  the  neck,  may  cure 
an  inflammation  of  the  eyes,  &.c.  ( P . 1«9.) 
Here  counter  irritation  is  the  principle  by 
which  an  explanation  is  usually  attempted. 
(See  Blisters.) 

Van  Swieten's  Commentaries  on  Boerhaave; 
Gorler's  Compendium  Medici  mu,  4 to.  Lu^d. 
1731  ; and  Chirurgia  Repur  gala,  4lo.  Lugd. 
1742.  Vacca.,  Liber  dt  Inflammalionis  mor- 
bosa , quae  in  humano  corpore  Jit,  natures . cau- 
sis,  effectibus,  et  curalione,  1765.  D Mage- 
nisie,the  Doctrine  of  Inflammations,  founded 
upon  reason  and  experience;  and  entirely 
cleared  from  the  contradictory  systems  of  Boer- 
haave, Van  Swieten,  and  others,  8 vo.  t.ond. 
1768.  Cullen’s  First  Lines  of  the  Practice 
of  Physic,  Vol.  1.  John  Hunter,  on  the  Blood, 
Inflammation, §’C.  4to.  London,  179  I.  Burns's 
Dissertations.  8vo  Glasgow,  lbOo.  Thom- 
son’s Lectures  on  Inflammation,  Edinb.  1813. 
Boyer,  Trait 6 des  Maladies  Chir.  T.  1.  Del- 
pech,  Precis  Elrn.  des  Alai.  Chir.  T.  1 ,chap. 
1,  Paris,  1816.  John  Herdmnn,  Hiss  on 
White  Swelling,  and  the  Doctrine  of  Inflam- 
mation, 8 vo.  Edinb.  1802.  F.  J.  V Brous- 
sais  Hist,  des  Phlegmasies  ou  Inflammations 
Chroniques,&fC.  2 Tom.  8vo.  Paris,  1808.  C. 
Wenzel,  fiber  die  Induration  und  das  Gesch- 
wiir  in  indurioten  Theilen,  8 vo  Mainz. 

1815,  Wilson  Philip,  on  Febrile  Diseases, 
Part  2.  Introduction,  Ed.  3 ; and  Bn  Expe- 
rimental Inquiry  into  the  Laws  of  the  Vital 
Functions,  Ed.  2.  8 vo.  Loud.  1818.  Caleb 
H.  Parry , Elements  of  Pathology  and  The- 
rapeutics, 8vo.  Loud.  1815.  Also,  Bn  Expe- 
rimental Inquiry  into  the  Nature,  fyc.  of  the 
Arterial  Pulse, 8vo.  Land.  1816.  Charles  H. 
Parry,  Additional  Experiments  on  the  Arteries 
of  Warm-blooded  Animals,  tyc.  8 vo.  Loud. 


1819.  James  Wilson,  Lectures  on  the  Blood , 
and  on  the  Anatomy,  Physiology,  and  Surgi- 
cal Pathology  of  the  l ascular  System,  8 vo. 
Lond.  1819.  C.  II.  Ronnefeld,  Animadver- 
siones  nonnullce  ad  Doctrinam  de  Infiamma- 
tione,4lo  Lips.  I S 1 7 . C.  Hastings,  a Trea- 
tise on  Inflammation  of  the  Mucou  Membrane 
of  the  Lungs,  <yc.  8lo.  Lond.  1820.  J.  H. 
James , Observations  on  some  of  the  General 
Principles  mid  on  th>  particular  Nature  and 
Treatment  of  the  different  Species  of  In  flam - 
ma, ion,  8 vo.  Lond.  Jb21.  This  work,  and 
those  of  Mr.  J.  Hunter,  Mr.  Wilson,  Mr  J. 
Burns,  Drs.  Parry,  Philip  and  Hostings,  de- 
serve attentive  perusal  by  every  body  desirous 
of  forming  a correct  judgment  of  the  nature 
of  inflammation. 

INJECTION.  A fluid  intended  to  be 
thrown  against,  or  into  a part  of  the  body 
by  means  of  a syringe.  Thus  port  wine  and 
water  form  an  injection,  which  is  used  by 
surgeons  for  radically  curing  the  hydrocele, 
and,  for  this  purpose,  it  is  introduced  into 
the  cavity  of  tiie  tunica  vaginalis,  where  it 
excites  the  degree  of  inflammation  necessa- 
ry to  produce  an  universal  adhesion  between 
this  membrane  and  the  albuginea. 

Thus  many  fluid  remedies  are  introduced 
int>  the  urethra  and  vagina  for  the  cure  of 
gonorrhoea.  In  the  article  Gonorrhoea , will 
be  found  an  account  of  the  best  injections 
employed  for  its  relief.  A few  additional 
remedies  of  this  class  are  here  subjoined. 

liNJECTIO  ACIDI  MURIATIC!.  R. 
Aquee  distil  ^iv.  Acid.  Mur.  gutt.  viij. 
Misce.  Useful  when  the  scalding  is  a very 
troublesome  symptom. 

lAJECTlO  ALUMIiNIS. — Alum  3j. 
Aq.  pur.Jjvj.  Misce. — Successtully  employed 
by  Dr.  Cheston,  as  an  injection  in  affections 
of  the  rectum,  either  when  the  internal  coat 
is  simply  relaxed,  and  disposed  to  prolapsus, 
or  when  it  is  studded  with  loose  fungated 
tumours.  In  such  cases,  camphor  is  also  of 
service.  The  quantity  of  alum  raaj  be  in- 
creased, if  the  parts  will  bear  it. 

1NJECTIO  CUPRI  AMMONIATI.  R. 
Liquoris  Cupri  ammon.  gutt.  xx.  Aquas 
rosae  ^iv.  Misce.  Strongly  recommended 
by  Mr.  Foot. 

liNJECTIO  QUERCUS.  R.  Deeocti  quer- 
cus  fbj  Aluminis  purificat.  |ss.  Misce. 
May  be  used,  when  the  lectum,  or  vagina, 
i£  disposed  to  prolapsus  from  relaxation,  or 
in  cases  ot  gleet. 

* i.NNOMlNATA  ARTER1A.  By  refer- 
ing  to  the  article  Aneurism,  in  the  Appendix, 
will  be  seen  the  case  at  full  length,  in  which 
professor  Mott  of  this  city  tied  the  Arteria 
Innominata  for  the  purpose  of  directing  the 
blood  from  an  aneurism  of  the  subclavian 
artery  ; together  with  some  remarks  upon 
the  criticisms  which  have  appeared  against 
it.  Am  Ed 

INOSCULATION  denotes,  in  the  lan- 
guage of  anatomy  and  surgery  the  union 
of  vessels  by  conjunction  of  their  extremi- 
ties. It  is  generally  synonymous  with 
anastomosis , though  sometimes  a distinction 
is  made,  anastomoses  signifying  the  union  of 
vessels  by  minute  ramifications,  and  inoscu- 


IiNO 


I NT 


13ll 


lotion  a direct  communication  by  trunks. 
The  great  use  of  inosculations  is  to  facilitate 
and  ensure  the  continuance  of  the  circula 
tion,  when  the  large  trunks  of  vessels  are 
obstructed  by  pressure,  disease,  &.e.  Thus, 
in  cases  of  aneurism,  when  the  main  artery 
of  a limb  is  tied,  the  inosculations  of  the 
branches,  given  off  above  the  ligature,  with 
other  branches  arising  below  it,  form  at 
once  a channel,  through  which  the  lower 
part  of  tne  limb  is  supplied  with  blood. 
Were  there  no  such  arrangement  in  the 
human  body  as  inosculations,  aneurisms 
could  never  be  cured  by  a surgical  opera- 
tion So  infinitely  numerous  indeed  are 
these  inosculations,  that  they  do  the  office 
of  the  subclavian,  carotid,  and  external  and 
internal  iliac  arteries,  when  these  vessels 
are  tied,  and  upon  this  fact  is  founded  the 
success  of  some  of  the  most  brilliant  opera- 
tions in  modern  surgery.  (See  Aneurism.) 
Even  the  aorta  itself  may  be  perfectly  ob- 
structed, the  circulation  go  on,  and  every 
part  be  fully  supplied  with  blood.  (See 
Aorta.)  In  dogs,  the  abdominal  aorta  has 
been  tied,  without  the  circulation  in  the 
hinder  extremities  being  stopped.  (See  the 
Experiments  of  Mr.  A.  Cooper  in  Med.  C/iir. 
T'rans.  Vol.  2,  p.  258;)  and  the  operation, 
performed  a few  years  ago,  in  Guv’s  hospi- 
tal, tends  to  prove  that  the  same  thing  is 
possible  in  the  human  subject  (See  Aorta.) 
From  the  observations  of  the  same  distin- 
guished surgeon  it  appears,  that  the  arteries, 
which  form  the  new  circulation  in  a limb, 
after  the  obliteration  of  the  principal  artery, 
are  not  only  enlarged  but  tortuous.  Any 
great  increase,  however,  in  the  diameter  of 
the  anastomosing  vessels  is  but  slowly  pro- 
duced ; for  Mr.  A.  C ooper  has  injected  a 
limb  several  weeks  after  the  operation  for 
popliteal  aneurism,  without  being  able  to 
force  the  injection  through  communicating 
vessels  into  the  parts  below.  The  limb  must 
have  active  exercise  before  the  vessels  en- 
large much.  On  account  of  the  arteries 
not  very  readily  enlarging,  the  limbs  of  per 
sons  who  have  undergone  the  operation  for 
aneurism,  are  for  a considerable  time  weak- 
er than  natural.  They  feel  the  influence  of 
cold  more,  and  are  more  disposed  to  ulce- 
rate from  slight  causes.  Hence,  the  utility 
of  covering  them  with  flannel,  or  fleecy  ho- 
siery. Hence,  the  rashness  of  applying  cold 
washes,  bandages,  &.c.  (See  A.  Cooper's  re- 
marks in  the  above-mentioned  l ol  p 249,  et 
seq) 

In  another  place,  the  same  gentleman  has 
published  an  interesting  description  of  the 
anastomoses  of  the  arteries  of  the.  groin. 

Hypothesis  (says  he)  w ould  lead  to  a be- 
lief, that  anastomosing  vessels  would  be 
numerous  in  proportion  to  the  lime  w hich 
had  elapsed  from  the  operation  ; but,  the 
reverse  of  this  is  the  fact  ; for,  at  first,  ma- 
ny vessels  convey  the  blood,  originally 
conducted  by  the  principal  artery7.  But, 
gradually,  tl^e  number  of  these  channels 
becomes  diminished  and,  after  a length  of 
time,  a few  vessels,  conveniently7  situated 
for  the  new  circulation,  become  so  much 


enlarged,  as  to  be  capable  of  conveying  an 
equal  portion  of  blood  to  that  which  passed 
through  the  original  trunk.” 

The  experience  of  Mr.  A.  Cooper  also 
tend*  to  confirm  the  important  fact,  that 
“ it  is  desirable  in  femoral  aneurism,  if  not, 
indeed,  in  all  others,  to  perform  the  opera- 
tion in  an  early  state  of  the  disease,”  as  the 
patient  then  recovers  the  use  of  the  limb 
much  more  quickly,  than  when  the  tumour 
lias  been  suffered  to  attain  a large  size. 
(See  Medico- ( hirurg  Trans.  Vol.  4,  p.  425, 
et  seq.) 

INTERRUPTED  SUTURES.  See  Su- 
tures. 

INTESTINES  WOUNDED.  See  Wounds 
of  the  Abdomen. 

IN  fitOSUSCEPTlON.  or  Intussusception, 
(from  ini  us , within  and  suscipio , to  receive.) 
Called  also  Volvulus  1*  a disease  produced 
by  the  passing  of  one  portion  of  an  intestine 
into  another,  and  it  U commonly  from  the 
upper  passing  into  the  lower  part.  (J.  Hun- 
ter) O this  subject.  Mr.  G.  Langstaff  lias 
published  an  interesting  paper,  in  the  Edinb. 
Surg.  Journal.  No.  XI ; which  1 shall  take 
the  liberty  of  freely  quoting. 

Tub  gentleman  remarks,  (hat  the  small 
intestines  of  children  are  -so  often  affected 
with  iutrosusception  in  a slight  degree,  that 
most  practitioners  must  have  had  opportuni- 
ties of  observing  the  form  of  the  complaint. 
The  greatest  par*  of  three  hundred  children 
who  died  either  of  worms,  or  during  denti- 
tion, at  the  HAi'ital  de  la  Sabpetriere,  and 
came  under  the  examination  of  M.  Louis, 
had  two,  three,  four,  and  even  more  volvuli, 
without  any  inflammation  of  the  parts,  or 
any  circumstances  leading  to  a suspicion  that 
these  a ft* -ct  ions  had  been  injurious  during 
life.  11  These  cases  (says  M.  Louis)  stem  to 
prove,  that  inirosusception  may  be  formed, 
and  destroyed  again  by  ihe  mere  action  of 
the  intestines.”  (Mnn.  de  VAcad.de  Chirurg. 
4/o.  Tom.  4.  p 22*2.)  This  opinion  is  con- 
firmed by  the  authority  of  Dr.  Badlie,  ( Mor- 
bid Anatomy,  2 d Edit  p.  162  ) w ho  observes, 
that,  ‘i  iu  opening  bodies,  particularly  of  in- 
fants, an  intussusception  is  not  'infrequently 
found,  which  had  been  attended  with  rio 
mischief ; the  parts  appear  perfectly  free 
from  inflammation,  and  they  w ould  probably 
have  been  easily  disentangled  from  each 
Ollier  by  their  natural  peristaltic  motion.” 

The  disease,  continues  Mr.  Langstaff,  as- 
sumes a more  dangerous,  and  indeed,  gene- 
rally a fatal  form,  uh  n it  occurs  at  the  ter- 
mination of  the  small  intestines  in  the  cce- 
cum.  A contracted  state  of  ihe  part  to  be 
introsu  cepted,  and  a dilatation  of  that  por- 
• ion  of  the  caifal  into  which  this  pari  must 
pass,  are  ssenlial  coudii  ions  to  the  formation 
of  a volvulus  ; and  those  exist,  nowhere  so 
completely  as  in  Ihe  situation  here  alluded  to. 
The  extent  to  which  the  affection  proceeds 
in  this  situation,  would  appear  almost  incre- 
dible, if  it  were  not  proved  by  well-authen- 
ticated facts.  A person  who  considered  the 
natural  situation  and  connexion  of  the  parts, 
would  of  course  require  the  strongest  evi- 
dence before  he  would  believe,  that  ihe  iltf- 


i N TROSU  8 CEPT  ION. 


Vdd 


mn,  cmcutn,  ascending  and  transverse  por- 
tions of  the  colon,  may  descend  into  the 
sigmoid  flexure  of  the  latter  intestine  ; nay 
more,  that  they  may  pass  through  the  rectum, 
and  1)0  protruded  in  the  form  of  a prociden- 
tia ani.  Sueh  cases,  however,  are  recorded. 
(Langstaff,  in  Edinb.  Med.  and  Surgical 
Journal,  No.  XJ.) 

This  gentleman  next  relates  the  case  of  a 
child  three  months  old,  the  body  of  which 
he  inspected  after  death,  and  found  to  con- 
firm t he  truth  of  the  preceding  account. 
The  example  was  particular  in  their  bein  in 
addition  to  an  extensive  introsascepti  n in 
the  usual  way,  a smaller  invagination  in  the. 
opposite  direction,  like  what  probably  occur- 
red in  the  case  related  by  Mi.  Spry;  Med. 
and  Physical  Journal , No.  Xf  Sir  E.  Home, 
(Trans,  of  a Society  for  Medical  and  Chir. 
Knowledge,  Pol.  1.)  ;nvntion>  anexumple  ot  a 
retrograde  intrdsuscepUon,  in  which  a worm 
was  found  coiled  up  round  the  iitrosuscepted 
part.  The  disease  took  place  in  a boy  who 
IAd  swallowed  arsenic. 

If  the  following  mode  of  accounting  for 
introsusception  be  just,  it  will  most  frequent- 
ly happen  downwards,  although  there  is  no 
reason  why  it  may  not  take  place  in  a con* 

• trary  direction  ; in  which  case,  the  chance 
of  a cure  will  be  increased  by  the  natural 
actions  of  tne  intestinal  canal  tending  to  re- 
place the  intestine  ; and  probably  from  this 
circumstance  it  may  oflener  occur  than  com- 
monly appears. 

When  the  introsusception  is  downwards, 
it  may  be  called  progressive,  and  when  it 
happens  upwards,  retrograde.  The  manner 
in  which  it  may  take  place  is,  by  one  portion 
of  a loose,  intestine  being  contracted,  and 
the  part  immediately  below  relaxed  and  di- 
lated ; under  which  circumstances,  it  might 
very  readily  happen  by  the  contracted  por- 
tion slipping  a little  Way  into  that  which  is 
dilated,  not  from  any  action  in  either  portion 
of  intestine,  hut  from  some  additional  weight 
in  the  gut  above.  How  far  the  peristaltic 
motion,  by  pushing  the  contents  on  to  the 
contracted  parts,  may  force  these  into  the 
relaxed,  Mr.  Hunter  will  not  determine,  but 
is  inclined  to  suppose  that  it  will  not. 

By  this  mode  of  accounting  for  an  acci- 
dental introsusception,  it  may  take  place 
either  upwards  or  downwards  ; but  if  a con- 
tinuance or  ari  increase  of  it  arises  from  the 
action  of  the  intestines,  it  must  be  when  it  is 
downwards,  as  we  actually  find  to  be  the 
case ; yet  this  does  not  explain  those  in 
which  a considerable  portion  of  intestine 
appears  to  have  been  carried  into  the  gut 
below  : to  understand  these,  we  must  con- 
sider the  different  parts  which  form  the  in- 
trosusception. It  is  made  up  of  three  folds 
of  intestine  ; the  inner,  which  passes  down, 
and  being  reflected  upwards,  forms  the  se- 
cond or  inverted  portion,  which  being  reflect- 
ed down  again,  makes  the  third  or  contain- 
ing part,  1 hat  is  the  outermost,  which  is 
always  in  the  natural  position.  (./.  Hunter.) 

The  outward  fold  is  the  only  one  which  is 
active,  the  inverted  portion  being  perfectly 
passive,  and  squeezed  down  by  the  outer. 


which  inverts  more  of  itself,  so  that  the  an- 
gle of  inversion  in  this  case  is  always  at  the 
angle  of  reflection  of  the  outer  into  the 
middle  portion  or  inverted  one,  while  the 
innermost  is  drawn  in.  From  this  we  can 
readily  see  how  an  introsusception,  once  be- 
gun, may  have  any  length  of  gut  drawn  in. 

The  external  portion  acting  upon  tne  other 
folds  in  the  same  way  as  upon  any  extrane- 
ous matter-  will  by  its  peri-taltic  motion  urge 
them  further  ; and  if  any  extraneous  sub- 
stance is  detained  in  the  cavity  of  the  inner 
portion,  that  part  will  become  a fixed  point 
for  the  outer  or  containing  intestine  to  act 
upon  l bus  it  will  be  squeezed  on,  till  at  last 
the  mesentery  preventing  more  of  the  inner- 
most part  from  being  drawn  in,  will  act  as  a 
kind  of  stay,  yet  without  entirely  hindering 
the  inverted  outer  fold  from  going  still  fur- 
ther. For  it  ‘being  the  middle  fold  that  is 
acted  upon  by  the  outer,  and  this  action 
continuing  after  the  inner  portion  becomes 
fixed,  the  gut  is  thrown  into  folds  upon  it- 
self; so  that  a foot  in  length  of  intestine 
shall  form  an  introsusception  not  more  than 
three  inches  long. 

The  outer  portion  of  intestine  is  alone  ac- 
tive in  augmenting  the  disease  when  once 
begun  ; but  if  the  inner  one  were  capable  of 
equal  action  in  its  natural  direction,  the  ef- 
fect would  be  the  same,  that  of  endeavouring 
to  invert  itself,  as  in  a prolapsus  ani  ; the 
outer  and  inner  portions,  by  their  action, 
would  tend  to  draw  in  more  of  the  gut, 
while  the  intermediate  part  only  would,  by 
its  action,  have  a contrary  tendency. 

The  action  of  the  abdominal  muscles  can- 
not assist  in  either  forming  or  continuing 
this  disease,  as  it  must  compress  equally  both 
above  and  below,  although  it  is  capable  of 
producing  the  prolapsus  ani. 

When  an  introsusception  begins  at  the 
valve  of  the  colon,  and  inverts  that  intestine, 
we  find  the  ileum  is  not  at  all  affected; 
which  proves  that  the  mesentery,  by  acting 
as  a slay,  prevents  its  inversion.  ( J . Hun- 
ter.) 

From  the  natural  attachment  of  the  me- 
sentery to  the  intestines,  one  would,  ul  the 
first  view  of  the  subject,  conceive  it  impos- 
sible for  any  one  portion  of  gut  to  get  far 
within  another;  as  the  greater  extent  of  me- 
sentery that  is  carried  in  along  with  it  would 
render  its  further  entrance  more  and  more 
difficult,  and  we  should  expect  this  difficulty 
to  be  greater  in  the  large  intestines  than  in 
the  small,  as  being  more  closely  confined  to 
their  situation  ; yet  one  of  t he  largest  intro- 
susceptions  of  any  known  was  in  the  colon, 
as  related  by  Mr.  Whateley.  ( Vid . Phil. 
Trans.  Vol.  70,  p.  305.) 

The  introsusception  appeared  to  have  be- 
gun at  the  insertion  of  the  ileum  into  the 
colon,  and  to  have  carried  in  the  cuecum 
with  ils  appendix.  The  ileum  passed  on 
into  the  colon,  till  the  whole  of  tin;  ascend- 
ing colon,  the  transverse  arch,  and  descend- 
ing colon,  were  carried  into  the  sigmoid 
flexure  and  rectum.  The  valv^of  the  colon 
being  the  leading  part,  is  at  last  got  as  low  as 
the  anus;  and  when  the  person  went  to 


INTROSUSCEPTION 


m 

stool  ho  only  emptied  the  ileum,  for  one  fore  advises  giving-  vomits,  with  a view  to 
half  of  the  large  intestines  being  filled  up  by  invert  the  peristaltic  motion  of  the  contain 


the  other,  the  ileum  alone,  which  passed 
through  the  centre,  discharged  its  contents. 
(J.  Hunter.) 

Two  questions  of  considerable  importance 
present  themselves  to  the  mind  in  consider- 
ing this  subject;  whether  there  are  any 
symptoms  by  which  the  existence  ot  the  af- 
fection can  he  ascertained  during  life  ? And 
whether  we  possess  any  means  of  relieving 
it,  supposing  that  its  existence  could  he  dis- 
covered ? The  symp.oms  attending  an  intro- 
susception  are  common  to  inflammation  of 
the  intestines,  hernia,  and  obstruction  of  the 
canal,  from  whatever  cause,  and  a volvulus 
is  the  least  frequent  cause  of  such  symptoms. 
(Langstaff.)  In  the  case  published  by  this 
gentleman,  md  in  those  related  by  Mr.  Hun- 
ter and  Mr.  Spry,  the  seat  of  *he  disease  was 
clearly  denoted  by  a hard  tumour  on  the 
left  side  of  the  abdomen.  This  circumstance, 
together  with  the  impossibility  of  throwing, 
up  more  than  a very  small  quantity  of  fluid 
in  cly-ters,  ( Hevin , Spry,  Langstaff,)  and  the 
presence  of  the  other  symptoms,  would  lead 
us  to  suspect  the  nature  of  the  disorder.  If 
£he  invaginated  portion  descended  so  low  as 
to  protrude  through  the  anus,  and  we  could 
ascertain  that  it  was  not  an  inversion  of  the 
gut,  the  case  might  be  considered  as  clear, 
and  we  should  have  no  hesitation  in  deliver- 
ing a prognosis,  which,  by  preparing  the 
friends  for  the  fatal  termination,  would  exo- 
nerate us  from  ail  blame  on  its  occurrence. 

( Langstaff .) 

In  tfie  treatment  of  this  disease,  bleeding, 
to  lessen  the  inflammation  that  might*  be 
brought  on,  and  quicksilver  to  remove  the 
cause,  have  been  recommended. 

Quicksilver  would  have  little  effect  eitherin 
one  way  or  the  other,  if  the  introsuscep  ion 
were  downward  ; for  it  is  to  be  supposed 
that  it  would  easily  make  its  way  through 
t lie  innermost  contained  gut,  and,  it  it  should 
be  stopped  in  its  passage,  it  would  by  increas- 
ing its  size,  become  a cause  (as  before  oh-, 
served)  of  assisting  the  disease.  In  cases  of 
the  retrograde  kind,  quicksilver,  assisted,  by 
the  peristaltic  motion,  might  be  expected  :o 
press  the  introsusception  back ; but  even 
under  such  circumstances  it  might  get  be- 
tween the  containing  and  inverted  gut  into 
the  angle  of  reflection,  and  by  pushing  it 
further  on,  increase  the  disease  it  is  intended 
to  cure.  {J.  Hunter.) 

Every  thing  that  can  increase  the  action 
of  the  intestine  downwards,  is  to  be  particu- 
larly avoided,  as  tending  to  increase  the  peri- 
staltic motion  of  the  outer  containing  gut, 
and  thus  to  continue  the  disease.  Medicines 
can  never  come  into  contact  with  the  outer 
fold,  and  having  passed  the  inner,  can  only 
act  on  the  outer  further  down,  and  therefore 
cannot  immediately  affect  that  portion  of 
the  outer  which  contains  the  introsusception  ; 
but  we  must  suppose  that  whatever  affects  or 
comes  into  contact  with  the  larger  portion  of 
the  Canal,  sU  as  to  throw  it  into  action,  will 
a !$<> affect  by  sympathy  any  part  that  may 
escape  such  application.  Mr,  Hunter  there- 


ing  gut,  which  will  have  a tendency  to  bring 
the  intestines  into  their  natural  situation. 

If  this  practice  should  not  succeed,  it  might 
be  proper  to  consider  it  as  a retrograde  intro- 
susception,  and  by  administering  purges 
endeavour  to  increase  the  peristaltic  motion 
downwards.  (J.  Hunter.) 

I cannot  agree  with  Mr.  Langstaff.  that  it 
is  to  be  regretted,  Hunter’s  name  should  be 
affixed  to  the  preceding  proposal,  or  that  it  is 
an  absurd  one  ; for  purgatives  and  emetics 
were  only  recommended  to  increase  the 
peristaltic  action,  tin*  former  downward,  the 
latter  upward,  according  as  the  supposed 
nature  of  the  case  might  require,  and  this 
affect  they  certainly  would  have,  notwith- 
standing vomiting  is  an  early  and  constant 
symptom  of  the  disease,  and  an  insuperable 
constipation  an  equally  invariable  attendant. 
The  method  I allow,  however,  is  not  very 
hopeful,  and  may  sometimes  be  frustrated  by 
the  formation  of  adhesions.  According  to 
Mr.  Langstaff,  the  Recherch-  s Historiq'ues  sur 
la  Gas'rotomie  dans  le  cas  de  Volvulus,  par 
M.  H via,  {Mem.  de  VAcad.  de  Chirurgie , 
Tom.  4,  4 to.)  contain  many  interesting  facts 
and  sound  reasoning.  There  we  find  a very 
ample  discussion  of  the  question,  concerning 
the  propriety  ot  opening  the  abdomen,  in 
order  to  disentangle  the  introsuscepted  intes- 
tine ; a proposal  which  M.  Hevin  very  pro- 
perly condemns. 

If  the  equivocal  and  uncertain  nature  of 
the  symptoms  of  volvulus  were  not  suffi- 
cient to  deter  us  from  undertaking  an  opera* 
tion,  which,  under  the  most  favourable  cir- 
cumstances, could  not  fail  to  be  extremely 
difficult,  and  imminently  hazardous  to  the 
patient,  the  state  of  the  invaginated  parts 
would  entirely  banish  all  thoughts  of  such 
an  imprudent  attempt ; for  the  different 
folds  of  the  intestine  often  become  ag- 
glutinated to  each  other,  so  that  they  can 
hardly  be  withdrawn  after  death  ; ( Simpson , 
Edinburgh  Med.  Essays,  Vol.  6,  Hevin' s 4th 
Obs.  Malcolm,  Physical  and  Lit.  Essays,  Vol. 
2,  p.  360.  Hunter,  Med.  and  Chir.  Trans,  and 
Soemmering  in  Transl.  of  Bail  lie’s  Morb. 
Anat.)  Nay,  the  stricture  on  the  introsus 
cepted  part  may  cause  it  to  inflame,  and 
even  mortify.  ( Soemmering .)  It  is  very 
clear  that,  in  this  state  of  parts,  the  opera- 
tion of  gastrotomy  wrould  be  totally  inad- 
missible, even  if  the  symptoms  could  clearly 
indicate  the  nature  of  the  case,  and  the 
affected  part  could  be  easily  reached  and 
examined.  (Langst  ff  ) 

The  forcible  injection  of  clysters  was 
found  useless  by  Dr.  Monro,  and  the  agglu- 
tination of  the  parts  must  produce  an  insu- 
perable obstacle  to  the  bowels  being  pushed 
back  by  this  means.  {Langstaff.)  Some 
have  proposed  the  employment  of  a long 
bougie,  or  a piece  of  whalebone,  to  push 
back  the  intestine  : and  this  proposal  may 
be  adopted,  when  we  are  furnished  with  an 
instrument,  adapted  to  follow  the  windings 
of  the  large  .intestine  to  its  origin  in  the 


134 


INI 


mi 


right  ilium,  without  any  risk  of  perforating 
the  gut  in  its  course.  ( Langst  ff.) 

it  must  be  confessed,  that  both  surgery 
and  medicine  are  almost  totally  unavailing 
in  the  present  disease.  Yet,  here,  as  in  many 
other  instances,  the  resources  of  nature  are 
exhibited  in  a most  wonderful  and  astonish- 
ing manner,  while  those  of  art  completely 
fail  The  invaginated  portion  of  intestine 
sometimes  sloughs,  and  is  discharged  per 
anum  while  the  agglutination  of  the  parts 
preserves  the  continuity  of  the  intestinal 
canal.  The  nnals  of  medicine  furnish  nume- 
rous instances,  in  which  long  pieces  of  gut 
have  been  discharged  in  this  manner,  and 
the  patient  has  recovered.  Hence,  some 
hope  may  he  allowed  under  the  most  un- 
promising circumstances.  In  a case,  related 
in  Duncan’s  Commentaries,  eighteen  inches 
of  small  intestine  were  voided  per  anum , 
Vol.  9 p.  278.  Three  similar  instances  oc- 
cur in  M.  Hevin’s  Memoir ; twenty-three  in- 
ches of  colon  came  away  in  one  of  these,  and 
twenty-eight  of  small  intestines  in  another. 
Other  cases  occur  in  the  Physical  and  Litera- 
ry Essays,  Yol.  2,  p.  361  ; in  Duncan’s  Annals, 
Vol.  6 p.  298  ; in  the  Medical  and  Chirurgical 
Transactions,  Vol.  2;  where  Dr  Baillie 
states,  that  a yard  of  intestine  was  voided. 
The  patients  did  not,  however,  ultimately 
survive  in  every  one  of  these  instances. 
(Lang staff  in  Edinb.  Med.  and  Surgical  Jour- 
nal.) 

Langenbeck  has  recorded  an  instance,  in 
which  a prolapsus  of  the  large  intestines 
protruded  half  an  ell  out  of  the  anus.  The 
disease  had  lasted  thirty  weeks.  Langen- 
beck made  an  incision  into,  or  rather  through, 
the  protruded  inverted  bowel,  immediately 
below  the  sphincter  ani.  He  first  divided 
the  inner  vascular  coat,  then  the  muscular, 
and  lastly  the  outer  coat  with  great  caution. 
He  now  discovered,  within  the  protruded 
inverted  bowel,  wThich  he  had  opened,  ano- 
ther part  of  the  intestinal  canal,  which  was 
not  yet  inverted.  He  remarked  upon  it  the  ap- 
pendices epiploicae,  and  the  w hite  shining 
peritonajal  coat.  This  last  portion  would 
also  have  become  inverted,  had  the  disease 
continued.  He  next  reduced  the  latter  uu- 
inverted  part,  and  afterward  succeeded  in 
replacing  the  rest,  of  the  protrusion;  which 
did  not  fall  dowm  again  w hen  the  boy  had 
stools.  No  bad  symptoms  immediately  fol- 
lowed ; but,  the  lad  being  very  weak,  survi- 
ved only  eight  days  (See  Bibl  fur  die  Chir. 
B.  3 p.  756,  Gult.  1811.) 

Hecin  in  Mem.  de  V Acad,  de  Chir.  Hunter's 
Observations,  in  the  Trans,  of  a Society  for 
the  Improvement  of  Medical  and  Chirurgical 
Know l dge,  l ol.  I , p.  103,  el  seq  V Encyclo- 
pedic Methodique,  Partie  Chir.  Art.  Gastro- 
tomie.  A.  Voter,  De  Invaginatione  Inieslinor- 
um;  ( Halier  Disp.  Anal.  1,  481.  > C.  //  Velse.  De 
Mut>ii>  Intestinorum  Ingrcssu,  &,-c.  Lugd  1742. 
( Haller,  Disp.  Anal  7 97.)  J.  C.  Lettsom,  The 
History  of  an  Extraordinary  Intussusception, 
wi  h an  account  of  the  dissection  by  Mr.  T.  IVhael- 
ly,  4 to.  Lonl.  1786.  And  Laigstaff's  Re- 
marksinthe  Edinb.  Med.  and  Surgical  Journal, 
J Vo.  XL 


INVERSION  OF  THE  UTERUS.  See 

Uterus , Inversion  of 

IRIS,  PROLAPSUS  OF.  As  long  as  the 
humours,  which  fill  the  cavity  of  the  eye, 
and  in  which  the  iris  is  immersed  and  sus- 
pended, remain  in  perfect  equilibrium  with 
respect  to  each  other,  that  membrane  retains 
its  natural  position,  and  a suitable- distance 
from  the  cornea,  and  although  of  a very  de- 
licate and  yielding  texture,  it  contracts,  and 
relaxes  itself,  without  ever  forming  any  ir- 
regular fold.  But,  when  the  aqueous  hu- 
mour has  escaped  through  an  accidental,  or 
artificial,  opening  in  the  cornea,  the  iris  is 
pressed  forward  by  the  humours  situated  be- 
hind it,  and  is  urged  gradually  towards  the 
cornea  until  a portion  of  it  protrudes  from 
the  eye,  at  the  same  opening,  through  which 
the  aqueous  humour  made  its  escape.  Thus 
a small  turner  of  the  same  colour  as  the 
iris  forms  on  the  cornea,  sometimes  named 
staphyloma  of  the  iris  ; sometimes  procidentia, 
or  prolapsus  of  the  iris. 

The  causes  of  this  complaint  are  such 
wounds  and  ulcers  of  the  cornea,  as  make 
an  opening  of  a certain  extent  into  the  an- 
terior chamber  of  the  aqueous  humour,  and 
such  violent  contusions  of  the  eyeball,  as 
occasion  a rupture  of  the  cornea.  If  the 
edges  of  a wound  in  this  situation,  whether 
accidental,  made  for  the  purpose  of  extract- 
ing the  cataract,  or  evacuating  the  matter  of 
hypopium,  be  not  brought  immediately  af- 
terward into  reciprocal  contact,  or  continue 
not  sufficiently  agglutinated  together  to  pre- 
vent the  escape  of  the  aqueous  humour  from 
the  anterior  chamber,  regularly  as  this  fluid 
is  reproduced  ; the  iris,  drawn  by  its  conti- 
nual flux  towards  the  cornea,  glides  between 
the  lips  of  the  wound,  becomes  elongated, 
and  a portion  of  it  gradually  protrudes  be- 
yond the  cornea,  in  the  form  of  a small  tu- 
mour. The  same  thing  lakes  place,  whene- 
verthe  eyeball  unfortunately  receives  a blow, 
nr  is  too  much  compressed  by  bandages,  dur- 
i g the  existence  of  a recent  wround  of  the  cor- 
nea. Also,  if  the  patient  should  be  affected, 
in  this  circumstance,  with  a spasm  of  the 
muscles  of  the  eye,  with  violent  and  repeat- 
ed vomiting,  or  with  strong  and  frequent 
coughing,  a prolapsus  of  the  iris  may  be 
caused.  When  an  ulcer  of  the  cornea  pene- 
trates the  anterior  chamner  of  the  aqueous 
humour,  the  same  inconvenience  happens 
more  frequently,  than  when  there  is  a recent 
wound  of  that  membrane  ; for,  the  solution 
of  continuity  in  the  cornea,  arising  from  an 
ulcer,  is  attended  with  loss  of  substance, 
and  in  a membrane,  so  tense  and  com- 
pact as  this  is,  the  edges  of  an  ulcer  do  not 
admit  of  being  brought  into  mutual  con- 
tact. 

The  little  tumour  is  likewise  necessarily 
of  the  same  colour  as  the  iris,  viz.  brown, 
or  grayish,  being  surrounded  at  its  base  by 
an  opaque  circle  of  the  cornea,  on  which 
membrane  there  is  an  ulcer,  or  a wound 
of  not  a very  recent  description. 

As  it  usually  happens,  that  the  cornea  is 
Oidy  penetrated  at  one  port  of  its  circumfer- 


IRIS. 


135 


ence  by  a wound,  or  ulcer,  so  in  practice, 
only  one  prolapsus  of  the  iris  is  commonly 
met  with  in  the  same  eye.  But  if  the  cor- 
nea should  happen  to  be  wounded,  or  ul- 
cerated at  several  distinct  points,  the  iris 
may  protrude  at  several  different  places  of 
the  same  eye,  forming  an  equal  number  of 
small  projecting  tumours  on  the  surface  of 
the  cornea.  Scarpa  has  seen  a patient  who 
had  three  very  distinct  protrusions  ot  the 
iris  on  the  same  cornea,  m consequence  of 
three  separate  ulcers  penetrating  the  ante- 
rior chamber  of  the  aqueous  humour;  one 
in  the  upper,  and  two  in  the  lower  segment 
of  the  cornea. 

If,  says  Scarpa,  the  delicate  structure  of 
the  iris  ; the  great  quantity  of  blood-vessels, 
which  enter  it;  and  the  numerous  nervous 
filaments,  which  proceed  to  be  distributed 
to  it,  as  a common  centre  ; Kfe  considered, 
the  nature  and  severity  of  those  symptoms 
may  be  readily  accounted  for,  which  are 
wont  to  attend  this  disease,  however  small 
the  portion  of  the  iris  projecting  from  the 
cornea  may  be,  even  if  no  larger  than  a 
fly’s  head.  The  hard  and  continu  1 frictions 
to  which  this  delicate  membrane  is  then  ex 
posed,  in  consequence  of  the  motions  of  the 
eyelids;  together  with  the  access  of  air, 
tears,  and  gum  to  it;  are  causes  quite  ade- 
quate to  the  production  of  continual  irrita- 
tion ; and  the  blood  which  tends  to  the 
point  of  the  greatest  irritation,  cannot  fail 
to  render  the  projecting  portion  of  the  iris 
much  larger,  almost  directly  after  its  pro- 
trusion, than  it  was  at  the  moment  of  its 
first  passing  through  the  cornea.  Hence 
it  becomes,  soon  after  the  prolapsus,  more 
incarcerated  and  irritated,  than  it  was  at 
first.  In  the  incipient  state  of  the  com- 
plaint, the  patient  complains  of  a pain,  simi- 
lar to  what  would  arige  from  a pin  penetra- 
ting the  eye  ; next  he  begins  to  experience, 
at  the  same  time,  an  oppressive  sensation  of 
tightness,  or  constriction,  over  the  whole 
eyeballs.  Inflammation  of  the  conjunctiva, 
and  eyelids,  a burning  effusion  of  tears,  and 
an  absolute  inability  to  endure  the  light, 
successively  take  place  As  the  protruded 
portion  of  the  iris  drags  after  it  all  the  rest 
of  this  membrane,  the  pupil  assumes  of  me- 
chanical necessity  an  oval  shape,  and  devi- 
ates from  the  centre  of  the  iris,  towards  the 
seat  of  the  prolapsus.  The  intensity  of  the 
pain,  produced  by  the  inflammation,  and 
other  symptoms  attendant  on  the  prolapsus 
of  the  iris,  does  not,  however,  always  con- 
tinue to  increase. 

Indeed,  in  practice,  cases  of  old  protru- 
sions of  the  iris  often  occur,  where,  after 
the  disease  has  been  left  to  itself,  the  pain 
and  inflammation  spontaneously  subside, 
and  the  tumour  of  the  iris  becomes  almost 
completely  insensible.  Scarpa  met  with  a 
man,  fifty  years  of  age,  who  had  had  a pro- 
lapsus of  the  iris  in  the  right  eye  ten  weeks  ; 
it  was  as  large  as  two  grains  of  millet  seed  ; 
the  patient  bore  it  with  the  greatest  indiffer- 
ence, and  without  any  other  inconvenience, 
than  a little  chronic  redness  of  the  conjune- 
tiva,  and  a difficulty  of  moving  the  eyeball 


freely,  in  consequence  of  the  friction  of  the 
lower  eyelid  against  the  tumour  formed  by 
the  iris.  When  the  extremity  of  the  finger 
was  applied,  the  little  tumour  felt  hard  and 
callous. 

In  the  early  stage  of  ibis  disease,  some 
direct  the  iris  to  be  replaced  in  its  proper 
situation  by  means  of  a wnalebone  probe  ; 
and  in  case  of  difficulty,  to  make  a ddata- 
tion  of  the  wound,  or  ulcer  of  the  cornea, 
by  an  incision,  proportioned  to  the  exigency 
of  the  case,  as  is  done  for  the  return  of  a 
strangulated  intestinal  hernia.  Others  only 
recommend  stimulating  tne  prolapsed  por- 
tion of  the  iris  with  the  view  01  making  it 
contract  and  shrink  into  the  eye  ; or  sud- 
denly exposing  the  eye  affected  to  a very 
vivid  light,  in  the  beliei,  that  as  tiie  pupil 
then  forcibly  contracts,  the  piece  of  the  iris, 
engaged  between  the  lips  of  the  wound,  or 
ulcer  of  the  cornea,  will  rise  to  its  proper 
place.  How  ever,  Scarpa  represents  all  such 
methods  as  absolutely  useless,  and  even 
dangerous.  Supposing  it  were  possible,  by 
such  attempts,  to  reduce  the  iris  to  its  pro- 
per situation,  without  tearing  or  injuring 
it,  still  the  aqueous  humour  would  escape 
again  through  the  wound,  or  ulcer  of  the 
cornea,  so  that  the  iris,  when  replaced, 
would  fall  down  the  moment  afterward,  and 
project  from  the  cornea  in  the  same  way  as 
before  the  operation.  Hence,  though  Scarpa 
admits  that  the  prolapsus  of  the  iris  is  a se- 
rious accident,  he  argues  that  as  surgery  has 
no  means  of  suppressing  at  once,  or  at  least, 
of  suspending  the  escape  of  the  aqueous  hu- 
mour through  a wound,  much  less  through 
an  ulcer  of  the  cornea,  when  either  exceeds 
certain  limits,  the  prolapsus  of  the  iris,  far 
from  being  an  evil  in  such  unfavourable  cir- 
cumstan-  es,  is  rather  useful,  and.  perhaps, 
the  only  means  of  preventing  the  total  loss 
of  the  organ  of  sight , for  the  flap  of  the  iris 
insinuates  itself,  like  a plug,  between  the 
edges  of  the  wound,  or  ulcer  of  the  cornea, 
and  thus  completely  prevents  the  exit  of  the 
aqueous  humour. 

Here  l ought  to  observe,  that  Scarpa's 
unlimited  condemnation  of  the  plan  oi  ever 
attempting  to  replace  the  iris  is  contrary  to 
the  advice  delivered  by  Beer,  as  may  be 
seen  by  referring  to  the  article  Cataract , 
where  the  treatment  of  the  protrusion  of 
the  iris  after  the  operation  of  extraction  is 
noticed.  And  even  with  respect  to  the  pro- 
lapsus of  the  iris  from  ulceration  making  its 
way  through  the  cornea,  Beer  distinctly 
states,  that  a recent  prolapsus  of  this  kind, 
formed  iu  the  second  still  existing  stu^e  of 
ophtbalmy,  may  not  only  be  lessened  by 
proper  treatment,  calculated  to  produce  a 
quick  cicatrization  of  the  ulcer,  but  the  iris 
may  be  again  completely  removed  from  tne 
cornea,  w ithout  any  adhesion  to  the  edge 
ot  the  ulcer  taking  place.  (B.  2 ) 
But  w'here  the  prolapsus  of  the  iris  remains, 
as  a consequence  of  previous  inflammation 
of  the  eye,  Beer  confesses  that  it  cannot  be 
cured,  without  a partial  adhesion  of  the  iris 
to  the  cornea  being  left,  and  a dense  scar  on 


IRIS. 


m 


the  latter  membrane  in  the  situation  of  the 
protruded  iris.  ( Vol . cit.p.  66.) 

In  conformity  to  Scarpa’s  principles,  there 
are  two  principal  indications  in  the  treat- 
ment of  the  recent  prolapsus  of  the  iris.  The 
first  is,  to  diminish,  as  speedily  as  possible, 
the  exquisite  sensibility  in  the  protruded 
part  of  the  iris  ; the  other  is  gradually  to 
destroy  the  projecting  portion  of  this  mem- 
brane to  such  a depth,  as  shall  be  sufficient 
to  prevent  the  little  tumour  from  keeping  the 
edges  of  the  wound,  or  ulcer  of  the  cornea 
asunder,  and  retarding  cicatrization.  The 
adhesion,  however,  which  connects  the  iris 
with  the  iuside  of  the  aeornea,  must  not  be 
destroyed 

For  fulfilling  these  indications,  nothing  is 
more  effectual,  than  touching  the  portion  of 
the  iris  projecting  from  the  cornea,  with  the 
oxygenated  muriate  of  antimony  ( butter  oj 
antimony,)  or  with  what  is  more  expeditious 
and  convenient,  the  argentum  nitratum,  so 
as  to  form  an  eschar  of  sufficient  depth. 
And,  in  order  that  this  operation  may  be 
effected  with  quickness  and  precision,  it  is 
necessary  that  an  assistant,  standing  behind 
the  patient’s  head,  should  support  the  upper 
eyelid  with  Pellier’s  elevator  ; and  that  the 
patient  should  keep  his  eye  steadily  fixed 
on  one  subject. 

While  the  assistant  gently  raises  the  upper 
eyelid,  the  surgeon  must  depress  the  lower 
one,  with  the  index  and  middle  fingers  of 
his  left  hand  ; and  with  the  right,  he  is  to  be 
ready  to  touch  the  little  prominence  formed 
by  the  iris,  with  the  argentum  nitratum, 
scraped  to  a point  like  a pencil.  This  is  to 
be  applied  to  the  centre  of  the  little  tumour, 
until  an  eschar  of  sufficient  depth  is  formed. 
The  pain  which  the  patient  experiences  at 
this  moment,  is  very  acute  ; but,  it  subsides 
as  soon  as  the  eye  is  bathed  with  warm  milk. 
The  caustic,  in  destroying  the  projecting 
portion  of  the  iris,  destroys  the  principal 
organ  of  sensibility,  by  covering  it  with  an 
eschar,  of  sufficient  depth  to  protect  the  part 
affected  from  the  effect  of  the  friction  of  the 
eyelids,  and  from  coming  into  contact  with 
the  air  and  tears.  This  is  the  reason,  not 
only  why  the  sense  of  pricking  and  con- 
striction in  the  eye  abates  after  the  applica- 
tion of  the  caustic,  but  also  why  the  inflam- 
mation of  the  conjunctiva  undergoes  a con- 
siderable diminution,  as  well  as  the  burning 
and  copious  effusion  of  tears. 

As  in  the  case  of  ulcer  of  the  cornea,  these 
advantages  only  last  while  the  eschar  re- 
mains adherent  to  the  little  tumour  formed 
by  the  iris  ; when  it  falls  off,  as  it  usually 
does  two  or  three  days  after  the  use  of  the 
caustic,  all  the  above-mentioned  symptoms 
are  rekindled,  with  this  difference,  that  they 
are  less  intense  and  acute,  than  they  were 
previously,  and  the  tumour  of  the  iris  is  not 
so  prominent  as  it  was  before  tbs  caustic 
was  applied.  When  these  symptoms  make 
their  appearance,  the  surgeon  must  once 
more  have  recourse  to  the  argentum  nitratum, 
with  the  precautions  explained  above  ; and 
he  is  to  employ  it  a third,  and  even  a fourth 
time,  as  occasion  may  rcqhire,  until  the 


prominent  portion  of  the  iris  is  sufficiently 
reduced  to  a level  with  the  edges  of  the 
wound,  or  ulcer  of  the  cornea,  and  no  obsta- 
cle is  left  to  the  granulating  process,  and 
complete  cicatrization. 

There  is  a certain  period,  beyond  which 
the  application  of  caustic  to  the  protruded 
iris  becomes  exceedingly  dangerous,  though 
at  first  it  may  have  been  highly  beneficial  : 
beyond  which,  the  eschar,  which  previously 
soot  .ed  the  pain,  exasperates  it,  and  repro- 
duces the  inflammation  of  the  conjunctiva 
in  almost  as  vehement  a degree  as  in  the 
beginning  of  the  disease.  This  appears  to 
Scarpa  to  be  the  case,  whenever  the  sur- 
geon continues  to  employ  the  caustic,  after 
the  little  tumour  of  the  iris  has  been  destroy- 
ed to  a level  with  the  external  edges  of  the 
wound,  or  ulcer  of  the  cornea,  and  the 
application  begins  to  destroy  the  granula- 
tions just  as  they  are  originating.  Hence, 
as  soon  as  tae  surgeon  perceives,  that  the 
part  of  the  iris,  projecting  from  the  cornea, 
is  sufficiently  lowered,  and  that  the  applica- 
tion of  the  argentum  nitratum,  far  from 
allaying,  only  irritates  the  disease,  he  must 
desist  entirely  from  using  the  caustic,  and  be 
content  with  introducing  between  the  eye 
and  eyelids,  every  two  hours,  the  collyrium 
zinci  sulphatis  with  tlie  mucilage  of  quince- 
seeds.  Every  morning  and  evening,  Janin’s 
ophthalmic  ointment,  weakened  with  a 
double,  or  triple  proportion  of  lard,  is  to  be 
applied.  If  the  stimulus  of  such  local  reme- 
dies should  not  disturb  the  work  of  nature, 
the  ulcer  gradually  diminishes,  and  heals  in 
the  course  of  a fortnight. 

The  adhesion,  which  the  projecting  part  of 
the  iris  contracts  to  the  internal  margin  of 
the  wound,  or  ulcer  of  the  cornea,  during 
the  treatment,  continues  the  same  after  the 
perfection  of  the  external  cicatrix,  and  of 
course  during  the  rest  of  the  patient’s  life. 
Hence,  even  afterthe  most  successful  treat- 
ment of  the  prolapsus  of  the  iris,  the  pupil 
remains  a.liltle  inclined  toward  the  place  of 
the  scar  in  the  cornea,  and  of  an  oval  figure. 
1 he  change  in  the  situation  and  shape  of  the 
pupil,  however,  cause* little  or  no  diminution 
of  the  patient’s  faculty  of  discerning  distinct- 
ly (he  smallest  objects;  and  is  much  less 
detrimental  to  the  sight,  than  one,  inexpe- 
rienced in  these  matters,  might  conceive  ; 
provided  the  scar  on  the  cornea  be  not  too 
extensive,  nor  situated  exactly  in  the  centre 
of  this  membrane.  In  the  first  case,  the 
sight  is  the  less  obstructed,  as  the  pupil, 
which,  on  the  first  occurrence  of  the  pro- 
lapsus, was  narrow,  oblong,  and  drawn 
considerably  toward  the  wound,  or  ulcer, 
gradually  enlarges,  and  forms  a less  con- 
tracted oval.  As  soon  as  the  wound  is 
completely  healed,  the  pupil  tends,  in  some 
degree,  to  occupy  its  former  situation  in 
the  centre  of  the  cornea  ; a fact,  also  noti- 
ced by  Richter. 

According  to  Scarpa,  the  reeision  of  the 
protrusion  with  scissors  can  only  be  practi- 
sed with  success,  when  the  iris  has  contract- 
ed a firm  adhesion  to  the  internal  edge  of 
the  wound,  or  ulcer  of  the  cornea  : mu! 


IRIS. 


137 


tu ore  especially,  in  that  ancient  prolapsus 
of  the  iris,  in  which  the  projecting  portion 
of  the  iris  has  become  with  time  almost  in- 
sensible, hard,  and  callous,  with  its  base 
strangulated  between  the  edges  of  the 
wound,  or  ulcer  of  the  cornea,  and  besides 
being  adherent  to  them,  having  also  a slen- 
der pedicle.  Scarpa  indeed  has  seen  an  in- 
carcerated one  fall  off  of  itself. 

In  such  circumstances,  the  recision  of  the 
old  prolapsus  of  the  iris  is  not  attended  with 
the  least  danger  ; for,  after  removing  with  a 
stroke  of  the  scissors,  that  prominent  portion 
of  the  iris,  which  has  already  contracted 
Internal  adhesions  to  the  ulcerated  margin 
of  the  cornea,  so  as  to  reduce  it  to  a level 
with  the  external  edges  of  the  ulcer,  there 
is  no  hazard  of  renewing  the  effusion  of  the 
aqueous  humour,  or  giving  an  opportunity 
for  another  piece  of  the  irisTo  be  protruded. 
One  or  two  applications  of  the  argentum 
nitratum  suffice  afterward  for  the  produc- 
tion of  granulations  on  the  ulcer  of  the 
cornea,  and  the  formation  of  a cicatrix. 
But,  it  is'not  so  in  the  treatment  of  the 
recent  prolapsus  of  the  iris,  which  has  rlo 
adhesions  to  the  internal  edges  of  the  wound, 
or  ulcer  of  the  cornea. 

In  four  subjects  recently  affected  with 
prolapsus  of  the  iris,  after  Scarpa  had  re- 
moved, with  a pair  of  convex-edged  scissors, 
a portion  of  that  membrane  projecting  be- 
yond the  cornea,  of  about  the  size  of  a fly’s 
head,  he  found,  on  the  ensuing  day,  that  a 
new  portion  of  the  iris,  not  less  than  the 
iirst,  had  made  its  way  through  the  ulcer  of 
the  cornea,  and  that  the  pupil  was  very  much 
contracted,  and  drawn  considerably  further 
toward  the  ulcer  of  the  cornea.  These 
circumstances  took  place,  notwithstanding 
the  wound  was  touched  immediately  after- 
ward with  the  argentym  nitratum-  Hence 
Scarpa  apprehends,  that  if  he  were  ever  to 
divide  such  a little  tumour  again,  it  would 
reappear,  and  always  with  an  additional 
protrusion  of  the  iris,  and  a further  distortion 
of  the  pupil.  The  advantage  of  caustic  in  the 
recent  sensible  prolapsus  of  the  iris  ; and 
the  use  of  scissors  only  in  old  callous  cases, 
agree  also  with  the  directions  given  both  by 
Beer  and  Mr.  Travers.  ( Lehre  von  den 

Augenkr.  B.  2.  p.  68  ; and  Synopsis,  p.  280.) 

There  is  a particular  species  of  prolapsus, 
much  less  frequent,  indeed,  than  that  of  the 
iris  : but,  which  does  oceur,  and,  in  Scarpa’s 
opinion,  is  very  improperly  termed  by  mo- 
dern  oculists,  “ prolapsus  of  the  tunic  of  the 
aqueous  humour."  ( Janirt , Peltier , Guirin, 
Gleizc , fyc.)  INeither  do  his  sentiments  upon 
this  subject  agree  with  those  of  Beer,  whose 
explanation  of  the  nature  of  the  case  is 
given  in  Vol.  I.  of  this  Dictionary.  We  shall 
there  see,  that  it  is  a case,  which  he  terms 
ceratocele,  and  which  he  thinks  arises  from  a 
yielding  of  the  inner  layers  of  the  cornea,  in 
consequence  of  the  outer  ones  not  having 
united.  And,  in  his  second  vol.  p.  59,  he 
has  given  a description  of  the  same  kind  of 
disease  from  the  support  of  the  outer  layers 
of  the  cornea  being  destroyed  by  ulceration. 
This  is  a point,  on  which  the  most  hxperien- 
Vor  If  '18 


ced  men  differ  so  much,  that  it  is  difficult  to 
reconcile  their  statements.  Dr  Vetch  seems 
to  have  full  reliance  upon  the  accuracy  of 
the  accounts  of  a protrusion  of  the  mem-  i 
brane  of  the  aqueous  humour.  {Treatise  on 
Diseases  of  the  Eye,p.  54,  fyc.)  Mr.  Travers 
inclines  to  Beer’s  view  of  the  subject,  and 
details  reasons  for  doubting,  that  the  vesicle 
is  a distinct  texture  : “ its  appearance  cor- 
responds accurately  to  that  of  the  innermost 
lamella  of  the  cornea.’’  ( Synopsis  of  the 
Diseases  of  the  Eye,  p.  116.) 

It  is,  says  Scarpa,  a transparent  vesicle, 
filled  with  an  aqueous  fluid,  and  composed 
of  a very  delicate  membrane,  projecting 
from  a wound,  or  uliper  of  the  cornea,  much 
in  the  same  way  as  the  iris  does  under- 
similar circumstances.  Scarpa  has  several 
times  seen  this  transparent  vesicle  full  of 
water,  elongating  itself  beyond  the  cornea, 
shortly  after  the  operation  for  the  extraction 
of  the  cataract,  and  sometimes,  also,  in  con- 
sequence of  an  ulcer  of  the  cornea,  espe- 
cially after  rescinding  a prolapsed  portion  of 
the  iris. 

The  generality  of  oculists  believe  that  tin's 
little  transparent  tumour  consists  of  the  deli- 
cate, elastic,  diaphanous  membrane,  which 
invests  the  inner  surface  of  the  cornea,  and 
is  described  by  Descemet  and  Demours. 
u As  soon  as  the  membrane  lining  the  cornea 
(they  say)  is  exposed  by  the  wound,  or  ulcer 
of  the  latter,  and  the  delicate  pellicle  can  no 
longer  resist  the  impulse  of  the  humours 
pressing  behind  it,  it  is  necessitated  to  yield 
gradually,  to  become  elongated,  and  to  pro- 
ject from  the  wound,  or  ulcer  of  the  cornea, 
exactly  in  the  form  of  a pellucid  vesicle.” 

But,  says  Scarpa,  how  remote  this  theory  is 
from  the  truth,  must  be  manifest:  1.  The 
delicate  and  elastic  pellicle,  described  by 
Descemet  and  Demours,  is  not  separable  by 
any  artifice  from  the  inner  surface  of  the 
cornea,  except  near  where  the  cornea  and 
sclerotica  unite.  Since  these  protruded 
vesicles  make  their  appearance  in  practice 
at  every  point  of  the  cornea,  and  even  at 
its  very  centre,  where  Ihe  above  pellicle  is 
certainly  neither  separable,  nor  distinct  from 
the  compact  texture  of  the  cornea  ; it  may 
at  least  be  asserted,  that  the  tunic  of  the 
aqueous  humour  does  not  in  every  instance 
constitute  the  transparent  vesicle  in  question 
2.  ft  is  a well-known  fact,  that  this,  vesicular, 
pellucid  prolapsus  happens  more  frequently 
after  fbe  extraction  of  the  cataract,  than  any 
other  occasion.  In  rhis  case,  since’  the  tunic 
of  the  aqueous  humour  has  certainly  been 
divided  to  afford  an  exit  to  the  crystalline, 
no  one  can  be  of  opinion,  that  the  transpa- 
rent vesicle,  which  protrudes  from  the 
cornea  after  this  operation,  ought  to  h& 
attributed  to  the  distention  and  protrusion  of 
the  tunic  of  the  aqueous  humour.  3.  If,  in 
cases  of  ulcers  of  the  cornea,  the  transparent 
vesicle  should  sometimes  appear  after  the 
recision  of  the  prolapsus  of  the  iris,  it  is 
obvious,  that  if  it  consisted  of  the  tunic  of 
the  aqueous  humour,  it  ought  invariably  to 
appear  before  the  prolapsus  of  the  iris! 

4.  Should  the  surgeon  Remove  the  dfo-truded 


/ 


IRls. 


138 

vesicle  to  a level  with  the  cornea  by  a stroke 
of  the  scissors,  a small  quantity  of  limpid 
water  is  seen  to  ooze  out,  at  the  moment 
when  the  incision  is  made,  without  any  part 
of  the  aqueous  humour  escaping  from  the 
anterior  chamber.  This  inconvenience 
would  be  inevitable,  were  the  protruded 
vesicle  in  question  formed  by  the  delicate 
elastic  pellicle,  which  is  said  to  invest  the 
inrter  surface  of  the  cornea.  Besides,  the 
little  transparent  tumour  disappears  when 
the  incision  is  made;  but  often  another  one 
exactly  similar  to  what  was  cut  oft',  is  found 
in  the  very  same  place  the  following  day. 
Iiad  the  little  transparent  tumour  been  com- 
posed of  the  tunic  of  the  aqueous  humour, 
elongated  out  of  the  wound,  or  ulcer  of  the 
cornea,  it  could  not  at  all  events  have  been 
reproduced  at  the  same  part  of  the  Cornea. 

Actuated  by  such  reflections,  it  is  clear  to 
Scarpa,  that  the  pretended  prolapsus  of  the 
tunic  of  the  aqueous  humour  is  not  what  it 
is  imagined  to  be  ; but  strictly  speaking, 
only  a forcible  protrusion  of  a portion  of  the 
vitreous  humour,  which,  from  too  much 
pressure  being  made  on  the  eye,  either  at 
the  time  of  the  operation,  or  afterward,  or 
from  a spagm  of  the  muscles  of  the  eye,  in- 
sinuates itself  between  the  edges  of  the 
wound  after  the  extraction  of  the  cataract, 
and  projects  in  the  form  of  a transparent 
vesicle.  The  same  thing  also  happens  after 
ulcers  of  the  cornea,  whenever  the  aqueous 
humour  has  escaped,  and  a portion  of  the 
vitreous  humour  is  urged  by  forcible  pres- 
sure towards  the  ulcer  facing  the  pupil ; or 
whenever  an  elongated  piece  of  the  vitre- 
ous humour;  after  the  recision  of  a prolap- 
sed portion  of  the  iris,  passes  by  a shorter 
route  than  through  the  pupil,  between  the 
lips  of  the  ulcer  of  the  cornea.  At  length, 
we  understand,  why  in  both  these  instances 
a transparent  vesicle  forms,  even  after  the 
recision  of  the  tunic  of  the  aqueous  humour, 
or  ulceration  of  the  cornea ; and  wrhy  it  very 
often  reappears  in  the  same  place,  though 
it  has  been  cut  away  to  a level  with  the  cor- 
nea. It  is  because  one  or  more  cells  of  the 
vitreous  humour,  constituting  the  transpa- 
rent vesicle,  are  succeeded  after  their  re- 
moval by  other  cells  of  the  same  humour, 
which  glide  between  the  lips  of  the  w ound, 
or  ulcer  of  the  cornea,  into  the  same  situa- 
tion. 

The  treatment  of  this  species  of  prolapsus 
consists  in  removing  the  transparent  vesicle, 
projecting  from  the  wound,  or  ulcer,  by 
means  of  a pair  of  curved  scissors  with  con- 
vex edges,  and  bringing  the  edges  of  the 
wound  of  the  cornea  immediately  afterw  ard 
into  perfect  apposition,  in  order  that  they 
iHly  unite  together  as  exactly  as  possible. 
But  when  there  is  an  ulcer  of  the  cornea,  as 
soon  as  the  vesicle  is  removed,  the  sore 
must  be  touched  with  the  argentum  nitra- 
tum,  so  that  the  eschar  may  resist  any  new 
prolapsus  of  the  vitreous  humour,  and  at  the 
same  time  dispose  the  ulcer  of  the  cornea  to 
granulate  and  heal. 

If,  in  some  particular  cases,  the  vesicle 
should  pot  project  sufficiently  ftom  the 


wound,  or  ulcer  oi  lire  cornea,  to  be  inclu- 
ded in  the  scissors,  the  same  object  may  be 
accomplished  by  puncturing  the  tumour 
with  a lancet,  or  couching-needle ; for  when 
the  limpid  fluid  which  it  contains  is  dis- 
charged, the  membrane  forming  it  shrink? 
within  the  edges  of  the  wound,  or  ulcer  of 
the  cprnea,  and  no  longer  hinders  the  union 
of  the  former,  or  the  cicatrization  of  the 
latter. 

Should  the  transparent  tumour  reappear 
in  the  same  situation,  the  day  after  its  reci- 
sion, or  puncture,  it  is  right  to  repeat  one 
of  these  operations,  and  to  adopt  further 
measures  for  maintaining  the  edges  of  the 
wound  of  the  cornea  in  contact ; or  if  it 
should  be  an  ulcer,  the  eschar  must  be  made 
to  adhere  more  deeply  to  its  bottom  and 
sides,  so  as  toXpnn  a greater  obstacle  to  the 
escape  of  the  vitreous  humour.  In  these 
circumstanees,  the  surgeon  must  take  all 
possible  care  to  obviate  such  causes  as  have 
a tendency  to  propel  the  vitreous  humour 
towards  the  wound,  or  ulcer  of  the  cornea  ; 
particularly  too  much  pressure  on  the  eye- 
lids, spasms  of  the  muscles  of  the  eye,  cough- 
ing, sneezing,  efforts  at  stool,  and  other  si- 
milar ones  ; and  care  must  also  be  taken  to 
check  the  progress  of  inflammation. 

The  choroid  coat  is,  likewise  not  exempt 
from  prolapsus.  Scarpa  has  seen  this  com 
plaint  in  M.  Bressanini,  an  apothecary  at 
Bescape.  "A  small  abscess,  formed  between 
the  sclerotica  and  choroid  coats,  at  the  dis- 
tance of  two  lines  from  the  union  of  the 
cornea  with  the  sclerotica,  in  the  inferior 
hemisphere  of  the  globe  of  the  eye,  in  con- 
sequence of  a severe  internal  and  external 
ophthalmy,  which  had  been  treated  in  its 
incipient  stale,  with  repellent  remedies. 
The  abscess  burst,  and  discharged  a small 
quantity  of  thick  viscid  lymph  ; then  a small 
blackish  body,  composed  of  the  choroid 
coat,  presented  itself  on  the  outside  of  the 
little  ulcer  of  the  sclerotica.  The  treatment 
consisted  in  applying  the  argentum  nitratum 
several  times  to  the  projecting  portion  of 
the  choroides,  until  it  wras  consumed,  and 
reduced  to  a level  with  the  bottom  of  the 
ulcer  of  the  cornea.  The  part  then  healed. 
The  eye  remained,  however,  considerably 
weakened,  and  the  pupil  afterward  became 
nearly  closed.  Scarpa  sulle  Principals  Ma- 
latlie  degli  Occhi.  Venezia , 1802.  Richter’s 
Anfangsgmnde  der  Wvndarzneykunst,  B.  3, 
Von  dtm  Vorfalle  dcr  Regenbogenhaut . Pel- 
lier,  Ohs.  sur  l'(Eil,  p.  350.  G.  J.  Beer, 
Lehre  von  den  Augcnkrardcheitcn,  B.  1,  § 402, 
518,  and  592,  and  B.  2.  § 58,  (32,  fyc.  8vo. 
Wien.  1813 — 1817.  J.  War  dr  op,  Essays  on 
the  Morbid  Anatomy  of  the  Human  Eye , Vol. 
2,p.51,  8 vo.  Load.  1848.  •/.  Vetch,  A Practi- 
cal' Treatise  on  the  Diseases  of  the  Eye,  p.  53, 
fyc.  Lond.  8 vo.  1820.  B.  Travers,  A Synopsis 
of  the  Diseases  of  the  Eye , p.  116,  280,  fyc. 
th'o.  Lond.  1820.  Weller  on  J)iseases  of  the 
Eye,  Transl.  by  Dr.  Monlcaih , 8ro.  Glasgow, 
1821. 

For  a description  of  the  manner  of  divid- 
ing the  iris,  order  to  make  *rn  rMl'ifin.-d 


pupil,  when  the  natural  one  is  closed,  rel’er 
to  Pupil,  Closure  of. 

Iris,  Effects  of  certain  narcotics  upon , see 
Belladonna  and  Cataract.  The  follow- 
ing work  upon  the  subject  also  merits  atten- 
tion. C.  Himly  de  la  Paralysie  dc  V Iris  par 
tine  application  locale  de  la  Jusquiaume,  el  de 
son  utililc  dans  le  iraitemenl  de  plusieurs  ma- 
ladies des  Yeux,  2 de  Ed.  Altona , 1805. 

IRITIS.  Inflammation  of  the  iris.  See 
Ophthalmy. 

ISCHU'RIA.  (From  ta-yje,  to  restrain  ; 
and  agsv,  the  urine.)  A suppression,  or  stop- 
page of  the  urine. 

The  distinction  between  a suppression  and 
retention  of  urine,  is  practical  and  judicious. 
The  former  most  properly  points  out  a de- 
fect in  the  secretion  of  the  kidneys  ; the  lat- 
ter, an  inability  ot  expelling  the  urine  when 
secreted.  {Hey.) 

The  first  disease  is  not  very  common,  is 
named  ischuria  rnialis,  or  suppression  of 
urine,  and  belongs  to  the  province  of  the 
physician ; the  second  is  an  exceedingly 
frequent  disorder,  is  n a meiVisch uria  vesi calls, 
or  retention  of  urine , and  its  treatment  is  al- 
together surgical.  Every  thing  relative  to 
it  will  be  found  in  the  articles  Catheter,  and 
Urine,  Retention  of. 

ISSUE  signifies  an  ulcer,  made  designed; 
ly  by  the  practitioner,  and  kept  open  a cer- 
tain time,  or  even  the  patient’s  whole  life, 
for  the  cure,  or  prevention,  of  a variety  of 
diseases. 

The  physician,  in  his  practice,  has  frequent 
occasion  to  recommend  the  making  of  an 
issue,  and  the  surgeon  finds  it  a principal 
means  of  relief  in  several  important  cases, 
as,  for  instance,  the  while  swelling,  the  dis- 
ease of  the  hip-joint,  caries  of  the  vertebra?, 
&c.  Many  persons  are  never  in  health, 
or,  at  least,  fancy  themselves  always  ill,  un- 
less they  have  an  issue  formed  in  some  part 
of  their  body  or  another.  The  making  of 
an  issue,  indeed,  is  not  unfrequently  consi- 
dered as  an  imitation  of  nature,  who,  of  her 
own  accord, often  forms  ulcers  and  abscesses 
in  various  parts  of  the  body  (as  is  not  un- 
commonly conjectured)  for  the  purpose  of 
discharging  pernicious  humours,  whereby 
people  are  supposed  to  be  freed  from  griev- 
ous disorders, and  have  their  health  preserved. 
The  humoral  pathologists  were  excessively 
partial  to  these  notions,  which,  at  the  pre- 
sent time,  will  be  found  by  every  experi- 
enced practitioner  to  influence  the  mass  of 
mankind,  and  render  the  formation  of  issues 
more  common,  than  perhaps  is  consistent 
with  the  better  established  principles  of  me- 
dical science.  Few  oid  subjects  will  allow 
a sore  of  long  standing  to  be  dried  up  (as 
the  expression  is,)  without  requiring  the 
surgeon  immediately  afterward  to  make  tin 
issue  for  them.  When  an  ulcer  has  existed 
a great  length  of  time,  the  constitution  may 
possibly  become  so  habituated  to  it,  that 
the  health  may  really  sutler  from  its  being 
healed.  11 1 have  often  (says  the  experien- 
ced Dr.  Parry)  seen  various  thoracic  affec- 
tions, a3  pulmonary  consumption,  asthma, 
carditis,  or  hydrothorax,  arise  from  flic 


spontaneous,  or  artificial  cure  of  ulcers,  per- 
petual blisters,  or  fistula?.”  {Elements  of 
Pathology,  fyc.  p.  385.)  Asthmatic  com- 
plaints, severe  headachs,  he.  are  frequently 
observed  to  follow  the  cicatrization  of  an 
oid  ulcer;  but  whether  they  would  have 
happened,  if  an  issue  had  been  made  in 
time,  is  a question  difficult  of  positive  de- 
termination ; for  many  persons  with  old 
ulcers  are  not  prevented  from  suffering 
from  asthma  and  headach.  The  plan  of 
making  an  issue,  however,  is  commendable 
both  as  rational  and  exempt  from  danger. 
Whatever  may  be  the  solidity  of  the  theo- 
ries, which  have  been  offered  by  medical 
writers,  in  regard  to  issues,  the  practitioner, 
who  has  his  eyes  open,  cannot  fail  to  see  the 
benefit  often  derived  from  such  means  ; and 
if  there  be  any  unquestionable  facts  in  me- 
dicine and  surgery,  we  may  confidently  set 
down  among  them  the  frequent  possibility 
of  relieving  one  disease  by  exciting  another 
of  a less  grievous,  and  more  curable  na- 
ture. 

There  are  two  ways  of  making  an  issue  ; 
one  is  with  a lancet,  or  scalpel;  the  other 
with  causlic. 

The  place  for  the  issue  being  fixed  upon, 
the  surgeon  and  his  assistant  are  to  pinch  up 
a fold  of  the  integuments,  and  with  a lancet 
or  knife,  make  in  them  an  incision  of  suffi- 
cient size  to  hold  a pea,  or  as  many  peas  as 
may  be  thought  proper.  The  pea,  or  peas 
are  then  to  be  placed  in  the  cut,  and  cover- 
ed with  a piece  of  adhesive  plaster,  a com- 
press, and  bandage.  The  peas  first  inserted, 
need  not  be  removed  for  three  or  four  days, 
when  suppuration  will  have  begun  ; but  the 
issue  is  afterward  to  be  cleaned  and  dressed 
every  day,  and  have  fresh  peas  put  into  it. 
The  preceding  is  the  ordinary  method  of 
making  such  issues  as  are  intended  to  con- 
tain only  one  or  two  peas. 

When  the  issue  is  to  be  larger,  which  is 
generally  proper,  in  cases  of  diseased  verte 
bra?,  white  swellings,  he.,  the  best  plan  is 
to  destroy  a portion  of  the  integuments  with 
caustic.  The  caustic  potassa,  blended  with 
quicklime,  is  mostly  preferred  for  this  pur- 
pose. The  situation  and  size  of  the  issue 
having  been  determined,  the  surgeon  is  to 
take  care  that  the  caustic  does  not  extend 
its  action  to  the  surrounding  parts.  With 
this  view,  he  is  to  take  apiece  of  adhesive 
plaster,  and  having  cut  a hole  in  it  of  the 
exact  shape  and  size  of  the  issue  intended 
to  be  made,  he  is  to  apply  it  to  the  part. 
Thus  the  plaster  will  defend  the  adjacent, 
skin  from  the  effects  of  the  caustic,  while 
the  uncovered  portion  of  integuments,  cor- 
responding to  the  hole  in  the  plaster,  is  that 
which  is  to  be  destroyed.  The  caustic  is  to 
be  taken  hold  of  with  a bit  of  lint,  or  tow, 
and  its  end,  having  been,  a little  moistened 
with  water,  is  to  be  steadily  rubbed  upon 
the  part  of  the  skin  where  the  issue  is  to  be 
formed.  The  frictions  ore  to  be  continued 
till  the  whole  surface,  intended  to  be  de- 
stroyed, assumes  a darkish  corroded  appear- 
ance. The  caustic  matter  may  now  be  care- 
fully washed  off  with  some  wet  tow.  The 


HO  JOINTS. 


plaster  is  to  he  removed,  and  a linseed  poul- 
tice applied.  As  soon  as  the  eschar  is  de- 
tached, or  any  part  of  it  is  loose  enough  to  be 
cut  away  without  pain,  or  bleeding,  the  peas 
are  to  be  inserted  and  confined  in  their  pro- 
per place  with  a piece  of  adhesive  piaster. 
Some  use  beans  for  the  purpose  ; others, 
beads,  which  answer  very  well,  and  have 
the  advantage  of  serving  for  any  length  of 
time,  when  washed  and  cleaned  every  day. 
If  the  issue  is  at  all  of  a longitudinal  shape, 
the  peas,  beans,  or  beads,  may  be  more 
easily  kept  in  their  places,  when  a thread  is 
passed  through  them. 

Issues  ought  always  to  be  made,  if  possible, 
in  a situation,  where  the  peas  will  not  he 
much  disturbed  in  the  ordinary  motions  of 
the  body,  nor  interfere  with  the  actions  of 
muscles.  The  interspaces  between  the  mar- 
gins and  insertions  of  muscles,  are  deemed 
the  most  eligible  places.  Thus,  issues  in  the 
arm  are  usually  made  just  at  the  inferior  an- 
gle of  the  deltoid  muscle,  by  the  side  of  the 
external  edge  of  the  biceps.  In  the  lower 
extremities,  issues  are  often  made  at  the 
inner  side  of  the  thigh,  immediately  above 
the  knee,  in  a cavity  that  may  be  readily 
felt  there  with  the  fingers.  Sometimes,  is- 
sues are  made  upon  the  inside  of  the  leg, 
just  below  the  knee.  For  the  relief  of  any 
affections  of  the  head  or  eye,  the  nape  of  the 
neck  is  commonly  selected  as  a good  situa- 
tion. In  caries  of  the  vertebras,  they  are 
made  on  each  side  of  the  spinous  processes. 
In  cases  of  diseased  hips,  they  are  formed  in 
a depression  just  behind  and  below  the  tro- 
chanter major.  When  the  nature  af  the  dis- 


J 

JOINTS,  DISEASES  OF.  The  joints  are 
subject  to  numerous  diseases,  which  are 
more  or  less  dangerous,  according  to  their 
particular  nature.  Like  ail  other  parts,  the 
joints  are  liable  to  inflammation  and  abscess 
es ; their  capsules  frequently  become  distend- 
ed with  an  aqueous  secretion,  and  the  disease 
termed  hydrops  articuli  is  produced  ; out, 
the  most  important  of  alt  their  morbid  affec- 
tious,  are  the  cases,  which,  a few  years  ago, 
were  indiscriminately  called  white  swellings, 
scrophulous  joints,  and  the  disease  of  the  hip- 
joint.  Here,  as  Mr.  Brodie  remarks,  the  same 
name  has  been  frequently  applied  to  different 
diseases,  and  the  same  disease  has  received 
different  appellations.  And  confusion,  with 
respect  to  the  diagnosis,  always  gives,. rise  to 
a corresponding  confusion,  with  respect  to 
the  employment  of  remedies.  Although, 
says  he,  diseases  in  their  advanced  stage  ex- 
tend to  all  the  dissimilar  parts,  of  which  the 
joints  are  composed,  such  is  not  the.  case  in 
the  beginning.  Here,  as  elsewhere,  the 
morbid  actions  commence,  sometimes  in  one, 
and  sometimes  in  another  texture,  differing 
in  their  nature,  and,  of  course,  requiring  to 
be  differently  treated,  according  to  the  me- 
uhanical  organisation,  and  vital  properties  of 


order  does  not  particularly  indicate  the  situa-v 
tion  for  the  issue,  the  ami  should  be  preferred 
to  the  leg,  as  issues  upon  the  upper  extre- 
mities, especially  the  left  arm,  are  much  (ess 
annoying,  than  upon  either  of  the  lower, 
limbs. 

The  great  art  of  keeping  an  issue  open,  for 
a long  while,  consists  in  maintaining  an  equal 
and  effectual  pressure  upon  the  peas,  by  which 
means,  they  are  confined  in  their  places,  little 
depressions  are  made  for  them,  and  the  gra- 
nulations hindered  from  rising.  Compresses 
of  pasteboard  and  sheet- iead  will  often  be 
found  highly  useful.  This  plan  is  the  surest 
one  of  preventing  the  issue  from  healing,  and 
the  most  likely  to  save  the  patient  all  the 
severe  and  repeated  suffering,  which  the  fresh 
application  of  the  caustic,  or  the  use  of  sti- 
mulating powders,  in  order  to  renew  the  sore 
and  repress  the  fungous  flesh,  unavoidably 
occasions. 

There  is  a method  of  making  issues  with 
the  caustic  made  into  a sort  of  paste,  which 
is  laid  upon  the  part  left  uncovered  by  the 
adhesive  plaster.  It  seems  to  me  to  be  u 
more  tedious  and  painful  plan,  and  I do  not 
recommencLil. 

It  has  been  suspected,  that  the  pain,  arising 
from  the  caustic,  might  be  lessened,  by  mix- 
ing opium  with  the  application  ; but,  the  idea 
seems  not  at  a!!  probable ; the  destruction  of 
a part  of  the  skin  must  inevitably  cause  con 
siderable  pain,  with  whatever  substance  it  is 
produced,  and  opium  itself,  so  far  from  being 
likely  to  diminish  the  agony,  is  itself  a violent 
stimulus,  whenever  it  comes  into  contact 
with.lhe  exposed  extremities  of  the  nerve  : . 


the  part,  in  which  they  originate.  (See 
Pathological  and  Surgical  Ohs.  on  Diseases  of 
the  Joints,  p.  2, 8vo  Load.  1818.)  It  was  this 
idea,  which  led  Mr.  Brodie  to  trace,  by  dis- 
section the  exact  parts,  in  which  several  of 
the  principal  di&eases  of  the  joints  commence, 
and  how  much  light  and  discrimination  his 
successful  investigations  have  produced,  it  is 
needless  for  me  here  to  insist  upon,  as  his 
merit  will  long  be  appreciated  by  every  sur- 
geon, who  recollects  the  perplexity  and 
ignorance  which  prevailed  only  a few'  years 
ago  in  this  very  interesting  branch  of  sur- 
gery. 

IVounds. — By  the  wound  of  a joint,  surgeons 
mean  a case,  where  the  capsular  ligament 
is  penetrated,  or  divided.  The  injury  is  often 
accompanied  with  a division  of  the  lateral., 
or  other  ligaments,  and  sometimes  also  w ith 
that  ot  the  cartilages  and  hones.  That  the 
capsular  ligament  is  u'ounded  may  generally 
be  learned  by  the  introduction  of  a probe,  and 
frequently  by  a discharge  of  a transparent 
viscid  fluid,  called  the  synovia.  But,  as  a 
similar  discharge  may  proceed  from  mere 
wounds  of  the  bursae  mucosas,  we  might  form 
an  erroneous  judgment,  were  we  unac- 
quainted with  the  situation- of  thc-so  little 


JOINTS. 


141 


membranous  bags,  Boyer  has  seen  several 
eases,  in  which  a lluid,  resembling  synovia, 
was  discharged  from  wounds  of  the  sheaths 
of  tendons.  (See  Trade  des  Maladies  Chirurg, 
T.  4,  p.  408.)  Here,  the  advice  which  t have 
given  in  another  place.  (See  Wounds  of  the 
Abdomen J respecting  the  temerity  of  being 
too  officious  with  the  probe,  is  equally  im- 
portant, inasmuch  as  the  rough  introduction 
of  this  instrument  into  a large  joint,  like  the 
Icnee,  would  be  very  likely  to  excite  inflam 
illation  of  the  synovial  membrane,  and  a train 
of  dangerous  and  even  fatal  consequences; 
while  the  information,  gained  by  such  em- 
ployment of  the  probe,  is  of  little  use  ; be- 
cause, whenever  a wound  is  suspected  to 
reach  into  the  caps  .lar  ligament,  exactly  the 
same  treatment  should  alwas  s be  followed,  as 
as  if  the  joint  were  positively  known  to  be 
penetrated. 

Notwithstanding  simple  wounds  even  of 
large  joints  often  heal  favourably,  without 
any  bad  symptoms,  this  is  not  constantly  the 
case,  and  the  records  of  surgery  furnish  many 
examples,  in  which  the  most  alarming  and 
fatal  consequences  ensued.  (See'  Hunter's 
Commentaries,  Part,  1,  p.  69)  When  pro- 
perly treated,  punctured  wounds  of  the  joints 
, 3 ys  Boyer)  are  not  in  general  attended  with 
danger  ; but,  as  some  of  these  -v  ounds,  which 
were  apparently  quite  simple,  have  bee?:  fol- 
lowed by  very  bad  symptoms,  and  even  death, 
we  should  always  be  extremely  circumspect 
in  the  prognosis.  (See  Traill  des  Mai.  Chir. 
T.  4,  p.  409 ) The  treatment  consist-  in 
endeavouring  to  heal  the  injury  by  the  first 
intention;  in  applying  cold  lotions;  forbid- 
ding all  motion  of  the  part  ; and  employing 
bleeding  and  other  antiphlogistic  remedies. 

Baron  Boyer  relates  two  cases  of  punctured 
wounds  of  the  elbo  v joint,  which  h aied  up 
in  a few  days,  without  any  unfavourable 
symptom.  He  acknowledges,  however,  that 
these  accidents  do  not  always  go  on  so  Well, 
and  that  the  consequences  are  sometimes  pe- 
rilous. 

Simple  incised  wounds  present  only  one 
indication ; viz.  that  of  healing  the  part  by 
the  first  intention.  At  the  moment  of  the 
accident,  some  of  the  synovia  is  discharged, 
indicating  that  the  capsular  ligament  i- wound- 
ed. Shouid  this  circumstance  not  have  been 
noticed  at  first,  tue  surgeon  may  see  the  syno- 
via flow  out  again,  if  he  move,  or  press  upon 
the  joint.  But,  in  making  this  examination, 
the  greatest  gentleness  should  be  used,  lest 
tbe  irritation  of  the  capsular  ligament  be  in- 
creased. When  the  wound  is  large,  and  there 
is  no  considerable  thickness  of  soft  parts,  the 
articular  surfaces  are.  exposed  to  view. 

The  prognosis  of  an  incised  wound  of  a 
joint  is  not  generally  unfavourable,  when 
the  edges  have  been  immediately  brought 
together,  the  cavity  of  the  joint  has  noi  been 
long  exposed,  arid  blood  is  not  extravasated 
in  it.  This  last  danger  is  also  exaggerated,  as 
will  be  noticed,  in  speaking  of  collections  of 
blood  in  joints.  With  these  exceptions,  says 
Boyer,  the  wound  may  heal  as  readily,  as  if 
the  joint  were  not  opened,  and  he  has  cited 
several  facts  in  proof  of  this  statement.  Tls 


truth  is  also  confirmed  by  the  success  which 
attend?  operations,  practised  for  the  purpose 
of  extracting  cartilaginous  substances  from 
the  knee.  'Nay  very  bad  cases  sometimes 
recover  under  judicious  management,  even 
thou,  h the  joint  be  large,  and  ab«ce-iSes  fol- 
low. Thus  I have  seen  in  St.  Bartholomew's 
hospital,  within  the  last  year  (1820)  two  ex- 
amples of  compound  fractures  oj  the  patella, 
where  the  opening  in  the  capsule  was  >o large, 
that  the  finger  could  readily  lie  passed  into 
the  cavit)  of  the  joint,  yet  alter  large  ab- 
scesses, a great  deal  of  fever,  and  separation 
of  none,  the  patients  recovered  with  stiff 
joints.  But,  I would  advise  surgeon- not  to 
let  am  facts  of  this  kind  prejudice  their 
judgment  in  the  Peatmen*  ot  gunshot 
wounds  of  the  large  joints,  where,  in  the 
cireu  mtam  e-  ehew  lic  e e\p|. lined  (see  Am- 
putation and  Gunshot  Wounds } amputation  is 
the  s.itest  practice.  In  a sabie,  or  cut  wound, 
the  principal  object  is  to  heal  the  wound  by 
the  first  intention.  The  res'  of  the  treatment 
consists  in  using  every  possible  means  for  the 
prevention  ol  inflammation,  by  perfect  quie- 
tude of  the  part;  the  use  of  cold  applica- 
tions. See. 

We  repeat,  however,  that  wounds  of  the 
joints  do  not  always  heai  in  (he  above  favour- 
able manner.  Even  among  those  cases, 
which  appear  the  most  slight  and  simple, 
.’here  are  but  too  many,  which  are  billowed 
by  such  aggravated  symptoms,  aseither  prove 
fatal,  r occasion  a necessity  for  amputation. 
And.  in  other  instances  of  a le»s  gri-  vous 
description,  when  the  patient  is  cured,  the 
termination  of  danger  is  not  without  an  an- 
chylosis by  which  the  motion  and  functions 
ot  tiie  joint  are  permanently  destroyed. 

The  experienced  Mr.  Hey  has  noticed 
wounds  ot  tne  joints,  a id  made  some  perti- 
nent rem  rksou  the  subject.  He  states,  that 
in  these  cases,  the  utmost  care  should  be 
taken  to  prevent  i Humiliation.  “ Upon  this 
circumstance  chiefly  depends  a successful 
termination.  I have  seen  (says  he)  many 
large  wounds  of  the  great  joints  healed  with- 
out the  supervention  of  any  dangerous  symp- 
toms, where  due  care  has  been  taken  to  pre- 
vent inflammation;  whilst  injuries, apparently 
trifling,  will  often  be  followed  by  a train  of 
distressing  and  dangerous  consequences, 
wnere  such  care  has  been  neglected.  It  is, 
generally,  easier  to  prevent  inflammation  in 
the  joints,  after  a wound,  than  to  arrest  its 
progress  when  once  begun  I speak  now  of 
inflammation  affecting  the  capsular  ligament. 
A siigiit  degree  of  redness  and  tenderness  in 
the  integuments  only  is  of  little  conse- 
quence; bus,  when  the  capsular  ligament 
becomes  inflamed,  the  formation  of  abscesses 
attended  vvitu  a high  degree  of  lever,  and 
ultimately  a stiffness  of  the  joint,  are  the 
common  consequences,  if  the  life  of  the  pa- 
tient is  preserved.”  (See  Hep's  Practical 
Observations  in  Surgery,  p.  354,  Edit.  2.) 

For  facts,  in  confirmation  of  the  loregoing 
account,  I particularly  refer  the  reader  to  se- 
veral cases  recorded  in  this  last  publication,' 
p.  355,  etseq.  and  by  Boyer . (Traitd  des  Mat, 
Chir.  T.  4,  p.  426,  fyc.) 


joints. 


142 


When  the  large  joints,  particularly  the  knee, 
are  wounded,  the  stomach  is  frequently  very 
much  affected.  I remember  being  shown  by 
Mr.  Best  of  Newbury,  a man,  who.  in  his  oc- 
cupation as  a wheelwright,  happened  to  give 
himself  a wound  by  whit  b one  side  of  the 
knee  was  laid  open  : a good  deal  <>f  inflam- 
mation and  suppuration  ensued;  but,  what 
particularly  struck  me,  nay  the  manner  in 
which  the  tfinn  complained  of  the  affection 
of  his  stomach. 

in  speaking  ot  cartilaginous  substances  in 
t he  joints,!  shall  have  occasion  to  advert  again 
to  the  danger  attendant  on  wounds  of  these 
parts  ; and  the  same  fact  is  still  further  con- 
sidered, in  the  articles  .’imputation,  Disloca- 
tions, Fractures,  and  Gunshot  Wounds,  in 
which  last  part  of  the  D ciionary,  tlie  senti- 
ments ot  Baron  Larrey,  and  other  writers  on 
military  surgery,  ate  laid  before  the  reader. 

Inflammation  of  Joints,  if  we  exclude  from 
consideration  specific  cases,  may  be  said 
usually  to  be  the  consequence  of  a contusion, 
sprain,  wound,  or  some  other  kind  of  injury  : 
out  with  respect  to  the  inflammation  of  the 
synovial  membrane,  as  described  by  Mr.  Bro- 
die,  no  cause  is  so  frequent,  as  the  application 
of  cold,  and  hence  he  explains  the  frequency 
of  this  disease  in  the  knee,  and  its  rarity  in 
the  hip  and  shoulder,  which  are  covered  with 
a thick  mass  of  flesh.  As  a late  writer  ob- 
serves, the  inflammation,  arising  from  a 
wound,  is  infinitely  the  most  severe  after 
it  has  once  commenced.  ( James  on  Inflam- 
mation, p.  157.) 

ihe  inflamed  joint  shows  thecommonsymp- 
toms  of  inflammation;  viz.  preternatural 
redness,  increased' heat,  throbbing,  pain,  and 
swelling,  while  the  constitution  is  also  dis- 
turbed by  the  common  symptoms  of  inflam- 
matory fever,  it  deserves  notice,  however, 
that  in  these  cases,  the  constitutional  symp- 
toms are  often  exceedingly  severe,  and  the 
pulse  is  more  frequent,  and  less  full  and 
' trong,  than  when  pans,  more  disposed  to 
return  to  a stale  of  health,  are  affected.  The 
inflammation  first  attacks  some  part  of  the 
capsular  ligament,  and  very  quickly  spreads 
over  its  whole  extent,  as  usually  happens  in 
all  inflammations  of  smooth  serous  mem- 
branes. 

The  capsules  of  the  joints  are  naturally  not 
very  sensible  ; but,  like  many  other  parts  si- 
milarly circumstanced,  they  often  become 
acutely  painful,  when  inflamed.  The  com- 
plain! is  accompanied  with  an  increased  se- 
cretion ot  the  synovia,  which  becomes  of  a 
more  aqueous,  and  of  a less  albuminous  qua- 
lity, than  it  is  in  the  healthy  state.  lienee, 
*itis  not  so  well  calculated  for  lubricating  the 
articular  surfaces,  and  preventing  the  effects 
ol  friction,  as  it  is  in  (he  natural  condition  of 
the  joint ; a circumstance,  which  may  ex- 
plain, why  a grating  sensation  is  often  per- 
ceived on  making  the  patella. 

The  capsular  ligaments,  like  other  parts, 
are  frequently  thickened  by  inflammation, 
and  sometimes,  coagulating  lymph  being 
effused  on  their  internal  surfaces,  organized 
cartilaginous,  or  osseous  bodies,  arc  formed 
within  the  joints.  * 


It  has  been  explained  by  Mr.  Brodie,  that 
the  usual  consequences  of  inflammation  of 
the  synovial  membrane,  or  capsular  liga- 
ment, are  ; 1.  a preternatural  secretion  of 
synovia,  2.  an  effusion  of  coagulating 
lymph  into  the  cavity  of  the  joint.  3.  a 
thickening  of  the  synovial  membrane,  a con- 
version of  it  into  a substance  rdSembling 
grisde,  and  an  effusion  of  coagulable  lymph, 
and  probably  of  serum  into  the  cellular 
structure,  by  which  it  is  connected  with  the 
external  parts.  The  same  gentleman  has 
seen  several  cases,  where,  from  the  appear- 
ance of  the  joint,  and  the  symptoms,  there 
was  every  reason  to  believe,  that  the  in- 
flammation had  produced  adhesions  of  the 
reflected  fold  of  the  membrane  to  each 
other:  and,  in  dissection,  he  has  occasion- 
ally observed  adhesions  which  might  have 
arisen  from  inflammation  at  some  former 
period.  u These  effects  of  inflammation  of 
the  synovial,  very  much  resemble  those  of 
inflammation  of  the  serous  membranes. 
There  are,  however,  some  points  of  differ- 
ence. In  the  former,  I have  reason  to  be- 
lieve, that  suppuration  rarely  takes  place 
independently  of  ulceration  ; but,  this  is  u 
frequent  occurrence  in  the  latter.  Inflam- 
mation of  the  peritonaeum,  or  pleura,  though 
very  slight  in  degree,  and  of  very  short  du- 
ration, terminates  in  the  effusion  of  coagu 
lable  lymph  ; but  it  is  only  violent  or  long- 
continued  inflammation,  which  has  this  ter- 
mination in  the  membranes  of  joints  ( Bro- 
die in  Med.  Chir.  Trans.  Vol.  4,  p.  216.) 

When  the  inflammation  attains  a high 
pitch,  an  abscess  may  occur  in  the  capsular 
ligament,  which  at  length  ulcerates,  and  the 
pus  makes  its  way  beneath  the  skin,  and  is, 
sooner  or  later,  discharged  through  ulcerated 
openings. 

An  abscess  rarely  takes  place  in  an  im- 
portant articulation,  in  consequence  of  acute 
inflammation,  without  the  system  being  also 
so  deranged  that  life  itself  is  imminently 
endangered.  Severe  febrile  symptoms 
always  atflict  the  patient,  and  occasionally, 
delirium  and  coma  taking  place,  death  itself 
ensues.  Two  rapidly  fatal  cases  of  ulcera- 
tion of  the  synovia!  membrane,  where  mat- 
ter had  formed  within  it  from  a sprain  of  the 
hip,  and  a contusion  of  the  shoulder,  are 
recorded  by  Mr.  Brodie.  (See  Pathol.  Chir. 
Obs.  p.  65  ) 

In  these  cases,  the  inflammatory  fever  is 
very  quickly  converted  into  the  hectic;  in- 
deed, when  an  abscess  has  taken  place  in  a 
large  joint,  in  consequence  of  acute  inflam- 
mation, hectic  symptoms  almost  immedi- 
ately begin  to  show  themselves,  and  the 
strong  actions  of  the  common  inflammatory 
fever  suddenly  subside,;  t , « 

Local  consequences,  even  worse  than 
those  above  described,  may  follow  inflam- 
mation of  a joint.  As  the  layer  of  the  cap-  * 
solar  ligament,  reflected  over  the  cartilages 
of  the  articulation,  is  often  inflamed,  the 
cartilages  themselves  may  Imvc  the  inflam- 
mation communicated  to  them.  Parts  of  a 
cartilaginous  structure,  being  very  incapa- 
ble of  bearing  the  irritation  of  disease,  often 


JOINTS* 


143 


ulcerate,  r,  hi  other  words,  arc  absorbed, 
so  as  to  leave  a portion,  or  the  whole,  of 
the  articular  surface  of  the  bones,  completely 
denuded  of  its  natural  covering.  At  length 
the  heads  of  the  bones  themselves  inflame, 
and  become  carious;  or  the  consequence 
may  be  anchylosis.  Mr.  Brodie  has  seen 
some  cases  in  which  there  was  exten- 
sive destruction  of  the  cartilages,  apparently 
in  consequence  of  neglected  inflammation 
of  the  synovial  membrane  ; but  he  believes, 
that  in  most  cases  where  ulceration  of  the 
cartilage  is  combined  with  such  inflamma- 
tion, the  former  is  the  primary  affection, 
and  the  latter  takes  place  subsequently,  in 
consequence  of  the  formation  of  an  abscess 
within  the  joint  ( Pathol . and  Surg.  Obs. 

fyc.p.  17.)  According  to  Mr.  Brodie,  who 
speaks  chiefly  of  the  inflammation  which 
begins  in  the  synovial  membrane  itself,  and 
is  not  communicated  to  it  from  other  tex- 
tures, the  disease  very  seldom  attacks  young 
children,  but  is  frequent  in  adult  persons, 
the  reverse  of  what  happens  in  some  other 
diseases  of  the  joints. 

The  inflammation  of  the  capsular  liga- 
ment, or  synovial  membrane,  frequently 
assumes  the  chronic  form,  and  is  then  very 
often  confounded  with  other  more  serious 
maladies,  under  the  general  appellation  of 
white  swelling.  The  disease  often  arises 
from  cold,  and  hence  is  more  common  in 
the  knee  and  ankle  than  in  the  hip  or 
shoulder.  It  may  also  arise  from  the  immo- 
derate use  of  mercury,  and,  in  particular 
constitutions,  from  rheumatism  and  general 
debility  of  the  system.  In  these  instances 
it  often  leaves  one  joint  and  attacks  ano- 
ther ; and  it  is  less  severe,  and  less  disposed 
to  produce  effusion  of  coagulating  lymph, 
or  a thickened  state  of  the  membrane,  than 
when  it  is  apparently  a local  disease.  (Bro- 
die, in  Med.  Chir.  Trans.  Vol.  4.  p.  218.)  In 
the  latter  case  the  disorder  is  more  likely  to 
assume  a severe  character,  and  may  be  of 
long  duration,  leaving  the  joint  with  its 
functions  more  or  less  impaired*  and  occa- 
sionally terminating  in  its  total  destruction. 
The  following  are  the  chief  symptoms  of 
the  complaint,  pointed  out  by  Mr.  Brodie. 
At  first,  although  some  pain  is  felt  over  the 
whole  joint,  the  patient  refers  it  principally 
to  one  spot,  and  it  is  not  at  its  height  be- 
fore the  end  of  a week  or  ten  days.  Some- 
times, even  at  this  period,  the  pain  is  trifling, 
but  sometimes  it  is  considerable,  and  every 
motion  of  the  joint  is  distressing.  In  a day 
or  two  after  the  commencement  of  the  pain, 
the  joint  is  affected  with  swelling,  which  at 
first  arises  entirely  from  a collection  of 
fluid  in  its  cavity,  and,  in  the  superficial 
joints,  an  undulation  may  be  distinguished. 
However,  after  the  inflammation  has  pre- 
vailed some  time,  the  fluid  is  rendered  less 
j perceptible,  either  in  consequence  of  the 
• synovial  membrane  being  thickened,  or  the 
effusion  of  lymph ; and  the  more  solid  the 
swelling  is,  the  more  is  the  mobility  of  the 
I joint  impaired.  The  form  of  the  diseased 
j|  joint  does  not  correspond  to  that  of  the 
| brads  of  the  bones  ; but,  as  the  swelling  is 


chiefly  caused  by  the  distention  of  the  syno- 
vial membrane,  u its  figure  depends  in  a 
great  measure  on  the  situation  of  the  liga- 
ments and  tendons,  which  resist  it  -in  certain 
directions,  and  allow  it  to  take  place  in 
others.  Thus,  when  the  knee  is  affected, 
the  3"  ellingis  principally  observable  on  the 
anterior  and  lower  part  of  the  thigh,”  where 
there  is  only  a yielding  cellular  structure 
between  the  extensor  muscles  and  the  bone. 

“ It  is  also  often  considerable  in  the  spaces, 
between  the  ligament  of  the  patella  and  the 
lateral  ligaments,  because  at  these  points 
the  fatty  substance  is  propelled  outward  by 
the  collection  of  fluid.  In  the  elbow,  the 
swelling  occurs  principally  above  the  ole- 
cranon, under  the  extensor  muscles  of  the 
forearm ; and  in  the  ankle,  it  is  between 
the  lateral  ligaments  and  the  tendons  in 
front  of  the  joint.  In  the  hip  and  shoulder, 
where  the  disease  is  less  frequent,  the  fluid 
cannot  be  felt,  but  the  swelling  is  percepti- 
ble through  the  muscles.  In  the  beginning 
of  this  disease  in  the  hip,  a fulness  both  in 
the  groin  and  nates  may  be  remarked  ; but 
afterward  the  nates  become  flattened,  and 
the  glutaei  wasted  from  want  of  use.  The 
pain  is  usually  confined  to  the  hip.  but  Mr. 
Brodie  has  seen  cases  in  which  it  was  also 
referred  .to  the  knee.  It  may  be  discrimina- 
ted from  the  case  in  which  the  cartilages  of 
the  hip  are  ulcerated,  by  observing,  that  the 
pain  is  more  severe  in  the  beginning  than  in 
the  advanced  stage  of  the  disease ; it  never 
amounts  to  the  excruciating  sensation  felt 
in  the  other  disease  ; and  it  is  aggravated  by- 
motion,  but  not  by  pressing  the  cartilagi- 
nous surfaces  against  each  other.  The 
wasting  of  the  glutaei  is  also  preceded  by  a 
fulness  of  the  nates.  After  the  inflammation 
has  subsided,  the  fluid  is  absorbed,  and  the 
joint  frequently  regains  its  natural  figure 
and  mobility;  but,  in  the  majority  of  cases, 
stiffness  and  swelling  remain,  and  the  pa- 
tient continues  very  liable  to  relapse,  the 
pain  returning,  and  the  swelling  being  aug- 
mented, whenever  the  patient  exposes  him- 
self to  cold,  or  exercises  the  limb  a great 
deal.  In  cases  where  the  synovial  mem- 
brane is  thickened,  a slow  kind  of  inflam- 
mation sometimes  continues  in  the  part, 
notwithstanding  the  fluid  has  been  absorbed, 
and  the  principal  swelling  has  subsided,  the 
disease  at  length  extending  to  the  cartilages, 
suppuration  taking  place,  and  the  articular 
surfaces  being  completely  destroyed.  Ac- 
cording to  Mr.  Brodie,  in  this  advanced 
stage,  the  history  of  the  disease,  and  not  its 
present  appearance,  is  the  only  thing  by 
which  one  can  learn  whether  the  primary 
affection  was  inflammation  of  the  synovial 
membrane,  or  ulceration  of  the  cartilages. 
Though  such  is  the  most  common  character 
of  inflammation  of  the  synovial  membrane, 
it  is  admitted,  that  its  nature  is  sometimes 
more  acute,  exhibiting  the  symptoms  men- 
tioned at  the  beginning  of  this  section.  (See 
Brodie' s Pathol,  and  Surg.  Obs.  p.  21,  fyc.') 
It  is  remarked  by  Mr.  Wilson,  that,  when 
coagulable  lymph  is  effused,  the  whole  of  k 
docs  not  always  adhere  to  the  inflamed 


JOINTS'. 


344 


face,  but  some  of  it  forms  flakes  which  float 
in  the  fluid  within  the  joint  in  masses  large 
enough  to  be  sometimes  felt  through  the 
capsular  ligament.  In  other  instances,  the 
lymph  becomes  solid,  adheres  to  the  inside 
of  the  synovial  membrane,  and  becomes 
vascular.  The  surface  of  this  adventitious 
coating  is  sometimes  smooth  ; but,  occa- 
sionally, it  forms  thick  projecting  masses, 
of  different  degrees  of  thickness  and  length, 
and  so  numerous  as  to  conceal  every  part  of 
the  original  smooth  surface  of  the  synovial 
membrane,  as  exemplified  in  a preparation 
in  Windmill-street.  (On  the  Skdeton  and 
Diseases  of  Bones  and  Joints,  p.  319.) 

When  inflammation  of  the  synovial  mem- 
brane has  arisen  from  a protracted  or  ill- 
conducted  course  of  mercury,  Mr.  Brodie 
recommends  a trial  of  sarsaparilla  ; and 
when  the  disorder  is  connected  with  rheu- 
matism, the  medicines  advised  are  opium 
with  diaphoretics,  preparations  of  colchi- 
eum  autumnale,  and  other  usual  remedies 
for  rheumatic  complaints.  In  some  instan- 
ces, however,  in  which  several  joints  were 
affected,  this  gentleman  has  known  benefit 
derived  from  moderate  doses  of  mercury, 
( p . 31.)  But  whether  the  disease  be  local, 
or  dependent  on  the  state  of  the  constitu- 
tion, Mr.  Brodie  considers  topical  remedies 
of  most  importance. 

It  will  considerably  shorten  what  we  have 
to  say  concerning  the  treatment  of  inflamed 
joints,  to  observe,  that,  in  the  acute  form  of 
inflammation  of  the  synovial  membrane,  the 
antiphlogistic  plan,  in  the  full  sense  of  the 
expression,  is  to  be  strictly  adopted.  But, 
as  there  is  a variety  of  means  often,  adapted 
to  the  same  purpose,  it  seems  necessary 
to  offer  a few  remarks  on  those  which 
Jay  the  greatest  claim  to  our  commendations. 

There  are  few  other  surgical  cases  in 
which  general,  and  especially  topical,  bleed- 
ing is  more  strongly  indicated.  The  vio- 
lence of  the  inflammation,  and  the  strength, 
age,  and  pulse  of  the  patient,  must  deter- 
mine with  regard  to  the  use  of  the  lancet ; 
but  the  application  of  leeches  may  be  said 
to  be  invariably  proper.  When  the  leeches 
fall  off,  the  bleeding  is  to  be  promoted  by 
fomenting  the  part.  The  surgeon  should 
daily  persist  in  this  practice,  until  the  acute 
stage  of  the  inflammation  has  subsided.  As 
Mr.  Brodie  observes,  attention  should  also 
be  paid  to  the  state  of  the  bowels,  and 
saline  draughts  and  diaphoretic  medicines 
be  exhibited.  ( Pathol . and  Surgical  Obs.  p. 
32.)  In  conjunction  with  this  treatment,  the 
iotio  plumbi  acetatis  must  be  employed. 

In  a few  instances,  however,  the  patient 
seems  to  derive  more  ease  and  benefit  from 
the  employment  of  fomentations  and  emol- 
lient poultices,  which,  according  to  Mr. 
Brodie,  is  the  case  when  the  swelling  has 
been  produced  rapidly,  and  is  attended  with 
considerable  tension.  But,  on  this  point,  as 
I have  remarked  in  speaking  of  Inflamma- 
tion, the  feelings  of  the  afflicted  should 
always  be  consulted  ; for,  if  the  pain  be  ma- 
terially alleviated  bv  this  or  that  application, 
pc  employment  will  hardly  ever  be  wrong 


Nothing  more  need  be  said  concerning 
the  rest  of  the  treatment,  proper  during 
the  vehemence  of  the  inflammation,  as  the 
duty  of  the  surgeon  is  not  materially  differ- 
ent from  what  it  is  in  other  inflammatory 
cases. 

As  soon  as  the  acute  stage  of  the  affection 
has  subsided,  the  grand  object  is  to  remove 
the  effects  which  have  been  left.  These 
are  a thickened  state  of  the  capsular  liga- 
ment, and  parts  surrounding  the  articu- 
lation ; a stiffness  of  the  joint,  and  pain 
when  it  is  moved  ; fluid  in  the  capsule,  &c. 

At  first,  as  Mr.  Brodie  has  observed,  the 
joint  should  he  kept  perfectly  quiet,  and 
blood  should  be  several  times  taken  from  the 
part,  by  means  of  leeches  and  cupping.  The 
latter  is  the  method  to  which  the  preceding 
writer  expresses  the  preference.  The  use  of 
cold  evaporating  lotions  is  also  to  be  con- 
tinued until  the  inflammation  has  further 
abated,  when  a blister  may  be  applied,  and. 
kept  open  with  the  savin  cerate,  or  a repeti- 
tion of  blisters  kept  up,  as  preferred  by  Mr 
Brodie.  “ l he  blisters  (he  says)  should  be 
of  considerable  size  ; and  if  the  joint  be 
deep-seated,  they  may  be  applied  as  near  to 
it  as  possible;  but,  otherwise,  at  a little  dis- 
tance. Thus,  when  the  synovial  membrane 
of  the  hip  is  affected,  they  may  be  placed  on 
the  groin  and  nates  ; but,  when  that  of  the 
wrist  is  inflamed,  they  should  be  applied  to 
the  lower  part  of  the  forearm.  Mr.  Brodie 
thinks  blisters  have  more  effect  than  any 
other  means,  in  removing  the  swelling  ; but, 
excepting  in  very  slight  cases,  he  very 
rightly  condemns  their  use,  unpreceded  by 
the  abstraction  of  blood.  After  the  subsi- 
dence of  the  inflammation,  moderate  exer- 
cise of  the  joint,  and  stimulating  liniments 
are  recommended.  The  camphor  liniment 
is  to  be  strengthened  with  the  addition  of 
liquor  ammonia?.  or  tinctura  lyttm,  or  thf 
following  formula,  adopted  as  that  to  which 
the  above  gentleman  seems  to  give  the  pre- 
ference. p,.  Olei  olivae  ^rss.  acid,  sulpli.  3s?- 
M.  He  speaks  also  favourably  of  the  effects 
of  the  antimonial  ointment,  in  the  proportion 
of  3j.  of  the  antim.  tart,  to  gj.  ung.  cetacei. 
Plasters  of  gum  ammoniac'' he  regards  a> 
sometimes  useful  in  preventing  relapsus. 
Issues  and  setons  are  never  serviceable,  un- 
less ulceration  of  the  cartilages  has  begun. 
For  the  removal  of  the  remains  of  the  swell- 
ing and  stiffness,  Mr.  Brodie  joins  other 
writers  in  praising  the  efficacy  of  friction 
and  exercise.  The  friction  may  he  made 
with  camphorated  mercurial  ointment,  or 
with  powdered  starch  ; but  the  friction  is  to 
be  employed  with  caution,  as  otherwise  it 
may  produce  a return  of  the  inflammation. 
When  this  happens,  it  is  to  be  discontinued, 
and  blood  taken  from  the  part.  On  the 
whole,  Mr.  Brodie  appears  to  consider  fric- 
tion better  adopted  to  cases,  where  the  stiff- 
ness depends  upon  the  state  of  the  external 
parts,  than  in  others,  where  it  arises  from 
disease  in  the  joint  itself.  With  respect  to 
the  plan  of  allowing  a column  of  warm  wa  - 
ter to  fall  on  the  part,  as  suggested  by  Lo 
T'rau,  and  practiced  «t.  the  v'atermg-plucr?. 


JOINTS. 


146 


he  allows,  that  it  is  beneficial,  but  that  it  rc- 
quires  the  same  caution  as  the  employment 
of  friction.  {Pathol,  and  Surg.  Obs.p.  30,  tyc.) 

1 have  met  with  several  instances,  in  which 
lotions,  composed  of  vinegar  and  muriate  ot 
ammonia,  sufficed  for  the  removal  of  the 
chronic  complaints,  left  after  the  acute  stage 
of  the  disorder. 

The  severity  of  the  constitutional  symp- 
toms is  mostly,  if  not  always,  greater,  when 
the  inflammation  of  a large  joint  arises  from 
a wound,  than  when  it  is  the  consequence 
of  a bruise  or  sprain. 

Loose  cartilages  in  joints. — Hard,  roundish, 
or  flattened  bodies,  mostly  of  a cartilaginous 
nature,  are  sometimes  formed  within  the  cap- 
sular ligaments,  occasioning  more  or  less 
pain  in  the  affected  joints,  and  a considera- 
ble impediment  to  the  freedom  of  their 
movements.  The  disorder,  though  not  no- 
ticed by  any  of  the  very  ancient  writers,  is 
far  from  being  uncommon.  Pare  is  the  first 
who  speaks  of  it : he  says,  that  a hard,  polish- 
ed, xokite  body,  of  the  size  of  an  almond , was 
discharged  from  the  knee  of  a patient,  in  the 
year  1558,  in  which  be  had  made  an  inci- 
sion for  an  aqueous  aposlume,  (without  doubt 
an  hydrops  articuli.)  {Lie.  25,  chap.  15,  p. 
772.)  A hundred  and  thirty-three  years 
afterward,  viz.  in  1691,  Pechtin  published 
the  full  details  of  another  case,  in  which  a 
cartilaginous  body  was  successfully  extracted 
from  the  knee.  ( Observat . Physico-Med. 
Obs.  38,  p.  306.)  Dr.  Alexander  Monro  in 
1726,  dissected  the  knee-joint  of  a woman, 
who  had  been  hung,  and  found  in  the  articu- 
lation a cartilaginous  body,  of  the  shape  and 
size  of  a small  bean.  These  were  the  only 
examples  of  the  disease  known  before  the 
year  1736,  at  which  period  Mr.  Simson  cut 
out  of  the  knee  a similar  substance,  which 
he  supposed  at  the  time  of  the  operation 
was  only  beneath  the  skin.  (See  Edinb. 
Med  Essays,  Vol.  4.) 

Since  the  publication  of  this  last  case,  the 
disease  has  been  several  times  met  with  in 
England  by  Bromfield,  Hewit,  Middleton, 
Gooch,  Ford,  Home,  Bell,  Aberneihy,  &sc. ; 
in  Germany,  by  Henckel,  Theden,  Loeffler, 
&c.  ; and  in  France  by  Desault,  Sabatier, 
and  many  , other  practitioners.  Hence,  as 
Boyer  remarks,  this  disorder  is  now  as  well 
known,  as  most  others,  to  which  the  joints 
are  subject.  (Traitc  des  Mai.  Chir.  T.  4,  p. 
434.) 

Such  detached  and  moveable  cartilages 
are  not  peculiar  to  the  knee,  as  they  occur 
in  other  joints  ; yet  they  are  most  frequently 
met  with  in  the  knee,  and  it  is  in  this  joint 
that  they  produce  symptoms,  which  render 
them  the  object  of  a chirurgical  operation. 
Morgagni  and  B.  Bell  met  with  them  in  the 
ankle  ; Haller  in  the  joint  of  the  jaw  ; and 
Hey  in  the  elbow. 

According  to  Sir  Everard  Home,  these 
substances  are  analogous  in  their  structure  to 
hone  j but  in  their  external  appearance,  (hey 
bear  a greater  resemblance  to  cartilage. 
They  are  not.,  however,  always  exactly  of 
■ he  same  structure,  being  in  some  instances 
Vol.  II,  i y 


softer  than  in  others.  Their  external  sur- 
face is  smooth  and  polished,  and,  being  lu- 
bricated by  the  synovia,  allows  them  to  be 
moved  readily  from  one  part  of  the  joint  to 
another.  They  seldom  remain  long  at  rest, 
while  the  limb  is  in  motion  ; and  when  they 
happen  to  be  in  situations  where  they  are 
pressed  upon  with  force  by  the  different 
parts  of  the  joint,  they  occasion  considera- 
ble pain,  and  materially  interfere  with  its 
necessary  motions. 

The  circumstance  of  their  being  loose, 
and  having  no  visible'  attachment,  made  it 
difficult  to  offer  good  conjectures  respecting 
their  formation  ; and,  according  to  Sir  E. 
Home,  no  satisfactory  account  of  their 
origin  had  been  given,  when  Mr.  Hunter 
made  his  observations.  In  the  course  of  his 
experiments,  instituted  with  a view  to  esta- 
blish a living  principle  in  the  blood,  Mr. 
Hunter  was  naturally  induced  to  attend  to 
the  phenomena,  which  took  place,  when 
that  fluid  was  exlravasated,  whether  in  con- 
sequence of  accidental  violence,  or  other 
circumstances.  The  first  change  he  found 
to  be  coagulation  ; and  the  coagulum  thus 
formed,  if  in  contact  with  living  parts,  did 
not  produce  an  irritation  similar  lo  ex- 
traneous matter,  nor  was  it  absorbed  and 
taken  back  into  the  constitution,  but  in 
many  instances  preserved  its  living  princi- 
ple. and  became  vascular,  receiving  brandi- 
es from  the  neighbouring  blood-vessels  for 
itssupport;  it  afterward  underwent  changes, 
rendering  it  similar  to  the  parts  to  which  it 
was  attached,  and  which  supplied  it  with 
nourishment.  When  a coagulum  adhered 
to  a surface,  which  varied  its  position,  the 
attachment  was  rendered  in  some  instances 
pendulous,  and  in  others  it  was  entirely 
broken. 

Hence,  it  was  easy  to  explain  the  mode, 
in  which  those  pendulous  bodies  are  formed, 
which  are  sometimes  attached  to  the  inside 
of  circumscribed  cavities,  and  the  principle 
being  established,  it  became  equally  easy 
for  Mr.  Hunter,  to  apply  it  under  other  cir- 
cumstances, since  it  is  evident  from  a known 
law  in  the  animal  economy,  that  extravasa- 
ted  blood,  when  rendered  an  organized  part 
of  the  body,  can  assume  the  nature  of  the 
parts  into  which  it  is  effused,  and  conse- 
quently, the  same  coagulum,  which,  in  an- 
other situation  might  form  a soft  tumour, 
would  when  situated  on  a bone,  or  in  tlm 
neighbourhood  of  bone,  often  form  a hard 
one.  The  cartilages,  found  in  the  knee- 
joint,  therefore,  appeared  to  him  to  originate, 
from  a deposit  of  coagulated  blood  upon  the 
end  of  one  of  the  bones,  which  had  ac- 
quired the  nature  of  cartilage,  and  had 
afterward  been  separated.  This  opinion 
was  further  confirmed  by  the  examination  of 
joints  which  had  been  violently  strained,  or 
otherwise  injured,  where  the  patients  had 
died  at  different  periods  after  the  accident. 
In  some  of  these  cases,  there  were  small 
projecting  parts,  preternatu rally  formed,  as 
hard  as  cartilage,  and  so  situated,  as  to  bo 
readily  knocked  off'  by  any  sudden  or 
violent,  motion  of  the  joint.  (Trans,  for  the 


146  JOINTS. 


Improvement  of  Med.  and  Chir.  Knowledge, 
Vol.  1.) 

Mr.  Brodie  met  with  two  cases,  however, 
in  which  the  loose  bodies  were  of  a different 
nature,  and  had  a different  origin  from  that 
referred  to  by  Sir.  E.  Home.  Sometimes 
disease  causes  a bony  ridge  to  be  formed, 
like  a small  exostosis,  round  the  margin  of 
the  cartilaginous  surfaces  of  the  joint.  In 
the  two  examples  alluded  to,  this  preterna- 
tural growth  of  bone  had  taken  place,  and  in 
consequence  of  the  motion  of  the  parts, 
portions  of  it  had  been  broken  off,  and  lay 
loose  in  the  cavity  of  the  joint.  ( Brodie  in 
Med.  and  Chir.  Trans.  Vol.  4 p.  276.)  And, 
in  a more  recent  publication,  he  remarks, 
that,  in  the  majority  of  cases,  which  he  has 
met  with,  no  inflammation  preceded  the 
formation  of  these  preternatural  substances, 
and,  therefore,  he  thinks  it  probable,  that,  in 
some  instances,  they  are  generated,  like 
other  tumours,  by  some  different  process. 
He  further  observes,  that  they  appear  to  be 
situated  originally  either  on  the  external  sur- 
face or  in  the  substance  of  the  synovial 
membrane,  since,  before  they  become  de- 
tached, a thin  layer  of  the  latter  may  be 
traced  over  them.  ( Pathological  and  Sur- 
gical Obs.  p.  298.) 

One  or  more  of  these  preternatural  bodies 
may  be  formed  in  the  same  joint.  Sir  E. 
Home  mentions  one  instance,  in  which  there 
were  three  ; they  are  commonly  about  the 
size  of  a horsebean,  often  much  smaller, 
and  sometimes  considerably  larger ; when 
very  large,  they  do  not  give  so  much  trouble 
to  the  patient  as  the  smaller  kind.  A sol- 
dier of  the  56th  regiment  had  one  nearly  as 
big  as  the  patella,  which  occasioned  little 
uneasiness,  being  too  large  to  insinuate  it- 
self into  the  moving  parts  of  the  joint. 
Morgagni  saw  twenty-live  in  the  left  knee  of 
an  old  woman,  who  died  of  apoplexy  ; and 
Haller  met  with  no  less  than  twenty  in  the 
articulation  of  the  lower  jaw.  When  there 
are  several  in  the  same  joint,  it  is  observed, 
that  their  size  is  generally  small.  (Boyer, 
Traitd  des  Mai.  Chir.  T.  4,  p.  436.) 

The  diagnosis  of  this  disease,  as  Boyer 
observes,  is  seldom  attended  with  any  diffi- 
culty. When  the  formation  of  the  extrane- 
ous substances  follows  a fall,  or  blow  upon 
the  joint,  the  complaint  begins  with  a swell- 
ing of  the  surrounding  soft  parts,  and  upon 
the  subsidence  of  this  swelling,  which  lasts 
for  a time  more  or  less  long,  the  presence 
of  the  little  cartilaginous  tumours  is  indica- 
ted by  certain  symptoms  which  are  peculiar 
to  them.  In  persons  who  have  had  no  blow, 
nor  fall  upon  the  knee,  the  disease  some- 
times commences  with  a more  or  less  acute 
pain  in  the  joint,  with  or  without  swelling  of 
the  surrounding  soft  parts,  and  which  affec- 
tion is  usually  regarded  as  rheumatism.  To 
these  first  symptoms,  which  are  common 
both  to  cases  of  foreign  bodies  in  the  joints, 
and  other  diseases  of  these  parts,  are  soon 
added  other  particular  signs,  by  which  the 
nature  of  the  case  is  evinced. 

As  the  extraneous  bodies  are  in  general 
free  and  moveable  in  the  joint,  they  can 


easily  be  made  to  slip  about  from  one  part 
of  ihe  articulation  to  another:  a circum- 
stance, which  is  facilitated  by  the  smooth- 
ness of  their  surface,  as  well  as  by  the  syno- 
via, which  is  mostly  in  larger  quantity  than 
natural.  According  to  the  situation,  which 
they  happen  to  occupy,  sometimes  they 
produce  acute  pain  ; sometimes  no  pain 
whatever.  When  they  lodge  in  a depression, 
where  they  are  not  compressed,  they  cause 
no  pain  ; and  if  they  could  be  always  kept 
in  this  position,  their  presence  would  not  be 
likely  to  excite  any  inconveniences.  But, 
when  they  get  between  the  articular  sur- 
faces which  in  certain  postures  of  the  limb 
come  into  contact  with  each  other,  the  fol- 
lowing are  the  effects  of  the  compression. 
Sometimes,  the  extraneous  substance  sud- 
denly glides  between  the  condyles  of  the 
thigh  bone  and  head  of  the  tibia,  and  while  it 
lodges  there,  excites  acute  pain  in  certain 
directions  of  the  limb,  and  instantaneous  loss 
of  the  power  of  moving  the  knee.  But, 
when  it  shifts  its  place  again,  either  naturally, 
or  accidentally,  during  an  examination  of  the 
affected  part,  the  compression  is  removed, 
the  pain  all  at  once  ceases,  and  the  functions 
of  the  joint  are  as  suddenly  restored.  Most 
frequently,  when  the  extraneous  body  gets 
behind  the  patella,  or  the  ligament  of  the  pa- 
tella, as  the  patient  is  walking,  he  is  com- 
pelled to  make  a sudden  stop,  and  would 
fall  down  from  the  acuteness  of  the  pain,  if 
nothing  were  at  hand  to  save  him.  Some 
patients  have  been  observed,  however.  who 
experienced  no  pain  in  these  circumstances. 
Reimarus  mentions  a man,  who  suffered 
great  pain,  and  could  not  move  his  leg,  when 
the  extraneous  body  was  at  the  side  of  the 
joint ; but  was  immediately  relieved  by  push- 
ing it  under  the  patella.  B.  Bell  met  with 
cases,  in  Which  the  pain  was  so  violent  at 
the  instant  when  the  patients  put  their  legs 
in  certain  postures,  that  fainting  was  brought 
on,  and  they  wen-  so  afraid  of  a return  of  the 
suffering,  that  they  preferred  remaining  per- 
fectly quiet  to  running  any  risk  of  causing 
the  pain  again.  He  even  asserts,  that  he 
had  known  some  persons,  in  whom  the  least 
motion  of  the  limb  would  cause  such  pain  as 
awoke  them  out  of  the  deepest  sleep.  The 
pain,  excited  by  the  situation  of  the  extrane- 
ous body  betwixt  the  articular  surfaces,  re- 
curs at  intervals  more  or  less  long,  and 
always  in  consequence  of  some  motion,  or 
exertion  Sometimes  it  ceases  directly  by 
the  effect  of  a movement,  contrary  to  that 
which  produced  it  ; but  most  frequently  it 
continues,  and  then  the  surrounding  soft  parts 
are  affected  with  swelling,  which  obliges 
the  patient  to  keep  his  bed,  and  have  re- 
course to  emollient  anodyne  applications. 
Sometimes,  as  I have  already  noticed,  the 
foreign  body  lies  at  a part  of  the  joint,  , 
where  it  causes  no  inconvenience,  and 
makes  no  pressure  on  the  articular  surfaces. 
In  this  case,  all  the  symptoms  have  been 
known  to  cease  for  several  months,  so  that 
the  patient  imagined  himself  cured,  when 
suddenly,  the  foreign  body  was  urged  by 
some  effort  into  another  situation,  where  if 


JOINTS. 


147 


occasioned  a renewal  of  all  the  former 
pain. 

The  foregoing  circumstances  afford  strong 
presumptive  evidence  of  the  presence  of  ex- 
traneous cartilaginous  substances  in  the 
joint ; but,  they  do  not  amount  to  certainty  ; 
this  can  only  be  acquired  by  the  touch.  In 
handling  the  knee  of  the  patient,  the  surgeon 
feels  a hard,  prominent  substance,  which 
slips  about  under  his  fingers,  and  glides  under 
the  patella,  or  the  ligament  of  this  bone,  and 
sometimes  under  the  tendon  of  the  extensor 
muscles  of  the  leg,  from  one  side  of  the 
joint  to  the  other.  The  extraneous  body 
may  make  its  appearance  either  at  the  inside 
or  the  outside  of  the  articulation  ; but,  it 
most  frequently  presents  itself  at  the  former 
part,  which  is  the  broadest  and  most  sloping, 
while  the  capsular  ligament  there  is  loosest. 
Desault  met  with  one  instance,  in  which  the 
capsular  ligament  and  soft  parts  were  so 
loose,  that  the  patient  could  turn  the  extra- 
neous substance  round  and  round. 

In  general,  the  complaint  is  not  danger- 
ous ; but,  as  it  is  painful,  and  obstructs,  or 
often  prevents  walking  ; and  usually  can  be 
cured  only  by  an  operation,  which  has  some- 
times had  fatal  consequences  ; we  cannot 
be  too  much  upon  our  guard  in  delivering  a 
prognosis. 

It  4s  only  in  the  knee,  that  the  disease  ever 
becomes  so  troublesome  as  to  require  an  ope- 
ration, or,  indeed,  any  surgical  treatment. 

If  we  except  making  an  incision  into  the 
joint,  for  the  purpose  of  extracting  the  carti- 
laginous tumours,  we  are  not  acquainted 
with  any  certain  means  of  freeing  a patient 
from  the  inconvenience  of  the  complaint. 
To  this  plan,  the  danger  attendant  on  all 
wounds  of  so  large  an  articulation  as  the 
knee,  is  a very  serious  objection.  Middleton 
and  Gooch  endeavoured  to  conduct  the 
extraneous  body  into  a situation,  where  it 
produced  no  pain,  and  to  retain  it  in  that 
position  a long  time  by  bandages,  under  the 
idea,  that  the  cartilaginous  substance  would 
adhere  to  the  contiguous  parts,  and  occasion 
no  future  trouble.  Some  will  be  inclined  to 
think,  that  no  positive  conclusion  ought  to 
be  drawn  from  the  cases  brought  forward  by 
these  gentlemen,  because  they  had  no  op- 
portunity of  seeing  their  patients  again  at 
the  end  of  a reasonable  length  of  time,  and 
we  know,  that  loose  cartilages  in  the  joints 
sometimes  disappear  for  half  a year,  and 
then  make  their  appearance  again.  Yet, 
perhaps,  the  very  circumstance  of  the  pa- 
tients not  applying  again,  may  justify  the 
inference,  that  sufficient  relief  had  been  ob- 
tained. 

However,  it  should  not  be  concealed, 
that  this  method  was  also  tried  in  St.  George’s 
Hospital  without  benefit,  and  that  in  one 
case,  the  pain  was  increased  by  it.  (See 
lieimarus  de  Fungo  Jlrticulorum,  § 27,  54, 
§'C-) 

Mr.  Hey,  aware  of  the  dangerous  symp- 
toms, which  have  occasionally  resulted  from 
the  most  simple  wounds  penetrating  the 
knee-joint,  was  induced  to  try  the  efficacy 
of  a laced  knee-cap.  and  the  cases,  which 


he  has  adduced,  clearly  demonstrate,  that 
the  benefit  thus  obtained,  is  not  temporary, 
at  least,  as  long  as  the  patient  continues  to 
wear  the  bandage.  In  one  case,  the  method 
had  been  tried  for  ten  years,  with  all  the 
success  which  the  patient  could  desire. 
Boyer  also  made  one  patient  use  a knee-cap 
for  a year  ; after  which  it  was  left  off,  the 
patient  appearing  cured.  And,  in  a second 
instance,  the  same  practitioner  tried  the 
plan,  which  put  a stop  to  the  pain,  and 
enabled  the  patient  to  walk  with  ease;  but 
it  was  not  known  whether  the  method  was 
properly  continued,  as  the  patient  had  not 
latterlv  been  seen.  {Boyer,  Traiti  des  Mai. 
C/iir.  T.  4,  p.  444.) 

Contemplating  the  evidence  upon  this 
point,  and  the  perilous  symptoms,  sometimes 
following  wounds  of  the  knee-joint,  I am 
decidedly  of  opinion,  that  the  effect  of  a 
knee-cap,  or  of  arollerand  compress,  applied 
over  the  loose  cartilage,  ought  generally 
to  be  tried,  before  having  recourse  to  exci- 
sion. I say  generally,  because  the  conduct 
of  the  surgeon  ought,  in  such  cases,  to  be 
adapted  to  the  condition  and  inclination  of 
the  patient.  If  a man  be  deprived  of  his 
livelihood,  by  not  beingable  to  use  his  knee  ; 
if  he  cannot,  or  will  not  take  the  trouble  of 
wearing  a bandage  ; if  he  be  urgently  de- 
sirous of  running  the  risk  of  the  operation 
after  things  have  been  impartially  explained 
to  him  ; if  a bandage  should  not  be  produc- 
tive of  sufficient  relief  ; and  lastly,  if  exces- 
sive pain,  severe  inflammation  of  the  joint, 
a great  deal  of  symptomatic  fever,  and 
lameness,  should  frequently  be  produced  by 
the  complaint,  (See  Brodie's  Pathological 
and  Surg.  Obs  p 299,)  I think  it  is  the  duty 
of  a surgeon  to  operate.  It  is  very  certain, 
that  success  has  generally  attended  the  ope- 
ration ; but,  small  as  the  chance  is  of  losing 
the  limb,  and  even  life,  in  the  attempt  to  get 
rid  of  the  disease,  since  the  inconveniences 
of  the  complaint  are,  in  most  cases,  very 
bearable,  and  are  even  capable  of  palliation 
by  means  of  a bandage,  endangering  the 
limb  and  life  in  any’’  degree,  must  seem  to 
many  persons  contrary  to  the  dictates  of 
prudence.  At  all  events,  we  must  agree 
with  Boyer,  that,  as  a laced  knee-cap  can  do 
no  harm,  we  ought  always  to  make  trial  of 
it,  and  never  perform  the  operation,  ex- 
cept when  pressure  does  not  answer,  and 
the  return  of  frequent  and  violent  pain 
makes  the  employment  of  the  knife  necessa- 
ry. (See  Traiti  des  Mai.  Chir.  T.  4,  p.  445.) 

I am  ready  to  allow,  with  M.  Brochier, 
that  the  danger  attendant  on  wounds  of  the 
large  joints,  has  always  been  exaggerated  in 
consequence  of  ancient  prejudices.  ( De- 
sault's Journ.  Vol.  2.)  But,  making  every 
allowance  for  the  influence  of  prejudice,  a 
man  must  be  very  sceptical  indeed,  who 
does  not  consider  the  wound  of  so  large  a 
joint  as  the  knee,  attended  with  real  cause 
for  the  apprehension  of  danger.  See  Case 
2,  in  my  Treatise  on  the  Diseases  of  the  Joints. 
At  the  end  of  Mr.  Ford’s  case,  (Med.  Obs, 
and  Inquiries , Pol.  5.)  we  read  on  the  subject 
of  cutting  loose  cartilages  out  of  the  knee  : 


148 


joints. 


t:  The  society  have  been  informed  of  several 
cases,  in  which  the  operation  has  been  per- 
formed ; some,  like  this,  have  healed  up 
without  any  trouble  ; others  have  been  fol- 
lowed by  violent  inflammation,  fever,  and 
death  itself.”  The  history  of  a case  has 
lately  been  published,  in  which  the  patient 
very  nearly  lost  his  life  from  suppuration  in 
the  knee-joint  after  this  operation.  (See 
Kirby's  Cases , p.  76.)  in  the  same  work, 
reference  is  also  made  to  two  other  cases, 
which  actually  had  a fatal  termination  ; (p. 
82:)  and  even  in  Mr.  Kirby’s  own  instance, 
the  recovery  was  not  effected,  without  the 
entire  loss  of  the  motions  of  the  knee. 

As  the  disorder  is  often  attended  with  a 
degree  of  heat  and  tenderness  in  the  articula- 
tion ; as  the  danger  of  the  operation  is,  in  a 
great  measure,  proportioned  to  the  subsequent 
inflammation  ; and,  as  much  of  the  danger 
is  at  once  removed,  if  the  wound  unite  by 
the  first  intention  ; the  advice  to  keep  the 
patient  in  bed  a few  days  before  operating, 
to  apply  leeches  and  cold  saturnine  lotions 
to  the  knee  during  the  same  time,  and  to 
exhibit  beforehand  a saline  purgative,  is 
highly  prudent. 

I shall  next  introduce  an  account  of  the 
plan  of  operating,  as  described  by  several 
of  the  best  modern  surgeons. 

“ As  these  loose  bodies  cannot  always  be 
found,  no  time  canbe  fixed  for  the  operation  ; 
but  the  patient,  who  will  soon  become 
familiar  with  his  own  complaint,  must  arrest 
them  when  in  a favourable  situation,  and 
retain  them  there  till  the  surgeon  can  be  sent 
for. 

“ Before  the  operation,  the  limb  should 
be  extended  upon  a table  in  an  horizontal 
position,  and  secured  by  means  of  assistants  ; 
the  loose  cartilages  are  to  be  pushed  into 
the  upper  part  of  the  joint  above  the  patella, 
and  then  to  one  side  ; the  inner  side  is  to  be 
preferred,  as  in  that  situation  only  the  vastus 
mternus  muscle  will  be  divided  in  the  ope- 
ration. Should  there  be  several  of  these 
bodies,  they  must  be  all  secured,  or  the  ope- 
ration should  be  postponed  till  some  more 
favourable  opportunity,  since  the  leaving  of 
one  will  subject  the  patient  to  the  repetition 
of  an  operation,  not  only  painful,  but 
attended  with  some  degree  of  danger. 

“ The  loose  bodies  are  to  be  secured  in 
the  situation  above-mentioned  by  an  assis- 
tant, a task  not  easily  performed  while  they 
are  cut  upon,  from  their  being  lubricated  by 
the  synovia  ; and  if  allowed  to  escape  into 
the  general  cavity,  they  may  not  readily,  if 
at  all,  be  brought  back  into  the  same  situa- 
tion. 

“ The  operation  consists  in  making  an 
incision  upon  the  loose  cartilage,  which  it 
will  be  best  to  do  in  the  direction  of  the 
thigh,  as  the  wound  will  more  readily  be 
healed  by  the  first  intention.  If  the  skin  is 
drawn  to  one  side,  previously  to  making  the 
incision,  the  wound  through  the  parts  under- 
neath will  not  correspond  with  that  made  in 
the  skin,  which  circumstance  will  favour 
their  union.  The  incision  upon  the  cartilage 
must  be  made  with  caution,  as  it  will  with 


difficulty  be  retained  in  its  situation  if  much 
force  is  applied.  The  assistant  is  to  endea- 
vour to  push  the  loose  body  through  the 
opening,  which  must  be  made  sufficiently 
large  for  that  purpose  ; but  as  this  cannot 
always  be  done,  the  broad  end  of  an  eyed 
probe  may  be  passed  under  it,  so  as  to  lift  it 
out,  or  a sharp-pointed  instrument  may  be 
stuck  into  it,  which  will  fix  it  to  its  situation, 
a>  d bring  it  more  within  the  management  of 
the  surgeon. 

“ The  cartilages  being  all  extracted,  the 
cut  edges  of  the  wound  are  to  be  brought 
together,  and,  by  means  of  a compress  of 
lint,  not  only  pressed  close  to  one  another, 
but  also  to  the  parts  underneath,  in  which 
situation  they  are  to  be  retained  by  sticking 
plaster,  and  the  uniting  bandage. 

“ As  union  by  the  first  intention  is  of  the 
utmost  consequence  after  this  operation,  to 
prevent  an  inflammation  of  the  joint,  the 
patient  should  remain  in  bed  with  the  leg 
extended,  till  the  wound  is  perfectly  united, 
or  at  least  all  chance  of  inflammation  at  an 
end.”  ( Home , in  Trans,  for  the  Improvement 
of  Med.  and  Chir.  Knowledge,  Vol.  1 ,p.  239, 
fyc.) 

In  one  instance,  Desault  proceeded  in  the 
following  manner  : the  surgeon,  after  relax- 
ing the  capsular  ligament  by  extending  the 
leg,  brought  the  extraneous  body  on  the  in- 
side of  the  articulation  against  the  attachment 
of  the  capsular  ligament,  and  secured  it  in 
this  situation,  between  the  index  finger  and 
thumb  of  the  left  hand,  whilst  an  assistant 
drew  the  integuments  forwards  towards  the 
patella.  The  parts,  covering  this  extraneous 
body,  were  now  divided  by  an  incision  one 
inch  in  length,  and  its  extraction  accomplish- 
ed by  pushing  it  from  above  downwards, 
and  raising  it  inferiorly  with  the  end  of  the 
knife.  This  substance,  on  examination,  was 
found  similar  in  colour  to  the  cartilages  that 
cover  the  articular  surfaces:  it  was  three- 
quarters  of  an  inch  in  length,  six  lines  and 
a half  in  width,  and  three  lines  in  thickness  : 
its  surfaces  were  smooth,  one  concave  and 
the  other  convex  : its  circumference  irregu- 
lar, disseminated  with  red  points,  forming 
small  depressions  ; the  inside  was  ossified, 
the  outside  of  a cartilaginous  texture.  As 
soon  as  the  substance  was  extracted,  the 
assistant  let  go  the  integuments  which  he 
had  drawn  forwards ; they  consequently- 
returned  to  their  natural  situation,  on  the 
inner  side  of  the  knee-joint,  in  such  a man- 
ner, that  the  external  wound  in  the  integu- 
ments was  situated  more  inward,  than  the 
one  in  the  capsular  ligament.  Two  advanta- 
ges were  procured  by  this  means  : on  the 
one  hand,  air  was  prevented  from  penetra- 
ting into  the  articulation  ; and  on  the  other, 
the  floating  portion  of  capsular  ligament, 
retained  inwards  by  the  skin,  was  more  like- 
ly to  attach  itself  to  the  condyle,  in  case  it 
did  not  unite  to  the  other  portion  of  the  cap- 
sule divided  near  its  attachment.  The  edges 
of  the  wound  were  brought  into  contact  by 
means  of  a uniting  bandage  ; dry  lint  and 
compresses  were  applied,  and  retained  on 
the  part  by  a slight  bandage  : and  the  limb 


JOINTS.  149 


was  kept  in  a siate  oi  extension.  (. Desault's 
Journal , T.  2.)  According  to  Mr.  Abernethy, 
the  inner  surface  of  the  internal  condyle  of 
the  os  femoris  presents  an  extensive  and 
nearly  a plain  surface,  which  terminates  in 
front  and  at  its  upper  part  by  an  edge  which 
forms  a portion  of  a circle.  If  the  points  of 
the  finger  be  firmly  pressed  upon  this  edge 
so  as  to  form  a kind  of  line  of  circumvalla- 
tion  round  these  (cartilaginous)  bodies,  they 
cannot  pass  into  the  joint  in  this  direction, 
nor  can  they  recede  in  any  other,  on  account 
of  the  tense  state  of  the  internal  lateral  li- 
gament. Here  these  substances  are  near 
the  surface,  and  may  be  distinctly  felt:  and 
they  may  be  exposed  by  simply  dividing  the 
integuments,  fascia,  and  the  capsule  of  the 
joint. 

In  an  interesting  case,  which  Mr.  Aber- 
nethy relates,  the  integuments  of  the  knee 
were  gently  pressed  towards  the  internal 
condyle,  and  the  fingers  of  an  assistant  ap- 
plied round  the  circular  edge  of  the  bone. 
The  integuments  were  gently  drawn  to- 
wards the  inner  ham  string,  and  longitudi- 
nally divided,  immediately  over  the  loose 
substance,  to  the  extent  of  an  inch  and  an 
half.  This  withdrawing  of  the  integuments 
from  their  natural  situation  was  designed  to 
prevent  a direct  correspondence  of  the  ex- 
ternal wound  to  that  in  the  capsule  of  the 
joint : for,  when  the  integuments  were  suf- 
fered to  regain  their  natural  position,  the 
wound  in  them  was  nearer  to  the  patella, 
than  the  wound  in  the  capsule.  The  fascia, 
which  covers  the  joint,  having  been  expo- 
sed by  the  division  of  the  integuments,  it 
was  divided  in  a similar  direction,  and  near- 
ly to  the  same  extent.  The  capsule  was 
now  laid  bare,  and  gently  divided  to  the  ex- 
tent of  half  an  inch,  where  it  covered  one 
of  the  hard  substances,  which  suddenly 
slipped  through  the  opening,  and  by  press- 
ing gently  upon  the  other,  it  was  also  dis- 
charged. The  bodies,  thus  removed,  were 
about  three-quarters  of  an  inch  in  length, 
and  half  an  inch  in  breadth.  They  had  a 
highly  polished  surface,  and  were  hard  like 
cartilage.  The  fluid  contained  in  the  joint 
was  pressed  toward  the  wound,  and  'about 
two  ounces  of  synovia  were  discharged. 
The  wound  of  the  integuments  was  then 
gently  drawn  towards  the  patella,  and  ac- 
curately closed  with  sticking  plaster.  ( Sur- 
gical Observations.  1804.) 

When  there  are  several  extraneous  carti- 
laginous bodies  in  the  joint  operated  upon, 
the  surgeon  ought  to  extract  them  all  through 
the  same  wound,  if  it  can  be  done  without 
producing  too  much  irritation  of  the  capsu- 
lar ligament,  and  they  will  admit  of  it.  But, 
frequently,  only  one  can  be  made  to  pre- 
sent itself  at  a time,  or  can  bt  easily  ex- 
tracted. Each  little  tumour  will  then  require 
a separate  operation,  which  is  a far  safer 
plan,  than  disturbing  the  part  by  long  and 
repeated  attempts  to  extract  them  all  at 
once.  ( Boyer , Traile  dcs  Mai.  Chir.  T.  4,  p. 
448.)  The  surgeon  is  also  often  obliged  to 
make  his  incision  at  a particular  point,  be- 
cause at  no  other  can  the  extraneous  sub- 


stance be  fixed.  A case  confirming  all  these, 
latter  observations  was  lately  published  by- 
Ur.  Clarke.  (See  Med.  Chir.  Trails.  Vol.  5, 
p.  67.)  In  this  instance,  the  operation  was 
thrice  performed  upon  the  same  knee-joint, 
with  perfect  success.  Mr.  Brodie  also  ex- 
tracted five  loose  cartilages,  by  three  differ- 
ent operations,  without  any  subsequent  un- 
pleasant symptoms,  although  the  patient  ap- 
pears to  have  been  previously  subject  to 
repeated  attacks  of  severe  inflammation  of 
the  joint.  (. Pathological  and  Surg.  Obs.  v 
299.) 

On  the  preceding  subject  some  observa- 
tions and  two  successful  operations  have 
been  lately  published  by  Baron  Larrey. 
(See  Memoir es  de  Chir.  Militaire , T.2,p.  421 , 
ty-c.)  With  the  exception  of  a few  wrong 
theories,  he  appears  to  have  given  a fair  ac- 
count of  the  disease 

Hydrops  Articuli  signifies  a collection  of  se  - 
rous  fluid  in  the  capsular  ligament  of  a joint. 
The  knee  is  more  subject,  than  other  joints, 
to  dropsical  disease,  which  has  been  known, 
however,  to  affect  the  wrist,  ankle,  and 
shoulder  joints.  ( Boyer , Traitt  des  Mai 

Chir . T.  4 ,p.  456.) 

Mr.  Russel  adopted  the  opinion,  that  some 
cases  of  this  kind  are  venereal,  and  others 
scrofulous  ; but,  he  has  not  supported  the 
doctrine  on  any  solid  foundation.  Hydrops 
articuli  generally  arises  from  contusions, 
rheumatism,  sprains,  exposure  to  severe 
cold,  the  presence  of  extraneous  cartilagi- 
nous bodies  in  the  joint,  and  in  general 
from  any  thing,  which  irritates  the  capsular 
ligament ; and,  as  already  explained,  it  is 
a common  attendant  on  inflammation  of 
the  synovial  membrane  ; the  complaint  also 
sometimes  follows  fevers ; but,  in  most  in- 
stances, it  is  purely  a local  affection,  quite 
independent  of  general  debility.  ( Boyer 
T.  4,  p.  467.) 

Hydrops  articuli  presents  itself  in  the  form 
of  a soft  tumour  ; circumscribed  by  the  at 
tachments  of  the  capsular  ligament ; with- 
out change  of  colour  in  the  skin ; accom- 
panied with  a fluctuation  ; it  is  indolent, 
and  very  little  painful ; causing  hardly  any 
impediment  to  the  motion  of  the  joint  ; 
yielding  to  the  pressure  of  the  finger,  but  not 
retaining  any  impression,  as  in  cedema. 
The  swelling  does  not  occupy  equally  every 
side  of  the  joint,  being  most  conspicuous 
where  the  capsular  ligament  is  loose  and 
superficial.  In  the  wrist  it  occurs  at  the 
anterior  and  posterior  parts  of  the  joint,  but, 
especially,  in  the  former  situation,  while  it 
is  scarcely  perceptible  at  the  sides.  In  the 
ankle,  it  is  more  apparent  in  front  of  the 
malleoli,  than  any  where  else  ; and,  in  the 
shoulder,  it  does  not  surround  the  joint,  but 
is  almost  always  confined  to  the  forepart  of 
it,  and  can  only  be  seen  in  the  interspace 
between  the  deltoid  and  great  pectoral  mus- 
cles. 

In  the  knee  joint,  whichTs  the  common 
situation  of  hydrops  articuli,  the  tumour 
does  not  occur  behind  the  articulation  ; but 
at  the  front  and  sides.  Behind,  the  capsular 
ligament  is  too  narrow  to  admit  of  being 


160 


JOINTS. 


much  distended  with  the  synovia  ; while,  in 
front,  and  laterally,  it  is  broad,  so  that  it  can 
there  yield  considerably  in  proportion  as 
the  quantity  of  fluid  increases.  The  swell- 
ing is  at  first  i-ircumscribed  by  the  attach- 
ments of  the  capsular  ligament ; but,  in 
consequence  of  the  accumulation  of  fluid, 
it  afterward  exceeds  these  limits  above,  and 
spreads  more  or  less  upward  between  the 
thigh  bone  and  the  extensor  muscles  of  the 
leg  which  are  lifted  up  by  it.  Boyer  has 
seen  it  reach  to  the  upper  third  of  the  thigh. 
The  swelling  is  irregular  in  shape  : it  is  most 
prominent  where  the  capsular  ligament  is 
wi  e and  loose,  and  it  is  in  some  measure  di- 
vided longitudinally  into  two  lateral  portions, 
by  the  patella,  the  ligament  of  the  patella,  and 
t'he  tendon  of  the  extensor  muscles  of  the  leg, 
all  which  parts  the  synovia  raises,  and  pushes 
forward,  though  in  a much  less  degree  than 
the  capsular  ligament.  Of  these  lateral 
portions,  the  internal  is  broadest  and  most 
prominent,  because  the  part  of  the  capsule 
between  the  patella  and  edge  of  the  inter- 
nal condyle  being  larger  than  that  situated 
between  the  patella  and  edge  of  the  exter- 
nal condyle,  yields  in  a g eater  degree  to 
the  distending  fluid.  The  motions  of  the 
leg,  which  are  generally  little  interrupted 
by  this  disease,  make  a difference  in  the 
shape  and  consistence  of  the  swelling.  In 
flexion,  the  tumour  becomes  harder,  tenser, 
and  broader  and  more  prominent  at  the 
sides  of  the  knee-pan,  which  is  somewhat 
depressed  by  its  ligament.  In  extension,  the 
tumour  is  softer,  and  the  fluctuation  plainer. 

In  order  to  feel  distinctly  the  fluctuation, 
which  is  one  of  the  best  symptoms  of  the 
disease,  the  ends  of  two  or  three  fingers 
should  be  placed  on  one  side  of  the  swell- 
ing, while  the  opposite  side  is  to  b ■ struck 
with  the  end  of  the  middle  finger  of  the 
other  hand. 

The  patella,  being  pushed  forward,  away 
from  the  articular  pulle  . , is  very  moveable, 
and,  as  it  were,  floating.  When  it  is  pressed 
backward,  while  the  leg  is  extended,  ii  can 
be  felt  to  move  a certain  ■ ay  before  it  meets 
with  the  resistance  of  the  articular  puhey. 
And  on  the  pressure  being  discontinued,  it 
immediately  separates  from  tins  part  again. 

By  such  symptoms,  hydrops  articuli  may 
easily  be  distinguished  f om  other  diseases 
of  the  joints,  from  tumours  of  the  bursa  mu- 
cosa under  the  extensor  tendons  of  the  leg; 
from  ganglions  in  front  of  the  knee-pan  ; 
from  rheumatism  ; oedema,  foe. 

The  prognosis  is  most  favourable,  when 
the  swelling  is  recent  and  small,  and  has 
been  quick  in  its  progress.  On  the  contrary, 
when  the  tumour  is  of  long  standing  and 
large;  the  effused  fluid  thick  and  viscid; 
and  the  synovial  membrane  thickened  ; the 
removal  of  the  fluid  by  absorption,  and  the 
restoration  oi  the  parts  to  their  natural  state, 
will  be  more  slow  and  difficult.  The  worst 
case  is  that  which  is  complicated  with  dis- 
ease of  the  capsular  ligament  cartilages,  md 
bones. 

The  cure  of  the  above-described  dropsi- 
cal affection  of  the  joints,  depends  upon  the 


absorption  of  the  effused  fluid.  And,  when 
the  case  is  combined  with  acute  or  chronic 
inflammation  of  the  synovial  membrane,  th© 
treatment  is  the  same  as  th  t already  recom- 
mended for  those  particular  forms  of  dis- 
ease. When  i-  flammation  subsides,  the 
absorption  of  the  fluid  is  sometimes  altoge- 
ther spontaneous,  and  it  may  always  be 
promoted,  by  mere  friction,  by  rubbing  the 
joint  with  camphorated  mercurial  ointment, 
and  particularly,  by  the  employment  of 
blisters. 

The  operation  of  a blister  may  be  very 
materially  assisted  with  a moderately  tight 
bandage.  Among  other  effectual  melt  ns  of 
cure,  we  may  enumerate  frictions  with  flan- 
nel impregnated  with  the  fumes  of  vinegar ; 
electricity  ; and  the  exhibition  of  mercurial 
purgatives.  When  hydrops  articuli  occurs 
during  the  debdity,  consequent  to  typhoid, 
and  other  fevers,  the  complaint  can  hardly 
be  expected  to  get  well,  before  the  patient 
has  regained  some  degree  of  strength. 

As,  however,  hydrops  articuli  is  generally 
quite  a local  disease,  Boyer  contends,  that 
it  should  be  chiefly  treated  with  topical  re- 
medies ; and  he  sets  down  diuretics,  sudo- 
rifics,  hvdragogues,  foe.  as  improper  or  in- 
efficient. (Op.  cit.  p.  467.)  He  is  strongly 
in  favour  of  repeated  blisters,  both  for  tho 
prevention  and  cure  of  the  disease. 

Circumstances  do  not  often  justify  making 
an  opening  into  the  joint : but,  excessive 
distention,  in  some  neglected  cases,  might 
certainly  be  an  urgent  reason  for  performing 
such  an  operation.  Also,  if  the  complaint 
should  resist  all  other  plans  of  treatment, 
and  the  irritation  of  the  tumour  greatly  im- 
pair a week  constitution,  the  practice  would 
be  justifiable.  An  interesting  example  of 
this  kind  is  related  by  Mr.  Latta.  ( System 
of  Surgery,  Vol.  2,  p.  490.) 

ft  is  best  to  make  the  opening  in  such  a 
way,  that  the  wound  in  the  capsular  liga- 
ment after  the  operation,  will  not  remain 
directly  opposite  the  wound  in  the  skin. 
For  this  purpose,  the  integuments  are  to  be 
pushed  to  one  side,  before  the  surgeon  di- 
vides them.  ( Encyclopedic  Method.  Part. 

Chir.  Art.  Hydropsie  des  Jointures.) 

The  operation  is  not  always  successful, 
being  sometimes  followed  by  alarming 
symptoms,  which  either  end  fatally,  or  oc- 
casion a necessity  for  amputation.  The 
fliiid  also  generally  collects  again,  and  as 
the  synovial  membrane  is  mostly  thickened, 
it  often  inflames,  and  suppuration  in  the 
joint  ensues.  Hence,  when  hydrops  articuli 
originates  from  rheumatism  ; when  it  is  re- 
cent, indolent,  and  not  |.  rge  ; and  when  it 
does  not  seriously  impair  the  functions  of 
the  joint  ; Boyer  recommends  the  operation 
not  to  be  done.  But,  be  sanctions  its  per- 
formance, when  the  disease  is  combined 
with  extraneous  cartilaginous  bodies  in  the 
joint:  or  when  it  is  very  considerable,  at- 
tended with  severe  pain,  and  impairment 
of  the  functions  of  the  joint.  (Op.  cit.  T.  4, 
p.  473.) 

Collections  of  Blood  in  Joints. — Most  sys- 
tematic writers  speak  of  this  kind  of  case. 


JOINTS 


though  it  must  be  uncommon.  Tumours 
about  th£  joints,  composed  of  blood,  and 
Set  down  in  numerous  surgical  works,  as 
extravasations  within  the  capsular  ligaments 
are  generally  on  the  outside  ot  them. 

Certainly,  if  a collection  of  fluid  were  to 
take  place  in  a joint  immediately  after  a 
sprain,  or  contusion,  and  to  continue  to  in- 
crease gradually  for  some  time  afterward, 
there  would  be  reason  to  believe  most  of 
the  contents  of  the  tumour  to  be  blood 
The  production  of  an  abscess,  and  the  se- 
cretion of  any  fluid,  would  have  required  a 
longer  time. 

VVere  blood  known  to  be  undoubtedly 
effused  in  a large  articulation,  however,  no 
man  would  be  justified  in  making  an  open- 
ing for  its  discharge.  No  bad  symptoms 
are  likely  to  result  from  its  mere  presence, 
and  the  absorbents  will,  in  the  end,  take  it 
away.  If  an  incision  were  made  into  the 
joint,  the  coagulated  state  of  the  extrava- 
sated  blood  would  not  allow  such  blood  to 
be  easily  discharged. 

The  best  plan  is  to  apply  discutient  re- 
medies ; a lotion  of  vinegar,  spirits  of  wine, 
and  muriate  of  ammonia  for  the  first  three 
or  four  days  ; and  afterw  ard,  friction  with 
camphorated  liniments  may  be  safely  adopt- 
ed. 

Mr.  Hey  relates  a case,  in  which  the  knee- 
joint  was  wounded,  and  blood  insinuated 
itself  into  the  capsular  ligament;  yet  though 
the  occurrence  could  not  be  hindered,  no 
harm  resulted  from  the  extravasation,  which 
was  absorbed,  without  having  created  the 
smallest  inconvenience.  ( Practical  Obs.  in 
Surgery,  p.  354.) 

White  Swelling. — The  white  swelling,  or 
spina  ventosa,  as  it  was  at  one  time  not  un- 
frequentlv  called,  in  imitation  of  the  Arabian 
writers,  Khazes  and  Avicenna,  has  been  a 
name  indiscriminately  applied  to  many  dis- 
eases, which  differ  widely  in  their  nature, 
curability, and  treatment.  Wiseman  was  the 
first  who  used  the  term  Whin-S welling  ; 
and  if  the  expression  did  not  confuse  to- 
gether complaints  of  very  different  kinds,  not 
much  fault  f ould  be  found  writh  it,  because  it 
unquestionably  conveys  an  idea  of  one  mark 
of  some  of  these  distempers,  which  is,  that 
notwithstanding  the  increase  of  size  in  the 
joint,  the  skin  is  generally  not  inflamed,  but 
retains  its  natural  colour.  (Pott.) 

The  name,  therefore,  appears  objection- 
able, only  inasmuch,  as  it  has  tended  to  pre- 
vent the  introduction  of  a sufficient  number 
of  well-founded  and  net.e>sary  distinctions. 
Systematic  writers  have  generally  been  con- 
tent with  a distinction  into  two  kinds,  viz. 
rheumatic , and  scrofulous. 

The  last  species  of  the  disease  they  also 
distinguish  into  such  tumours,  as  primarily 
affect  the  bones,  and  then  the  ligaments  and 
soft  parts ; and  into  other  cases,  in  w'hich 
the  cartilage*,  ligaments,  and  soft  parts  be- 
come diseased  before  there  is  any  morbid 
affection  of  the  hones. 

Mr.  Brodie  has  endeavoured  to  form  a 
more  correct  classification  of  the  different 
complaints,  to  which  the  term  white-swelling 


is  applied  ; and  his  descriptions  are  valuable, 
because  confirmed  by  extensive  observation, 
and  numerous  dissections.  With  respect  to 
the  disease  beginning  in  the  ligaments,  if  the 
capsular  ligaments  be  put  out  of  considera- 
tion, it  is,  as  this  gentleman  observes,  a rare 
occurrence,  and  he  has  never  met  with  a 
case,  in  which  the  fact  was  ptoved  by  dis- 
section. (Pathol,  and  Surgical  Obs.  p.  7.) 

1.  Tiie  first  case  is  mtiaimnalion  ol  the 
synovial  membrane,  as  described  in  the  fore- 
going pages,  especially  that  torrn  ot  the  dis- 
ease which  often  arises  from  cold,  and  con- 
stitutes the  disease  formerly  often  termed  a 
rheumatic  w hite  swelling. 

2.  Another  form  ot  disease,  ordinarily 
comprised  under  the  general  name  ol  white- 
swelling,  has  been  particularly  described  by 
Mr.  Brodie  : the  disease  originates  in  the 
synovial  membrane,  which  loses  its  natural 
organization,  and  becomes  converted  into  a 
thick,  pulpy  substance,  of  a light  brown,  and 
sometimes  ot  a reddish  brow  n colour,  inter- 
sected by  white  membranous  lines,  and  from 
1-4  to  1-2  ot  an  inch,  or  even  more  than  an 
inch  in  thickness.  As  this  disease  advances, 
it  involves  ail  the  parts  of  which  the  joint  is 
composed,  producing  ulceration  of  ibe  car- 
tilages, caries  ot  the  bones,  wasting  ot  the 
ligaments,  and  abscesses  in  different  places. 
The  complaint  has  invariably  proved  slow 
in  its  progress,  and  sometimes  has  remained 
nearly  in  an  indolent  state  for  many  months, 
or  even  for  one  or  two  years  ; but  (says  Mr. 
Brodie)  I have  never  met  with  an  instance, 
in  which  a real  amendment  was  produced  ; 
much  less  have  I known  any  in  which  a cure 
was  effected.’  (bee  Medico- Chir.  Trans . 
Vol.  4,  p.  220,  <Jpc.)  The  wlio.e,  or  nearly 
the  whole  ot  the  synovial  membrane  has 
always  been  found  affected;  though  if  a 
very  early  examination  were  made,  Mr. 
Brodie  conceives  that  this  might  not  be  the 
case,  and  in  one  example,  he  found  only  a 
half  of  the  membrane  tbus  altered,  while 
the  rest  w as  ot  its  natural  siruciure.  ( Pathol 
and  Surg.  Obs.  p.  94.)  Tnis  gentleman 
further  acquaints  u-,  that  the  preceding  affec- 
tion of  (he  synovial  membrane  is  rareiy  met 
with,  except  in  the  knee,  that  he  bas  never 
known  an  instance  ot  it  in  the  hip  or  shoul- 
der; that  it  is  peculiar  to  the  synovial  mem- 
brane of  the  joints  ; tliai  he  has  never  know'n 
an  instance  oi  it  in  other  serous  m<  mbranes, 
nor  even  in  ihe  synovial  membranes,  w hich 
constitute  (he  ur-aj  mucosae  and  sheaths  of 
tendons  ; and  that  it  generally  lakes  place  in 
young  persons,  under,  or  not  much  abuve  the 
age  of  puberty.  In  tact,  Mr.  Brodie  has  no" 
met  with  more  than  one  in.-tance,  in  which 
it  occurred  afier  the  middle  period  ot  life. 
“ In  the  origin  of  this  disease,  there  is  a 
slight  degree  of  stiffness  and  tumefaction, 
without  pain,  and  producing  only  the  most 
trifling  inconvenience.  These  symptoms 
gradually  increase  : at  last,  the  joint  scarcely 
admits  of  the  smallest  motion,  the  stiffness 
being  greater  than  where  it  is  the  conse- 
quence of  simple  inflammation.  The  form 
of  the  swelling  bears  some  resemblance  to 
that  in  cases  of  inflammation  of  the  synovial 


JOINTS. 


152 


membrane,  but  it  is  less  regular.  The  swell- 
ing is  soft  and  elastic,  and  gives  to  the  hand 
a sensation  as  if  it  contained  fluid.  If  only 
one  hand  be  employed  in  making  the  exami- 
nation, the  deception  may  be  complete,  and 
the  most  experienced  surgeon  may  be  led  to 
suppose,  there  is  a fluid  in  the  joint  when 
there  is  none  ; but  if  both  hands  be  employ- 
ed, one  on  each  side,  the  absence  of  fluid  is 
distinguished  by  the  want  of  fluctuation 
“ The  patient  experiences  little  or  no  pain, 
until  abscesses  begin  to  form,  and  the  cartila- 
ges ulcerate  ; and  even  then  the  pain  is  not 
so  severe,  as  where  the  ulceration  of  the 
cartilages  occurs  as  a primary  disease,  and 
the  abscesses  heal  more  readily,  and  discharge 
a smaller  quantity  of  pus,  than  in  cases  of 
this  last  description.  At  this  period,  the  pa- 
tient becomes  affected  with  hectic  fever,  loses 
his  flesh,  and  gradually  sinks,  unless  the  limb 
be  removed  by  an  operation.”  ( Brodie , in 
Med.  Chir.  Trans.  Vol.  5,  p.  251,  252.)  In 
the  majority  of  cases,  this  gentleman  believes 
that  the  gradual  progress  of  the  enlargement , 
the  stiffness  of  the  joint  without  pain,  and  the 
soft  elastic  svjelling  without  fluctuation , will 
enable  the  practitioner  readily  to  distinguish 
this  from  all  other  diseases  of  the  joints. 
However,  when  the  diseased  synovial  mem- 
brane happens  to  be  distended  with  a quanti- 
fy of  turbid  serum  and  flakes  of  c-oagulable 
lymph,  the  complaint  somewhat  resembles  in 
its  feel  and  appearance  that  stage  of  common 
inflammation  of  the  synovial  membrane, 
where  this  part  is  left  thickened,  and  more 
or  less  distended  with  coagulable  lymph,  but 
the  impossibility  of  relieving  the  former  ca  e 
by  the  same  means  which  cure  the  latter, 
and  due  attention  to  the  history  of  the  dis- 
ease, will  prove  the  difference  between  them. 
( Brodie , Pathol,  and  Surg.  Obs.  p.  96.) 

3.  Ulceration  ot  the  articular  cartilages 
takes  place  in  the  advanced  stage  of  several 
diseases  of  the  joints,  and  ii  also  exists  in 
many  instances  as  a primary  affection,  in  the 
early  stage  ut  o hich,  the  bones,  synovial 
membrane,  and  ligaments,  are  in  a natural 
state.  If  neglected,  it  ultimately  occasions 
the  entire  destruction  of  the  an  mutation.  It 
may  be  the  consequence  ot  infl  miiiation  of 
the  cartilage  itself,  or  of  the  bony  surface, 
with  which  it  is  connected  ; but  ,<s  Mr.  Bro- 
die further  observes,  in  many  instances  there 
are  no  evident  marks  >f  the  disorder  being 
preceded  by  any  inflammatory  action  in  one 
part  or  the  other,  and  the  inflammation, 
which  afterward  lakes  place,  appears  rather 
to  be  theattendant  upon,  than  thee  us«  of  ihe 
ulcerative  process.  One  striking  peculiarity 
ot  ulceration  of  the  articular  cartila.  es  is, 
that  ihe  process  may  lake  place  without  the 
formaiion  of  pus;  for  the  disease  often  pro- 
ceeds so  far  as  to  cause  caries  of  the  bones, 
and  y et  no  purulent  matter  is  found  within 
the  joint.  (See  Brodie  s Pathol,  and  Surgi- 
cal Obs.  tyc.  p.  102.)  The  investigations  of 
the  same  author  dispose  him  to  believe,  that 
a conversion  of  these  cartilages  into  a soft 
fibrous  structure,  is  a frequent  .hough,  not 
constant  forerunner  of  ulceration.  {P.  105.) 
When  the  ulceration  of  the  cartilage  occurs 


in  the  superficial  joiuts,  it  constitutes  one  of 
the  diseases  which  have  been  known  by  the 
name  of  white-swelling.  From  cases  which 
Mr.  Brodie  has  met  with,  he  is  led  to  con- 
clude, that  when  it  takes  place  in  the  hip,  it 
is  this  disease,  which  has  been  variously 
designated  by  writers,  the  “ morbus  coxariusf 
the  “ Disease  of  the  Hip,”  the  “Scrofulous 
Hip,”  the  Scrofulous  Caries  of  the  Hip 
Joint.”  At  least,  says  Mr.  Brodie,  it  is  to  this 
disease,  that  these  names  have  been  princi- 
pally applied,  though  probably  other  morbid 
affections  have  been  occasionally  confounded 
with  it.  {Med.  Chir.  Trans.  Vol.  4,j?.236.) 
The  ulceration  of  the  articular  cartilages 
takes  place  as  a primary  disease,  chiefly  in 
children,  or  adults  under  the  middle  age. 
“ Ot  sixty-eight  persons  affected  with  this 
disease,  fifty-six  (according  to  Mr.Brodie)were 
under  thirty  years  of  age  : the  youngest  was 
an  infant  of  about  twelve  months  the  old- 
est was  a woman  of  sixty.  As  the  knee  is 
more  frequently  affected  by  inflammation  of 
the  synovial  membrane,  so  is  the  hip  more 
liable,  than  other  joints,  to  the  ulceration  of 
tue  cartilaginous  surfaces.  In  general  tne 
disease  is  confined  to  a single  joint ; but  it 
is  not  very  unusual  to  find  two  or  three 
joints  affected  in  the  same  individual,  either 
at  the  same  time,  or  in  succession.  Some- 
times the  patient  traces  the  beginning  of  his 
symptoms  to  a local  injury,  or  to  his  having 
been  exposed  to  cold  ; but  for  the  most  part  , 
no  cause  can  be  assigned  for  the  complaint.” 
(see  Med.  Chir.  Trans.  Vol.6,p.  319.) 

The  symptoms  of  the  disease  of  the  hip- 
joint  will  be  described  in  the  ensuing  section, 
and  we  shall  here  confine  our  remarks  to  the 
symptoms  characterizing  ulceration  of  the 
cariilages  of  ihe  knee,  as  pointed  out  by  Mr. 
Brodie.  ihey  differ  from  those  of  inflam- 
mation ot  the  synovial  membrane,  by  the 
pain  being  slight  in  the  beginning,  and  gra 
dually  becoming  very  intense,  which  is  the 
reverse  of  what  happens  in  the  latter  affec- 
tion. The  pain  in  the  commencement  is 
also  unattended  witu  any  evident  swelling, 
w Inch  never  comes  on  in  less  than  four  or 
five  weeks,  and  often  not  till  after  several 
months.  It  is  not  to  be  inferred,  however, 
that  every  slight  pain  of  thp  joint,  unaccom- 
panied with  swelling,  must  of  course  arise 
from  ulceration  of  the  cartilages.  But,  says 
Mr.  Brodie,  when  the  pain  continues  to  in- 
crease, and  at  last  is  very  severe  ; when  it  is 
aggravated  by  the  motion  of  the  bones  on 
each  other,  and  when,  after  a time,  a slight 
tumefaction  <>t  the  joint  takes  place,  we  may 
conclude  that  the  disease  consists  in  such 
ulceration.  The  swelling  arises  from  a slight 
inflammation  of  the  cellular  membrane  on 
the  outside  of  the  joint : it  has  the  form  of 
the  articulating  ends  of  the  bones ; and  for 
the  most  part  it  appears  greater  than  it  really 
is,  in  consequence  of  the  muscles  being 
wasted.  No  fluctuation  is  perceptible,  as 
where  the  synovial  membrane  is  inflamed  ; 
nor  is  there  the  peculiar  elasticity,  which 
exists  where  the  synovial  membrane  has  un- 
dergone a morbid  alteration  ot  its  structure. 
Ml*  Brodie  has  explained,  however,  that 


JOINTS. 


153 


in  some  cases,  the  swelling  has  a different 
shape,  and  communicates  the  feel  of  a lluc- 
tuation.  This  happens  when  inflammation  of 
the  synovial  membrane,  attended  with  a 
collection  of  the  synovia  of  the  joint,  or 
abscesses  in  the  surrounding  soft  parts,  or  in 
the  articulation  itself,  occur  as  secondary 
diseases.  When  there  has  been  considerable 
destruction  of  the  soft  parts  from  abscesses 
and  ulceration,  the  head  of  the  tibia  may 
become  dislocated  and  drawn  towards  the 
ham.  (See  Med.  Chir.  Trans.  Vol.  6,  p.  326, 

4^0 

4.  I shall  pass  over  ulceration  of  the  syno- 
vial membrane,  which  Mr.  Biodie  considers 
in  a separate  section,  and  now  proceed  to 
scrofulous  white-swelling.  In  the  scrofu- 
lous disease  of  the  joints,  the  bones  are  pri- 
marily affected,  in  consequence  of  which, 
ulceration  takes  place  in  the  cartilages  cover- 
ing their  articular  extremities.  The  cartilages 
being  ulcerated,  the  subsequent  progress  of 
the  disease  (says  Mr.  Brndie)  is  the  same  as 
where  this  ulceration  takes  place  in  the  first 
instance.  ( Medico- Chir . Trans.  Vol.  4,  p. 
266.) 

By  Mr.  Lloyd,  scrofulous  white  swellings 
are  divided  into  three  stages;  the  first  being 
that  in  which  the  affection  is  confined  to  the 
bone  ; the  second,  that  in  which  the  exter- 
nal parts  become  thickened  and  swelled ; 
and  the  third  being  what  he  names  the  sup- 
purative stage,  attended  with  ulceration  of 
the  cartilages,  inflammation  of  the  synovial 
membrane,  and  abscesses.  (On  Scrofula,  p. 
321.)  It  was  formerly  a common  notion, 
that  in  white-swellings,  the  heads  of  the 
bones  were  always  enlarged.  Mr.  Russel,  I 
believe,  is  the  first  writer  who  expressed  an 
opposite  sentiment,  and  he  distinctly  declares, 
that  he  had  never  heard , nor  known  of  an  in- 
stance in  which  the  tibia  was  enlarged  from  an 
attack  of  white-swelling.  (P.  37.)  The  inac- 
curacy of  the  opinion  was  afterward  pointed 
out  by  Mr.  Lawrence,  to  the  late  Mr.  Crovv- 
ther,  and  the  subject  was  mentioned  in  the 
earliest  edition  of  the  li  First  Lines  of  the 
Practice  of  Surgery.” 

Deceived  by  the  feel  of  many  diseased 
ioints,  and  influenced  by  general  opinion,  I 
once  supposed,  that  there  was  generally  a 
regular  expansion  of  the  heads  of  scrofu- 
lous bones.  But  excepting  an  . occasional 
enlargement,  which  arises  from  spiculae  of 
bony  matter,  deposited  on  the  outside  of  the 
tibia,  ulna,  &c.  and  which  alteration  cannot 
be  called  an  expansion  of  those  bones,  I 
never  until  lately  saw  the  head  of  a bone 
enlarged,  in  consequence  of  the  disease 
known  by  the  name  of  white-swelling.  I was 
formerly  much  in  the  habit  of  inspecting  the 
state  of  the  numerous  diseased  joints,. which 
were  every  year  amputated  at  St.  Bartholo- 
mew’s Hospital,  and  though  I was  long  at- 
tentive to  this  point,  my  searches  after  a 
really  enlarged  scrofulous  bone  always 
proved  in  vain.  Nor  was  there  at  that  peri- 
od any  specimen  of  an  expanded  head  of  a 
scrofulous  bone  in  Mr.  Abernetby’s  museum. 
Within  the  last  few  years,  however,  a speci- 

Vo  r . u * ' ' 20 


men  of  an  enlargement  of  the  upper  head  of 
the  ulna  has  been  found,  and  it  was  some 
time  ago  shown  to  me.  by  Mr.  Stanley.  My 
friend,  Mr.  Langstaflf,  is  said  to  have  in  his 
possession  a knee-joint,  in  which  the  femur 
and  tibia  are  much  expanded,  lt  the  external 
laminae  of  the  bones  not  being  thicker  than 
when  the  bones  are  of  their  natural  size,  and 
the  caneelli  healthy,  though  of  rather  greater 
solidity  than  natural.  (Lloyd  on  Scrofula,  p. 
148.)  However,  this  last  form  of  disease 
evidently  does  not  resemble  the  common 
scrofulous  affection  of  the  heads  of  the  bones. 
I may  add,  that  Mr.  Wilson,  whose  dissec- 
tions have  beer,  very  numerous,  concurs  with 
the  best  modern  writers,  concerning  the  rari- 
ty of  an  actual  expansion  of  the  .substance 
of  the  heads  of  (he  bones.  (On  the  Skele- 
ton, fo.  p.  336.)  I have  also  heard  of  a few 
other  instances  in  which  the  heads  of  the 
bones  were  actually  enlarged  in  cases  of 
white-swelling.  However,  I believe  the 
occurrence  is  far  from  being  usual,  and 
doubts  may  yet  be  entertained,  whether 
such  enlargement  is  combined  with  the  fol- 
lowing alteration  of  structure.  The  change 
which  the  head  of  the  tibia  undergoes  in 
many  cases,  is  first  a partial  absorption  of 
the  phosphate  of  lime  throughout  ilstexturej 
while  at  first  a transparent  fluid,  and  after- 
ward a yellow  cheesy  substance  are  deposit- 
ed in  the  caneelli.  In  a more  advanced 
s<age,  and  indeed,  in  that  stage,  which  most 
frequently  takes  place  before  a joint  is  am- 
putated, the  head  of  the  bone  has  deep  ex- 
cavations in  consequence  of  caries,  and  its 
structure  is  now  so  softened,  that  when  an 
instrument  is  pushed  against  the  carious  part, 
it  easily  penetrates  deeply  into  the  bone. 
Occasionally,  as  my  friend  Mr.  Lloyd  has 
observed,  all  the  bones  of  a joint  are  affect- 
ed in  this  way  ; but  frequently  only  One  of 
them.  (On  Scrofula,  p.  120.) 

According  to  a modern  writer,  ‘“'The  mor- 
bid affection  appears  to  have  its  origin  in  the 
bones,  which  become  preternaturally  vascu- 
lar, and  contain  a less  than  usual  quantity  of 
earthy  matter,  while,  at  first,  a transparent 
fluid,  and  afterward  a yellow  cheesy  sub- 
stance, is  deposited  in  their  caneelli.  From 
the  diseased  bone,  vessels,  carrying  red  blood, 
shoot  into  the  cartilage,  which  afterward  ulce- 
rates in  spots,  the  ulceration  beginning  on  that 
surface,  which  is  connected  to  the  bone.  As 
the  caries  of  the  bones  advances, pus  is  collect- 
ed in  the  joint.  At  last,  the  abscess  bursts  ex- 
ternally, having  formed  numerous  and  circui- 
tous sinuses.”  (Brodie,in  Med.  Chir.  Trans. 
Vol  4,;;.  272,  and  Pathol  Obs.p.  227.)  The 
above-described  alteration  of  the  structure  of 
the  bones,  this  author  has  never  seen  in  the 
cranium,  uor  in  the  middle  of  the  cylindrical 
bones ; but,  it  is  asserted  by  another  iate 
Writer,  that  the  cheesy  matter  sometimes 
pervades  the  canceii  of  the  whole  bone,  and 
is  deposited  in  innumerable,  portion's  of  the 
most  minute  size.  (E.  A.  Lloyd  on  Scrofu- 
la, p.  120.)  Also,  with  respect  to  the  increa- 
sed vascularity  of  the  diseased  part  of  the 
bone,  although  Mr.  Lloyd  assents  to  the  truth 


164 


JOINTS. 


of  this  statement,  as  applied  to  the  early 
stage  of  the  disorder,  he  represents  the  vas- 
cularity as  afterward  being  diminished,  in 
proportion  as  the  quantity  of  cheeselike  de- 
posit increases.  ( Vol . cit.p.  122,  123.) 

A cursory  examination  of  a diseased  joint, 
even  when  it  is  cut  open,  will  not  suffice  to 
show,  that  the  heads  of  the  bones  have  not 
acquired  an  increase  of  size.  In  making  a 
dissection  of  this  kind,  in  the  presence  of  a 
medical  friend,  I found  that,  even  after  the 
joint  had  been  opened,  the  swelling  had  every 
appearance  of  arising  from  an  actual  expan- 
sion of  the  bones.  The  gentleman  with  me 
felt  the  ends  of  the  bones  after  the  integu- 
ments had  been  removed,  and  he  coincided 
with  me,  that  the  feel,  which  was  even  now 
communicated,  seemed  to  be  caused  by  a 
swelling  of  the  bones  themselves.  But,  on 
cleaning  them  the  enlargement  was  demon- 
strated to  arise  entirely  from  a thickening  of 
the  soft  parts.  So  unusual,  indeed,  is  the 
expansion  of  the  heads  of  the  bones,  that 
the  late  Mr.  Crowther,  who  paid  great  atten- 
tion to  these  cases,  joined  Mr.  Russel  in 
Relieving,  that  such  a change  never  happen- 
ed : a conclusion  not  entirely  correct.  (See 
Practical  Obs.  on  White-Swelling,  fyc.  Edit.  2, 
p.  14,  1808.) 

Mr.  Russel  has  particularly  noticed  how 
much  the  soft  ports  frequently  contribute  to 
the  swelling.  He  describes  the  appearances 
on  dissection  thus : “ The  great  mass  of  the 
swelling  appears  to  arise  from  an  affection  of 
the  parts,  exterior  to  the  cavity  of  the  joint, 
and  which,  besides  an  enlargement  in  size, 
seem  also  to  have  undergone  a material 
change  in  structure.  There  is  a larger,  than 
natural,  proportion  of  a viscid  fluid,  intermix- 
ed with  the  cellular  substance  ; and  the  cel- 
lular substance  itself  has  become  thicker, 
softer,  and  of  a less  firm  consistence,  than  in 
a state  of  health.”  (On  the  Morbid  Affections 
of  the  Knee,  p.  30.)  The  manner,  in  which 
the  soft  parts  are  affected,  is  also  described  by 
Mr.  Brodie : “ Inflammation  takes  place  of 
the  cellular  membrane,  external  to  the  joint. 
Serum,  and  afterward  coagulable  lymph, 
are  effused,  and  hence  arises  a puffy  elastic 
swelling  in  the  early,  and  an  cedemalous 
swelling  in  the  advanced  stage  of  the  disease. 

<£  Scrofula  attacks  only  those  bones,  or 
portions  of  bones,  which  have  a spongy  tex- 
ture, as  the  extremities  of  the  cylindrical 
bones,  and  the  bones  of  the  carpus  and  tar- 
sus ; and  hence,  the  joints  become  affected 
from  their  contiguity  to  the  parts,  which  are 
the  original  seat  of  the  disease.”  (See  Medi- 
co-Chir.  Trans.  Vol.  4,  p.  273.) 

In  the  cavity  of  the  joint,  we  sometimes 
find  a quantity  of  curdy  matter,  and  the  car- 
tilages absorbed  in  various  places,  but  more 
particularly  round  the  edges  of  the  articular 
surfaces. 

As  the  name  of  the  disease  implies,  the  skin 
is  not  at  all  altered  in  colour.  According  to 
Mr.  Lloyd,  the  first  decided  symptom  of  dis- 
ease going  on  in  the  articulating  extremity  of 
a bone,  is  an  occasional  deep-seated,  dull, 
heavy  pain,  unattended  by  swelling,  and  not 
increased  by  motion ; and  if  it  be  the  hip, 


knee,  or  ankle,  which  is  affected,  the  patient 
keeps  the  knee  rather  bent,  and  never  fully 
extends  it  in  progression.  (On  Scrofula, p. 
138.)  In  some  instances,  the  swelling  yields 
in  a certain  degree  to  pressure  ; but  it  never 
pits,  and  is  almost  always  sufficiently  firm  to 
make  an  uninformed  examiner  believe,  that 
the  bones  contribute  to  the  tumour.  It  is 
remarked  by  Mr.  Brodie,  that  while  the  dis- 
ease is  going  on  in  the  cancellous  structure 
of  the  bones,  before  its  effects  have  extended 
to  the  other  textures,  and  while  there  is  still 
no  evident  swelling,  the  patient  experiences 
some  degree  of  pain,  which  however,  is  ne- 
ver very  severe,  and  often  is  so  slight,  that  it 
is  scarcely  noticed.  After  a time,  varying 
from  a few  weeks  to  several  months,  the  ex- 
ternal parts  begin  to  swell,  and  serum  and 
coagulable  lymph  to  be  effused  in  the  cellu- 
lar membrane  so  as  to  form  a puffy,  elastic 
swelling.  (Pathol.  Obs.  p.  231.)  In  the  ma- 
jority of  scrofulous  white -swellings,  let  the 
pain  be  trivial,  or  more  severe,  it  is  particu- 
larly situated  in  one  part  of  the  joint : viz. 
either  the  centre  of  the  articulation,  or  the 
head  of  the  tibia.  Sometimes,  the  pain  con- 
tinues without  interruption  ; sometimes  there 
are  intermissions;  and  in  other  instances,  the 
pain  recurs  at  regular  times,  so  as  to  have 
been  called  by  some  writers,  periodical.  Al- 
most ail  authors  describe  the  patient,  as  suf- 
fering more  uneasiness  in  the  diseased  pari, 
when  he  is  warm,  and  particularly,  when  he 
is  in  this  condition  in  bed. 

In  the  early  stage  of  the  disease,  the  swell- 
ing is  mostly  very  inconsiderable,  or  there  is 
even  no  visible  enlargement  whatever,  ex- 
cepting perhaps  after  exercise.  In  the  little 
depressions,  naturally  situated  on  each  side 
of  the  patella,  a fullness  generally  first  shows 
itself,  and  gradually  spreads  all  over  the  affect- 
ed joint.  According  to  Mr.  Lioyd,  however, 
when  the  soft  parts  on  the  outside  of  the 
knee-joint,  permanently  swell,  the  swelling 
often  commences  *on  each  side,  just  behind 
the  condyles,  so  that  the  joint  appears  wider, 
and  he  says,  that  he  has  often  seen  the  en- 
largement commence  by  the  swelling  of  n 
gland,  immediately  above  the  inner  condyle. 
He  observes,  however,  that  there  is  no  point 
of  the  joint,  where  the  swelling  may  not 
begin.  (Op.  cit.  p.  139.) 

The  patient,  unable  to  bear  the  weight  of 
his  body  on  (lie  disordered  joint,  in  conse- 
quence of  the  great  increase  of  pain  thus 
created,  gets  into  the  habit  of  only  touching 
the  ground  with  his  toes,  and  the  knee  being 
generally  kept  a little  bent  in  this  manner, 
soon  loses  the  capacity  of  being  completely 
extended  again.  When  white-swellings  have 
lasted  a good  while,  the  knee  is  almost  al- 
ways found  in  a permanent  state  of  flexion. 
In  scrofulous  cases,  the  pain  constantly 
precedes  any  appearance  of  swelling;  hut 
the  interval  between  the  two  symptoms  differs 
very  much  in  different  subjects. 

The  morbid  joint,  in  the  course  of  time, 
acquires  a vast  magnitude.  Still  the  integu- 
ments retain  their  natural  colour,  and  remain 
unaffected.  The  enlargement,  however, 
always  seems  greater  than  it  really  is,  in  con* 


JOINTS 


sequence  of  the  emaciation  o i’  tiie  limb  both 
above  and  below  the  disease. 

An  appearance  of  blue  distended  veins,  and 
a shining  smoothness,  are  the  only  alterations 
to  be  noticed  in  the  skin  covering  the  enlarged 
joint.  The  shining  smoothness  seems  attri- 
butable to  the  distention,  which  obliterates  the 
natural  furrows  and  wrinkles  of  (he  cutis. 
When  I he  joint  is  thus  swollen,  the  integu- 
ments cannot  be  pinched  up  into  a fold,  as 
they  could  in  the  state  of  health,  and  even 
in  the  beginning  of  the  disease. 

As  the  distemper  of  the  articulation  advan- 
ces, the  cartilages  ulcerate,  and  collections 
of  matter  form  around  the  part,  andat  length 
burst.  Their  progress,  as  Mr  Brodie  has  sta- 
ted, is  slow,  and  when  they  burst,  or  are 
opened,  they  discharge  a thin  pus,  with  por- 
tions of  a curdy  substance  floating  in  it.  The 
discharge  afterward  becomes,  less  copious, 
and  thicker.  ( Pathol . Obs.  p.  23d.)  The 
ulcerated  openings  sometimes  heal  up  ; but, 
such  abscesses  are  generally  followed  by 
other  collections,  which  pursue  the  same 
course.  In  some  cases,  these  abscesses  form 
a few  months  after  the  first  affection  of  (he 
joint  ; on  other  occasions,  several  years 
elapse,  and  no  suppuration  of  this  kind  makes 
its  appearance.  They  sometimes  communi- 
cate with  the  cavity  of  the  diseased  joint,  or 
lead  down  to  diseased  bone,  portions  of  which 
occassionally  exfoliate.  In  the  generality  of 
cases,  several  abscesses  take  place  in  succes- 
sion, some  healing  up,  and  others  ending  in 
sinuses. 

As  the  cartilages  continue  to  ulcerate,  Mr. 
Brodie  has  observed,  that  the  pain  becomes 
aggravated,  though  not  in  a very  great  de- 
gree, and,  he  says,  that  it  is  not  severe,  until 
an  abscess  has  formed,  and  the  parts  over  it 
are  distended  and  inflamed.  ( Pathol . Obs.  p. 
234.)  : 

The  local  mischief  must  necessarily  produce 
moue  or  less  constitutional .''disturbance.  The 
patient’s  health  becomes  gradually  impair- 
ed, he  loses  his  appetite  and  natural  rest  and 
sleep;  bis  pulse  is  small  and  frequent ; and  ob- 
stinate debilitating  diarrhoea,  and  profuse  noc- 
turnal sweats  ensue.  These  complaints  are, 
sooner  or  later,  followed  by  dissolution,  un- 
less the  constitution  he  relieved  in  time, 
either  by  the  amendment  orj  removal  of  the 
diseased  part.  In  different  patients,  how- 
ever, the  course  of  the  disease,  and  its  effects 
upon  the  system,  vary  considerably,  in  rela- 
tion to  the  rapidity  with  which  they  occur. 

Rheumatic  white-swellings,  or  inflamma- 
tions and  thickenings  of  the  synovial  mem- 
brane from  cold,  or  other  causes,  are  very 
distinct  diseases  from  the  scrofulous  distemper 
of  the  large  joints.  In  the  first,  the  pain  is 
said  never  to  occur  without  being  attended 
with  swelling.  Scrofulous  white-swellings, 
on  the  other  hand,  are  always  preceded  by  a 
pain,  which  is  particularly  confined  to  one 
point  of  the  articulation.  In  rheumatic 
cases,  the  pain  is  more  general,  and  diffused 
over  the  whole  joint. 

Mr.  Lloyd  thinks,  that  the  scrofulous 
white-swelling  may  be  distinguished  from  all 
other  diseases  of  the  joints,  by  its  being  at- 


155 

teuded  with  less  pain,  by  the  great  degree  of 
external  swelling  often  existing  for  a long 
time  before  matter  forms  in  the  cavity  of  the 
articulation,  and  by  the  swelling  being  but 
little  diminished  by  any  discharge  of  matter, 
which  may  take  place.  In  its  first  stage,  before 
the  interior  of  the  joint  is  affected,  it  may 
be  distinguished  from  primary  ulceration  of 
the  cartilages,  by  the  pain  not  being  much  in- 
creased by  motion.  The  grating,  produced 
by  moving  the  joint,  is  also  commonly  less  in 
this  disease,  than  in  ordinary  ulceration  of 
the  cartilages.  ( Lloyd  on  Scrofula , p.  142.) 
And,  according  to  Mr.  Brodie,  the  principal 
criterion  between  scrofulous  diseases  ofjoints 
and  the  primary  ulceration  of  cartilages,  is 
the  little  degree  of  pain  in  the  former  cases, 
which  is  never  much  complained  of  before 
an  abscess  forms,  not  particularly  severe, 

11  except  in  a very  few  instances,  and  in  the 
most  advanced  stage  of  the  disease,  when  a 
portion  of  ulcerated  bone  has  died,  and  ha- 
ving exfoliated,  so  as  to  lie  loose  in  the  cavi- 
ty of  the  joint,  irritates  the  parts,  with  which 
it  is  in  contact,  and  thus  becomes  a source  of 
constant  torment.”  (Brodie's  Pathol . Obs.  p , 
236.) 

It  seems  probable,  that  cases,  in  which  the 
cancellous  structure  of  the  bones  is  found 
quite  undiseased,  and  in  which  the  mass  of 
disease  is  confined  to  the  soft  parts,  are  not 
scrofulous  white-swellings.  Few  persons, 
who  have  attained  the  age  of  five  and 
twenty,  without  having  had  the  least  symptom 
of  scrofula , ever  experience,  after  this 
period  of  life,  a first  attack  of  the  white- 
swelling  of  the  strumous  kind.  The  general 
correctness  of  this  observation,  I believe,  is 
universally  admitted,  and  that  there  are  but 
few  exceptions  to  it  is  confirmed  by  the 
statements  of  Volpi,  of  Pavia.  However, 
Mr.  Lloyd  attended  a man,  who,  at  the  age 
of  between  forty  and  fifty,  died  of  phthisis 
and  had  at  the  time  a scrofulous  ankle, 
besides  several  abscesses  about  his  hip  and 
groin.  And  tbe  same  gentleman  met  with 
another  patient  upwards  of  forty  years  old, 
with  a similar  disease.  (On  Scrofula,  p. 
137.)  But,  if  these  patients  had  had  no  marks 
of  scrofula  in  their  younge-r  days,  a circum- 
stance not  specified,  they  form  deviations 
from  what  is  usual,  as  indeed  Mr.  Lloyd 
seems  to  admit.  My  own  observations  lead 
me  fully  to  concur  with  Mr.  Brodie,  that  the 
scrofulous  affections  of  the  joints,  so  fre- 
quent in  children,  are  rare  after  the  age  of 
thirty.  (Pathol.  Obs.  p.  229.)  All  cases,  in 
which  the  internal  structure  of  the  heads 
of  the  bones  becomes  softened,  previously 
to  the  affection  of  the  cartilages,  and  soft 
parts,  are  probably  scrofulous. 

Mr.  Russel  has  noticed  the  frequent  en- 
largement of  the  lymphatic  glands  in  the 
groin,  in  consequence  of  the  irritation  of  the 
disease  in  the  knee  ; but  he  justly  adds,  that 
this  secondary  affection  never  proves  long 
troublesome. 

When  the  bones  are  diseased,  the  head  of 
the  tibia  always  suffers  more  than  the  con- 
dyles of  the  thigh  bone.  (Russel.)  The 
articular  surface  of  the  femur  sometimes  has 


JOINTS. 


104* 


not  a single  rough  or  carious  point,  liolwith-  had  not  been  completely  cured.  K.  Lovveras 
.Standing  that  of  the  tibia  may  have  suffered  also  maintains  a similar  opinion.  Even 
a .great  deal.  The  cartilaginous  coverings  though  a few  persons  have  scrofulous 
of  the  heads  of  the  bones  are  generally  diseases  of  the  joints,  for  the  first  time,  after 
eroded  first  at  their  edges  ; and,  in  the  knee,  the  age  of  twenty-five,  this  occurrence,  like 
the  cartilage  of  the  tibia  is  always  more 
affected,  than  that  covering  the  condyles  of 
the  thigh-bone.  Indeed,  when  white-swell- 
ings have  their  origin  in  the  bones,  and  the 
knee  is  the  seat  of  the  disorder,  there  is  some 
ground  for  supposing,  that  it  is  in  the  tibia, 
that  the  morbid  mischief  usually  first  com- 
mences. 


the  first  attack  of  scrofula  after  this  period 
must  be  considered  as  extremely  uncommon. 
Another  argument,  in  favour  of  the  doc- 
trine, which  sets  down  particular  kinds  of 
white-swellings  as  scrofulous,  is  founded 
on  the  hereditary  nature  of  such  forms  of 
disease. 

Numerous  continental  surgeons,  particu- 
The  ligaments  of  the  knee  are  occasionally  larly  Petit  and  Brambilla,  have  noticed  how 
so  weakened,  or  destroyed  that  the  tibia  and  very  subject  the  English  are  both  to  scro- 
fibula  become,  more  or  less,  dislocated  back-  fula  and  white-swellings  of  the  joints, 
ward,  and  drawn  towards  the  tuberosity  of  We  every  day  see,  that  young  persons 
the  ischium,  by  the  powerful  action  of  the  afflicted  with  he  present  disease,  are  gene- 
flexor  muscles  of  the  leg.  It  is  observed  by  rally  manifestly  scrofulous  or  have  once, 
Mr.  Brodie,  that,  just  as  ulceration  of  the  been  so.  Frequently  enlarged  lymphatic 
cartilages  is  sometimes  followed  by  disloca-  glands  in  the  neck  denote  this  fatal  peculi- 
tion  of  the  hip,  so  we  find,  that  dislocation  arity  of  constitution  ; and  very  often  the 
of  the  knee  occasionally  takes  place  from  patients  are  known  to  have  descended  from 
the  same  cause.  Where  there  has  been  parents  who  had  strumous  disorders.  ( Crow - 
considerable  distention  of  the  soft  parts,  in  ther.)  The  disease  is  also  frequently  com- 
consequence  of  ulceration  extendiiigtothem,  bined  w ith  swelled  mesenteric  glands,  or 
the  head  of  the  tibia  is  gradually  drawn  back-  tuberculated  lungs.  {Brodie' s Pathol.  Obs , 
ward  by  the  action  of  the  flexor  muscles  ; p.  221.)  As  the  same  author  remarks,  since 
and  Mr.  Brodie  has  even  known  this  hap-  the  disease  depends  upon  a certain  morbid 
pen,  previously  to  the  formation  cf  any  condition  of  the  general  system,  it  is  not 
abscesses.  ( Pathol . Obs.p.  159.)  surprising,  that  we  should  sometimes  find  it 

I have  seen  a curious  species  of  white-  affecting  several  joints  at  the  same  time,  or 
swelling,  in  which  the  leg  could  be  bent  to  that  it  should  show  itself  in  different  joints 
each  side  to  a very  considerable  distance,  in  succession  ; attacking  a second  joint  after 
both  when  the  knee  was  extended  and  bent : it  has  been  cured  in  the  first,  or  after  the 
a state  implying  a preternatural  looseness,  first  has  been  removed  by  amputation.  (P. 
or  perhaps  a destruction,  of  the  ligaments  of  230.) 

the  articulation.  Besides  the  general  emblems  of  ascrofu- 

Scrofulous  w hite-swellings,  no  doubt,  lous  constitution,  which  will  be  noticed  in 
are  under  the  influence  of  a particular  kind  the  article  Scrofula , we  may  often  observe 
of  constitution,  termed  a scrofulous  or  slru-  a shining,  coagulated,  flaky  substance,  like 
mous  habit , in  which  every  cause,  capable  white  of  egg,  blended  with  the  contents  of 
of  exciting  inflammation,  or  any  morbid  and  such  abscesses  as  occur  in  the  progress  of 
irritable  state  of  a large  joint,  may  bring  on  the  disease.  This  kind  of  matter  is  almost, 
the  present  severe  disease.  On  the  other  peculiar  to  scrofulous  abscesses,  and  forms 
hand,  in  a man  of  a sound  constitution,  a another  argument  in  support  of  the  foregoing 
similar  irritation  would  only  induce  common  observations,  relative  to  the  share,  which 
healthy  inflammation  of  the  joint.  In  scro-  scrofula  frequently  has  in  the  origin  and 
fulous  habits,  it  also  seems  as  if  irritation  course  of  many  white-swellings, 
of  a joint  is  much  more  easily  produced,  Mr.  Brodie’s  experience  leads  him  to  be- 
than  in  other  constitutions  ; and  no  one  lieve,  that  in  scrofulous  cases,  the  chance 
can  doubt,  that  when  once  excited  in  the  of  ultimate  recovery  is  much  less,  where  the 
former  class  of  subjects,  it  is  much  more  disease  attacks  the  complicated  joints  of 
dangerous,  and  difficult  of  removal,  than  in  the  foot  and  hand,  than  when  it  is  situated 
other  patients.  in  larger  articulations  of  a more  simple  struc- 

The  doctrine  of  particular  white-swellings  ture.  ( Pathol . and  Surg.  Obs.  p.  235.) 
being  scrofulous  diseases,  is  supported  by  Treatment  of  White-swellings — In  practice 
many  weighty  reasons,  the  opinions  of  the  we  meet  with  all  these  cases  both  scrofu- 
most  accurate  observers,  and  the  evidence  lous  and  rheumatic,  in  two  very  opposite 
of  daily  experience.  Wiseman  (j Book  4,  states  ; sometimes  the  diseased  joint  is 
chap.  4)  calls  the  sphta  veniosa  a species  of  affected  with  a degree  of  acute  inflarama- 
scrofula,  and  tells  us,  that  infants  and  tion  ; in  other  instances,  the  malady  is 
children  are  generally  the  subjects  of  this  entirely  chronic. 

disease.  The  disorder  is  said  by  Severinus  The  imprudence  of  patients  in  walking 
to  be  exceedingly  frequent  in  young  sub-  about,  and  disturbing  the  diseased  part,  is 
jects.  Petrus  de  Marchettis  has  observed  very  olten  the  occasion  of  a degree  of  acute 
both  male  and  female  subjects  affected  with  inflammation,  which  is  denoted  by  the 
what  are  called  strumous  diseases  of  the  tenderness  of  the  joint  when  handled  by  the 
joints,  as  late  as  the  age  of  five  and  twenty  ; surgeon,  and  also  by  the  integuments  feel- 
bat  not  afterward,  unless  they  had  suffered  ing  hotter  than  those  of  the  healthy  knee, 
from  scrofula  before  that  period  of  life,  and  When  such  stab;  exists,  there  can  be  no 


JOINTS. 


<ioubt,  that  topical  bleeding,  fomentations, 
emollient  poultices,  or  cold  saturnine  lotions, 
are  means  which  may  be  eminently  service- 
able. The  antiphlogistic  regimen  is  now 
strongly  indicated.  Cooling  purges  of  the 
saline  kind  should  also  be  exhibited.  Blood 
may  be  taken  from  the  arm,  and  also  from 
the  diseased  part,  either  by  means  of  leeches 
or  cupping.  Mr.  Latta  gives  the  preference 
to  the  latter  method,  whenever  it  can  be 
employed  ; and  he  very  properly  remarks, 
that  little  advantage  can  be  expected  from 
topical  bleeding  of  any  kind,  unless  the 
quantity  of  blood  taken  away  be  consider- 
able. Ten  or  twelve  ounces  by  cupping 
shou.d  be  taken  away  at  a time,  and  the 
operation  should  be  repeated  at  proper 
intervals,  till  the  tenderness  and  heat  of  the 
skin  have  entirely  subsided.  When  leeches 
are  used,  the  number  ought  to  be  consider- 
able, and  Mr.  Latta  recommends  the  appli- 
cation of  at  least  sixteen  or  twenty.  ( System 
of  Surgery,  Vol.  1*  Chap.  6.) 

Although  antiphlogistic  means  are  judi- 
cious w hen  acute  inflammation  prevails ; 
yet  such  practitioners  as  lose  weeks  and 
months  in  the  adoption  of  this  treatment, 
are  highly  censurable.  While  the  skin  is 
hot  and  tender,  while  the  joint  is  affected 
with  very  acute  and  general  pain,  and  while 
the  patient  is  indisposed  with  the  usual 
symptoms  of  inflammatory  fever,  great 
benefit  may  be  rationally  expected  from  the 
above  plan.  When,  however,  the  disease 
is  truly  chronic,  different  plans  are  indicated. 
In  ordinary  cases  of  scrofulous  disease  of 
the  joints,  Mr.  Brodie  considers  topical 
bleeding  as  usually  unnecessary.  ( Pathol . 
and  Surgical  Obs.  p.  240.) 

It  is  quite  unnecessary  to  expatiate  on  the 
mode  of  treating  white-swellings,  compli- 
cated with  acute  inflammation,  particularly 
as  the  treatment  of  those  cases,  which  con- 
sist of  inflammation  of  the  synovial  mem- 
brane, has  been  already  noticed,  and  may 
be  said  to  be  applicable  to  other  forms  of 
white-swelling,  when  they  are  attended  with 
heat  and  inflammation  of  the  soft  parts. 
The  most  eligible  plan  of  arresting  the  mor- 
bid process  in  the  bones,  cartilages,  and  soft 
parts  surrounding  the  articulation,  and  the 
most  successful  method  of  lessening  the 
chronic  enlargement  of  the  joint,  are  the 
subjects  at  present  demanding  our  earnest 
investigation. 

The  works  of  Hippocrates,  Celsus,  Rhazes, 
Hieron,  Fabricius,  &,c.  compared  with 
modern  surgical  books,  will  soon  convince 
us,  that  the  practice  of  the  ancients,  in  the 
treatment  of  diseased  joints,  does  not  differ 
much  from  the  plan  now  pursued  by  the  best 
modern  surgeons.  Mr.  Crowtber  remarks, 
that  the  ancients  used  lot  al  and  general 
blood-letting,  the  actual  and  potential  cau- 
tery, with  vesicating  and  stimulating  applica- 
tions to  the  skin.  They  further  maintained, 
that  sores,  produced  by  these  means,  should 
have  their  discharge  promoted,  and  continued 
for  a considerable  length  of  time. 

With  regard  to  the  cases  which  Mr.  Brodie 
describes  as  depending  upon  a total  loss  of 


157 

the  natural  structure  of  the  synovial  mem  - 
brane, which  is  converted  into  a pulpy  sub- 
stance, one  quarter  or  one  half  of  an  inch 
in  thickness,  though  the  progress  of  the 
disease  may  be  somewhat  checked  by  rest 
and  cold  lotions,  it  is,  according  to  this  gen- 
tleman, incurable,  and  at  length  it  ends  in 
ulceration  of  the  cartilages,  abscesses,  he. 
When  there  is  considerable  pain,  in  conse- 
quence of  the  cartilages  beginning  to  ulce  - 
rate, partial  relief  may  be  derived  from 
fomentations  and  poultices  but  nothing- 
will  effect  a cure  Hence,  when  the  health 
begins  to  suffer,  he  considers  amputation  to 
be  indicated.  (Med.  Chir.  Trans,  p.  254.) 

When  white-swellings  are  accompanied 
with  ulceration  of  the  cartilages,  all  motion 
of  the  joint  is  extremely  hurtful.  Indeed,  as 
Mr.  Brodie  well  observes,  keeping  the  limb 
in  a state  of  perfect  quietude  is  a very  im- 
portant, if  not  the  most  important  circum- 
stance, to  be  attended  to  in  the  treatment. 
According  to  this  gentleman,  it  is  in  these 
cases,  in  which  ulceration  of  the  cartilages 
occurs  as  a primary  disease,  that  caustic 
issues  are  usually  productive  of  singular 
benefit ; but  he  deems  them  of  little  use  in 
any  other  diseases  of  the  joints.  He  thinks 
setons  and  blisters,  kept  open  with  savine 
cerate,  may  also  be  used  with  advantage. 
Bleeding  is  indicated  only  when,  from 
improper  exercise,  the  articular  surfaces 
are  inflamed,  and  there  is  pain  and  fever. 
Mr.  Brodie  asserts,  that  the  warm  bath  re- 
lieves the  symptoms  in  the  early  stage,  if 
it  does  not  stop  tiie  progress  of  the  disease ; 
but  he  condemns  plasters  of  gum  ammoniac, 
embrocations,  liniments,  and  frictions,  as 
either  useless  or  hurtful.  (S ee  Medico- Chir. 
Trans.  Vol.  6,  p.  332 — 334.) 

Topical  applications,  consisting  of  strong 
astringents  of  the  mineral  and  vegetable 
kingdom,  are  of  no  service  in  examples  of 
ulceration  of  the  cartilages,  or  of  the  scro- 
fulous form  of  the  disease,  though  they 
often  suffice  for  the  cure  of  some  mild  de- 
scriptions of  white-swelling,  depending 
upon  a thickening  of  the  synovial  mem- 
brane. A decoction  of  oak  bark,  containing 
alum,  was  recommended  by  Mr.  Russel. 

My  own  experience  will  not  allow  me  to 
say  any  thing  in  favour  of  electricity,  as  an 
application  for  the  relief  of  white-swellings; 
and  it  must  be  more  likely  to  do  harm  than 
good,  whenever  the  indication  is  to  lessen 
irritation. 

“ If  the  tumour  is  quite  indolent,  (says 
Richerand)  the  application  of  galvanism 
may  be  proposed;  it  is  not,  however,  ex- 
empt from  danger  . and,  on  one  occasion, 
where  I employed  it,  lancinating  pains  and 
swelling  of  the  joint  were  brought  on  by  it.s 
(JVosogr.  Chir.  T.  3,  p.  174,  Ed.  2.) 

Mr.  John  Hunter  had  confidence  m cicuta 
and  sea  bathing,  as  possessing  power  over 
many  scrofulous  diseases ; and  that  such 
diseases  of  the  joints  are  often  materially 
benefited  by  the  patient’s  going  to  the  sea- 
side and  bathing,  is  a fact  which  cannot  be 
doubted,  whatever  may  be  the  mode  of 
explaining  the  benefit  thus  obtained.  I fully 


JOINTS. 


138 


believe  that  sea-air  and  sea-bathing  have  a 
beneficial  influence  over  scrofulous  dis- 
eases of  the  joints ; but  probably  their 
effects  are  produced  on  the  part  through  the 
medium  of  tiie  constitution,  and  they  should 
only  be  recommended  as  an  auxiliary  plan, 
to  be  adopted  in  conjunction  with  other 
still  more  efficacious  measures. 

Every  one  is  well  acquainted  with  the 
efficacy  of  friction  in  exciting  the  action  of 
the  absorbents.  To  this  principle  we  are 
to  impute  the  great  benefit  which  arises 
from  what  is  termed  dry  rubbing , in  cases 
of  • white-swellings.  This  kind  of  friction  is 
performed  by  the  mere  hands  of  an  attend- 
ant, without  using  at  the  same  time  any 
kind  of  liniment,  or  other  application  what- 
soever, excepting  sometimes  a little  flour, 
or  powdered  starch,  arid  the  rubbing  is  con- 
tinued several  hours  every  day.  At  Oxford 
many  poor  persons  earn  their  livelihood  by 
devoting  themselves  to  this  species  of 
labour,  for  which  they  are  paid  a stipulated 
sum  per  hour.  This  practice,  however,  is 
chiefly  advantageous  in  the  chronic  stage 
of  while-swelling,  arisingfrom  inflammation 
of  the  synovial  membrane. 

I look  upon  all  mere  emollient  appiica- 
eations,  such  as  fomentations  and  poultices, 
as  quite  destitute  of  real  efficacy,  except 
when  great  pain  or  active  inflammation  is 
present,  and,  though  they  serve  to  amuse  the 
patient,  they  ought  not  to  be  recommended. 
That  surgeon,  who  merely  strives  to  please 
his  patient’s  fancy,  without  doing  any  real 
good  to  him.  in  regard  to  his  affliction,  may 
be  considered  as  doing  harm,  because  the 
semblance  of  something  being  done  too 
often  hinders  other  really  useful  steps  from 
being  pursued.  The  French  surgeons  are 
particularly  liberal  in  the  praises  which 
they  bestow  on  warm  emollient  remedies, 
poultices,  steam  of  hot  water,  fomentations, 
Lc.  and  they  adduce  instances  of  white- 
swellings  being  cured  in  this  manner.  But 
the  cases  to  which  they  refer  were  no  doubt 
mere  inflammations,  and  thickening  of  the 
synovial  membrane ; a disease  which  in 
general  readily  yields  to  several  other 
plans. 

The  only  method  of  treatment  which  my 
own  personal  experience  enables  me  to 
recommend  for  scrofulous  white-swellings 
in  a chronic  state,  consists  in  keeping  up  a 
discharge  from  the  surface  of  the  diseased 
joints.  The  opportunities  which  I have  had 
of  observing  the  effects  of  blisters,  and  caus- 
tic issues,  rather  incline  me,  however,  to 
prefer  the  former  to  the  latter.  1 have  seen 
great  good  derived  from  both  ; but  more 
from  blisters  than  the  other  kind  of  issue. 
There  are  instances  in  which  1 should 
employ  vesicating  applications;  there  are 
others  in  which  I should  prefer  making  an 
eschar  with  caustic.  In  particular  indivi- 
duals blisters  create  so  much  irritation, 
heat,  fever,  and  suffering,  that  a perseve- 
rance in  them  would  be  rashness. 

The  blister  should  always  be  large.  Many 
-urgeons,  instead  of  following  Mr.  Crow- 
ther’s  plan,  prefer  blistering,  first,  one 


side  of  the  joint,  and  then  the  other,  alter- 
nately, for  a considerable  length  of  time. 
“ Blisters  (says  Mr.  Latta)  maybe  put  upon 
each  side  of  the  patella,  and  ought  to  be  of 
such  a size  and  shape  as  to  cover  the  whole 
of  the  swelling  on  the  inside,  from  the 
hinder  part  of  the  joint,  at  the  .edge  of  the 
hollow  of  the  thigh,  to  the  edge  of  the 
patella,  over  the  whole  extent  of  the  swell- 
ing above  and  below.  As  soon  as  the  blister 
is  taken  off'  from  one  side,  it  ought  to  be 
applied  to  the  other,  and  thus  repeated, 
alternately,  until  both  swelling  and  pain  be 
completely  removed.  When  this  is  the 
case,  the  patient  ought  to  be  directed  to 
rub  the  joint  well  with  a liniment,  compo- 
sed of  half  an  ounce  of  camphor,  dissolved 
in  two  ounces  of  oil,  with  the  addition  of 
half  an  ounce  of  spir.  sal-ammon.  caust.  or, 
as  it  is  now  called,  liquor  ammoniaj.  This 
is  to  be  used  three  times  a day  ; and  in  this 
way,  (continues  Mr.  Latta)  l have  success- 
fully treated  many  cases  of  white-swellings.” 
(Syst.  of  Surgery , Vol.  1,  chap.  6.) 

In  the  beginning,  caustic  issues  are  even 
more  painful  than  blisters  ; but  they  after- 
ward become  more  like  indolent  sores,  and 
are  more  easily  kept  open  for  a length  of 
time  than  blisters.  Such  issues,  are  com- 
monly made  on  each  side  of  the  diseased 
joint,  and  of  about  the  size  of  a half  crown. 
The  manner  of  making  the  eschars,  and 
keeping  these  issues  open,  has  been  already 
explained.  (See  Issue.) 

The  question  has  been  contested,  among 
surgical  writers  and  practitioners,  whether 
blisters  and  issues  produce  benefit  upon  the 
principle  of  counter  irritation,  or  in  conse- 
quence of  the  discharge  which  they  occa- 
sion. They  probably  operate  efficaciously 
in  both  ways  ; for  there  is  no  doubt  that 
mere  rubefacients  possess  the  power  of 
rousing  the  action  of  the  absorbents,  and 
they  may  also  modify  the  vascu!ar>  action 
in  diseased  parts.  These  applications  can 
obviously  only  act  upon  the  principle  of 
counter  irritation,  and  they  have  not  been 
here  recommended  particularly  for  white- 
swellings,  because,  it  seems  to  me,  .that 
whenever  some  good  might  be  derived 
from  their  employment,  much  more  benefit 
might  always  be  obtained  from  blisters  and 
issues.  This  sentiment  is  confirmed  by  ex- 
perience, and  we  must,  therefore,  impute  a 
great  degree  of  efficacy  to  the  maintenance 
of  a purulent  discharge  from  the  vicinity  of 
the  diseased  part. 

Though  my  own  observations  have  led 
me  to  think  issues  and  blisters  as  efficient 
as  any  means  hitherto  devised  for  stopping 
the  progress  of  scrofulous  disease  of  the 
heads  of  the  bones,  l am  far  from  meaning 
to  say,  that  sucli  disease  can  generally  be 
stopped  by  these  or  any  other  remedies, 
local  or  general.  Mr.  Brodie  has  seldom 
known  any  benefit  derived  from  blisters  or 
stimulating  liniments;  nor  has  he  seen  the 
same  degree  of  good  produced  by  issues  in 
scrofulous  cases,  as  in  examples  of  primary 
ulceration  of  the  cartilages.  Cold  evnpo 
rating  lotions  in  the  early  stage  of  the  coir 


JOINTS. 


plaint ; peiTect  quietude  of  the  joint ; atten- 
tion to  the  patient’s  health  ; and  riding  in  a 
carriage  in  the  fresh  air ; are  the  means 
which  this  gentleman  particularly  recom- 
mends in  scrofulous  diseases  ot  the  joints. 
During  the  formation  of  abscesses,  he  ap- 
proves of  fomentations  and  poultices.  {Pa- 
thol. Ohs.  p.  242.) 

We  have  noticed  the  efficacy  of  friction 
in  exciting  the  action  of  the  absorbents,  by 
which  the  thickened  state  of  parts  around 
the  affected  joint  may  be  considerably  less- 
ened, and,  on  this  principle,  the  utility  of 
dry  rubbing  arises.  We  have  now  to  notice 
the  method  of  producing  the  same  effect  by 
pressure,  a plan  which  yet  seems  to  merit 
a more  extensive  trial.  I have  seen  in  St. 
Bartholomew’s  Hospital,  a few  cases  in 
which  the  swelling  of  the  joints  was  mate- 
riaPy  diminished,  by  encircling  the  morbid 
articulations  with  strips  of  adhesive  plaster, 
applied  with  moderate  tightness. 

A somewhat  similar  plan,  though  its  mo- 
dus operandi  is  differently  accounted  for, 
appears  also  to  have  been  tried  in  France. 

11  J’ai  dans  quelques  occasions  (says  Ri- 
cberand)  obtenu  les  plus  grands  avantages 
de  ^application  d’uri  taffetas  eire  autour  de 
l’articulation  tumefiee.  On  coupe  un  mor- 
ceau  de  cotte  etoffe,  assez  large  pour  enve- 
lopper  la  totalite  de  la  tumeur ; on  enduit 
les  bords  d’une  gomme  dissoute.  dans  le 
vinaigre,  et  susceptible  de  la  faire  adherer 
intimement  h la  peau ; on  l’applique  en- 
suite  de  maniere  que  toute  1’acces  soit  inter- 
dit  k Pair  entre  lui  et  les  teguments.  Lors- 
qu’au  bout  de  quelques  jours  on  leve  cet 
appareil,  on  trouve  la  peau  humide,  ramollie 
par  l’humeur  de  la  transpiration  condens6e 
en  goutelettes  a la  surface  interieure  du 
taffetas.  Dans  ce  procede,  on  fetablit  un 
espece  de  bain  de  vapeur  autour  de  l’articu- 
lation  malade.”  (Nosogr.  Chir.  T.  3 ,p  175, 
Edit.  2.) 

My  friend,  the  late  Mr.  Clement  Wilson 
Cruttwell,  of  Bath,  sent  me  a very  excel- 
lent case,  illustrative  of  the  efficacy  of 
treatment  by  pressure.  He  remarks  that, 
“ After  cupping  the  part,  and  endeavouring 
to  quiet  the  inflammation,  I used  blisters  ; 
but  they  excited  such  intolerable  pain,  and 
produced  so  great  a degree  of  swelling  and 
inflammation,  that  I was  under  the  necessity 
of  healing  them  immediately.  After  two 
months  strict  confinement  to  bed,  and  the 
use  of  leeches  and  refrigerant  washes,  the 
inflammation  having  again  subsided,  and 
the  pain  being  removed,  I again  ventured 
to  apply  one  small  blister,  and  again  a 
similar  attack  of  pain,  swelling,  and  inflam- 
mation was  produced.  The  joint  became 
distended  with  fluid,  of  which  it  had  always 
contained  a large  quantity,  and  the  irritation 
of  the  constitution  was  excessive.  By  the 
liberal  use  of  opium  I once  more  succeeded 
in  quieting  the  disturbance,  and,  convinced 
of  the  hazard  of  using  blisters  in  such  a sub- 
ject, I applied  moderate  pressure,  by  means 
of  a roller,  together  with  a wash,  containing 
a large  proportion  of  spirit,  in  order  to  keep 
up  a constant  evaporation.  Th#  skin,  which 


was  before  much  inflamed,  and  hard,  has  be 
come  natural  and  flaccid,  the  pain  has  cea 
sed,the  swelling  has  diminished,  and  I have 
every  prospect  of  effecting  a cure,  with 
the  preservation  of  tolerably  free  motion  in 
the  joint.” 

Mr.  Cruttwell,  in  a subsequent  letter,  in- 
formed ine,  that  this  case  got  completely 
well  by  the  treatment  with  pressure,  and 
had  remained  so  for  upwards  of  six  months 
under  full  and  free  exercise. 

This  example  dearly  evinces  the  impro- 
priety of  using  blisters  in  certain  constitu- 
tions. In  some  remarks,  annexed  to  the 
above  case,  Mq.  Cruttwell  expresses  his  con- 
viction, that  absolute  rest,  cold  applications, 
and  pressure,  would  succeed  in  very  many 
cases,  without  local  counter  irritation. 
Pressure,  he  adds,  succeeds  best  when  fluid 
is  effused,  and  the  disease  is  indolent ; but 
he  is  convinced  that  it  may  be  used  with 
advantage  in  later  stages,  when  abscesses 
have  formed,  and  sinuses  already  exist ; and 
he  reminds  me  how  very  serviceable  con- 
tinued pressure  is  to  the  scrofulous  finger- 
joints  of  children. 

The  good  effects  of  pressure  in  scrofulous 
cases  are  confirmed  by  the  observations  of 
Mr.  Brodie:  when,  says  he,  after  several 
abscesses  have  taken  place,  the  tendency 
to  suppuration  has  ceased,  and  the  swollen 
joint  has  become  diminished,  anchylosis  is 
probably  disposed  to  take  place.  At  this 
period,  pressure,  by  means  of  strips  of  linen . 
spread  with  soap-cerate,  or  some  other  mo- 
derately adhesive  plaster,  and  applied  in  a 
circular  manner  round  the  limb,  will  be 
productive  of  benefit.  ( Pathol . and  Sur z 
Obs.  p.  243.) 

When  the  knee  is  affected,  the  limb  1ms 
a tendency  to  become  permanently  bent 
It  must  undoubtedly  be  judicious  to  pre 
vent  this  position,  by  means  of  splints, 
which  will  also  serve  to  prevent  all  motion 
of  the  diseased  joint,  an  object  of  the  verv 
highest  importance.  Were  the  disease  to 
end  in  anchylosis,  the  advantage  of  having 
the  limb  in  a state  of  extension  need  scarcely 
be  mentioned. 

In  cases  which  commence  in  the  cancel- 
lous structure  of  the  heads  of  the  bones,  it 
seems  rational  to  combine,  with  the  local 
treatment,  the  employment  of  such  internal 
remedies  as  have  been  known  to  do  good  in 
other  scrofulous  diseases.  “ It  is  to  be  sup- 
posed, (as  Mr.  Brodie  observes)  that  the 
air  of  a crowded  city  must  be  more  or  less 
unfavourable  ; and  that  a residence  on  the 
seacoast  is  likely  to  be  more  beneficial  than 
a residence  in  the  country  elsewhere.  The 
patient  should  live  on  a nourishing,  but 
plain  diet ; he  should  be  in  the  open  air  in 
summer,  as  much  as  he  can,  without  exer- 
cising the  joint.  His  mode  of  life  should, 
in  all  respects,  be  regular  and  uniform,  " 
Mr.  Brodie  has  found  more  benefit  derived 
from  the  long  use  of  steel  medicines  than 
any  others,  suspending  their  use,  however, 
and  substituting  the  mineral  acids  for  them, 
when  the  formation  of  abscesses  excites 
febrile  action.  With  such  means,  in  child- 


ren,  he  combines  Ihe  occasional  exhibition  of 
mercurial  purgati  ves.  ( Pathol . Obs.  p.245.) 
In  a work,  whicfai  Mr.  Lloyd  has  just  pub- 
lished, it  is  assumed  as  a fact,  that,  in  scro- 
fula, there  always  is  more  or  less  disorder 
of  the  functions  of  the  digestive  organs,  and 
primarily  of  no  other  important  function. 
Hence,  the  regulation  of  diet,  the  state  of 
the  bowels,  and  the  hepatic  secretions,  is 
with  this  geritlema  n a principal  object ; and, 
with  the  latter  views,  he  employs,  after 
Mr.  Abernethy’s  plan,  five  grains  of  the 
blue  pill  every  night,  and  half  a pint  of 
decoct,  sars.  twice  a day,  with  opening 
medicines,  if  necessary,  to  procure  regular 
daily  evacuations.  When  acidity  of  the 
stomach  is  present,  he  gives  soda,  and, 
when  the  stomach  is  weak,  cinchona,  steel, 
and  mineral  acid<;.  (On  Scrofula,  p.  37, 
«!pc.)  However,  no  doubt  can  be  entertain- 
ed, that  these  means,  like  many  others,  have 
no  specific  power  over  scrofulous  diseases, 
and,  like  sea-air  and  sea-bathing,  only 
answer  by  sometimes  improving  the  state 
of  the  constitution.  In  the  local  treatment 
of  scrofulous  joints,  Mr.  Lloyd  commends 
quietude  of  the  limb,  which  is  to  Jbe  confi- 
ned in  a sling,  or  im  splints,  the  occasional 
resistance  of  inflammatory  action  by  leeches, 
and  a diminution  of  temperature  ; poul- 
tices when  abscesses  form  ; opening  such 
collections  of  matter  early;  and,  after  all 
irritation  has  ceased,  issues,  setons,  blisters, 
or  the  antimoniaj  ointment  ; or  compres- 
sion upon  Mr.  Baynton’s  plan.  (P.  152, 
fyc.)  With  respect  to  opening  these  ab- 
scesses early,  Mr.  Lloyd  differs  from  many 
excellent  surgeons,  especially  Dr.  Albers, 
who  distinctly  states,  that  it  is  generally 
best  to  allow'  them  to  burst  of  themselves. 
On  this  subject,  however,  great  diversity  of 
opinion  prevails,  and  Langenbeck  is  among 
the  advocates  for  making  an  early  opening. 
(Bibl.  B.  2,  p.  39.)  Hectic  symptoms  are 
those  which  we  commonly  have  to  palliate 
in  these  cases.  When  the  appetite  is  im- 
paired, and  the  stomach  will  bear  bark,  this 
medicine  should  be  given  with  the  aromatic 
confection.  Above  all  internal  remedies, 
opium  claims  the  highest  recommendation, 
as  it  at  once  tends  to  keep  off  and  relieve 
a debilitating  diarrhoea,  which  too  frequently 
prevails,  at  the  same  time  that  it  alleviates 
pain  and  procures  deep.  The  objection, 
made  against  its  exhibition  on  the  ground 
ihat  it  increases  perspiration,  seems  exceed- 
ingly frivolous,  when  the  above  important 
benefits  are  taken  into  consideration. 

Too  often,  however,  the  terrible  disease 
of  which  we  are  now  treating,  baffles  all 
human  skill  and  judgment,  and  the  unhappy 
patient’s  health  having  declined  to  the  lowest 
state,  he  is  necessitated  to  submit  to  ampu- 
tation, as  the  only  chance  of  preserving  life. 
It  has  been  explained  in  speaking  of  Amputa- 
tion, that  the  condition  of  the  patient’s 
health,  and  not  of  the  diseased  joint,  forms 
the  principal  reason  for  recurring  to  the 
severe  operation  of  removing  the  limb.  If 
the  patient’s  constitution  be  equal  to  a longer 
struggle,  no  man  can  pronounce  that  every 


prospect  oi  saving  the  limb  is  at  an  end. 
Many  diseased  joints,  apparently  in  the  most 
hopeless  condition,  frequently  take  a favour- 
able turn,  and,  after  all,  allow  the  limb  to 

be  saved. 

The  proposal  of  cutting  out  diseased 

joints,  has  been  considered  in  the  article 
Amputation. 

Disease  of  the  Hip-joint. — This  complaint 
is  very  analogous  in  its  nature  to  the  white- 
swelling  of  other  articulations.  In  the  same 
vay  ns  the  latter  disorder,  it  seems  probable, 
that  the  disease  of  the  hip  has  its  varieties, 
some  of  which  may  be  connected  with 
scrofu!a,  while  others  cannot  be  suspected 
to  have  any  concern  with  it.  Mr.  Brodie’s 
investigations  lead  him  to  believe,  however, 
that  ihe  disease  is  of  that  nature,  in  which 
the  first  change  is  disease  and  ulceration  of 
the  cartilages.  The  present  complaint  is 
most  frequently  seen  in  children  under  the 
age  of  fourteen  ; but,  no  age,  no  sex,  no 
rank,  nor  condition  of 'life  is  exempt  from 
the  possibility  of  being  afflicted,  so  that 
though  children  form  a large  proportion  of 
those  subjects,  who  are  attacked  ; yet  the 
number  of  adults,  and  even  of  old  persons,  is 
considerable. 

The  approach  of  the  disease  of  the  hip- 
joint  is  much  more  insidious,  than  that  of  a 
white-swelling.  Some  degree  of  pain  always 
precedes  the  latter  affection  ; but,  the  only 
forerunner  of  the  former  is  frequently  a slight 
weakness,  and  limping  of  the  affected  limb. 
These  trivial  symptoms  are  very  often  not 
sufficiently  urgent  to  excite  much  notice, 
and,  when  observed  by  superficial  practition 
ers,  are  commonly  neither  understood,  nor 
treated  according  to  the  dictates  of  surgical 
science.  As  there  is,  also,  sometimes  an 
uneasiness  in  the  knee,  w'hen  the  hip  is 
affected,  careless  practitioners  frequently 
mistake  the  seat  of  disease,  and  I have  man) 
times  seen  patients,  on  their  entrance  into 
an  hospital,  having  a poultice  on  their  knee, 
while  the  wrong  state  of  the  hip  was  not  at 
all  suspected. 

This  mistake  is  extremely  detrimental  to 
the  patient,  not  on  account  of  any  bad  effect, 
resulting  from  the  applications  so  employed  ; 
but,  because  it  is  only  in  the  incipient  period 
of  the  complaint,  that  a favourable  prognosis 
can  be  made.  In  this  stage  of  the  disease, 
mere  rest  and  repeated  topical  bleeding,  will 
do  more  good  in  the  course  of  a fortnight, 
than  large  painful  issues  will  afterward 
generally  accomplish  in  the  long  space  of 
a twelvemonth. 

The  symptoms  of  the  disease  of  the  hip- 
joint,  when  only  looked  for  in  the  situation 
of  that  articulation,  arc  not  very  obvious  to 
the  surgical  examiner.  Though,  in  some 
instances,  the  attention  of  the  surgeon  is 
soon  called  to  the  right  situation  of  the 
disease,  by  the  existence  of  a fixed  pain 
behind  the  trochanter  major  ; yet,  it  is  too 
often  the  case,  that  mere  pain  about  an 
articulation,  entirely  destitute  of  visible  en 
largcment  and  external  alteration  ot  colour, 
is  quite  disregarded,  as  a complaint  of  no 
importance  in  young  subjects,  and  as  a TO  or*' 


JOINTS. 


161 


rheumatic,  or  gouty  affection,  in  adults. 
Patients  frequently  complain  of  their  most 
painful  sensations  being  in  the  groin,  and  all 
accurate  observers  have  remarked,  that,  in 
the  hip  disease,  the  pain  is  not  confined  to 
the  real  seat  of  disease,  but  shoots  down 
the  limb,  in  the  course  of  the  vastus  exlernus 
muscle  to  the  knee. 

The  pain,  says  Mr.  Brodie,  is  at  first 
trifling,  and  only  occasional  ; but,  it  after- 
ward becomes  severe  and  constant.  It  re- 
sembles a good  deal  the  pain  of  rheumatism, 
since  it  often  has  no  certain  seat.  As  the 
disease  advances,  the  pain  becomes  exceed- 
ingly severe,  particularly  at  night,  when  the 
patient  is  continually  roused  from  his  sleep 
by  painful  startings  of  the  limb.  Sometimes 
he  experiences  a degree  of  relief  in  a parti- 
cular position  of  the  joint,  and  no  other.  As 
the  pain  increases  in  intensity,  it  becomes 
more  fixed.  In  the  greater  number  of  in- 
stances, it  is  referred  both  to  the  hip  and 
knee,  and  the  pain  in  the  latter  joint  is  gene- 
rally the  most  severe.  At  other  times,  there 
is  pain  in  the  knee,  and  none  in  the  hip.  A 
boy,  in  St.  George’s  hospital,  complained  of 
pain  in  the  inside  of  the  thigh  near  the 
middle  ; and  another  patient  referred  the 
pain  to  the  sole  of  the  foot.  Wherever  the 
pain  is  situated,  it  is  aggravated  by  the 
motion  of  the  joint,  and  especially  by  what- 
ever occasions  pressure  of  the  ulcerated 
cartilaginous  surfaces  against  each  other. 
(Brodie's  Pathol.  Obs.  p.  139.) 

The  early  symptoms  of  disease  in  the  hip- 
joint  are  only  strongly  delineated  to  such 
practitioners,  as  have  acquired  the  necessary 
information  relative  to  this  part  of  surge- 
ry, from  careful  study  and  extensive  experi- 
ence. 

We  shall  next  trace  those  characters  of 
the  present  disease,  which  serve  to  denote 
its  existence. 

It  is  a curious  circumstance,  that  when 
the  functions  of  a limb  are  obstructed  by  dis- 
ease, the  bulk  of  the  member  generally 
diminishes,  and  the  muscles  become  emacia- 
ted. Nearly  as  soon  as  the  least  degree  of 
lameness  can  be  perceived,  the  leg  and  thigh 
have  actually  wasted,  and  their  circumfer- 
ence has  diminished 

If  the  surgeon  make  pressure  on  the  front 
of  the  joint,  a little  on  the  outside  of  the 
femoral  artery,  after  it  has  descended  below 
the  os  pubis,  great  pain  will  be  experienced. 

“ Soon  after  the  commencement  of  the 
complaint,  (as  Mr.  Brodie  remarks,)  the  hip- 
joint  is  found  to  be  tender,  whenever  pres- 
sure is  made  on  it  either  before  or  behind. 
The  absorbent  glands  become  enlarged,  and 
occasionally  there  is  a slight  degree  of  gene- 
ral tumefaction  in  the  groin.”  The  same 
gentleman  has  also  adverted  to  the  curious 
circumstance  of  there  being  in  some  cases  a 
tenderness  of  the  parts,  to  which,  though  not 
diseased  themselves,  the  pain  is  referred 
from  sympathy  with  the  disease  of  the  hip. 
This  occurrence  he  has  observed  in  the  knee 
several  times,  and  in  one  instance  in  the 
course  of  the  peroriaeal  nerve.  He  has  also 
seen  a slight  degree  of  puffv  swelling  of  the 
Vol.  II.  ’ 21 


knee  in  a case,  in  which  pain  was  referred 
to  this  joint,  in  consequence  of  disease  of 
the  hip.  (P.  142,  143.) 

The  limping  of  the  patient  is  a clear  proof, 
that  something  about  the  limb  is  wrong,  and, 
if  such  limping  cannot  be  imputed  to  disea- 
sed vertebrae,  or  some  recent  accident,  and 
if,  at  the  same  time,  the  above-mentioned 
emaciation  of  the  limb  exists,  there  is  great 
cause  to  suspect,  that  the  hip  is  diseased, 
particularly  when  the  pain  is  augmented  by 
pressing  the  tront  of  the  acetabulum. 

Diseased  vertebrae,  perhaps,  always  pro- 
duce paralytic  affection  of  both  legs  at  once, 
and  they  do  not  cause  painful  sensations 
about  the  knee,  as  the  hip  disease  does. 

The  increased  length  of  the  liinb,  a symp- 
tom that  has  been  noticed  by  all  practition- 
ers since  De  Haen,  is  a very  remarkable  and 
curious  occurrence,  in  tue  early  stage  of  the 
present  disease.  This  symptom  is  easily  de- 
tected by  a comparison  of  the  condyles  of 
the  os  femoris,  the  trochanter  major,  and 
malleoli,  of  the  diseased  limb,  with  those 
parts  of  the  opposite  member,  taking  care 
that  ihe  patient’s  pelvis  is  evenly  situated. 
The  thing  is  the  more  striking,  as  the  in- 
creased length  of  the  member  is  frequently 
as  much  as  four  inches.  The  rationale  of 
this  fact,  John  Hunter  used  to  explain  by 
the  diseased  side  of  the  pelvis  becoming 
lower  than  the  other.  (Croivther,  p.  266.) 
The  same  thing  bad  also  been  noticed  by 
Falconer,  (On  fschias,  p.  9)  long  before  the 
period,  when  Mr.  CrowtUer  printed  his  se- 
cond edition. 

It  is  easy  (says  Mr.  Brodie,)  to  understand 
how  the  crista  of  one  ilium  becomes  visibly 
depressed  below  the  level  of  the  other,  when 
the  position  is  remembered,  in  which  the 
patient  places  himself  when  he  stands  erect. 
u He  supports  the  weight  of  his  body  upon 
the  sound  limb,  the  hip  and  knee  of  which 
are  in  consequence  maintained  in  the  state 
of  extension.  At  the  same  time,  the  oppo- 
site limb  is  inclined  forward,  and  the  foot 
on  the  side  of  the  disease  is  placed  on  the 
ground  considerably  anterior  to  the  other, 
not  for  the  purpose  of  supporting  the  super- 
incumbent weight,  but  for  that  of  keeping 
the  person  steady,  and  preserving  the  equi- 
librium. Of  course,  this  cannot  be  done, 
without  the  pelvis  on  the  same  side  being 
depressed.  The  inclination  of  the  pelvis  is 
necessarily  attended  with  a lateral  curvature 
of  the  spine,  and  hence  one  shoulder  is 
higher  than  the  other,  and  the  whole  figure 
in  some  degree  distorted.”  ( Pathol . Obs.  p. 
146.)  These  effects,  says  Mr.  Brodie,  are  in 
general  all  removed  by  the  patient’s  lying  in 
bed  a few  weeks,  except  when  the  deformity 
has  continued  a long  time  in  a young  growing 
subject. 

In  justice  to  the  memory  of  the  late  res- 
pected Dr.  Albers,  of  Bremen,  I ought  here 
to  mention,  that  he  appears  in  his  work  on 
Coxalgia,  to  have  firs!  pointed  out  the  de- 
formity of  the  spine  in  this  disease,  and  the 
reason  of  such  change,  the  tenor  of  his  ob- 
servations upon  this  point  agreeing  with 
those  subsequently  made  bv  Mr.  Brodie 


JOINTS. 


m 


An  appearance  of  elongation  of  the  limb 
is  not  exclusively  confined  to  the  early  stage 
of  the  morbus  coxarius  : it  may  attend  other 
4 eases.  I remember  seeing  in  one  of  the 
wards  of  St.  Bartholomew’s  Hospital,  a little 
girl,  with  a diseased  knee,  whose  pelvis  was 
considerably  distorted  in  this  manner,  so 
that  the  limb  of  the  same  side  appeared 
much  elongated  Her  hip- joint  was  quite 
Sound.  This  case  was  pointed  out  to  Mr. 
Lawrence  and  myself  by  Mr.  Cother,  of 
Gloucester. 

Vo!pi,  Albers,  and  several  other  foreign 
vrritex’s,  point  out  the  fact,  that  the  early 
stage  of  this  disease  is  sometimes  attended 
with  an  appearance  of  elongation,  sometimes 
with  that  of  a shortening  of  the  limb.  An 
explanation  of  the  circumstance  is  given  by 
Mr  Brodie,  as  follows  : “ In  a few  cases, 
where  the  patient  is  in  the  erect  position,  it 
may  be  observed,  that  the  foot,  which  be- 
longs to  the  affected  limb,  is  not  inclined 
more  forward  than  the  other,  but  the  toes 
only  are  in  contact  with  the  ground,  and  the 
heel  raised,  at  the  same  time  that  the  hip 
and  knee  ave  a little  bent.  This  answers  to 
the  patient  the  same  purpose  of  enabling  him 
to  throw  the  weight  of  his  body  on  the  other 
foot ; but  it  produces  an  inclination  of  the 
pelvis  in  the  opposite  direction.  The  crista 
of  the  ilium  is  higher  than  natural,  and  there 
is  an  apparent  shortening,  instead  of  elonga- 
tion of  the  limb  on  the  side  of  the  disease.” 
( Pathol . and  Surg.  Obs.  p.  147.) 

Mr.  Ford  has  very  accurately  called  the 
attention  of  surgeons  to  the  alteration,  with 
respect  to  the  natural  fulness  and  convexity 
of  the  nates,  that  part  appearing  flattened, 
which  is  usually  most  prominent.  I he  glu- 
tasus  raagnus  becomes  emaciated,  and  its 
edge  no  longer  forms  so  bold  a line,  as  it  na- 
turally does  at  the  upper  and  back  part  of 
the  thigh,  in  the  sound  state  of  the  limb. 

Although  this  symptom,  in  combination 
with  others,  is  of  importance  to  be  attended 
to,  it  has  been  explained  by  Mr.  Brodie,  that 
{C  it  is  not  in  itself  to  be  regarded , as  a certain 
diagnostic  mark  of  disease  in  the  hip  ; since, 
in  its  early  stage,  this  symptom  is  wanting  ; 
and  it  is  met  with  in  other  diseases,  in  which 
the  muscles  in  the  neighbourhood  of  the  hip 
are  not  called  into  action,  although  the  joint 
itself  is  unaffected.  (See  Medico- Chir.  Trans. 
Vol.  6,  p.  322.) 

Though  there  may  be  more  pain  about 
the  knee  than  the  hip,  at  some  periods  of 
the  malady  in  its  incipient  state,  yet  the 
former  articulation  may  be  bent  and  extend- 
ed, without  any  increase  of  uneasiness  ; but, 
the  os  femoris  cannot  be  moved  about, 
without  putting  the  patient  to  immense  tor- 
ture. 

The  patient  soon  gets  into  the  habit  of 
bearing  the  weight  of  his  body  chiefly  upon 
the  opposite  limb,  while  the  thigh  of  the 
affected  side  is  bent  a little  forward,  that  the 
ground  may  only  be  partially  touched  with 
the  foot.  This  position  is  found  to  be  the 
most  comfortable,  and  every  attempt  to 
extend  the  limb  occasions  a*i  increase  of 
pfttn, 


This  is  the  first  stage  of  the  disease, 
or  that  which  is  unaccompanied  with  sup  pu- 
ration. 

The  symptoms  which  precede  the  forma- 
tion of  pus,  vary  in  different  cases,  accord- 
ing as  there  is  acute,  or  chronic  inflamma- 
tion present.  When  the  diseased  joint  is 
affected  with  acute  inflammation,  as  gene- 
rally happens,  the  surrounding  parts  become 
tense  and  extremely  painful ; the  skin  is 
even  reddish  ; and  symptoms  of  inflamma- 
tory fever  prevail.  When  the  severity  of 
the  pain  abates,  a swelling  occurs  in  the 
vicinity  of  the  joint,  and  a pointing  quickly 
follows.  In  this  stage  startings  and  catchings 
during  sleep  are  said  to  be  among  the  most 
certain  signs  of  the  formation  of  matter. 
“ The  shortening  of  the  limb,”  says  Mr. 
Brodie,  “ which  usually  takes  place  in  the 
advanced  stage  of  the  disease,  is  usually, 
but  not  always  the  precursor  of  abscess.  The 
formation  of  matter  is  also  indicated  by  an 
aggravation  of  the  pain  ; by  more  frequent 
spasms  of  the  muscles,  by  a greater  wasting 
of  the  whole  limb,  and  by  the  circumstance 
of  the  thigh  becoming  bent  forward,  and 
being  incapable  of  extension,”  and  by  the 
pulse  becoming  quick,  the  tongue  furred, 
and  the  whole  system  being  in  a state  of  pre- 
ternatural excitement.  f\  The  abscess  usu- 
ally shows  itself  in  the  form  of  a large  tu- 
mour over  the  vastus  externus  muscle ; some- 
times on  the  inside  of  the  thigh,  near  the 
middle  ; and  occasionally  two  or  three  ab- 
scesses appear  in  different  parts,  and  burst  in 
succession.”  ( Brodie's  Pathol.  Obs.  p.  152.) 

We  have  noticed  the  commonly  lengthen- 
ed-state  of  the  limb,  in  the  first  periods  of 
the  hip  disease.  This  condition  is  not  of 
very  long  duration,  and  is  sooner  or  later 
succeeded  by  a real  shortening  of  the  affect- 
ed member.  The  foot  may  be  turned  in- 
wards ; but,  as  Mr.  Brodie  observes,  if  left 
to  itself,  it  is  generally  turned  outwards.  In 
other  cases,  the  limb  is  shortened  ; the  thigh 
is  bent  forwards  ; the  toes  are  turned  inwards, 
and  do  not  admit  of  being  turned  outwards  ; 
(Pathol.  Obs.p.  148;)  and  all  the  symptoms 
of  a luxation  of  the  thigh  upwards  and  out- 
wards may  be  observed,  the  head  of  the  bone, 
indeed,  being  actually  drawn  into  the  external 
iliac  fossa,  and  carried  betwixt  the  os  inno- 
minatum  and  glutaeus  minimus,  which  is 
raised  up  by  it.  (See  Richerand  JYosogr. 
Chir.  T.  3,  p.  171,  172,  Ed.  2.) 

When  the  retraction  is  very  considerable, 
it  arises  from  nothing  less  than  an  actual  dis- 
location of  the  head  of  the  thigh-bone,  in 
consequence  of  the  destruction  of  the  car- 
tilages, ligaments,  and  articular  cavity.  This 
retraction  sometimes  comes  on  long  before 
any  suppuration  takes  place  The  head  of 
the  bone  is  sometimes  dislocated,  and  the 
disease  terminates  in  anchylosis,  without 
any  abscess  whatever.  However,  if  sup- 
puration has  not  taken  place,  Mr.  Brodie  be- 
lieves, it  rarely  happens,  that  the  limb,  after 
the  cure,  does  not  regain  its  natural  degree 
of  mobility.  (See  Med.  Chir.  Trans.  Vol.  6, 
p.  325.) 

It  is  worthy  of  particular  notice,  that  the 


JOINTS. 


163 


head  of  the  hone  is  always  luxated  upwards 
and  outwardB  ; and  the  only  exception  to 
this  observation,  upon  record,  is  a case  re- 
lated by  Cocchi,  in  which  a spontaneous  dis- 
location of  the  thigh-bone,  as  it  is  termed, 
happened  upwards,  forwards,  and  a little 
inwards.  (See  LeviilU,  JYouvelle  Doctrine 
Chir.  T.  3.  p.  695.)  On  a egalement  vu  la 
tete  du  femur  luxee  en  dedans  et  en  bas,  et 
placee  sur  le  trou  obturateur,  mais  cette 
mode  de  deplacement  consecutif, dans  lequel 
le  membre  est  alonge,  est  infiniment  rare. 
(Richerand,  JYosogr.  Chir  T 3,  p.  172.) 

The  hip  disease  generally  induces  hectic 
symptoms,  after  it  has  existed  a certain  time. 
In  some  subjects,  such  symptoms  soon  come 
on  ; in  others,  the  health  remains  unaffected 
a very  considerable  time. 

“ The  health  of  the  patient  (says  Mr.  Bro- 
die)  usully  suffers, even  before  abscesses  have 
formed,  from  the  want  of  exercise  pain,  and 
particularly  from  the  continued  disturbance 
of  his  natural  rest.  I recollect  no  instance 
of  an  adult,  in  w hom  abscesses  had  formed, 
and  who  did  not  ultimately  sink  exhausted 
by  the  hectic  symptoms  which  these  indu- 
ced. Children  may  recover  in  this  ultimate 
stage  of  the  disease  ; but,  seldom  without  a 
complete  anchylosis  of  the  joint.”  (Med. 
Chir.  Trans.  Vol  A i,  loco  cit.) 

When  abscesses  of  the  above  description 
burst,  they  contir.ue,  in  general,  to  emit  an 
unhealthy  thin  kind  of  matter  for  a long 
time  afterward. 

With  respect  to  the  morbid  anatomy  of 
the  disease  in  its  incipient  state,  until  lately 
little  was  known.  A few  years  ago  tw  o dis- 
sections related  by  Mr.  Ford  were,  perhaps, 
the  only  ones  throwing  light  upon  this  point. 
In  one,  there  was  a tea-spoonful  of  matter 
in  the  cavity  of  the  hip  joint.  The  head  of 
the  thigh-bone  was  a little  inflamed,  tfce  cap- 
sular ligament  a little  thickened,  and  the 
ligamentum  teres  united  in  its  natural  way 
to  the  acetabulum.  The  cartilage  lining  the 
cotyloid  cavity  was  eroded  in  one  place, 
with  a small  aperture,  through  which  a probe 
might  be  passed,  underneath  the  cartilage, 
into  the  internal  surface  of  the  os  pubis  on 
one  side,  and  on  the  other,  into  the  os  iscliii  ; 
the  opposite,  or  external  part  of  the  os  in- 
uominatum  showing  more  appearance  of 
disease,  than  the  cotyloid  cavity.  In  the 
other  instance,  the  disease  was  more  advan- 
ced. These  examples  are  important,  inas- 
much as  they  prove  that  what  is  commonly 
called  the  disease  of  the  hip  joint,  primarily 
affects  the  cartilages,  ligaments,  and  bones, 
and  not  the  surrounding  soft  parts,  as  De 
Haen  and  some  others  would  lead  one  to 
believe. 

As  the  disorder  advances,  the  portions  of 
the  os  ischium,  os  ilium,  and  os  pubis,  com- 
posing the  acetabulum,  together  with  the  in- 
vesting cartilage,  and  synovial  gland,  are 
destroyed.  The  cartilage  covering  the  head 
of  the  os  femoris,  the  ligamentum  teres,  and 
capsule  of  the  joint,  suffer  the  same  fate, 
and  caries  frequently  affects  not  only  the 
adjacent  parts  of  the  ossa  innominata,  but 
also  the  head  and  neck  of  the  thigh- 


bone. The  bones  of  the  pelvis,  however, 
are  always  more  diseased  than  the  thigh- 
bone, a fact  which  displays  the  absurdity  of 
ever  thinking  of  amputation  in  these  cases. 
Mr.  Ford  observes,  “In  every  case  of  dis 
ease  of  the  hip  joint,  which  has  terminated 
fatally,  I have  remarked,  that  the  os  inno- 
minatum  has  been  affected  by  the  caries  in 
a more  extensive  degree,  than  the  thigh  bone, 
itself’  (Observations  on  the  Disease  oj  the 
H>p  joint,  p.  107.) 

Sometimes  how  ever,  the  head  and  neck 
of  the  thigh-bone  are  annihilated, as  well  as 
the  acetabulum. 

Mr.  Brodie  has  had  opportunities  of  dis- 
secting some  diseased  hip  joints  both  in  the 
incipient  and  advanced  stage  of  the  com- 
plaint. From  his  observations,  it  appears ; 
1st.  That  the  disease  commences  w ith  ulcera- 
tion of  the  cartilages,  generally  that  of  the 
acetabulum  first,  and  that  of  the  femur  after- 
ward. 2.  That  the  ulceration  extends  to 
the  bones,  which  become  carious  ; the  head 
of  the  femur  diminishing  in  size,  and  the 
acetabulum  becoming  deeper  and  wider. 
3.  That  an  abscess  forms  in  the  joint,  w hick 
after  some  time  makes  its  w ay  by  ulceration, 
throng! i the  synovial  membrane  and  capsu- 
lar ligament,  into  the  thigh  and  nates,  or  even 
through  the  bottom  of  the  acetabulum  into 
the  pelvis.  Mr.  A.  Cooper  showed  Mr.  Bro- 
die two  specimens,  in  which  the  abscess  had 
burst  into  the  rectum.  4.  In  consequence 
of  the  abscess,  the  synovial  membrane  and 
capsular  ligament  become  inflamed  and 
thickened.  The  muscles  are  altered  in 
structure ; sinuses  are  formed  in  various 
parts,  and,  at  last,  all  the  soft  parts  are 
blended  together  in  one  confused  mass, 
resembling  the  parietes  of  an  ordinary 
abscess.  (Brodie,  in  Medico-Chir.'  Trans. 
Vol.  4,p.  246,  247.) 

Such  are  the  beginning  and  progress  of 
the  ordinary  disease  of  the  hip  joint;  but, 
it  is  admitted  by  Mr.  Brodie,  that  there  are. 
other  scrofulous  cases,  in  which  the  mis- 
chief begins  in  the  cancellous  structure  of 
the  bones,  and  also  other  instances,  which 
consist  in  chronic  inflammation  and  abscesses 
of  the  soft  parts  in  the  neighbourhood  of 
the  hip.  (Op.  cit.  Vol  6,  p.  326.) 

External  violence;  lying  down  on  the 
damp  ground  in  summertime  ; and  all  kinds 
of  exposure  to  damp  and  cold;  are  the 
causes  to  which  the  disease,  has  sometimes 
been  referred  No  doubt,  scrofula  has, 
frequently,  some  concern  in  its  origin  ; but, 
often,  no  rational  cause  is  assignable  for  the 
complaint. 

Treatment  of  the  disease  of  the  Hip  Joint. 
— The  writings  of  Hippocrates,  Celsus,  C&- 
lius  Aurelianus,  Hi c.  prove,  that  the  ancients 
treated  the  present  disease  much  in  the  same 
way,  as  it  is  treated  by  the  moderns.  Form- 
ing an  eschar,  and  keeping  the  sore  open  ; 
topical  bleeding ; cupping  ; fomenting  the 
part,  &.c.  were  all  proceedings  adopted  in  the 
earliest  periods  ot  surgery.  Drs.  Charlton, 
Oliver,  and  Falconer,  have  extolled  Bath 
w ater,  as  a most  efficacious  application  to 
diseased  Jiip  joints,  previ«us  to  the  suppura^ 


164  joints; 

live  stage.  However,  had  not  their  accounts  in  children,  and  even  in  grown-up  persons, 
been  exaggerated,  all  patients  of  this  kind  when  the  complaint  is  recent,  they  agree  in 
would  long  ago  have  flocked  to  Bath,  and  thinking  blisters  capable  of  affording  com- 
the  surgeons  in  other  places  would  never  plete  relief.  Mr.  Brodie  states,  that  in  these 
have  had  further  occasion  to  adopt  a more  cases  they  are  more  efficacious  when  kept 
painful  mode  of  treatment.  The  plan  pur-  open  with  the  savine  ointment,  than  repeat- 
sued  at  Bath,  is  to  put  the  patient  in  a warm  edly  applied.  With  respect  to  issues,  he  ac- 
bath,  two  or  three  times  a week,  for  fifteen  knowledges,  that  behind  the  great  trochan- 


or  twenty-five  minutes. 

In  the  first  stage  of  coxalgia,  the  late  Dr. 
Albers,  however,  had  a very  high  opinion  of 
warm  bathing,  fomentations  with  decoctions 
of  herbs,  and  of  bathing  in  mineral  waters 
and  the  sea.  But,  though  he  commenced 
the  treatment  with  the  frequent  use  of  the 
warm  hath,  and  continued  the  plan  a long 
while,  it  is  to  be  remarked,  that  he  also  com- 
bined with  it  an  issue.  After  the  patient 
had  been  in  the  bath  a period  not  exceeding 
half  an  hour,  he  was  taken  out,  and  his  wrholc 
body  well  rubbed  with  flannel.  It  appears 
to  me,  that  one  objection  to  this  practice 
must  be  the  considerable  disturbance  occa- 
sioned by  moving  the  patient  in  this  manner 
every  morning ; for  if  it  be  true,  that  most 
of  these  diseases  commence  in  the  cartilages 
of  the  joint,  all  motion  of  the  limb  must  be 
particularly  injurious. 

In  the  early  period  of  the  disease,  entire 
rest,  the  application  of  fomentations,  and 
the  employment  of  topical  bleeding,  parti- 
cularly cupping,  are  highly  proper.  Such 
practice,  also,  is  invariably  judicious,  when- 
ever the  case  is  attended  with  symptoms  of 
acute  inflammation.  When  the  fomenta- 
tions are  not  applied,  the  lotio  aquae  lithar- 
gyri  acetati  may  be  used. 

This  method  of  treatment  ought  never  to 
be  employed,  unless  manifest  signs  of  active 
inflammation  be  present.  When  no  such 
state  exists,  this  plan  can  only  be  regarded 
as  preventing  the  adoption  of  a more  effica- 
cious one,  and,  therefore,  censurable. 

“Where  the  cartilages  of  the  hip  are  ul- 
cerated (says  Mr.  Brodie,)  the  patient  should 
in  the  first  instance,  be  confined  to  a couch, 
if  not  to  his  bed  . and  if  the  disease  is  far 
advanced,  the  limb  should  be  supported  by 
pillows  properly  disposed,  so  as  to  favour 
the  production  of  an  anchylosis,  by  allow- 
ing it  to  vary  as  little  as  possible  from  one 
position.’  (S ee Medico- Chir.  Transs.  Vol.6,p. 
335.) 

Quibus  diuturno  dolore,  says  Hippocrates,, 
ischiadico  vexalis  roxa  excidil , iis  femur  con- 
tabescit  et  claudicant , nisi  urdntnr.  Forming 
an  eschar,  or  issue,  is  the  most  efficacious 
plan  of  treating  the  disease  even  now 
known.  A caustic  issue  seems  to  me  more 
beneficial  than  a blister.  The  depression, 
just  behind  and  below  the.  trochanter  major, 
is  the  situation  in  which  surgeons  usually 
make  the  issue,  and  ihe  size  of  the  eschar 
should  be  nearly  as  large  as  a crown-piece. 
It  is  generally  necessary  to  keep  the  issue 
open  a very  long  time.  When  the  thigh-bone 
is  dislocated,  and  the  patient  survives,  the 
case  mostly  ends  in  anchylosis. 

For  the  cure  of  the  disease  ia  adults, 
Mr-  Brodie  and  Dr.  Albers  have  also  ex- 
pressed a preference  to  caustic  issues ; but 


ter  is  the  most  convenient  place  for  them  ; 
but  be  believes  that  they  have  more  effect, 
when  made  on  the  outside  of  the  joint  on 
the  front  edge  of  the  tensor  vaginae  femoris 
muscle.  Instead  of  keeping  the  issue  open 
with  beans,  Mr.  Brodie  has  found  it  a more 
effectual  practice  to  rub  the  sore,  two  or 
three  times  a week,  with  the  potassa  fusa, 
or  sulphate  of  copper.  In  particular  cases, 
where  the  pain  was  very  severe,  this  gen- 
tleman made  a seton  in  the  groin  over  the 
trunk  of  the  anterior  crural  nerve,  which 
plan,  he  says,  affords  quicker  relief,  though 
in  the  end  it  is  less  to  be  depended  upon  for 
a cure,  than  caustic  issues. 

In  Dr.  Albers’s  work,  the  great  efficacy  of 
issues  and  blisters  in  giving  immediate  relief 
to  the  severe  pain  in  the  knee,  is  illustra- 
ted by  some  valuable  observations.  He 
speaks  also  very  favourably  of  the  rnoxa, 
the  employment  of  which  he  says  is  not 
very  painful ; a remark,  in  which  Langen- 
beck  concurs.  (See  Bibl.  B.  2,  p.  27.)  Dr. 
Albers,  in  the  hectical  stages,  recommends 
opium  as  highly  useful,  especially  when 
combined  with  musk,  or  camphor. 

The  occurrence  of  suppuration  makes  a 
vast  difference  in  the  prognosis.  “ The 
formation  of  even  the  smallest  quantity  of 
pus  in  the  joint  in  cases  of  this  disease,  in 
the  young  person,  considerably  diminishes, 
and  in  the  adult  almost  precludes  the  hope 
of  ultimate  recovery.”  ( Brodie , in  Medico - 
Chir.  j£rnns.  Vol.  6,  p.  347.)  This  gentleman 
is  no^much  in  favour  of  opening  the  ab- 
scesses early,  at  least  before  the  joint  has 
been  kept  for  some  time  perfectly  at  rest. 
He  has  seen  no  ill  consequences  arise  from 
the  puncture  of  the  lancet  remaining  open, 
and  he  has  not  found,  that  in  cases  of  cari- 
ous joints,  the  method  of  evacuating  the 
matter,  recommended  by  Mr.  Abernethy 
(see  Lumbar  Abscess,)  is  attended  with  any 
particular  advantage. 

Mr.  J.  Burns,  in  the  second  vol.  of  his 
“ Dissertations  on  Inflammation,”  p.  314, 
has  recorded  a remarkable  instance, in  which 
this  joint  was  affected  with  that  intractable 
and  fatal  distemper,  the  fungus  hasmatodes. 
The  case  was  at  first,  supposed  to  be  the  dis- 
ease, of  which  we  have  just  been  treating  in 
the  preceding  columns.  The  limb  seemed 
to  be  elongated,  and  issues  »vere  employed, 
without  any  material  benefit.  The  upper 
part  of  the  thigh  swelled,  while  the  lower 
wasted  away.  The  patient  lost  ii is  appetite, 
had  a quick  pulse,  and  passed  sleepless 
nights.  The  part  was  rubbed  with  anodyne 
balsam  arj,d  laudanum  given  <rvery  night ; 
but,  these  means  were  only  productive  of 
temporary  benefit.  After  some  months,  a 
difficulty  of  making  water  came  on,  which 
ended  in  a complete  retention.  It  being 


KAL 


KNB 


105 


found  impracticable  4o  introduce  a catheter, 
and  a large  elastic  tumour,  supposed  to  be 
the  distended  bladder,  being  felt  within  the 
rectum,  a trocar  was  pushed  into  the  swell- 
ing. A good  deal  of  bloody  fluid  was  thus 
discharged.  Afterward  a considerable  quan- 
tity of  high-coloured  fetid  urine  continued 
to  escape  from  the  urethra  In  about  a 
week  after  this  operation,  the  patient  died. 

On  dissection,  Mr.  Burns  found  the  hip 
joint  completely  surrounded  with  a soft 
matter  resembling  brain,  enclosed  in  thin 
cells,  and  here  and  there  other  cavities,  full 
of  thin  bloody  water,  presented  themselves. 
The  acetabulum  and  head  of  the  os  femoris . 
were  both  carious  The  muscles  were  quite 
pale,  and  almost  like  boiled  liver,  having 
lost  their  fibrous  appearance.  The  same 
kind  of  substance  w as  found  in  the  pelvis, 
and  most  of  the  inside  of  the  affected 
bones  was  carious.  Large  cells,  cantain- 
ing  bloody  water,  w’ere  observed  in  the  dis- 
eased substance,  and  it  was  into  one  of 
these  cavities  that  the  trocar  had  entered, 
when  the  attempt  was  made  to  tap  the  blad- 
der. Gil.  Budceus,  De  Curandis  Articularibus 
Morbis,  12mo.  Paris , 1539.  J G.  Widdmann , 
De  Genuum  Slructvra  eorumque  Morbis , 
Hehnstad,  1744  ( Haller , Disp  Chir.  4,  489.) 
Ford’s  Observations  on  the  Disease  of  the  Hip 
joint,  to  which  are  added,  some  remarks  on 
White-Swelling,  8 vo.  Lond.  1794.  Doerner, 
De  Gravioribus  quibusdam  Cartilaginum 
Mutationibns,  8 vo.  Tubingee,  1798.  Crow- 
ther  on  White- Swelling.  &,c.  Edit.  2,  1808. 
J.  Burns  on  Inflammation,  l of.  2,  p.  311. 
Wm.  Falconer,  A Dissertation  on  Ischias,  and 
on  the  Use  of  the  Bath  Waters  as  a Remedy, 
8 vo.  Lond.  1805.  Russel  on  Morbid  Affec- 
tions of  the  Knee,  8ro.  Edinb.  1802.  H. 
Park,  An  Account  of  a New  Method  of  treat- 
ing Diseases  of  the  Joints  of  the  Knee  and 
Etboxo,  8vo.  Lond.  1783  Also  H.  Park  and 
P.  F.  Moureau,  Cases  of  the  Excision  of  Ca- 
rious Joints ; with  Obs.  by  Dr.  J.  Jeffray, 
12 mo.  Glasg.  1806.  J.  A.  Albers,  Abhand- 
lungen  uber  die  Coxalgie,  oderdas  sogenannte 
freyiiillige  Hinken  der  Kinder,  4to.  Wien. 
1807.  This  icork  includes  many  valuable  re- 
marks, but  owing  to  the  crowded  state  of  this 
edition,  it  tins  been  impossible  to  do  his  merit 
sufficient  justice.  G.  Wirth,  De  Coxalgia, 
12 mo.  Wiceb.  1809.  Palelta , Adversaria 


Chir.  Prim  a,  4 to.  Iley's  Practical  Observa- 
tions in  Surgery,  p.  354,  fyc.  Edit.  3.  Boyer, 
TraiU  des  Maladies  Chir.  T.  4,  Paris,  1814. 
Reimarus,  De  Tumore  Ligamentorum  circa 
articulos , Fungo  articulorum  diclo,  Leyden, 
1757.  Brambilla,  in  Ada  Acad.  Med.  Chir. 
Vindob.  T.  1.  Brodies  Pathological  Re- 
searches, respecting  the  Diseases  of  Joints,  in 
Vol.  4.  5,  and  6 of  the  Medico- Chir urgical 
Transactions.  Also  his  Pathological  and  Sur- 
gical Observations  on  the  Joints , 8vo.  Lond. 
1818  ; a work  containing  a great  dea<  of  cor- 
rect and  original  information.  Schreger,  Chi- 
rurgische  VersHche,  B.  2,  p.  209,  fyc.  Beilrage 
zur  Nosologic  der  Gtltukkrankheilen,  Sr o. 
Numb  erg,  1818.  J N.  Rust,  Arthrokakolo- 
gie , oder  uber  die  Verrenkungen  durch  innere 
Bedirigung,  4to.  Wien.  18!  7.  A publication 
of  great  merit.  Dr.  Tomaso  Volpi,  Abhandl. 
uber  die  Koxalgie,  aus  dem  Hal.  ^bersetzt  von 
Dr  P.  Heineken.  The  original  I have  not 
seen,  but  the  translation  contains  copious  ex- 
tracts from  the  prize  essay,  which  I drew  up 
some  years  ago,  with  additional  observations 
and  cases.  Rtcherand's  Nosogr.  Chir.  T.  3, 
p.  1 70,  Sgc.  Ed.  4.  Langenbeck,  Neue  Bibl. 
B.  2,  p.  337.  G.  Golz,  De  Morbis  Ligamen - 
torum  4 to.  Berol.  1799.  Delpech , Precis 

Element,  des  Mai  Chir.  T.  2.  p.  377,  T.  3, 
p.  194,  p.  470,  p.  711,  fyc.  Paris , 1816.  H. 
Mayo,  on  an  acute  Form  of  Ulceration  of  the 
Cartilages  of  Joints,  in  Med.  Chir.  Trans. 
Vol.  2,  p.  104.  J.  Wilson,  Lectures  on  the 
Structure  and  Physiology  of  the  Skeleton,  and 
Diseases  of  the  Bones  and  Joints , 8ro.  Lond. 
1820.  E.  A.  Lloyd , A Treatise  on  the  Na- 
ture; ^c.  of  Scrofula,  Svo.  Lond.  1821.  The 
two  last  publications  deserve  attentive  perusal, 

JUGULAR  VEIN,  how  to  bleed  in.  See 
Bleeding. 

Jugular  vein,  internal,  wounded.  Dr. 
Giraud  cursorily  mentions  a case,  in  which 
a French  surgeon,  at  the  military  hospital 
of  Toulouse,  early  in  the  year  1814,  passed 
a ligature  round  the  trunks  of  the  common 
carotid  artery  and  internal  jugular  vein. 
Both  these  vessels  had  been  wounded  by  a 
musket-shot.  On  the  sixth  day  from  the  ap- 
plication of  the  ligature,  nothing  unfavoura- 
ble had  occurred  ; but  the  final  result  of  the 
case  is  not  related.  (See  Journ.  G6n6rale  de 
Med.  fyc.  par  Sedillot.) 


K. 


K ALT  See  Potassa. 

KERATONYXIS.  The  term,  keratonyxis, 
derived  from  a horn,  and  a 

puncture,  is  employed  by  the  professors  in 
Germany  to  denote  the  operation  of  couch- 
ing performed  through  the  cornea,  or  horny 
coat  of  the  eye,  the  opaque  lens  being  in 
this  manner  sometimes  depressed,  some- 


times broken  piecemeal,  and  in  other  in- 
stances, merely  turned,  so  as  to  place  its  an 
tenor  and  posterior  surface  in  the  horizon- 
tal position.  The  latter  method  is  what  the 
German  surgeons  particularly  imply  by  the 
phrase  reclination.  See  Cataract. 

KNEE,  DISEASES,  AND  INJURIES 
OF  THE.  See  Dislocations;  Fractures; 
Gunshot  Wounds ; Joints,  fyc, 


LACHRYMAL  ORGAN* 


m 

L. 


ACHRYMAL  ORGANS,  Diseases  of  the. 
The  lachrymal  gland  cannot  be  said  to 
be  apart  which  is  frequently  ihe  seat  of  dis- 
ease. Richerand  has  s<  en  no  instance  of 
an  inflammation  of  this  gland,  unless  by 
this  expression  be  implied  cases  in  which 
all  the  contents  of  the  orbit  are  more  or  less 
affected.  ( JVosogr . t'hir.  T 2,  p.  32.)  I be- 
lieve that  the  surrounding  cellular  substance 
is  more  frequently  attacked  with  inflamma- 
tion and  suppuration,  than  the  gland  itself. 
According  to  Professor  Beer,  ( Lehre  von  den 
Augenkr.  B.  i,  p.  349,)  true  idiopathic  in- 
flammations of  the  lachrymal  gland  are  very 
rare,  and  he  declares,  that  in  the  course  of 
a practice  of  twenty-seven  years,  he  has  but 
seldom  met  with  them.  On  this  point  he 
differs  from  Schmidt,  who  fancied  that  he 
had  often  had  under  his  care  cases  of  this 
description  in  gouty  and  scrofulous  sub- 
jects. ( JJeher  die  Krankh.  des  Thranenor- 
gans,  p.  134.)  When  the  lachrymal  gland 
is  attacked  with  inflammation,  its  secretion, 
far  from  being  augmented,  as  Richerand  de- 
scribes, is  always  considerably  lessened, 
and  therefore  one  of  the  earliest  symptoms 
is  an  uneasy  dry  state  of  the  eye,  the  secre- 
tion from  the  meibomian  glands,  and  mu- 
cous membrane  of  the  eyelids,  not  being 
alone  sufficient  for  keeping  the  eye  duly 
moist  and  lubricated.  This  state  is  succeed- 
ed by  a throbbing  acute  pain  in  the  temple, 
shooting  to  the  eyeball,  f rehead,  upper  and 
lower  jaws,  and  back  of  the  head.  In  the 
mean  while,  the  temporal  portion  of  the 
upper  eyelid  becomes  swelled,  tense,  red, 
and  exceedingly  tender,  the  tunica  conjunc- 
tiva being  scarcely  at  all  affected,  and 
merely  exhibiting  a slight  degree  of  redness 
and  tumefaction  towards  the  outer  canthus. 
However,  as  the  swelling  of  the  gland  in- 
creases, the  eyeball  becomes  pushed  more 
or  less  downwards,  and  inwards  towards  the 
nose.  But  though  there  is  little  or  no  red- 
ness, nor  any  mark  of  inflammation  about 
the  eye,  this  organ  is  tense,  and  extremely 
tender.  The  freedom  of  its  movements, 
towards  the  temple  is  much  lessened  in  the 
beginning  of  the  complaint,  and,  when  the 
tumour  has  acquired  a very  large  size,  is 
quite  destroyed.  The  impairment  of  vision 
is  always  proportionate  to  the  protrusion  of 
the  eyeball,  the  pupil  being  diminished,  and 
the  iris  motionless.  The  second,  or  suppu 
rative  stage,  Beer  describes  as  ushered  in  by 
fiery  appearances  before  the  eye  ;.  an  in- 
creased displacement  of  the  eyeball ; throb- 
bing pain;  great  increase  of  the  swelling  of 
the  upper  eyelid,  and  of  the  conjunctiva, 
towards  the  temple  ; an  annoying  sensation 
of  cold,  and  heaviness  in  the  eye  and  orbit. 
Now,  under  febrile  symptoms,  rigours,  be. 
a yellowish  point  presents  itself,  either  on 
the  reddened  portion  of  the  conjunctiva  or 
on  the  outside  of  the  eyelid,  and  a fluctua- 
tion becomes  distinguishable.  ( Beer  L hre , 

B.  l,jp.  350.)  beer  speaks  of  abscesses 


sometimes  forming  in  the  vicinity  of  the 
lachrymal  gland,  and  terminating  in  a small 
sinus,  w hich  communicates  with  one  of  the 
principal  excretory  tubes,  and  discharges 
occasionally  a thin  limpid  fluid.  (Lehre  von 
den  Augenkr.  B.  2,p.  184.)  The  experience 
of  this  author  leads  him  to  consider  these 
sinuses  either  as  a consequence  of  an  un- 
skilfully treated  abscess  of  the  upper  eye- 
lid, or  of  a similar  neglected  affection  of  the 
•cellular  membrane,  near  the  lachrymal 
gland  ; or,  lastly,  of  the  presence  of  a por- 
tion of  the  sac  of  a burst  encysted  tumour. 
According  to  Mr.  Travers,  the  lachrymal 
gland  often  suppurates  in  children,  and  oc- 
casions an  excessive  swelling  above  the 
upper  eyelid,  depressing  the  tarsus  so  as 
completely  to  conceal  the  eye.  The  ab- 
scess, he  says,  may  be  conveniently  opened, 
and  discharged  beneath  the  eyelid.  (Sy- 
nopsis of  the  Diseases  of  the  Eye,  p.  228.) 
With  respect  to  the  treatment  of  any  local 
inflammation  in  and  about  the  lachrymal 
gland,  the  best  means  of  relief  would  be 
leeches,  fomentations,  emollient  poultices, 
and  other  common  antiphlogistic  remedies.  In 
the  suppurative  stage,  Beer  recommends  mix- 
ing with  the  poultice  a good  deal  of  hemlock. 

Ti>e  lachrymal  gland  is  subject  to  scirrhous 
enlargement,  and,  in  cases  of  carcinoma  of 
the  eye,  it  is  one  of  the  parts  in  which  a re- 
turn of  the  disease  is  apt  to  occur.  Hence, 
it  is  now  generally  considered  right  to  re- 
move, it  as  soon  as  the  eyeball  has  been  taken 
away.  (See  Eye.)  Sometimes  the  gland  is 
primarily  affected,  and  Guerin  removed  one 
in  the  state  of  scirrhus,  and  so  much  enlarged, 
that  the  eye  was  entirely  covered  by  it. 
This  operation  was  performed  with  such 
dexterity,  that  the  ex’ernal  straight  muscle 
was  not  at  all  injured.  Mi . Travers  has  also 
removed  a scirrhous  and  enlarged  lachrymal 
gland.  The  vision  of  the  eye  had  suffered 
considerably  during  the  growth  of  the  tu- 
mour. The  only  deformity  after  the  opera- 
tion, was  a slight  prolapsus  of  the  eyelid. 
'This  gentleman  recommends  operations  of 
this  kind  to  be  always  done,  if  possible,  be- 
neath the  eyelid.  ( Synopsis , fyc.  p.  22<S.) 

The  caruncula  lachrymalis  is  liable  to 
chronic  induration  and  enlargement,  consti- 
tuting the  disease  already  spoken  of  in  a 
foregoing  part  of  this  work,  under  the  name 
of  Encanthis , of  which  there  is  also  a scir- 
rhous, carcinomatous,  or  malignant  form, 
quickly  extending  its  effects  to  the  eyeball, 
and  the  adjacent  thin  hones  of  the  orbit. 
(Beer,  Lehre  von  den  Augenkr.  B.  2 ,p.  188.) 

From  these  subjects,  I proceed  to  consider 
the  diseases  of  the  excreting  parts  of  the 
lachrymal  organs;  cases  which,  though  of 
the  most  various  natures,  were  formerly  all 
confounded  together  under  the  title  ol  fistula 
lachrymalis,  and  it  is  only  within  the  last 
few  years,  that  these  complaints  have  been 
subjected  to  tin  same  principles  and  distinc- 
tions, which  are  conceived  to  be  highly  nw- 


LACHRYMAL  ORGANS. 


Ittf 

\ 


tul  iu  ether  branches  ot  surgery.  As  Mr. 
M‘Kenzie  has  judiciously  remarked,  the 
consequence  of  not  distinguishing  the  dif- 
ferent diseases  of  the  excreting  parts  of  the 
lachrymal  organs  from  each  other,  has  been 
an  attempt  to  discover  some  single  successful 
method  of  curing  them  all.  “ Now,  there 
is  no  one  method  of  treatment  by  which  this 
can  be  accomplished ; and  hence  it  is,  that 
the  several  remedies  which  have  been  pro- 
posed, being  eminently  successful  in  one  or 
other  of  these  diseases,  but  not  adapted  to 
all  the  rest,  have  at  different  times  been  held 
in  such  various  degrees  of  estimation.”  (On 
Diseases  of  the  Lachrymal  Organs , p.  10,  8 vo. 
Lond.  1819.)  And  an  intelligent  critic  ob- 
serves, that  in  lachrymal  diseases,  obstruction 
of  the  nasal  duct  appears  to  be  almost  the 
only  circumstance  against  which  the  treat- 
ment recommended  by  the  surgeons  of 
France  and  England,  has  been  directed. 
“ On  sait  qu’au  r6tr6cissement  ou  k l oblitera- 
tion  du  canal  nasal  produits  par  une  cause 
quelconque,  cst  due,  dans  presque  tous  les 
cas,  la  maladie  qui  nous  occupe ; soit  que., 
restees  intactes,  les  parois  du  sac  presentent 
une  tumeur  lachrymale,  d\>u  les  larmes  re- 
fluent continuellement  sur  les  joues,  k t ravers 
les  points  lachrymaux:  soit  qu’en  partie  de- 
truites  et  ulcerees,  res  parois  presentent  une 
fistule,  qui  offre  aux  larmes  un  passage  rontre 
nature,  sans  cesse  entretenue  par  elles  ; en 
sorte  que  ces  deux  htats,  latumeur  et  la  fistule, 
soot  presque  toujours  des  degres  differeus 
d’une  meme  affection,  et  que  le  traiteraent 
qui  convient  k Tune  repose  sur  les  tnemes 
bases  que  celui  indiquh  dans  I’autre.”  (( Euv - 
res  Chir.  de  Desault,  T.2,p.  120.)  It  is  evi- 
dent from  the  writings  of  Pott  and  Ware, 
that  even  these  authors  considered  the  ob- 
struction of  the  nasal  duct,  as  the  foundation 
of  all  the  train  of  varied  symptoms  present- 
ed by  the  excreting  lachrymal  organs.  “ An 
obstruction  in  the  nasal  duct  is  most  fre- 
quently the  primary  and  original  cause  of  the 
complaint.”  “ The  seat  of  this  disease  is  the 
same  in  almost  every  subject,”  says  Mr. 
Pott  ( Obs . on  the  Fistula  Lachrymalis ;)  and 
Mr.  Ware,  in  his  observations  on  the  same 
disease,  sets  out  with  the  same  assumption. 
Now,  obstruction  of  the  nasal  duct  is  an  oc- 
casional consequence  merely  of  inflamma- 
tion of  the  excreting  lachrymal  organs ; in 
most  of  their  diseases,  obstruction  of  the0 
nasal  duct  has  no  part;  and  one  might,  with 
as  much  propriety,  treat  all  the  affections  of 
the  bladder  and  urethra,  by  the  dilatation  of 
the  latter  part,  as  treat  all  the  diseases  of  the 
excreting  lachrymal  organs,  by  dilating  the 
nasal  duct.  The  false  assumption  in  ques- 
tion has  led  to  most  erroneous  treatment. 
For  instance,  in  blennorrhcea  of  the  sac, 
and  in  hernia  of  the  sac.  though  in  both 
these  diseases  the  nasal  duct  is  patent, 
the  common  treatment  in  this  country 
is  to  open  the  sac  by  the  knife,  and  thrust 
down  a style,  or  some  other  instrument 
into  the  nose  . thus  destroying  the  organiza- 
tion of  the  parts  which  are  affected  merely 
with  a gleety  secretion  in  the  one  case,  and 
with  extreme  relaxation  in  the  other.  Sup- 


pose (says  the  some  critical  writer)  that 
some  charlatan  should  make  oath  at  the 
Man-ion-t  louse,  that  hp  had  cured  fiftv  or  a 
hundred  cases  of  gonorrhoea  by  opening  the 
urethra  in  the  perinmum,  and  passing  a bou- 
gie through  that  tube,  from  behind  forwards, 
who  would  approve  of  such  an  operation  ? 
Yet  the  laying  open  of  the  lachrymal  sac, 
and  thrusting  a probe  down  into  the  nose, 
when  the  nasal  duct  is  either  perfectly  pa- 
tent,oral  the  most,  slightly  tumid  from  inflam- 
mation, is  neither  less  preposterous,  nor  less 
cruel.  (See  Quarterly  Journ.  of  Foreign 
Medicine  Vol.  1,  p.  293.)  Indeed,  it  is  some- 
what surprising,  that  errors  of  this  kind  should 
have  prevailed  so  long,  particularly  as  expe- 
rience had  taught  Mr.  Pott,  that  slight  cases 
might  be  benefited  by  the  simple  employment 
of  a vitriolic  collyrium  ; a fact  which  ought 
to  have  convinced  him,  that  the  disease 
did  not  always  depend  upon  obstruction  of 
the  nasal  duct.  It  is  curious,  therefore,  that 
he  did  not  fully  see  this  mistake  ; for,  that 
he  knew  of  these  diseases  having  great  va- 
riety, is  evident  from  the  following  remark: 
As  the  state  and  circumstanc.es  of  this  disease 
are  really  various,  and  differ  very  essentially 
from  each  other,  the  general  custom  of  call- 
ing them  all  by  the  one  name  of  fistula  lach- 
rymalis  is  absurd.’*  I believe,  that  one 
great  cause  of  deception  has  been  the  fact, 
that,  though  laying  open  the  lachrymal  sac, 
and  the  introduction  of  instruments  down 
the  nasal  duct,  have  been  frequently  practi- 
sed, when  milder  plans  would  have  answer- 
ed every  purpose,  yet  a cure  has  often  fol- 
lowed the  practice,  and  thus  confirmed  the 
supposition  of  relief  having  been  effected  by 
the  removal  of  the  imaginary  obstruction  in 
the  nasal  duct.  Thus  the  late  Mr.  Rums- 
den,  of  St.  Bartholomew’s,  with  whom  I 
served  my  apprenticeship,  always  followed 
the  common  plan  of  passing  a probe  down 
the  nasal  duct,  and  letting  the  patient  keep  a 
piece  of  bougie,  or  a style,  in  the  part  for 
two  or  three  months  afterward;  and  I 
scarcely  recollect  an  instance  in  whicb  he 
failed  to  accomplish  a cure,  though  I have 
no  doubt  that  the  same  benefit  might  some- 
times have  been  obtained  without  any  opera- 
tion at  all.  And  a discerning  practitioner 
should  never  forget  that,  if  no  permanent 
obstruction  exist  in  the  nasal  duct,  a cure 
will  generally  follow,  on  the  subsidence  of  in- 
flammation, and  a change  taking  place  in  the 
action  of  the  parts,  whether  a probe, style,  can- 
nula, bougie,  or  seton-  be  employed,  or  net. 
Erysipelas  of  the  Parts  covering  the  La- 
chrymal Sac. — Beer  considers  it  highly  ne- 
cessar>  that  this  case  should  bediscriminated 
from  infl  ruination  of  the  sac  it- elf,  which  is 
otten  but  little  affected,  and  this  even  when 
an  abscess  forms.  Unless  the  true  ; ature  of 
the  disease  be  comprehended,  the  surgeon  is 
apt  to  suppose,  that  the  matter  is  in  the  sac 
itself,  and  believes  that,  when  he  makes  an 
opening,  he  is  puncturing  that  receptacle, 
\vherea9  lie  is  in  reality,  merely  dealing  with 
a superficial  abscess  of  the  integuments. 
Nor,  as  Beer  has  observed,  is  the  mistake 
free  from  ill  consequences  ; for,  imagining 


LACHRYMAL  ORGANS. 


KiS 


that  the  wound  is  made  into  the  sac,  the 
surgeon  pokes  about  with  his  probe  so  long, 
that  a good  deal  of  unnecessary  pain  and  in- 
flammation is  produced.  According  to  the 
same  author,  the  case  is  not  very  frequent, 
and  is  mostly  met  within  scrofulous  subjects, 
who  have  had  for  a considerable  time  a 
blennorrhcea  of  the  lachrymal  sac.  The  in- 
flammation partakes  of  the  usual  characters 
of  erysipelas,  and  commonly  extends  to  the 
eyelids,  particularly  (tie  upper  one.  The  ab- 
sorption and  conveyance  of  the  tears  into 
the  lachrymal  sac  are  interrupted,  because 
the  inflammation  constantly  fleets  the  la- 
chrymal ducts  and  papillae,  the  latter  appear- 
ing considerably  shrunk.  When  the  inflam- 
mation spreads  over  the  side  of  the  face. 
Beer  says  there  is  usually  a discharge  ol  thin 
mucus  from  the  nose;  anil  when  the  affec- 
tion extends  more  deeply  to  the  anterior  por- 
tion of  the  lachrymal  sac,  as  may  easily  hap- 
pen when  <he  case  is  neglected,  or  treated 
in  its  first  stage  with  stimulating  applications, 
a bean-shaped,  circumscribed,  hard,  painful 
tumour  may  be  felt,  oris  even  denoted  by  its 
very  red  appearance.  The  puncta  lacbry- 
tnalia  are  now  completely  closed,  the  papil- 
lae shrivelled  up,  and  the  nostril  on  the  af- 
fect'd side  very  dry  and  tender. 

If  in  the  first  stage  of  the  disorder,  the  la- 
chrymal papillae  and  canals  have  not  been 
too  violently  affected,  the  former  parts  ex- 
pand again,  and  the  absorption  of  the  tears 
recommences  with  the  second  stage.  But, 
at  this  period,  according  to  the  observations 
of  Professor  Beer,  a good  deal  of  mucus  is 
secreted  from  the  caruncula  lachrymalis  and 
Meibomian  glands,  and  collects  and  glues 
the  eyelids  tegether,  especially  during  sleep. 
At  the  same  time,  mucus  generally  accumu- 
lates in  the  lachrymal  sac  itself,  and  may 
be  voided  both  through  the  puncta  lachry- 
malia  and  nasal  duct,  by  gentle  pressure. 
The  mucous  discharge  from  the  nostril  also 
acquires  a thicker  consistence.  Should  the 
lachrymal  papiilse  and  ducts  have  suffered 
more  severely  in  the  first  stage  of  the  dis- 
ease, the  due  absorption  of  the  tears  does 
not  begin  after  the  subsidence  of  the  inflam- 
mation, and  a dropping  of  them  over  the 
cheek,  a slillicidium  lachrymarum  frequently 
continues  a long  while  after  the  termination 
of  the  other  symptoms.  It  depe  ds  upon  the 
atony  of  the  lachrymal  puncta  and  ducts, 
and  is  very  troublesome  in  cold  wet  weather. 
And,  when  the  lachrymal  sac  itself  has  been 
a good  deal  inflamed  in  the  first  stage  of  the 
complaint,  a large  quantity  of  mucus  collects 
within  it  in  the  second  stage,  and  may  be 
discharged  by  pressure.  Sometimes  the 
subcutaneous  abscess  actually  communicates 
with  the  cavity  of  the  sac  ; a case,  which 
Beer  terms  a spurious  fistula  of  the  lachry- 
mal sac,  the  matter  not  being  formed  in  that 
receptacle  itself,  but  getting  into  it  from  the 
external  abscess.  As  the  skin  is  generally 
rendered  very  thin,  these  abscesses  near  the 
bridge  of  the  nose  usually  burst  by  several 
openings.  Beer  remarks,  that  it  is  easy  to 
learn,  whether  the  ulceration  extends  through 
the  lachrymal  sac  ; for  when  this  has  hap- 


pened, the  slightest  pressure  upon  the  supe* 
rior  part  of  the  sac  produces  a discharge  of 
pus  and  mucus  from  the  external  opening, 
and,  if  the  lachrymal  canals  have  already 
recommenced  their  functions,  the  discharge 
will  also  be  mixed  withtears.  (See  M‘Kenzie 
on  Diseases  of  the  Lachrymal  Organs,  p.  22.) 
The  quantity  of  matter,  which  flows  out,  is 
likewise  so  copious,  that  it  is  evident  it 
could  not  have  been  all  lodged  between  the 
skin  and  orbicularis  palpebrarum  muscle,  but 
must  have  come  partly  out  of  the  lachrymal 
sac.  I he  use  of  a fine  probe  will  remove 
any  doubt  which  may  be  left.  (Beer,  Lehre 
von  den  Jhtgenkr  B.  1,  p.  332 — 35.) 

On  the  subject  of  the  causes  of  this  com- 
plaint, the  preceding  author  delivers  no  re- 
mark worthy  of  notice.  In  speaking  of  the 
prognosis,  he  observes,  that  when  the  case  is 
not  neglected,  nor  wrongly  treated  in  its  first 
stage,  and  the  inflammation  has  not  extend- 
ed to  the  lachrymal  sac,  the  prognosis  is 
very  favourable  ; for,  after  the  subsidence 
of  the  inflammation,  a temporary  atony  of 
the  lachrymal  puncta  and  ducts,  an  imper- 
fect conveyance  of  the  tears  into  the  nose, 
and  of  course  a slight  oozing  of  them  over 
the  cheek,  most  troublesome  in  cold,  wet 
weather,  are  the  chief  inconveniences  which 
remain.  But,  when  the  lachrymal  sac  par- 
ticipates in  the  inflammation,  the  prognosis 
is  much  less  favourable  ; because,  when 
suppuration  takes  place,  ulceration  is  apt  to 
form  an  opening  in  the  front  part  of  the  sac, 
or  else,  during  (he  second  stage,  a large 
quantity  of  mucus  may  collect  in  the  sac, 
and,  if  not  skilfully  treated,  it  frequently 
ends  in  a very  obstinate  blennorrhcea  of  that 
part.  As  Beer  observes,  this  is  a case  which 
is  often,  though  quite  erroneously,  named 
a fistula  lachrymalis.  (B.  1,  p.  336.) 

The  prognosis  is  also  very  favourable  in 
the  second  stage  of  the  complaint,  as  long 
as  the  suppuration  is  restricted  to  the  inte- 
guments, and  it  is  characterized  by  desqua- 
mation and  scabbing  ; but,  the  case  is  more 
serious,  when  a large  collection  of  matter 
forms,  and  particularly  when  the  abscess 
makes  its  way  into  the  lachrymal  sac.  In 
these  last  circumstances,  an  obstinate  blen- 
norrhoea  from  the  sac  often  follows,  notwith- 
standing the  fistulous  sore  be  treated  in  the 
most  skilful  manner,  and  sometimes  the 
PAatter  spreads  so  far  around,  as  to  spoil,  and 
even  annihilate,  I he  lachrymal  canals,  and 
cause  an  irremediable  dropping  of  tears 
over  the  cheek,  during  the  rest  of  the  pa- 
tient’s life.  (Beer.) 

The  suppuration  (says  Mr  M'Kenzie)  may 
destroy  the  ligamentous  layer  of  the  lower 
eyelid,  and  end  in  the  total  obliteration  of 
the  cavity  of  the  sac.  But  when  the  sac  is 
not  thus  annihilated,  and  the  lachrymal 
canals  are  destroyed,  it  is  necessary  that  the 
cavity  of  the  sac  should  be  obliterated  by 
artificial  means  ; for  otherwise  a form  of  dis- 
ease will  follow,  which  Beer  denominates 
hydrops  sued  lachrymalis , and  Mr.  M‘Kenzie, 
mucocele,  as  will  be  hereafter  noticed. 

“ In  common  cases,  a piece  of  folded 
linen,  dipped  in  cold  water,  and  applied  to 


LACHRYMAL  ORGANS 


' tic  parts  affected,  and  the  administration  of 
gentle  doses  of  sulphate  of  magnesia,  make 
op  the  treatment.  In  severe  gases,  it  will 
be  found  necessary,  not  only  to  continue  the 
cold  applications,  and  to  open  the  bowels, 
but  to  administer  an  emetic  of  tartrate  of 
antimony,  to  purge  freely,  and  even  some- 
times to  take  away  blood  from  the  arm.” 
(M‘Kenzit,  p.  24.) 

In  the  second  stage,  a warm  dry  air,  and 
a linen  compress,  are  commended,  with  the 
exhibition  of  diaphoretics.  In  the  two  first 
ot  these  means,  1 confess,  that  I should  place 
little  or  no  confidence.  When  the  formation 
of  matter  cannot  be  prevented,  poultices  are 
to  be  used.  Beer  particularly  cautions  us 
not  to  leave  the  abscess  to  burst  of  itself, 
but  to  open  it  immediately  a fluctuation  can 
be  felt,  so  as  to  prevent  an  ulcerated  open- 
ing from  taking  place  in  the  anterior  part  of 
the  lachrymal  sac.  And,  if  the  surgeon  has 
not  been  consulted  before  such  a commu- 
nication has  been  established  between  the 
sac  and  subcutaneous  abscess,  he  should 
avoid  all  unnecessary  disturbance  of  the 
parts  with  probes  and  syringes,  and  at  most, 
only  wash  out  the  abscess  once  a day  with 
An  el's  syringe,  filled  with  lukewarm  water 
and  a little  of  the  vinous  tincture  of  opium. 
Beer  also  recommends  introducing  into  the 
superficial  abscess,  but  not  into  the  sac,  a 
small  quantity  of  lint,  dipped  in  the  tincture. 
If  the  blennorrhoea  of  the  sac  continue,  it  is 
to  be  treated  as  will  be  explained  in  consi- 
dering the  second  stage  of  inflammation  of 
that  part. 

Inflammation  of  the  Lachrymal  Sac. — Ac- 
cording to  Beer,  the  symptoms  of  the  first 
stage  of  this  complaint  are  as  follows  : in  the 
corner  of  the  eye,  precisely  in  the  situation 
of  the  lachrymal  sac,  a circumscribed,  very 
hard,  tender  swelling  arises,  of  tbe  shape  of 
a bean,  producing  a lancinating  pain  when  it 
is  touched,  and  gradually  acquiring  consi- 
derable redness.  The  absorption  and  con- 
veyance of  the  tears  into  the  lachrymal  sac, 
and  thence  into  the  nose,  are  completely  in- 
terrupted ; the  lachrymal  papillae  are  shrunk; 
the  puncta  cannot  be  seen  ; and  of  course 
the  tears  fall  over  the  cheek.  The  nostril  on 
the  affected  side  is  at  first  very  moist,  but 
soon  becomes  perfectly  dry,  the  mucous 
membrane  being  a good  deal  affected.  As 
the  inflammation  also  constantly  spreads  to 
the  orbicular  muscle  and  integuments  in  the 
corner  of  the  eye,  the  complaint  often  pre- 
sents an  erysipelatous  appearance,  extending 
to  the  eyelids  and  down  the  cheek  ; but, 
the  circumscribed  swelling,  caused  by  the 
inflamed  sac,  is  still  not  only  capable  of 
being  distinctly  felt,  but  even  seen.  It 
rarely  happens,  in  cases  of  common  in- 
flammation, that  on  the  change  of  the  first 
stage  into  the  second,  the  nasal  duct  is  ren- 
dered impervious  by  an  effusion  of  lymph  ; 
but  such  an  occurrence  is  more  frequent 
where  the  inflammation  is  not  of  a healthy 
description,  and  the  patient  is  scrofulous. 
Gnder  these  circumstances,  the  lachrymal 
canals  may  also  be  rermanentlv  obliterated. 
Vol,  !!.  22 


1(59 

In  weak,  irritable  constitutions,  towards  the 
end  of  the  first  stage  of  the  inflammation,  a 
degree  of  symptomatic  fever  prevails,  with 
severe  headach,  great  redness.and  swelling 
of  the  whole  inner  canlhus,  involving  the 
caruncula  lachrymalis,  the  semilunar  fold, 
the  conjunctiva,  the  edges  of  the  eyelids, 
and  the  lachrymal  puncta. 

Here  as  in  inflammation  of  every  mucous 
membrane,  at  the  very  commencement  of 
the  second  stage,  a copious  morbid  secretion 
takes  place,  and  accumulates  in  large  quan- 
tity ; for,  either  in  consequence  of  the 
thickening  of  the  mucous  membrane,  ‘the 
adhesion  of  the  sides  of  the  nasal  duct 
together,  or  there  being  no  mixture  of  the 
tears,  the  secretion  within  the  sac  cannot 
escape  either  into  the  nostril,  or  out  of  the 
lachrymal  puncta,  and  consequently  it  dis- 
tends in  a prodigious  degree  the  anterior 
side  of  the  sac,  where  it  is  uncovered  by 
bone.  Hence,  the  swelling  is  here  very 
manifest,  and  a fluctuation  may  be  felt  in  ii, 
even  before  the  suppurative  stage  lias  actually 
begun.  According  to  Beer,  whoever  is  in- 
duced by  the  fluctuation  to  open  the  lachry- 
mal sac  at  this  period,  will  certainly  bring 
on  a very  hurtful  suppuration  of  the  part, 
exceedingly  likely  to  render  the  excreting 
parts  of  the  lachrymal  organs  completely  un- 
serviceable. At  the  beginning  of  the  second 
stage,  there  is  also  a morbid  secretion  from 
the  mucous  membrane  of  the  nostril  and 
caruncula  lachrymalis.  Now  not  only  the 
swelling  of  the  lachrymal  sac  increases 
more. and  more,  the  redness  acquires  a 
deeper  colour,  the. skin  becomes  more  shining, 
the  fluctuation  still  more  evident ; and,  at. 
length,  in  the  centre  of  the  tumour  formed 
by  the  lachrymal  sac,  a yellowish,  soft  point 
presents  itself.  In  this  state  of  things,  in 
order  to  prevent  a true  fistula,  the  surgeon 
should  make  an  opening  in  the  lachrymal 
sac,  without  the  least  delay ; for,  if  the  ab- 
scess be  left  to  itself,  the  pus  will  at  last 
make  a passage  for  itself  through  the  orbi- 
cular muscle  and  integuments  . but  it  will 
only  be  a small  fistulous  opening,  surrounded 
with  callous  hardness,  and  merely  capable 
of  letting  some  of  the  pus  and  mucus  of  the 
sac  escape,  so  that  the  thicker  part  of  tbe 
matter  remains  behind,  and,  consequently, 
though  the  swelling  diminishes  after  the 
formation  of  a spontaneous  opening,  it  does 
not  entirely  subside.  A quantity  of  hlood  is 
also  remarked  to  be  blended  with  the  dis- 
charge from  the  sac.  This  last  is  the  case, 
which  Beer  denominates  a true  fistula  of 
lachrymal  sac.  Y\  hen  the  abscess  bursts  of 
itself,  the  fistulous  opening  in  the  sac  is  not 
alwaj^s  exactly  opposite  the  aperture  in  the 
skin,  and,  though  there  is  commonly  but  one 
communication  with  the  sac,  it  sometimes 
happen^,  that  several  small  external  openings 
are  produced  more  or  less  distant  from  the 
sac.  The  diagnosis  is  easy  enough  ; for,  on 
pressing  upon  the  upper  portion  of  that  re- 
ceptacle, mucus  and  pus,  blended  together, 
are  immediately  discharged  from  ali  thefistu- 
lous  apertures.  After  the  disease  has  lasted 
a good  while,  it  net  unfreque fitly  happen-. 


170  LACI1R1MA 

that  tears  are  also  voided  from  the  fistulous 
opening  ; a grcumstance,  indicating  the  re- 
stored action  of  the  lachrymal  puncta  and 
canals;  but,  according  to  Beer,  such  tears 
are  never  duly  blended  with  the  mucous  and 
purulent  matter.  He  further  remarks,  that, 
when  the  second  period  oi  the  second  stage, 
or  the  suppurative  process  is  over,  a morbid 
secretion  of  mucus  still  continues  in  the 
third  period  of  the  second  stage,  that  secre- 
tion becoming  whitish,  thick,  opaque,  and 
onty  partly  resembling  pus.  As,  in  con- 
quence  of  its  thickness,  and  the  swelling  of 
the  mucous  membrane  of  the  nasal  duct,  the 
secretion  cannot  descend  into  the  nose,  it 
collects  in  the  sac,  and  sometimes  pushes  off 
any  piece  of  lint,  or  plaster,  with  which  the 
external  opening  in  the  sac  has  been  closed. 
At  length,  by  means  of  judicious  treatment, 
this  third  period  of  the  second  stage  is  also 
brought  to  a termination  ; the  mucus  is  se- 
creted again  in  due  quantity  ; it  becomes 
transparent  like  white-of-egg,  and  viscid  ; 
but  white  streaks  maybe  for  some  time  per- 
ceived in  it.  Afterward  the  mucus  becomes 
thinner,  and,  if  the  functions  of  the  lachry- 
mal puncta  arid  ducts  are  not  destroyed,  it  is 
thoroughly  mixed  with  the  tears.  The  open- 
ing in  the  lachrymal  sac  now  either  heals  up 
of  itself,  or  under  skilful  treatment ; but,  in 
general,  a minute  fistulous  aperture  still  re- 
mains, from  which  the  tears  and  mucus  are 
occasionally  voided,  if  the  passage  through 
the  nasal  duct  be  not  free.  However,  if  the 
small  fistulous  aperture  should  happen  to 
heal  up  completely,  the  mucus  and  tears 
accumulate  in  the  sac,  and  the  patient  is 
obliged  to  press  them  out  through  the  puncta 
lachrymalia  several  times  a day. 

When  the  surgeon  is  consulted  early 
enough,  and  proper  treatment  is  adopted, 
Beer  sets  down  the  prognosis  in  the  first 
stage  of  the  inflammation  as  very  favourable. 
But,  if  the  practitioner  be  called  in  later,  it 
will  not  be  in  his  power  completely  to  dis- 
perse the  inflammation,  and  prevent  the 
morbid  secretion,  and  accumulation  of  mu- 
cus in  the  lachrymal  sac  ; the  blennorrhea  of 
this  part,  of  professor  Beer,  or  the  dacryops 
bltnnoideus,  of  Schmidt  ; a state,  however, 
which  soon  gives  way  to  judicious  treatment. 
But,  when  the  case  is  neglected,  or  wrongly 
managed  at  the  period,  when  the  lachrymal 
sac  is  violently  inflamed,  a complete,  or  par- 
tial closure  of  the  nasal  duct  by  adhesive 
inflammation  is  apt  to  be  the  consequence. 
And,  the  same  effect  may  also  be  produced 
in  die  lachrymal  canals,  in  which  event,  the 
absorption  of  the  tears  is  for  ever  impeded, 
and  the  patient  must  remain  the  rest  of  his 
life  afflicted  with  a stillicidiumlachrymarum. 

With  regard  to  the  prognosis  in  the  second 
stage  of  inflammation  of  the  lachrymal  sac, 
Beer  considers  it  as  very  dubious, on  account 
of  the  impairment  of  the  functions  of  the 
excreting  parts  of  the  lachrymal  organs;  for, 
v says  he,  no  surgeon  can  exactly  know,  what 
may  have  been  the  result  of  the  first  stage, 
in  relation  to  the  perviousness  of  the  nasal 
duct  and  lachrymal  canals,  and  an  officious 
examination  of  thi  parts  with  a probe,  for 


b ORGAAA' 

llio  purpose  of  obtaining  information,  would 
be  attended  with  considerable  mischief. 
However,  generally  speaking,  the  prognosis 
is  most  hopeful  at  the  first  period  of  the  se- 
cond stage,  just  when  the  morbid  secretion 
of  mucus  is  beginning;  the  suppuration  may 
yet  be  moderated  by  right  treatment,  and 
the  excreting  parts  of  the  lachrymal  organs 
preserved.  But,  if  the  suppurative  stage  has 
already  come  on,  much  will  depend  upon 
the  consideration,  whether  the  matter  has 
been  originally  formed  in  the  lachrymal  sac, 
has  lodged  there  a good  while,  and  the  sac 
is  ready  to  burst,  or  whether  there  is  actually 
an  opening  in  the  sac  opposite  that  in  the 
skin,  or,  lastly,  whether  the  openings  do  not 
correspond.  In  the  first  case,  the  suppura- 
tion yet  admits  of  being  regulated  by  judi- 
cious treatment,  and  the  lachrymal  sac  can 
be  punctured;  but,  in  the  other  circumstan- 
ces, the  management  of  the  case  is  far  more 
difficult,  especially  when  the  patient  s con- 
stitution is  not  good.  However,  the  surgeon 
should  be  careful  not  to  disfigure  the  patient 
with  a large  scar  ; and  the  aim  should  be  to 
prevent  atony  of  the  lachrymal  puncta  and 
ducts,  and  a consequent  stillicidium  lachrj- 
marum.  These  are  the  least  serious  evils  to 
be  apprehended  from  mismanagement ; for, 
if  the  case  be  ill  treated,  or  neglected,  in  the 
latter  stage  of  the  suppurative  process,  ne- 
cessarily attending  a fistulous  state  of  the 
sac,  the  lachrymal  organs  may  be  rendered 
quite  useless,  or  even  entirely  destroyed, 
and  the  nasal  duct  obliterated,  or  obstructed 
by  the  effects  of  caries.  In  some  few  in- 
stances, indeed,  the  whole  lachrymal  sac  is 
destroyed,  or  will  require  to  be  so  by  art,  as 
will  be  presently  explained.  It  is  always 
a favourable  circumstance  when  the  tears 
are  seen  to  issue  from  the  fistulous  opening 
with  the  mucus  and  pus,  as  it  is  a proof  that 
the  absorption  and  conveyance  of  the  tears 
into  the  lachrymal  sac  are  established  again, 
and  that  now  the  only  question  is  about  the 
state  of  the  nasal  duct,  which  point  cannot 
be  determined  before  the  fistula  is  com- 
pletely healed,  and  the  third  period  ot  the 
second  stage  is  entirely  obviated.  (Beer, 
Lehre  von  den  Jhigenkr.  B.  1 ,p.  356 — 367.) 

lu  the  first  stage,  the  indication  is  to  en- 
deavour to  resolve  the  inflammation.  “ It 
is,  (as  Mr.  M‘Kenzie  observes)  by  combat- 
ing the  inflammation,  that  we  are  to  cure 
this  disease,  and  not  by  attacking  merely 
one,  or  even  several  of  the  symptoms.  Di- 
latation, for  instance,  by  the  introduction 
of  probes  through  tbe  canals  into  the  sac 
and  even  into  the  nose,  would  only  be  sub- 
jecting the  inflamed  parts  to  a new  cause 
of  irritation,  and  might  thus  produce  ^^cts 
which  would  render  a complete  cure  diffi- 
cult, if  not  impossible.”  On  the  contrary, 
in  the  first  stage,  Mr.  M‘Kenzie  joins  Beer 
in  praise  of  antiphlogistic  measures ; the 
application  of  cold  lotions  to  the  part;  and, 
in  severe  cases,  venesection  and  leeches 
are  set  down  as  proper,  together  with  open- 
ing and  diaphoretic  medicines.  (On  Dis- 
eases of  the  Lachrymal  Organs , p.  33,  34.) 
in  the  second  stage,  when  resolution  i 


LACHRYMAL  ORGANS. 


no  longer  practicable,  emollient  applications 
are  the  most  beneficial,  and  all  debilitating 
means  are  to  be  stopped,  by  the  further  use 
of  which  an  incurable  blennorrhcea  of  the 
lachrymal  sac  would  be  likely  to  be  indu- 
ced. And,  as  soon  as  the  sac  is  so  distended 
with  mucus  and  matter,  that  the  centre  of 
the  swelling  begins  to  be  soft,  and  a fluctu- 
ation  is  perceptible,  the  sac  should  be  freely 
opened,  so  as  to  let  its  contents  have  a rea- 
dy outlet.  If,  after  this  evacuation,  there 
should  be  any  deep-seated  hardness  of  the 
lachrymal  sac,  Beer  recommends  the  ap- 
plication of  a camphorated  hemlock  poul- 
tice. Afterward,  the  wound  in  the  skin  and 
sac  is  to  have  introduced  into  it  a little  bit 
of  lint,  dipped  in  the  vinous  tincture  of  opi- 
um, over  which  dressing  a piece  of  diachy- 
lon plaster  may  be  placed.  When,  under 
such  treatment,  the  suppuration  diminishes, 
but  a preternatural  secretion  of  mucus  yet 
continues,  Beer  introduces  into  the  wound 
every  day  a piece,  of  lint,  on  which  is  spread 
a little  bit  of  the  following  ointment  : H 
Butyri  recentis  insulsi,  ^ss.  Hydrargyri  Ni- 
trico-Oxydi,  gr.  x.  tutia3,  ptt.  gr.  vj.  M.  And, 
on  changing  the  dressings,  some  of  the  fol- 
lowing lotion  may  be  dropped  into  the  in- 
ner canthus,  and  injected  lukewarm  into 
the  sac  itself:  Subacetatis  Cupri,  Potas- 

saj  Nitratis,  aluminis,  a a gr.  iij. — vj.  Cam- 
phors: tritee  grij. — iv  Aqua3  distillates  gss. 
Solve  et  cola.  Liquori  colato  adde  Vini 
Opii  3j. — 3ij.  Aquae  Rosae  ^iv.  JV1  Pro 
lessor  Beer  makes  a mass  of  the  three  first 
articles  melted  together  in  equal  propor- 
tions, and  terms  it  the  lapis  divinus , of  which 
he  makes  the  lotion,  and  then  adds  the 
other  ingredients.  When,  by  means  of  such 
treatment,  the  mucous  secretion  from  the 
sac  has  been  brought  into  a healthy  state, 
and  all  the  induration  has  subsided,  the  pe- 
riod has  arrived  for  the  surgeon  to  think  of 
taking  measures  for  the  re-establishment  of 
the  passage  through  the  nasal  duct,  if  it 
should  not  already  have  become  pervious  of 
itself,  which,  when  the  inflammation  has 
been  of  a healthy  kind,  and  the  treatment 
iudicious,  very  frequently  happens.  ( Beer , 
Lehre,  fyc.  B.  1,  p.  369—371.) 

Chronic  Blennorrhcea  of  the  excreting  Parts 
of  the  Lachrymal  Organs. — Mr.  M£Kenzie, 
whose  Essay  contains  a faithful  account  of 
Beer’s  opinions  upon  the  present  subject, 
describes  the  inflammation,  with  which  this 
iorm  of  disease  commences,  as  seldom  con- 
siderable, and  in  scrofulous  patients,  it  is 
said  to  be  not  unfrequently  quite  disregard- 
ed, no  advice  being  taken  until  the  lachry- 
mal sac  is  much  distended  with  mucus.  By 
means  of  pressure  upon  the  bean-shaped  tu- 
mour, caused  by  such  distention  of  the  sac, 
a quantity  of  puriform  mucus  is  forced  out 
of  the  puncta  lachrymalia,  and  overflows 
the  eye  ; and  so  far  are  the  lachrymal  ca- 
nals from  being  obstructed,  that,  excepting 
when  any  return  of  inflammation  happens, 
they  even  absorb,  and  convey  the  tears  into 
the  sac.  Pressure,  however,  will  rarely 
make  the  contents  of  the  sac  pass  through 
tlie  nasal  duct,  on  account  of  the  thickened 


state  of  the  mucous  membrane,  and  there- 
fore the  nostril  is  generally  very  dry.  “ In 
the  course  of  this  tedious  disease,  the  accu- 
mulated mucus  varies  much  both  in  quantity 
and  quality.  For  instance,  the  mucus  ac- 
cumulates more  rapidly,  aqd  is  much  thick- 
er after  a good  meal,  than  at  other  times. 
The  secretion  of  it  is  very  plentiful,  but 
thinner  than  usual,  when  the  patient  con- 
tinues long  in  a moist  cold  atmosphere.  In 
this  case,  the  overfilling  of  the  sac  takes 
place  so  rapidly,  that  the  compression  ot 
the  orbicularis  palpebrarum  in  the  action  ot 
winking  is  sufficient  to  evacuate  the  sac 
through  the  canals  to  such  a degree,  that 
the  whole  surface  of  the  eyeball  is  suddenly 
overflowed,  and  the  puriform  fluid  runs 
down  upon  the  cheek.  After  the  patient 
remains  for  a short  time  in  a warm  and  dry 
atmosphere,  the  morbid  secretion  becomes 
sparing  and  ropy.  We  find,  that  this  chro- 
nic blennorrhcea  almost  completely  disap- 
pears in  many  individuals  during  warm 
weather,  upon  which  the  yet  unexperienced 
patient  and  the  unexperienced  surgeon  arc. 
apt  to  express  a great,  but  a premature  joy, 
for,  on  the  very  first  change  to  cold  and  wet 
weather,  the  ^disease  most  frequently  re- 


turns.” 

During  chronic  blennorrhcea,  the  lachry- 
mal sac  is  extremely  liable  to  repeated  at- 
tacks of  inflammation  and  sometimes  a lis 
tula,  with  a good  deal  of  induration  of  the 
surrounding  cellular  substance,  is  produced. 
Mr  M£Kenzie  represents  this  disease  as  the 
most  frequent  of  all  those  to  which  the  ex- 
creting parts  of  the  lachrymal  organs  are 
liable,  and  as  consisting  in  inflammation  ot 
these  organs,  modified  by  scrofula,  gene- 
ral debility,  disorder  of  the  digestive  or- 
gans, or  other  constitutional  causes  which 
prolong  its  second  stage.  “ Even  regarded 
locally,  the  present  disease  is  seldom  a pri- 
mary affection,  but  is  most  frequently  ex- 
cited by  catarrhal  inflammation  ot  the 
Schneiderian  membrane,  or  by  a long-con  - 
tinued disorder  of  the  Meibomian  glands.' 
(j \PKenzie  on  Diseases  of  the  Lachrymal  Or 
gans,  p.  37 — 40.) 

Scarpa’s  opinions  on  the  present  subject 
are  in  some  degree  peculiar  to  himself ; for 
he  considers  the  affection  of  the  Meibomian 
glands  and  inside  of  the  eyelids,  the  puri- 
form palpebral  discharge,  as  he  terms  it,  as 
constituting  the  first  degree  of  all  those 
complaints  which  have  usually  gone  under 
the  name  of  fistula  lachrymalis  ; the  sepond 
degree,  or  effect,  being  the  tumour  of  the 
lachrymal  sac  ; and  the  third,  the  fistula,  or 
ulcerated  opening  in  thelatter  part.  Scarpa 
asserts,  that  the  chief  part  of  the  yellow 
viscid  matter,  whieh  accumulates  in  the 
lachrymal  sac,  is  secreted  by  the  lining  ot 
the  eyelids,  and  by  the  little  glands  of  Met- 
bomius  ; and  that  the  altered  quality  of  this 
secretion  has  a principal  share  in  the  cause 
of  the  disease.  He  states,  that  the  truth 
of  this  fact  may  at  once  be  ascertained  by 
everting  the  eyelids,  and  especially  the 
lower  one  of  the  affected  side  ; and  by  com- 
paring them  with  those  ol  the  opposite  eye. 


LACHRVMAL  ORGANS' 


The  former  will  always  exhibit  an  unnatural 
redness  of  the  interna!  membrane,  which 
has  a villous  appearance  till  over  the  extent 
of  the  tarsus;  while  the  edge  of  tiic  lid  is 
swollen,  and  numerous  varicose  vessels  are 
distinguishable  on  it.  The  follicles  of  Mei- 
bomius  are  also  turgid  and  prominent,  and 
when  examined  with  a magnifying  glass, 
not  unfrequently  appear  to  be  slightly  ulcer- 
ated. 

“ The  villous  structure  then,  which  the 
surface  of  the  internal  membrane  of  the 
palpebra  assumes  in  these  cast  s,  becomes 
an  organ  secreting  a larger  quantity  of  fluid 
than  usual,  resembling  viscid  lymph,  which, 
as  before  stated,  being  mixed  with  the  seba- 
ceous matter,  copiously  effused  from  the 
glands  of  Meibomius,  constitutes  the  whole 
of  the  viscid  fluid,  with  which  the  eyelids 
are  imbued,  and  which  is  continually  car- 
ried by  the  puncta  lachrymaliajnto  the  sac, 
so  as  to  fill  and  also  frequently  distend  it, 
until  it  forms  a Tumour. 

“ if,  indeed,  the  lachrymal  sac  is  emptied 
of  this  matter,  by  means  of  compression, 
and  the  eye  and  internal  surface  of  the  pal- 
pebrae  are  carefully  washed,  so  that  none  of 
the  glutinous  humour,  pressed  from  the  sac, 
may  remain  upon  them,  and  the  eyelids  are 
everted  half  an  hour  afterward,  the  internal 
surface,  especially  of  the  lower  one,  will  be 
found  covered  with  a fresh  effusion  of  mu- 
cus mixed  with  sebaceous  matter,  which 
has  evidently  not  flowed  back  from  the 
lachrymal  sac  to  the  eve,  but  has  been 
generated  between  the  eye  and  the  pal- 
pebral.” Another  argument,  brought  for- 
ward by  Scarpa,  in  support  of  his  theory,  is, 
that,  if  the  morbid  secretion  of  the  eyelids 
be  retarded,  or  suppressed,  either  accident- 
ally or  by  means  of  astringent  applications, 
little  or  none  of  the  viscid  secretion  collects 
in  the  lachrymal  sac,  or  can  be  forced  out 
« of  the  puncta  lachrymalia.  He  has  also 
constantly  observed,  that  the  puriform  dis- 
charge may  be  radically  cured  at  its  com- 
mencement, and  before  it  has  induced  any 
flaccidity  of  the  sac  by  a timely  correction 
of  the  morbid  secretion  from  the  inside  of 
the  eyelids,  and  keeping  the  lachrymal  pas- 
sages cleansed,  by  means  of  injections,  of 
simple  water  through  the  puncta  lachrynra 
lia  into  the  nose.  As  for  the  internal  mem- 
brane of  the  sac  itself,  he  argues,  t hat  its 
structure  does  not  qualify  it  for  secreting  a 
tenacious  unctuous  matter,  like  what  is 
chiefly  discharged  from  it,  as  it  is  entirely 
destitute  of  sebaceous  glands,  and  can  in 
reality  only  furnish  a thin  mucus.  However, 
he  admits,  th<jt  if  the  sac  happen  to  he  in- 
flamed and  ulcerated,  a turbid  matter  may 
issue  frtffn  it  with  the  tears;  but,  says 
he,  this  matter  is  true  pus,  and  quite  differ- 
ent from  the  curdy  unctuous  fluid  which 
takes  place  in  the  puriform  palpebral  dis- 
charge. (On  the  Principal  Diseases  of  the 
Eyes,  Trmsl.  by  Briggs,  Ed.  2.  p.  3—7) 

The  foregoing  opinions  of  Scarpa  have 
not  met  with  universal  assent,  and  though 
there  is  probably  much  truth  in  them,  he 
r ay  have  overlooked  too  much  the  possible 


simultaneous  affection  of  the  mucous  tnetifi 
brane  of  the  lachrymal  sax;  and  nasal  duct. 
To  Scarpa’s  hypothesis,  Himly  and  Flajani 
have  made  the  following  objections  : First, 
that  they  iiave  observed  the  fistula  lachry- 
inalis,  without  the  least  morbid  alteration 
of  the  eyelids  and  Meibomian  glands.  Se- 
condly, that  every  puriform  discharge  of  the 
eyelids  is  not  succeeded  by  a fistula  lachryma- 
lis.  vastly, that  the  fistula  lachrymalisis  cured 
by  means  of  the  operation  alone,  without 
any  attention  being  paid  to  the  morbid  state 
of  the  eyelids,  when  it  exists.  And  Mr. 
Travers  aiso  regards  Scarpa’s  account  of  the 
origin  of  the  disease,  independently  of  a 
permanent  stricture,  as  'hypothetical ; for  if 
founded  in  fact,  the  distention  of  the  lachry- 
mal sac,  and  tee  regurgitation  of  the  fluid 
on  pre  sure,  would  attend  every  severe  lip- 
pitudo,  or  ophthalmia  with  puriform  dis- 
charge, which  is  not  the  case.  If  Scarpa’5 
account  were  correct,  .r.  i'ravers  sees  no 
reason  why  the  fluid,  once  admitted,  should 
be  arrested,  or  regurgitate,  instead  oi  pass- 
ing into  the  nose,  (see  also  Nicod.  in  Rente 
Med.  T 1,  p.  155,)  and  he  thinks  there  is 
every  reason  to  believe  that  the  fluid,  so 
discharged,  is  the  proper  secretion  of  the 
sac.  and  cases  are  frequent,  in  which  it 
is  retained  and  cannot  be  expressed,  owing 
to  strictures  both  of  the  lachrymal  and  nasal 
ducts.  ( Synopsis  of  Ike  Diseases  of  the  Eye , 
p.  360.)  Some  of  the  arguments  with  which 
Scarpa  meets  this  reasoning,  are  already 
anticipated,  especially  that  which  refers  to 
the  difference  between  the  secretion  of  the 
sac  itself,  and  thai  of  the  sebaceous  glands 
t the  eyelids.  Also,  in  asserting  that  the 
origin  of  the  fistula  lachryrnalis  generally 
manifests  itself  on  the  eyelids,  before  the 
lachrymal  passages  are  affected,  Scarpa  de- 
clares, that  he  does  not  pretend  thereby  to 
exclude  altogether  the  possibility  of  a case, 
in  which  the  membranes  of  the  nasal  duct 
and  lachrymal  sac  may  not  he  thickened 
and  ulcerated,  independently  of  the  disease 
of  the  eyelids.  That  this  is  the  case,  1 think 
is  evident  from  the  account  already  deliver- 
ed in  the  two  first  sections  ot  this  article,  of 
Beer’s  opinions,  respectingthe  consequences 
of  inflammation  of  the  integuments  and 
other  parts  about  the  inner  angle  of  the  eye, 
as  well  as  respecting  the  effects  of  acute  in- 
flammation of  the  lachrymal  sac  itself.  How- 
ever Scarpa  admits  the  fact,  and  the  ques- 
tion left  is,  whether  he  is  right  in  assigning 
the  morbid  secretion  from  the  inside  of  the 
eyelids,  as  the  most  common  cause  of  the 
swelling,  ulceration,  &c.  of  the  lachrymal 
sac  ? That  every  puriform  discharge  from 
the  eyelids  is  not  followed  by  fistula  lachry- 
malis,  he  allows,  is  unquestionable ; ami 
this,  he  conceives,  most  probably  happens, 
because  the  lippitudo  has  not  been  entirely 
neglected,  or  because  the  secretion  being 
less  dense  and  viscid  than  usual,  descends 
freely  with  the  tears  into  the  nose  through 
the  lachrymal  canals,  which  are  large  and 
pervious.  But  in  the  acute  stage  of  the  pu- 
rulent ophthalmia,  he  asserts  that  the  reason 
why  the  discharge  is  not  conveyed  into  the 


lachrymal  organs 


'-ac  is,  that  the  inflammation  and  swelling  ac- 
tually close  the  puncta  lachrymalia,  and 
change  their  direction,  so  that  both  the  pu- 
riform  matter  and  the  tears  fall  over  the 
cheek,  and  cannot  descend  into  the  sac. 

As  for  the  instances  of  cure,  without  any 
remedies  being  applied  for  the  correction  of 
the  state  of  the  eyelids,  Scarpa  deems  the 
argument  inconclusive,  because  particular 
vices  of  the  constitution,  under  the  use  of  ap- 
propriate internal  remedies  and  a well-regu- 
lated diet,  disappear,  or  are  tra  sferred  to 
other  parts,  without  the  use  of  topical  re- 
medies. 

For  my  own  part,  I am  disposed  to  believe, 
that,  whether  the  disease  begin  in  the  eyelids, 
or  elsewhere,  generally  both  their  lining,  and 
that  of  the  sue  and  nasal  duct  are  also  more 
or  less  affected ; and,  consequently*  though 
Scarpa’s  theory  may  not  be  in  every  Ye'spect 
satisfactory,  nor  at  all  applicable  to  certain 
disorders  of  the  excreting  parts  of  the  la- 
chrymal organs,  the  practice,  to  which  his 
sentiments  lead,  will,  in  the  generality  of 
cases,  which  Beer  denominates  chronic  bleu- 
ziorr/ixa,  be  highly  advantageous. 

According  to  Mr.  M‘Kenzie,  he  local 
treatment  of  chronic  blennorrbcee  does  not 
differ  essentially  from  that  of  inflammation 
of  the  excreting  pans  of  the  lachrymal  or- 
gans. But,  every  possible  means  must  also 
be  employed  for  improving  the  general 
health  ; for,  otherwise  all  local  remedies  will 
be  unavailing.  In  scrofulous  cases,  particu- 
lar attention  must  be  paid  to  diet  and  mode 
of  living.  In  weakly  persons,  the  preparations 
of  iron  will  be  highly  beneiicial  : and,  when 
t he  disease  is  eonnecied  with  disorder  of  the 
digestive  organs,  the  treatment  recommended 
by  Mr.  Aberaetby  is  that  to  which  Mr.  M‘ 
Kenzie  expresses  a preference.  The  employ- 
ment of  Anel’s  syringe  and  probe  are’ strongly 
reprobated.  “ i grant,  (sayrs  this  author,) 
that  the  application  of  certain  substances  to 
the  mucous  membrane  affected,  is  one  of  the 
most  powerful  means,  which  we  possess,  of 
correcting  its  disposition  to  chronic  blennor- 
rheea.  But,  he  who  believes,  1 hat  the  best  man- 
ner of  applying  these  substances,  is  to  inject 
them  with  AneTs  syringe,  introduced  through 
the  puncta,  is  lamentably  mistaken.  He.  i?, 
in  fact,  closing  his  eyes  upon  what  h<-  must 
know  of  the  functions  of  the  several  pai  ls  of 
the  lachrymal  organs,  and  is  doing  that  very 
thing,  which  is  calculated  to  prolong  and  tx- 
aspeiate  the  disease.  Except  at  the  time  of 
a smart  renewal  of  the  inflammation,  the 
puncta  and  canals,  during  thisdise  .se.  con- 
tinue in  the  exercise  of  their  functions.  Wh  t- 
ever  fluid,  therefore,  is  dropped  into  the  lacus 
lachrymarum,  will  be  taken  up  by  ike  puncta, 
conveyed  through  the  canals,  and  applied  to 
the  whole  internal  surface  of  the  Sic.  Even 
ointments,  placed  within  reach  of  the  puncta, 
will  be  absorbed  in  the  same  manner.  “ We 
ought  then  first  of  all  to  empty  the  sac  by 
pressure,  and,  if  possible,  through  the  nasal 
duct  into  tiie  nose.  Having  placed  the  pa- 
tient upon  his  back,  we  drop  into  the  lacus 
I.mbrymarura  a small  quantity  of  a weak  so- 


i i i# 

lution  of  corrosive  sublimate.  aq.  ros. 
t-iv.  hydrarg.  oxymunatis  gr.ss.  grj  Muciioj. 
vmi  opii  3j.  M.  Atier  remaining  lor  a quarter 
of  an  hour  in  that  position,  he  ought  to  rise, 
byt  without  wiping  away  any  ot  the  colly  - 
rium,  which  may  remain.  After  another  quar- 
ter of  an  hour,  tfie  eyelids  are  to  be  careiully 
dried,  and  a little  ol  Janins’s  ophthalmic  oint- 
ment applied  with  a caincl-haii  pen  il  to  the 
carunculu'lrtcbry  maiis  and  edges  of  the  eyelids. 
All  this  is  10  he  carefully  repeated  twice  a 
day.”  Professor  Schmidt  recommends  the 
following  col!)  rium.  ]^.  Aq.  rosaj  |vj.  acid 
nitrici  3j.  alcnoholis  3j-  M.  For  in,  iemo- 
v.d  ot  Uic  induration  over  the  sat  gentle  tric- 
tion,  with  camphorated  mercurial  ointment  is 
recommended.  And,  says  Mr.  lYPKenzie, 
it  the  bleuiiorrhoeo  depend  upon  chronic  in- 
flammation ol  the  Meibomian  glands,  the 
diluted  ciirin  ointment  is  to  he  applied  every 
evening  at  bed-time.  (On  Diseases  of  the, 
Lachrymal  Organs,  p.  43,  «^c.)  In  tue  first 
Stage  ui  what  Scarpa  terms  the  puriform 
discharge  ot  the  palpebral,  when  the  weeping' 
is  incipient,  this  author  slates,  that  a cure 
may  be  effected,  without  dividing  the  sac,  or 
any  other  painful  operation.  His  practice 
consists  m restraining  the  immoderate 
secretion  from  the  Meibomian  glands  and 
internal  membrane  ol  the  palpebral,  and 
in  cleansing  the  viae  laciirymales  through 
their  whole  extent  by  means  it  injec- 
tions of  warm  water,  rendered  more  ac- 
tive by  the  addition  of  a little  spirit  of  wine, 
aud  thrown  into  the  puncta  lachrvmaiia 
every  morning  and  evening;  a measure, 
which,  u?  already  stated,  is  disapproved  of 
by  Mr.  .VTKenzie,  Schmidt,  k.e.  Scarpa 
considers  Janins’s  ophthalmic  ointment, 
weakened  with  lard,  or  fresh  butter,  as  the 
best  application  tor  correcting  the  moibid 
secretion  of  the  eyelids.  A portion,  equal  to 
the  size  ot  a barley  corn,  is  to  be  introduced 
upon  ihe  point  ol  a bium  probe,  every  morn- 
ing 'tint  evening,  between  the  eye  and  eye- 
lids, near  he  external  angle,  and  ihe  edges  of 
the  )ends  are  to  be  smeared  with  it.  The 
eye  ts  .nen  to  be  shui-  and  the  eyelids  gently 
rubbt.d,  so  lhai  the  ointment  may  be  distri- 
buted upon  ihe  whole  of  their  internal  sor- 
lace.  A compress  and  bandage  should  be 
applied,  and  t tie  eyelids  kept  closed  for  two 
hours.  At  the  end  ot  this  tune,  ine  eye 
stiou.d  be  washed  with  the  zinc  colfynum. 
When  there  are  superficial  ulcerations  at  ihe 
edges  ot  the  tyeiiu's,  Scarpa  applies  to  them 
either  Janins’s  ointment,  or  die  uugueulum 
hydrarg.  nitrat.,  and  in  very  obsi male  cases, 
the  argentum  nuraiura  itself,  li  the  vessels 
ot  die  co.ijuiu  ivaare  varicose,  he  drops  into 
.lie  eye  me  on  mra  thebaica.  (bcarpa,  Ed, 
2,  by  Briggs,  chap.  1.) 

Tue  i.t;e  .vi..  VV  a iv  was  earlier  than  Scar- 
pa in  pointing  out  the  advantage  ot  making 
applications  to  the  inside  ot  the  ey(  lias,  for 
the  leliei  of  certain  tonus  ol  disease,  usually 
classed  with  fistula  lachrymalis. 

‘‘  When  an  epiphora  (says  he)  is  occasioned 
by  an  acrimonious  discharge  from  the  seba- 
ceous glands  on  the  edges  of  the  eyelids,  it 
must  be  evident,  that  injections  into  the  sac 


174 


LACHRYMAL  ORGANS. 


will  be  very  insufficient  to  accomplish  a cure, 
because  the  sac  is  not  the  seal  of  the  disorder. 
The  remedies  that  are  employed  must  be  di- 
rected, on  the  contrary,  to  the  ciliary  glands 
themselves,  in  order  to  correct  the  morbid 
secretion  that  is  made  by  them  ; and  for  this 
purpose,  I do  not  know  any  application  that 
is  so  likely  to  prove  so  effectual  as  the  unguen- 
turn  hydrargyri  nitratn,  of  the  new  London 
Dispensatory,  which  should  be  used  here  in 
the  same  manner,  in  which  it  is  applied  in 
common  cases  of  the  psorophthalmy.  It  will 
be  proper  to  cleanse  the  eyelids  every  morn- 
ing, from  the  gum  that  collects  on  their  edges 
during  the  night,  with  some  soft  unctuous 
applications  ; arid  I usually  advise  to  apply  to 
them,  two  or  three  times,  in  the  course  of 
the  day,  a lotion  composed  of  three  grains  of 
white  vitriol,  in  two  ounces  ot  rose  or  elder- 
flower  w’ater.”  (Additional  Remarks  on  the 
Epiphora.) 

In  a modern  periodical  work  may  be  pe- 
rused some  interesting  remarks  by  M.  Nicod, 
which  perfectly  accord  with  the  sentiment 
already  expressed,  that  whatever  may  be  its 
primary  seat  the  chronic  inflammation  is  not 
gener'dly  limited  to  the  inside  of  the  eyelids, 
but  extends  throughout  the  membranous  li- 
ning of  the  sac  and  nasal  duct,  and  that  this 
circumstance,  in  conjunction  with  the  altered 
and  viscid  nature  of  the  secretion.^,  accounts 
for  their  not  readily  descending  into  the  nose, 
but  regurgitating  tmough  the  puncta.  M. 
Nicod  also  relates  cases  exemplityingthat  the 
ointment  applied  to  the  inside  of  the  eyelids 
actually  passes  with  the  matter  into  the  la- 
chrymal sac,  and  thence  into  the  nose,  so  as 
to  act  upon  and  cure  the  chronic  inflammation 
of  the  sac  and  nasal  duct,  as  well  as  that  of 
the  Meibomian  glands  and  lifting  of  ihe  eye- 
lids. (Sf,e  Revue  Medicate  Historique,  ty-c.  T. 

p.  156,  8 vo.  Paris,  1820.)  The  proceedings 
for  adoption,  when  tne  nasal  duct  is  obstruct- 
ed, vvili  now  be  considered. 

Obstruction  of  the  Nasal  Duct. — That  a 
permanent  closure  of  this  canal  does  notso  fre- 
quently attend  diseases  of  the  lachrymal 
organs,  as  writers  have  generally  imagined, 
must  be  evident  from  the  remarks  already 
delivered ; and  also  that  its  perviousness, 
when, interrupted  partly  by  inflammation  and 
thickening  of  its  lining,  and  partly  by  the 
viscid  curdy  nature  of  the  matter,  may  gene 
rally  be  restored,  w itnout  thrusting  any 
probes,  tubes, or  other  instruments  down  the 
passage,  (measures,  more  likely,  under  these 
circumstances,  to  do  harm  than  good,)  is  a 
fact,  which  is  no  longe;  questionable.  The 
treatment,  necessary  in  such  cases,  mu-t  be 
already  i telligible  from  what  has  been  said 
in  the  preceding  sections,  ’he  indication  being 
the  diminution  of  the  thickened  state  of  the 
mucous  membrane,  by  means  adapted  to  the 
acute,  or  chronic  form  of  (he  inflammation, 
an  i,  in  n any  cases,  the  correction  also  of  the 
morbid  state  ol  the  Meibomian  glands  arid 
internal  membrane  of  the  eyelids.  It  is  only 
when  the  treatment,  conducted  upon  these 
mild  principles,  is  found  ineffectual,  that  the 
surgeon  should  think  of  examining  the  state 
of  the  nasal  duct,  ami  learning,  bv  the  intro- 


duction of  a fine  probe  into  the  passage, 
whether  any  permanent  stricture,  orobstruo 
tion,  is  present.  It  does  not  appear  to  me, 
that  it  is  a matter  of  much  importance,  ube 
t her  the  probe  he  made  of  whalebone,  as 
Beer  recommends,  or  of  silver  ; but,  that  it 
should  nut  be  too  thick  is  a thing  certainly  de- 
serving greater  attention.  Supposing  there  is 
no  direct  opening  through  the  skin  into  the 
lachrymal  sac,  one  should  be  made  with  a 
lancet.  However,  a mere  puncture  will  suf- 
fice, as  a large  incision,  beginning  just  below 
the  tendon  of  the  orbicularis  palpebrarum 
muscle,  and  extending  in  a semilunar  form, 
nearly  an  inch  dounwrards  and  outwards,  as 
used  to  be  the  old  practice,  can  here  answer 
no  rational  object,  the  surgeon  merely  having 
occasion  for  a small  direct  opening,  through 
which  he  may  conveniently  pass  a small 
probe,  for  the  purpose  of  ascertaining  the 
state  of  the  nasal  duct.  “ The  probe,  (as  Mr. 
iVPKenzie  observes,)  is  to  be  introduced  hori- 
zontally till  it  touches  the  nasal  side  of  the 
sac;  it  should  then  be  raised  into  a vertical 
position,  and  its  point  directed  down  wards 
and  a little  backwards.  Turning  ihe  probe 
upon  its  axis,  we  pass  if  from  the  sad  into  the 
duct;  and  as  we  continue  to  press  it  gently 
downwards,  the  instrument,  it  the  sac  is  per- 
vious- enters  the  nose.  If  its  point  meets  w ith 
some  obstruction,  we  must  not  immediately 
conclude,  that  there  is  an  obliteration  of  the 
duct.  We  must  press  down  the  probe  a lit- 
tle more  strongly,  yet  w ithout  violence,  turn- 
ing it  round  between  the  fingers,  and  giving 
it  different  directions.  By  these  means,  the 
obstacle  is  frequently  overcome,  and  the 
probe  suddenly  descends.  If  the  obstacle 
remains  as  before,  and  is  extremely  firm,  still 
this  is  no:  sufficient  ground  for  us  to  conclude, 
that  there  is  a real  obliteration,”  because,  as 
the  author  proceeds  to  point  out,  the  difficulty 
may  arise  from  a mere  thickening  of  the  mu  - 
cous membrane  and  swelling  and  induration 
of  its  cryptic.  {M: Kensie  on  the  Lachrymal 
Organs , p.  78.) 

When  the  probe  has  entered  a good  way 
down  the  n.isai  duct,  and  becomes,  as  it 
were,  wedged,  Beer  leaves  the  instrument  in 
this  position,  until  the  next  time  of  dressing, 
taking!  are,  however,  to  fix  it  to  the  forehead, 
so  that  it  may  not  slip  out  again.  At  the  same 
time,  he  introduces  into  the.  lachrymal  sac  a 
tent,  which  he  keeps  in  with  a piece  of  stick- 
inn  piaster.  ( Lehre  von  den  Augenkr.  B.  2, 
p.  168  ;)  a measure  which  I conceive  may  he 
advantageously  dispensed  with.  When,  at 
length,  the  probe  can  be  made  to  pass  with 
some  trouble  into  the  nostril,  Beer  recom- 
mends introducing  the  instrument  regularly 
every  day,  u til  the  increased  diameter  of 
the  passage  allows  it  to  be  put  in  and  with- 
draw n without  ihe  slightest  difficulty.  The 
period  is  now  arrived,  when  Beer  conceives, 
that  some  measure  should  be  taken  for  ten- 
dering the  perviousne<s  of  the  nasal  duct 
complete  and  permanent,  and  thus  entirely 
re-establishing  (he  efficiency  of  the  excre- 
ting parts  of  the  lachrymal  organs.  But 
says  this  author,  whoever  merely  aims  at; 
restoring  the  natural  diameter  of  the  nast 


LACHRYMAL  ORGANS 


duct  by  mechanical  means,  fulfils  only  one, 
and  that  not  the  most  essential  indication. 
And  in  order  that  the  duct  may  retain  its 
natural  diameter,  and  the  tears  and  mucus 
descend  freely  into  the  nose,  it  is  necessary, 
that  the  morbid  state  of  the  mucous  mem- 
brane be  first  removed,  and  the  action  of  the 
excreting  parts  of  the  lachrymal  organs 
rectified  again  ; objects  which  cannot  be 
performed  by  any  mechanical  means.  Hence, 
Beer  places  considerable  stress  upon  the  ne- 
cessity of  obviating  every  unfavourable 
state  of  the  health,  likely  to  affect  the  mucous 
membrane  of  the  lachrymal  sac.  For  the 
purpose  of  restoring  the  natural  diameter  of 
the  nasal  duct,  the  experience  of  many  years 
has  convinced  him,  that  pieces  of  violin  cat- 
gut, which  are  to  be  gradually  increased  in 
size,  are  the  best.  The  end  of  the  piece, 
which  is  to  be  introduced,  is  to  be  first  sof- 
tened a little  between  the  teeth,  straightened, 
and  dipped  in  sweet  oil.  Then  at  least  six 
inches  of  it  are  to  be  introduced,  so  that  its 
lower  end  may  be  easily  drdvvri  out  of  the 
nostril;  a business,  which  Beer  always  lets 
;he  patient  do  himself.  The  upper  portion  of 
the  catgut  is  coiled  up,  and  kept  within  a lit- 
tle linen  compress,  on  the  patient’s  forehead. 
Beer  also  places  in  the  opening  of  the  sac  a 
imal)  dossil  of  lint,  and  covers  it  with  bit  of 
sticking  plaster.  In  two  hours,  the  patient  is 
to  try  to  force  the  lower  end  of  the  catgut 
out  of  the  nostril,  by  driving  the  air  through 
the  opening,  while  the  mouth  and  opposite 
nostril  are  shut.  As  soon  as  the  end  of  the 
catgut  is  secured,  it  is  to  bp  turned  over  the 
side  of  the  nose,  and  fixed  there  with  a piece 
of  sticking  piaster.  The  next  day,’  the  bit 
of  plaster  over  the  sac  is  to  be  loosened  with 
warm  water,  and  together  with  (he  dossil  of 
lint,  taken  awav,  and  one  of  the  lotions, 
hereafter  specified,  injected  down  the  pas- 
sage. The  upper  end  of  the  catgut  on  the 
forehead  is  next  to  be  unfastened,  and  a fresh 
portion  of  it  covered  with  some  of  the  ap- 
plications, presently  mentioned,  wheri  the 
patient  is  to  draw  it  into  the  sac  and  duct,  by 
gently  pulling  the  end,  which  hangs  out  of 
the  nostril.  The  superfluous  lower  piece  of 
catgut  is  now  cut  away,  and  the  new  piece 
turned  up,  and  fixed  to  the  side  of  the  nose. 
The  injection  is  again  repeated,  and  he 
dressings  applied,  as  before.  The  same  me- 
thod is  to  be  continued,  until  ihe  whole  of  the 
first  piece  of  catgut  is  expended.  Sotne  wa- 
ter, coloured  ‘with  the  vinous  tincture  of 
opium,  is  now  to  be  thrown  down  die  sac, 
in  order  to  see,  whether  any  part  of  the  fluid 
will  pass  into  the  nose,  and  what  progress 
lias  been  made.  Then  a larger  piece  of  cat- 
gut is  to  be  employed,  exactly  in  the  manner 
ol  the  first,  and  when  if  is  ali  exhausted,  the 
coloured  injeeiion  is  to  be  used  again,  in  or- 
der to  learn  w hat  advance  has  been  m de  in 
the  re-establishment  of  the  natural  diameter 
of  the  passage.  Lastly,  a catgut  of  still  larger 
size  is  to  be  used^  after  which  the  coloured 
injection  w ill  be  found,  when  the  patient  in 
dines  bis  bead  forwards,  to  run  freely  out  of 
the  nostril,  and  not  merely  drop  into  it,  as  it 
did  previously  When  this  is  the  stste  of 


things,  all  further  dilatation  becomes  unne- 
cessary. (Beer,  Lehr e von  den  Augenkr.B. 
2,p.  169—172.) 

This  author  then  repeats  his  decided 
opinion,  that  the  mechanical  treatment  with 
catgut,  bougies,  cannula;,  &c.,  will  only- 
answer,  when  attention  is  paid  to  rectifying 
the  morbid  state  of  the  mucous  membrane 
of  the  lachrymal  sac  by  means  of  suitable 
applications,  the  use  of  which,  he  thinks, 
ought  to  commence  with  the  first  employ- 
ment of  the  catgut.  And,  he  adds,  that  even 
such  treatment  will  only  succeed,  w hen  the 
diseased  state  of  be  membrane  of  the  sac  is 
entirely  a local  complaint,  and  uncomplica- 
ted w ith  any  unfavourable  condition  of  the 
health.  In  the  beginning,  if  the  probe  can 
be  introduced  without  any  great  trouble, 
and  the  lining  of  the  duct  js  only  trivially 
thickened,  Beer  moistens  the  catgut,  on  its 
daily  introduction  into  the  passage,  with  the 
vinous  tincture  of  opium,  and  injects  into 
the  sac  a lukewarm  lotion,  containing  the 
proportions  of  subacetate  of  copper,  nitrate 
of  potass,  alum,  camphor,  and  vinum  opii, 
specified  in  one  of  the  preceding  columns. 
The  lint,  wdiich  Beer  places  in  the  orifice  of 
the  sac,  is  also  dipped  in  the  vinum  opii. 
When  the  probe  meets  with  more  resist- 
ance, the  catgut  is  smeared  with  the  ungu- 
entum  hydrargyri  nitrati,  which  is  to  be  at 
first  weakened,  and  afterward  gradually  in- 
creased in  strength.  The  wound  is  also  to 
be  dressed  with  the  same  application,  and 
some  of  the  following  lotion  injected  down 
the  sac  twice  a day  : Aq  Ros  J!v.  Hy- 

drarg.  Oxyrnur.  grj.  ss.  gr.  j.  Mucil  pur.  3j* 
Vim  opii  3j.  M.  When  any  irregularities 
and  indurated  points  are  felt  with  the  probe 
in  the  course  of  the  nasal  duct,  Beer  smears 
the  catgut  with  an  ointment,  containing  a 
small  quantity  of  red  precipitate,  and  directs 
frictions  w ith  a little  camphorated  mercurial 
ointment  to  be  employed  every  day  round 
the  external  opening. 

Beer  joins  the  generality  of  writers  in  be- 
lieving. that  a long  perseverance  in  the  me- 
chanical means  is  necessary,  in  order  to  re- 
move all  disposition  in  the  nasal  duct  to 
close  again.  (P.  176.)  And,  as  the  use  of 
the  probes,  syringe,  catgut,  and  dossils  of 
lint,  may  be  supposed  to  have  done  more  or 
less  injury  to  the  lachrymal  ducts,  so  as  to 
cause  some  impediment  to  the  due  convey- 
ance of  the  tears  into  the  lachrymal  sac, 
Beer  advises  a trial  to  be  made,  whether  a 
couple  of  drops  of  some  coloured  fluid,  in- 
troduced  into  the  inner  canthus,  while  (he 
patient  is  lying  upon  his  hack,  w ill  pass  into 
the  lachrymal  sac  ; and,  if  they  will  not  do 
so,  the  same  author  thinks,  that  an  attempt 
should  be  immediately  made  to  clear  the  la- 
chrymal ducts,  by  means  of  Anel’s  probe, 
(P.  1 77.) 

According  to  Beer,  the  foregoing  treat 
ment  is  perfectly  useless,  whenever  the  la- 
chrymal puncta  and  ducts  are  obliterated 
because,  even  ij^  it  were  practicable  to  re- 
store their  perviousness,  it  would  yet  be  im 
possible  to  communicate  to  the  new-formed 
apertures  and  canals  the  potver  of  absorbin'.. 


i7b 


LACHRYMAL  ORGANS. 


the  tears  and  conveying  them  into  the  la- 
chrymal sac.  He  thinks,  that,  in  this  state 
of  things,  the  practitioner  need  not  trouble 
himself  about  the  condition  of  the  nasal 
duct;  because,  even  if  it  were  rendered 
duly  pervious,  this  improvement  would  not 
continue  long,  as  Beer’s  experience  has  fully 
convinced  him,  that,  when  the  mucous  se- 
cretion of  the  lachrymal  sac  is  not  blended 
with  the  tears,  a closure  of  the  nasal  duct 
sooner  or  later  ensues,  and  of  course  an  ac- 
cumulation of  the  mucus  of  the  sac,  a dis- 
ease sometimes  termed,  under  such  circum- 
stances, hydrops  sacculi  lachry walls.  And  in 
order  to  prevent  this  complaint  in  the  state 
of  things  just  now  described,  Beer  is  an  ad- 
vocate for  the  total  obliteration  of  the  cavi- 
ty of  the  sac  with  escharotics.  (B.  2,  p. 
181.) 

Such  is  the  practice  of  Beer,  with  the 
view  of  clearing  away  obstruction  in  the 
nasal  duct,  and  restoring  its  natural  diame- 
ter. Let  us  now  consider  what  methods 
have  been  suggested  by  others.  Beginning 
then  with  the  screw,  invented  by  Fabricius 
ab  Aquapendente,  for  compressing  the  dis- 
tended lachrymal  sac,  f need  only  remark 
with  M.  Nicod,that,  as  this  plan  was  not  di- 
rected against  the  cause  of  1 he  disease,  it  is 
not  surprising,  that  it  should  have  been  una- 
vailing. and  ultimately  banished  from  prac- 
tice. In  the  year  1716,  Anel  invented  a 
probq  of  so  small  a size,  that  it  was  capable 
of  parsing  from  the  upper  punctual  lachry- 
male  into  the  lachrymal  sac,  and  nasal  duct, 
the  obstructions  in  which  latter  passage  it 
was  intended  to  remove.  Anel  also  invented 
a syringe,  v\  hose  pipe  was  sm  >11  enough  to 
enter  one  of  the  puncta,  and  by  that  means 
to  furnish  an  opportunity  of  injecting  a liquor 
into  the  sac  and  duct  ; and  with  these  two 
instruments  he  pretended  to  be  able  to  cure 
the  disease  whenever  it  consisted  in  obstruc- 
tion merely,  and  the  discharge  was  not  much 
discoloured.  “ The  first  of  these,  viz.  the 
passage  of  a small  probe  through  the  puncta, 
('says  Mr.  Pott)  has  a plausible  appearance, 
but  will,  upon  trial,  be  found  very  unequal 
to  the  task  assigned  ; the  very  small  size  of 
it,  its  necessary  flexibility,  and  the  very  little 
resistance  it  is  capable  of  making,  are  mani- 
fest deficiencies  in  the  instrument ; the  quick 
sensation  in  the  lining  of  the  sac  and  duct, 
and  its  diseased  state,  are  great  objections  on 
the  side  of  the  parts,  supposing  that  it  was 
capable  of  answering  any  valuable  end, 
which  it  most  certainly  is  not.”  {Poll.) 

It  must  be  at  once  obvious,  that  Anel’s 
instruments  were  devised  with  the  view  of 
avoiding  a puncture  in  the  lachrymal  sac  ; 
but  the  principle  has  been  strongly  objected 
to  by  Beer,  there  being  no  comparison  be- 
tween the  inconveniences  of  a small  open- 
ing made  in  the  sac,  and  the  injury  done  to 
rhe  lachrymal  puncta  and  canals  by  the  long 
and  repeated  introduction  of  instruments 
through  them,  whereby  their  functions  are 
likely  to  be  for  ever  ruined,  of  which  Beer 
has  seen  some  sad  examples.  ( Lekrc , ^-c.  B. 
2,  p.  169.) 

The  next  practice  deserving  notice,  is  that 


of  Laforest,  who  used  to  introduce  into  the 
termination  of  the  nasal  duct  in  the  nostril  a 
probe,  with* which  he  cleared  away  the  ob- 
struction in  the  passage.  He  also  introdu- 
ced into  the  same  orifice  a curved  tube, 
which  was  left  in  the  part  three  or  four 
months,  for  the  purpose  of  employing  injec- 
tions. The  method,  however,  was  found  not 
only  troublesome  and  difficult,  on  account 
of  the  anatomical  varieties  to  which  the  ter- 
mination of  the  nasal  canal  was  liable,  but 
also  on  account  of  the  treatment,  when 
practised,  being  subject  to  frequent  failures. 

Following  up  the  principles  of  Anel, 
another  French  surgeon,  Mejean,  dilated  the 
nasal  duct  with  a seton,  which  was  drawn 
up  into  the  lachrymal  sac  by  means  of  a 
thread  first  introduced  fro  m the  upper  punc- 
tual lachrymaie.  But  it  was  soon  discover- 
ed, that  what  was  gained  on  one  side,  was 
lost  on  the  other ; the  lodgment  of  the 
thread  in  the  lachrymal  duct  for  several 
months,  and  the  irritation  of  its  orifice  in 
changing  the  seton  every  day,  not  only 
causing  inflammation  of  the  punctum  lachry- 
maie, but  even  such  ulceration  and  cicatri- 
ces, as  sometimes  destroyed  the  functions  of 
the  parts. 

J.  L.  Petit,  sensible  of  live  inconveniences 
of  Mejean’s  practice,  and  disgusted  with  the 
barbarous  imitation  of  the  ancient!  in  cauter- 
izing th^  fistula,  sac,,  and  os  unguis,  concei 
ved  that,  instead  of  these  plans,  or  that  of 
perforating  the  os  unguis,  as  proposed  by 
Woodiouse,  it  would  be  better  to  endeavour 
to  restore  the  natural  passage,  by  removing 
the  obstruction  in  the  nasal  duct,  which  ob- 
struction Petit  regarded  as  the  cause  of  the 
disease.  His  method  consisted  in  opening 
the  lachrymal  sac  with  a small  bistoury,  in- 
troducing through  the  wound,  sac,  and  nasal 
duct  a probe,  down  into  the  nostril,  anil 
then  using  bougies  for  the  dilatation  of  the 
passage.  This  method  may  be  said  to  be 
the  model  of  that  which  has  been  most  ex- 
tensively followed  even  down  to  the  present 
time.  Pellier  and  Wathen  recommended 
introducing  a metahic  tube  down  the  ductus 
nasalis,  and  leaving  it  for  a time  in  that  situa- 
tion, with  a view  of  preventing  the  duct  from 
closing  again  ; and  the  use  of  a cannula  is 
even  now  preferred  by  Dupuytren,  the 
greatest  surgeon  of  France. 

The  desire  of  avoiding  any  puncture  of 
the  sac  has  influenced  many  practitioners 
besides  Anel,  and  given  rise  to  various  inge- 
nious inventions.  Thus,  in  17S0,  Sir  William 
Blizard  proposed,  instead  of  injecting  water, 
to  introduce  quicksilver  through  a small 
pipe,  communicating  with  a long  tube  full 
of  this  fluid.  I he  specific  gravity  of  the 
quicksilver,  when  the  sa  was  distended 
with  it,  he  believed  would  have  more  power 
than  water  propelled  through  a syringe,  to 
remove  the  lachrymal  obstruction. 

The  late  Mr  Ware,  after  trying  Sir  Wil- 
liam Blizard’s  plan,  gave  the  preference  to 
Anel’s  syringe,  with  which  he  generally  in- 
jected warm  water,  through  the  lower  punc- 
tual lachrymaie,  into  the  lachrymal  sac,  and 
put  a finger  over  the  superior  puUCt »nf» 


m 


LACHRYMAL  ORGANS. 


prevent  the  Quid  from  escaping  through  it. 
With  his  finger  he  also  occasionally  com- 
pressed the  lachrymal  sac,  in  order  to  assist 
in  propelling  the  water  down  into  the  nose. 
Mr.  Ware  sometimes  used  the  injection 
thrice  a day,  though,  in  general,  much  less 
frequently.  (See  Ware  on  the  E pi  for  a.) 

11 1 in  general  begin  the  treatment  by  in- 
jecting some  warm  water  through  the  infe- 
rior punclum  laebryrnale,  and  I repeat  the 
operation  four  or  five  days  in  succession. 
If  in  this  space  of  lime,  none  of  the  water 
pass  through  (he  duct  into  the  nose,  and  if 
the  watering  of  the  eye  continue  as  trouble- 
some as  it  was  before  the  injection  was  em- 
ployed, I usually  open  the  angular  vein,  or 
direct  a leech  to  be  applied  near  the  lach- 
rymal sac  ; adding  here  a caution,  that  the 
leech  be  not  suffered  to  fix  on  either  of  the 
eyelids,  lest  it  produce  an  extravasation  of 
blood  in  the  adjacent  cells.  About  the  same 
time  that  blood  is  taken  away  in  the  neigh- 
bourhood of  the  eye,  I usually  vary  the 
injection,  and  try  the  effects  cither  of  a 
weak  vitriolic,  or  anodyne  lotion.  In  some 
instances  also,  when  I have  found  it  impos- 
sible, after  several  attempts,  to  inject  any 
part  of  the  liquid  through  the  duct,  I have 
introduced  a golden  probe,  about  the  siae 
of  a bristle,  through  the  superior  puncturn 
lachrymale,  and,  attending  to  the  direction 
of  the  duct,  have  insinuated  its  extremity 
through  the  obstruction,  and  conveyed  it 
fully  into  the  nose;  immediately  after  which 
I have  found  that  a liquid,  injected  through 
the  inferior  puncturn,  has  passed  without 
any  difficulty  ; and  by  repeating  these  ope- 
rations for  a few  successive  days,  I have  at 
length  established  the  freedom  of  t he  pas- 
sage, and  completed  the  cure.  In  other  in- 
stances, I have  recommenced  a strongly 
stimulating  sternutatory  to  he  snuffed  up 
the  nose,  about  an  hour  before  the  time  of 
the  patient’s  going  to  rest,  which,  by  exciting 
a large  discharge  from  the  Schneiderian 
membrane,  has  sometimes  also  greatly  con- 
tributed to  open  the  obstruction  in  the  nasal 
duct 

“ Cases  occur  very  rarely  which  may  not 
be  relieved  by  some  of  the  means  above  re- 
lated.” {Ware's  Additional  Remarks  on  the 

Epiphora. ) 

Wfrfen  the  discharge  was  fetid,  Mr.  Ware 
sometiipes  found,  that  a vitriolic  lotion  in- 
jected into  the  sac,  quickly  corrected  the 
quality  of  the  matter. 

In  a subsequent  tract,  Mr.  Ware  observes, 
that  if,  after  “ about  a week  or  ten  days, 
there  be  not  some  perceptible  advance  to- 
wards a cure,  or,  if,  from  the  long  continu- 
ance of  the  obstruction,  there  be  reason  to 
fear,  that  it  is  too  firmly  fixed  to  yield  to 
this  easy  mode  of  treatment,  I do  not  hesitate 
to  propose  the  operation  which  is  now  to  be 
described.  .The  only  persons,  with  respect 
to  whom  I entertain  any  doubts  as  to  the 
propriety  of  this  opinion,  are  infants.  In 
such  subjects,  1 always  think  it  adviseable  to 
postpone  the  operation,  unless  the  symp- 
toms-be  particularly  urgent,  until  they  are 
eigljX  or  nine  years  old. 

Yh t,  FT  ' * 


“ If  the  disease  has  not  occasioned  an 
aperture  in  the  lachrymal  sac,  or  if  this 
aperture  be  not  situated  in  a right  line  with 
the  longitudinal  direction  of  the  nasal  duct, 
a puncture  should  be  made  into  the  sac,  at  a 
small  distance  from  the  internal  juncture  of 
the  pnlpebr®,  and  nearly  in  a line  drawn 
horizontally  from  this  juncture  toward  the 
nose,  with  a very  narrow  spear-pointed 
lancet.  The  bl  unt  end  of  a silver  probe,  of 
a size  rather  smaller  than  the  probes,  that 
are  commonly  used  by  surgeons,  should  then 
be  introduced  through  the  wound,  and  gently, 
but  steadily,  be  pushed  on  in  the  direction 
of  the  nasal  duct,  with  a force  sufficient  to 
overcome  the  obstruction  in  this  canal,  and 
until  there  is  reason  to  believe,  that  it  has 
freely  entered  into  the  cavity  of  the  nose. 
The  position  of  the  probe,  when  thus  intro- 
duced, will  be  nearly  perpendicular ; its 
side  will  touch  the  upper  edge  of  the  orbit : 
and  the  space  between  its  bulbous  end  in 
the- nose  and  the  wound  in  the  skin  will 
usually  be  found,  in  a full-grown  person,  to 
be  about  an  inch  and  a quarter,  or  an  inch 
and  three-eighths  The  probe  is  then  to  be 
withdrawn,  and  a silver  style  of  a size  nearly 
similar  to  that  of  the  probe,  but  rather  small  - 
er, about  an  inch  and  three-eighths  in  length, 
with  a Hat  head  like  that  of  a nail,  but. 
placed  obliquely,  that  it  may  sit  close  on  the 
skin,  is  to  be  introduced  through  the  duct,  in 
place  of  the  probe,  and  to  be  left  constantly 
in  it.  .For  the  first  day  or  two  after  the 
style  has  been  introduced,  it  is  sometimes 
adviseable  to  wash  the  eye  with  a weak  satur- 
nine lotion,  in  order  to  obviate  any  tendency 
to  inflammation  which  may  have  been  exci- 
ted by  the  operation  ; but  this  in  general  is 
so  slight,  that  l have  rarely  had  occasion  to 
use  any  application  to  remove  it.  The  style 
should  be  withdrawn  once  every  day  for 
about  a week,  and  afterward  every  second 
or  third  day.  Some  warm  water  should 
each  time  be  injected  through  the  duct  into 
the  nose,  and  the  instrument  he  afterward 
replaced  in  the  same  manner  as  before.  I 
formerly  used  to  cover  the  head  of  the  style 
with  a piece  of  dyachylon  plaster  spread  on 
black  silk  ; but  have  of  late  obviated  the 
necessity  for  applying  any  plaster  by  black- 
ening the  head  of  the  style  with  sealing 
wax.” 

Mr  Ware  did  not.  on  first  trying  this  me- 
thod, expect  any  relief,  till  the  style  was  left 
off.  However,  he  found,  that  the  watering 
of  the  eye  ceased,  as  soon  as  the  style  was 
introduced, and  the  sight  became  proportion- 
ably  more  useful  and  strong. 

The  wound,  which  Mr.  Ware  makes  in  the 
sac,  when  there  is  no  suitable  ulcerated 
aperture,  is  only  just  large  enough  to  admit 
the  end  of  the  probe,  or  style  ; and  this  soon 
becomes  a fistulous  orifice,  through  which 
the  style  may  be  passed  without  the  least 
pain.  In  short,  in  about  a week  or  ten 
days,  the  treatment  becomes  so  easy,  that 
the  patient,  or  any  friend,  is  fully  competent 
to  do  what  is  necessary.  It  merely  consists 
in  withdrawing  the  style,  two,  or  three  times 
a week,  occasionally  injecting  some  warm 


23 


ns 


LACHRYMAL  ORGANS. 


water,  and  then  replacing  the  instrument  as 
before. 

Some,  finding  no  inconvenience  from  the 
style,  and  being  afraid  to  leave  it  off,  wear  it 
for  years;  many  others  disuse  it  in  about  a 
month,  or  six  weeks,  and  continue  quite 
well.  The  ulcerations,  sometimes  existing 
over  the  lachrymal  sac,  commonly  heal,  as 
soon  as  the  tears  can  pass  down  into  the 
nose  ; but  Mr.  Ware  mentions  two  instances, 
in  which  such  sores  did  not  heal  until  a 
weak  solution  of  the  hydrargyrus  rauriatus, 
and  bark,  were  administered.  (See  Ware 
on  the  Fistula  Lachrymalis.) 

Great  as  the  recommendation  of  the  fore- 
going practice  is,  as  delivered  by  Mr.  Ware, 
Mr.  Travers  is  strongly  disposed  to  doubt, 
whether  any  permanent  benefit  was  ever 
derived  from  letting  the  style  remain  in  the 
passage.  When  an  abscess  over  the  sac  has 
been  opened,  this  gentleman,  instead  of  the 
introduction  of  a style  into  the  ductus  nasa- 
l’s, recommends  simply  the  examination  of 
the  duct  with  a fine  probe.  “ if  the  probe 
passes  without  resistance  into  the  nose,  the 
ease  requires  no  further  operative  treatment, 
the  integument  recovers  its  healthy  condi- 
tion under  an  emollient  application,  the 
discharge  gradually  diminishes,  and  the 
wound  heals.  If,  on  the  other  hand,  upon 
examination  with  the  probe,  introduced 
through  the  wound,  into  the  sac,  resistance 
is  offered  to  its  passage  into  the  nose,  no 
more  favourable  opportunity  will  be  pre- 
sented for  overcoming  such  resistance. 
This,  therefore,  should  be  accomplished, 
but  to  this  the  operative  process  should  be 
limited,  and  the  wound  should  be  suffered 
to  heal  without  further  disturbance.”  When 
there  is  what  Mr  Travers  terms  a stricture 
in  the  nasal  duct,  and  the  passage  of  the 
probe  is  more  firmly  resisted,  he  admits  that 
some  means  must  be  employed  for  keeping 
the  duct  pervious,  after  it  has  been  reopen- 
ed. He  never  interferes  with  the  integu- 
ments, except  in  the  case  ol  abscess  disco- 
louring the  skin,  and  threatening  to  produce 
a fistula ; and  for  the  purpose  of  restoring 
the  passage,  he  uses  a set  of  silver  probes,  of 
about  five  inches  long,  of  various  sizes, 
flattened  at  one  end,  and. slightly  bulbous  at 
the  point.  When  there  is  no  obstruction, 
these,  he  says,  may  be  introduced  with 
perfect  facility  from  either  of  the  puncta 
lachrymalia  into  the  nostril.  lt  If  the  punc- 
tual be  constricted,  it  is  readily  entered,  and 
dilated  by  a common  pin  ; and,  upon  with- 
drawing it,  by  one  of  the  smaller  probes. 
The  direction  and  relative  situation  of  the 
lachrymal  ducts,  the  sac,  and  nasal  canal, 
point  out  the  proper  course  of  the  instru- 
ment. It  is  confirmed  by  its  advance,  with- 
out the  employment  of  force,  and  the  sensa- 
tion conveyed  by  the  free  and  unincumbered 
motion  of  its  point.  Until  the  point  is  fairly 
within  the  sac,  it  is  necessary  to  keep  the 
eyelid  gently  stretched  and  slightly  everted ; 
the  upper  lid  being  drawn  a little  upward 
toward  the  brow  ; the  lower,  as  much  down- 
ward toward  the  zygoma.  The  point  carried 
borne  to  the  sac,  and  touching  lightly  its 


nasal  side,  the  lids  may  be  left  at  liberty, 
while  a half  circular  motion  is  performed  by 
the  instrument  ; the  surgeon  neither  suffer- 
ing the  point  to  recede,  nor,  on  the  other 
hand,  allowing  it  to  become  entangled  in 
the  membrane.  The  probe  now  rests,  in  a 
perpendicular  direction,  upon  the  eyebrow, 
toward  its  inner  angle,  and,  in  this  direction, 
it  is  to  be  gently  depressed,  until  it  strikes 
upon  the  lloor  of  the  nostril,  where  its  pre- 
sence is  readily  ascertained  by  a common 
probe  passed  beneath  the  inferior  turbinated 
bone.  The  probe,  of  smallest  dimensions, 
is  of  sufficient  firmness  to  preserve  its  figure 
in  its  passage  through  the  healthly  duct,  but 
it  is  too  flexible  to  oppose  any  considerable 
obstruction.  For  the  stricture  of  the  lachry- 
mal ducts,  it  is  of  sufficient  strength.  Very 
many,  cases  of  recent  origin,  and  in  which 
the  stricture  has  no  great  degree  of  firmness, 
(Mr.  Travers  says)  are  completely  cured  by 
three  or  four  introductions  of  the  probe  into 
the  nostril,  at  intervals  of  one,  or  two  days. 

I have  seldom  met  with  a stricture  so  firm  as 
not  to  yield^to  the  full-sized  probe.”  When 
the  resistance  is  not  altogether  removed, 
after  this  plan  has  been  tried  some'  days, 
Mr.  Travers  introduces  a style,  having  a small 
fiat  head,  a little  sloped,  through  the  pane- 
turn  lachrymale  into  the  nose,  and  leave  it 
in  the  nasal  duct  for  twenty-four  hours.  It 
worn  longer,  he  says,  that  it  causes  ulcera- 
tion of  the  orifice.  A day  or  two  is  to  elapse, 
before  the  style  is  again  introduced,  which 
must  now  be  passed  through  the  other  lach- 
rymal duct.  On  the  intervening  days,  tepid 
water  should  be  injected  with  Anel  s syringe. 
(Synopsis  of  the  Diseases  of  the  Eye.  p.  369, 
370,  372,  374.) 

Thus,  we  see,  that  Mr.  Travers’s  practice 
bears  a considerable  resemblance  to  that  of 
Anel,  inasmuch  as  the  sac  is  never  opened, 
except  when  likely  to  ulcerate,  and  nearly 
every  thing  is  done  with  probes  and  injec- 
tions, introduced  through  the  lachrymal 
puncta  and  ducts.  I wish  that  my  views  of 
the  nature  of  these  diseases,  and  of  the  parts 
concerned,  would  allow  me  to  think  the 
latter  proceedings,  in  the  ease  of  stricture  of 
the  nasal  duct,  as  commendable  as  another 
part  of  Mr.  Travers’s  practice,  where,  in 
cases  of  slighter  obstruction,  he  contents 
himself  with  opening  the  sac,  clearing  away 
the  stoppage  of  the  nasal  duct  with  a probe, 
and  healing  up  the  wound,  without  leaving 
an>  style,  cannula,  or  seton  in  the  passage. 
Where  the  obstruction  is  very  slight,  such 
practice  must  be  judicious.  But  if,  in  other 
cases,  it  he  deemed  right  for  the  prevention 
of  a relapse,  that  the  nasal  duct  should  be 
either  filled  with  some  dilating  instrument  a 
certain  time,  or  repeatedly  probed,  I am 
decidedly  of  opinion  with  Professor  Beer, 
M.  Nicod,  &c.  that  the  object  of  not  making 
a small  opening  in  the  sac  is  attended  with 
no  advantage,  at  ali  likely  to  counterbalance 
the  mischief,  which  must  be  done  to  the 
lachrymal  puncta  and  ducts,  not  only  by 
the  repeated  introduction  of  probes  and  of 
syringes,  but  by  the  lodgment  of  the  former 
in  them  for  the  space  <»i  twenty-four  hour* 


LACHRYMAL  ORGANS, 


m 


together.  If  there  be  an  opening  in  the  sac, 
its  convenience  iri  permitting  the  easy  use 
of  a probe  is  generally  acknowledged  ; and, 
in  order  to  gain  this  advantage,  and  avoid 
the  evils,  which  are  inseparable  from  taking 
too  much  liberty  with  the  lachrymal  puncta 
and  ducts,  surely  a slight  puncture  in  the 
sac,  if  there  be  no  opening  already , must  be 
the  most  rational,  simple,  and  successful 
practice. 

When  the  perviousness  of  the  nasal  duct 
cannot  be  restored  by  any  use  of  the  probe, 
and  the  obstructed  part  has  a very  elastic 
feel,  is  of  inconsiderable  extent,  and  near 
the  termination  of  the  duct  in  the  nostril, 
Beer  recommends  a perforation  to  be  made 
with  a trocar-shaped  probe,  the  point  of 
which  is  to  be  covered  with  a bit  of  wax, 
in  order  that  it  may  not  hurt  the  parts  in  its 
passage  downward.  Some  discharge  of 
blood  from  the  nose  indicates,  that  the  perfo- 
ration is  made.  The  sharp-pointed  probe  is 
then  to  be  withdrawn,  a blunt  one  used  for 
the  purpose  of  dilating  the  passage,  and,  at 
length,  the  catgut,  as  already  explained. 
(Beer,  B.2,p.  181.) 

Supposing  the  nasal  duct  to  be  obliterated 
for  a considerable  part  of  its  extent,  by  a 
firmer  substance,  what  practice  should  then 
foe  followed  ? Ought  the  formation  of  an 
artificial  passage  to  be  attempted  ? On  this 
point,  modern  practitioners  differ,  but,  as 
the  expedients  adopted  for  this  purpose 
cannot  be  judged  of  previously  to  their 
description,  it  will  be  better  in  the  first  place 
briefly  to  notice  them.  As  Mr.  Pott  has  re- 
marked, the  upper  and  hinder  part  of  the 
lachrymal  sac  is  firmly  attached  to  the  os 
unguis,  a small,  and  very  thin  bone,  just 
within  the  orbit,  which  bone  is  so  situated, 
that,  if  it  be  by  any  means  broken  through, 
the  two  cavities  of  the  nose  and  orbit  com- 
municate with  each  other:  consequently, 
the  os  unguis  forms  the  partition  Jaetween 
the  hinder  part  of  the  lachrymal  sac,  and 
the  upper  part  of  the  cavity  of  the  nose  ; 
and  it  is  by  making  a breach  in  this  partition, 
that  the  formation  of  an  artificial  passage 
has  been  attempted.  In  Mr.  Pott’s  time, 
the  cautery  had  long  been  disused  for  ma- 
king an  aperture  in  the  os  unguis,  and  vari- 
ous instruments  were  recommended  for  this 
object,  such  as  a large  strong  probe,  a kind 
of  gimblet,  a curved  trocar,  &sc.  each  of 
which,  says  this  practical  writer,  if  dexter- 
ously and  properly  applied,  will  do  the 
business  very  well  ; the  one  necessary  cau- 
tion is,  so  to  apply  whatever  instrument  is 
used,  that  it  may  pierce  through  that  part  of 
the  bone  which  ifes  immediately  behind  the 
sacculus  laArymalis,  and  not  to  push  too 
far  up  into  the  nose,  for  fear  of  injuring  the 
os  spongiosum  behind,  while  it  breaks  its 
way.  Mr.  Pott  adds,  that  he  himself  has 
always  used  a curved  troc&r,  the  point  of 
which  should  be  turned  obliquely  down- 
ward, from  the  angle  of  the  eye,  toward  the 
inside  of  the  nose.  The  accomplishment  of 
the  broach  will  be  known  by  the  discharge 
of  blood  from  the  nostril,  and  of  air  from  the 
woalid,  upon  blowing  the  nose.  Care -must 


be  taken  to  apply  the  instrument  to  the  part 
of  the  bone,  anterior  to  the  perpendicular 
ridge,  which  divides  it. 

As  soon  as  the  perforation  is  made,  a tent 
of  lint  should  be  introduced,  of  such  size  as 
to  fill  the  aperture,  and  so  long  as  to  pass 
through  it  into  the  cavity  of  the  nose  : this 
should  be  permitted  to  remain  in  two,  three, 
or  four  days,  and  afterward  a fresh  one 
should  be  passed  every  day,  until  the  clean 
granulating  appearance  of  the  sore  makes 
it  probable,  that  the  edges  of  the  divided 
membrane  are  in  the  same  state.  The 
business  now  is  to  prevent  the  incarnation 
from  closing  the  orifice  ; for  which  purpose, 
the  end  of  the  tent  may  be  moistened  with 
diluted  vitriolic  acid,  or  a piece  of  lunar 
caustic,  so  included  in  a quill,  as  to  leave 
little  more  than  the'extremity  naked,  may  at 
each  dressing,  or  every  other,  or  every 
third  day,  be*  introduced ; by  which  the 
granulations  will  be  repressed,  and  the  open- 
ing maintained  ; and  when  this  has  been 
done  for  some  little  time,  a piece  of  bougie 
of  proper  size,  or  a leaden  cannula,  may  be 
introduced  instead  of  the  tent;  and  leaving 
off  all  other  dressings,  the  sore  may  be  suf- 
fered to  contract  as  much  as  the  bougie  will 
permit;  which  should  be  of  such  length, 
that  one  extremity  of  it  may  lie  level  with 
the  skin  in  the  corner  of  the  eye,  and  the 
other  be  within  the  nose. 

The  longer  time  the  patient  can  be  prevail- 
ed upon  to  wear  the  bougie,  the  more  likely  *> 
will  be  the  continuance  of  the  opening  ; and 
when  it  is  withdrawn,  the  external  orifice 
should  be  covered  only  by  a superficial 
pledget,  or  plaster,  and  suffered  to  heal  un- 
der moderate  pressure . (Pott.) 

After  the  perforating  instrument  was  with- 
drawn, Mr.  Ware  recommended  a nail- 
headed  style,  about  an  inch  long,  to  be  in- 
troduced through  the  aperture,  in  the  same 
way  in  which  it  is  introduced  through  the 
nasal  duct,  in  cases  in  which  the  obstruction 
is  not  so  great  as  to  prevent  its. passing  in 
this  direction  ; and  it  may  remain  here  with 
as  much  safety  as  in  this  last-mentioned  in- 
stance, for  as  long  a time  as  its  continuance 
may  be  thought  necessary  to  establish  the 
freedom  of  the  communication. 

Unfortunately  for  the  scheme  of  making  an 
artificial  passage,  nature  was  generally  so 
busy,  that  sin1  completely  frustrated  the  aim 
of  the  surgeon  by  gradually  filling  up  the 
new  aperture  again.  Hence,  some  practi- 
tioners were  not  content  with  drilling  a hole 
through  the  os  unguis,  but  actually  removed 
a portion  of  this  bone  either  with  the  for- 
ceps proposed  by  Lamorier  in  1729.  (See 
M6m.  de  l’ Acad,  des  Sciences ,)  or  with  cutting 
instruments,  among  which  the  most  celebra- 
ted is  the  sharp-edged  kind  of  cannula  de- 
vised by  Hunter.  While  this  was  being  ap- 
plied, however,  it  was  necessary  to  sup- 
port the  os  unguis  with  something  passed  up 
ihe  nose,  and  a piece  of  horn  was  found  to 
answer  very  well.  Instead  of  these  methods, 
Scarpa  prefers  destroying  a portion  of  the 
os  unguis  with  the  actual  cautery  passed 
through  a cannula;  a practice;  long  ago  ba- 


LACHRYMAL  ORGANS. 


isv 


11  i shed  from  good  surgery,  and  most  justly 
condemned  by  Richter. 

1 do  not  feel  it  necessary  to  enter  very 
particularly  into  the  details  of  these  methods 
of  forming  an  artificial  passage  between 
the  lachrymal  sac  and  nostril,  i have  never 
seen  a case,  in  which' 1 should  have  deemed 
such  practice  adviseable,  and  that  the  neces- 
sity for  it  must  be  rare  must  be  inferred  from 
what  Mr.  Travers  has  observed,  viz.  that  he 
does  not  believe  the  perforation  of  the  os  un- 
guis ever  really  required  it.  (Synopsis, p.  379.) 
Beer’s  remarks  are  also  decidedly  against 
the  practice  ; for,  he  states  that,  in  order 
that  the  new  opening  may  not  be  closed 
with  lymph,  it  must  be  made  too  high  up  to 
serve  the  purpose  of  a diain,  through  which 
the  mucus  can  descend  by  its  own  gravity. 
He  has  not  met  with  a single  case,  either  in 
his  own  practice,  or  among  the  patients 
whom  he  has  had  opportunities  of  seeing 
under  other  practitioners,  where  the  per- 
foration of  the  os  unguis  had  a successful 
result.  On  the  contrary,  in  one  healthy  lad, 
the  operation,  which  had  been  done  by  an 
experienced  surgeon,  was  followed  by  the 
destruction  of  the  nasai  process  of  the  up- 
per maxillary  bone,  one  of  the  ossa  nasi, 
and  all  the  bones  contributing  to  the  forma- 
tion of  the  passage  from  the  orbit  into  the 
nose.  (See  Lehre  von  den  Augenkr.  B.  2, 
p.  182)  Hence,  Beer  thinks,  that  the  pa- 
tient had  better  either  submit  to  the  incon- 
venience of  being  obliged  to  empty  the  dis- 
tended sac  by  pressure  several  times  a day, 
or  let  the  cavity  of  the  sac  be  obliterated  by 
means,  calculated  to  excite  the  adhesive  in- 
flammation in  it.  But,  if  the  lachrymal 
puncta  and  ducts,  as  well  as  the  nasal  duct, 
are  obliterated,  Beer  conceives  that  there  is 
no  alternative,  because,  if  the  cavity  of  the 
sac  be  left,  tjie  case,  which  he  terms  hydrops 
sacculi  lachrymalis,will  ensue,  whenever  the 
fistula  is  closed. 

Of  Hernia  and  Hydrops  of  the  Lachrymal 
Sac. — The  diseases,  described  by  Beer  undgr 
these  appellations,  are  not  discriminated  in 
this  country,  although  they  are  characteri- 
zed by  widely  different  symptoms,  and  re- 
quire opposite  methods  of  treatment.  In 
the  case  of  hernia,  or  simple  relaxation,  the 
lachrymal  sac  forms  a tumour,  which  never 
surpasses  the  size  of  a common  horse-bean, 
the  integuments  are  of  their  natural  colour, 
the  tumour  is  soft  and  yielding  to  pressure,  by 
which  the  contents  of  the  sac  are  readily  dis- 
charged through  the  puncta,  or  nasal  duct. 
Hydrops  grows  tothe  s.ze  oi  a pigeon’s  egg,  is 
purplish  from  the  beginning,  very  hard  and  in- 
capable of  being  emptied  by  t he  strongest 
pressure.  Hernia  is  cured  by  compression, 
and  the  application  of  astringents  to  the  re- 
laxed parts  ; hydrops  requires  the  incision 
of  the  sac.  In  hernia,  the  nasal  duct  is 
natural;  in  hydrops,  it  and  sometimes  the 
puncta  are  obstructed. 

Stillicidium  Lachrymarum. — According  to 
Beer,  the  valuable  treatise  of  Schmidt  is  the 
only  work,  in  which  the  important  practical 
distinction  is  drawn  between  stillicidium 


lachrymarum  and  epiphora;  the  immediate 
cause  of  the  first  complaint  being  some  im- 
pediment to  the  passage  of  the  tears  from 
the  lacus  lachrymarum  into  the  lachrymal 
sac  ; while  the  other  affection  consists  in  a 
redundant  and  extraordinary  secretion  of 
the  tears.  The  curable  form  of  stillicidium, 
here  to  be  noticed,  arises  from  relaxation  of 
the  lachrymal  puncta  and  canals,  in  conse- 
quence of  previous  inflammation  of  the 
parts.  The  puncta  are  widely  open  ; but  in 
other  respects,  have  quite  a natural  appear- 
ance. When  touched  with  Anel’s  probe, 
they  do  not  contract,  as  in  the  healthy 
state.  The  tears,  which  from  time  to  time 
fall  over  the  cheek,  are  not  in  considerable 
quantity,  only  trickling  from  the  inner  can- 
thus  by  drops  at  intervals;  and  the  nostril 
on  the  affected  side  is  found  to  be  rather 
drier  than  natural. 

Erysipelatous  inflammation  of  the  eyelids 
and  parts  over  the  lachrymal  sac,  and  the 
purulent  kinds  of  ophthalmy,  frequently 
cause  this  sort  of  stillicidium.  The  latter 
cases  indeed  the  more  readily  produce  the 
disorder,  inasmuch  as  the  semilunar  fold  of 
the  conjunctiva  is  relaxed  and  swelled,  so 
as  to  push  the  puncta  out  of  their  right  po- 
sition for  the  due  performance  of  the  absorp- 
tion of  the  tears,  and  obstruct  this  function 
more  than  Would  be  the  case,  if  the  dimi- 
nished action  of  those  orifices  and  the  la- 
chrymal ducts  were  the  only  thing  con- 
cerned. 

Beer  delivers  an  exceedingly  favourable 
prognosis,  observing,  that  the  complaint 
often  disappears  of  itself  on  the  approach  of 
warm  dry  weather,  and  may  almost  always 
be  readily  cured,  by  means  of  astringents. 
Among  other  remedies  specified  by  this  au- 
thor, 1 need  only  mention  a solution  of  the 
sulphate  of  iron,  to  which  a small  quantity 
of  camphorated  spirit,  or  tincture  of  opium, 
has  been  added  It  is  to  be  dropped  out  of 
a pen  into  the  inner  angle  frequently  in  the 
course  of  the  day,  the  patient  lying  upon  his 
back  for  some  time  after  each  application, 
so  as  to  let  the  medicine  have  more  effect 
upon  the  parts  (See  Lehre  von  den  Au * 
genfer.  B.  2,  p.  41 — 43.) 

Mr.  Travers  mentions  a constricted  state 
of  the  lachrymal  puncta  and  canals,  which  is 
curable  by  the  introduction  of  a small  probe. 

( Synopsis , fyc.  p.  366.)  All  moden.  write  s 
agree,  that  the  obliterated  puncta  and  canals 
can  never  be  restored.  (See  Memoires  de 
I'Academie  de  Chirurgie,  T.  5,  Edit.  12 mo.  in 
which  are  several  essays  on  fistula  lachrymalts 
viz.  one  by  M.  Bordenavc,  entitled,  “ Examen 
des  (inflexions  critiques  de  M.  j\k>linelli,  inve- 
rses dans  les  MSmovres  de  l i nsiimt  de  Bolvgnc , 
contre  le  Mcmoire  de  M.  Petit,  sur  la  Fist  ale 
Lachrymale,  insure  parmi  ceux  de  l' Acad.  Hoy • 
ale  aes  Sciences  de  Paris.  Annie  1734.  Another  * 
essay  by  M.  de  la  Forest,  styled  u JVouvcllc  Me - | 
thodc  de  Iraitcr  les  Maladies  du  Sac  Lack - 
ryrnal,  nominees  commandment  Fislults  Lack- 
ry mules .”  A third  by  M.  Louis , called  “ Be-  if 
flexions  sur  V Operation  de  laflstuU  Lachry- 
male." O.  E.  Stahl , Programma  da  Fistula 


LAC* 


lAfe 


Lachrymali,  Halve,  1702'.  J.  C.  Scholunger, 
J9e  Fistula  Lachrymali , Basil,  1730.  D. 
Metzger,  Curationum  Chir.  quce  ad  Fistulam 
Lachrymalem  sive  usque J'uere  adliibitee , Hislo- 
ria  Critica,  8 vo.  Monarferii , 1772.  P. 

Qucestio,  <^c.  An  fistula-,  lachrymali  cau- 
terium  actuale?  Paris , 1738.  J.  L PefiJ, 
Tra/te  des  Mai.  Chir.  T.  \\,p.  289,  fyc.  8vo. 
Paris,  1774.  M.  A Magnabal.  De  Morbis 
Viarum  Lachrymalium,  ac  pracipue  de  fistula 
lachrymali,  Monlp.  1765.  A.  Berlrandi, 
Traite  des  Jpdrations,  p.  297,  8 vo.  Paris, 
1784.  Ariel  has  described  his  plan  of  treat- 
ment in  various  icorks  : Observation  sivgu- 

licre  sur  la  fistule  lacrymale , dans  laquelle  I on 
apprendra  la  methodt  de  la  guerir  radical  e- 
ment .”  Turin,  1713)  in  4 to.  u Nouvelle 
Mtihode  de  gu6rir  les  fistules  lacry males." 
Turin,  1713,  in4to.  u Suite  de  la  JYouvelle 
Methode,"  fyc.  ibid.  1714 , in  4 to.  “ Disst  r- 

lation  sur  la  nouvelle.  d6couverte  de  I’hydropisie 
du  conduit  lacrymat ,"  Paris,  1716,  in  12 mo. 
And , lastly , Anti  has  published  in  the  M6m. 
de  1'Acad.  des  Sciences,  annee  1713,  “ Pricis 
de  sa  nouvelle  mamtre  de  gudrir  les  fistules 
lacrymales."  Me  jean  in  Mdm.  de  VAcad.  de 
Chir . T.  2,  p.  Iy3,  4to.  Palucci,  Methodus 
curanda  fistulce  lachrymalis,  l 'indob.  1762; 
a tube  preferred.  Sabatier,  Midecine  Opdra- 
foire,  T.  2,  Ed.  2.  Richter's  Anfanccsgriinde  dtr 
fVundarzneykunst,  B.  2.  Kap.  11.  Pott's 
observations  relative  to  the  disorder  of  the 
comer  of  the  eye,  commonly  called  the  Fistula 
Lachrymalis,  8 vo.  Loud.  1758.  Sir  W.  Bli- 
zard , A New  Method  of  treating  the  Fistula 
Lachrymalis,  4lo.  Lond.  1780.  Ware  on  the 
Epiphora  and  Fistula  Lachrymalis;  8vo. 
Lond.  1792 — 95.  Scarpa  sulle  principali 
Malattie  degli  Occhi,  Capo  1.  Walken's  New 
and  easy  Method  of  applying  a Tube  for  the 
Fistula  Lachrymalis,  Lond.  1781,  and  2d  Ed. 
1792.  Sprengel,  Geschichte  der  Wichtigsten 
Chir.  Operalionen,  p.  105.  Nicod,  Memoire 
sur  la  Fistule  Lacrymale  in  Revue  M6d. 
Historique,  fyc.  livr.  1 et  2,  8 vo.  Paris, 
1820.  Fournier,  Diss.  de  lAppare.il  des  voies 
lachrymales  ; Montpellier,  1803  J.  L.  Angely, 
Cornmentatio  Medica  de  Oculo  Organisque  La- 
chrymalibus  ratione  Alt  at  is,  Sexus.  Gentis,  et 
Variorum  Animalium . S vo.  Erlangce,  ISOS. 
Reil,  Diss.  de  Chir.  Fistulas  Lachrymalis  Cu- 
ratione,  Berol.  1812;  Flajani , Collezione  d'  Os- 
servazioni,  T.  3.  Desault,  (Euvres  Chir.  T. 
2,p.  119,  8 vo.  Paris,  1801.  J.  C.  Rosenmul- 
ler,  Partium  Externarum  Oculi  Humani , im- 
primis Organorum  lachrymalium,  Descriplio 
Anatomica ; ico?iibus  illuslrata,  4 to.  Lips. 
1810.  C.  H.  T.  Schreger,  Versuch  einer 
Vergleichenden  Anatomic  des  Auges  und  der 
Tiirdnenorgane  des  Menschen  und  der  vbrigen 
Tkitrklassen,  8vo.  Leipz.  1810.  Beer,  Lehre 
von  den  Augenkrankheiten^  2 B.Sco.  Wien, 
1813 — 1817.  Wm.  Mackenzie,  An  Essay  on 

the  Diseases  of  the  Excreting  Parts  of  the  La- 
chrymal Organs,  8 vo.  Lond.  1819 ; contains 
many  valuable  observations  from  the  writings 
of  Beer . B.  Travers , A Synopsis  of  the  Dis- 
eases of  the  Eye,p.  228 — 359,  fyc.  8 vo.  Lond. 
1820.  Ph.  v.  Waltaer  ueber  die  steinigen 
Concrctionen  der  Thrcinenjlussigkeit,  in  Journ. 
far  Chirurgie  von  C.  Graefe,  B.  I,  p.  163. 


iSl 

8vo.  Berlin,  1820.  J.  A.  Schmidt  iiber  die 
Krankheiien  des  Thriineuorgans ; a work  of 
the  highest  reputation. 

L AGOPHT  H AL  MIA,  orLAGOPHTHAL 
MOS.  (from  \oyos,  a hare  ; and  c< an 
eye.;  The  Hare's  Eye.  Oculus  Leporinus. 
A disease,  in  which  the  eye  cannot  be  com- 
pletely shut.  The  following  complaints 
may  arise  from  it ; a constant  weeping  of 
the  organ,  in  consequence  of  the  interrup- 
tion of  the  alternate  closure  and  opening  of 
the  eyelids,  which  motions  so  materially 
contribute  to  the  propulsion  of  the  teurs 
into  the  nose  ; blindness  in  a strong  light,  in 
consequence  of  the  inability  to  moderate 
the  rays,  which  enter  the  eye ; on  the  same 
account,  the  sight  becomes  gradually  very 
much  weakened  , incapacity  to  sleep  where 
there  is  any  light;  irritation, pain, andredne  s 
of  the  eye,  from  this  organ  being  exposed 
to  the  extraneous  substances  in  the  atmos- 
phere. 

An  enlargement,  or  protrusion  of  the 
whole  eye,  o a staphyloma,  may  obviously 
produce  lagophthalmos.  But,  affections  of 
the  upper  eyelids  are  the  common  causes. 
Heister  lias  seen  the  complaint  originate 
from  a disease  of  the  lower  one.  Now  and 
then  lagophthalmos  depends  on  paralysis  of 
the  orbicularis  muscle.  A cicatrix,  after  a 
wound,  ulcer,  or  burn,  is  the  most  frequent 
cause. 

When  lagophthalmos  arises  from  a paraly- 
tic affection  of  the  orbicularis  palpebrarum, 
the  eyelids  may  be  rubbed  with  a liniment 
containing  the  tinctura  lyttas,  or  the  linimen- 
tum  camphorae.  Electricity  and  cold  bath- 
ing are  also  considered  principal  means  of 
cure,  ( Chandler ) together  with  the  exhibition 
of  bark,  the  use  of  the  shower-bath,  &c. 

When  the  affection  arises  from  spasm  of 
the  levator  palpebrai  superioris,  electricity, 
admail  blister  on  the  neighbouring  temple, 
and  rubbing  the  eyelid  and  eyebrow  with 
the  tinctura  opii,  are  recommended,  together 
with  antispasmodic  medicines. 

WTien  lagophthalmos  arises  from  the  con- 
traction of  a cicatrix,  its  relief  is  to  be  at- 
tempted precisely  on  the  same  principles  a5 
the  ectropium.  (See  Ectropium .)  How 
ever,  when*the  eyelid  is  shortened  as  well 
as  everted,  nothing  will  remove  the  defor- 
mity 

The  inconveniences,  depending  on  the 
eye  being  unable  to  shelter  itself  from  the 
light,  are  to  be  obviated  by  wearing  agreeri 
shade. 

Whoever  is  acquainted  with  German,  and 
is  desirous  of  more  minute  information  on 
this  subject,  may  find  an  excellent  account 
of  lagophthalmos  in  Richter's  Anfavgsgr. 
der  Wundarzn.  B.  2.  Von  dem  Hasenauge. 
See  also  Beer's  Lehre  von  den  Angenkr.  B.  2, 
p.  239,  8fC.  87-0.  Wien,  1817. 

LARYNGO  1'OMY.  (from  the  la- 

rynx; a nd^Mva,  to  cut.)  The  operation  of 
making  an  opening  into  the  larynx.  (See 
Bronchotomy .) 

LATERAL  OPERATION.  One  mode  of 
cutting  for  the  stone.  (See  Lithotomy 
LENTICULAR,  (from  leniim!airer doubly 


convex.)  An  instrument,  contained  in  every 
trephining  case,  and  employed  for  removing 
the  irregularities  of  bone  from  the  edge  of 
the  perforation,  made  in  the  cranium  with 
the  trephine.  One  side  of  its  blade  is  con- 
vex, the  other  concave  ; and  one  of  its 
edges  is  sharp.  On  the  end  of  the  blade  is 
fixed  a little  shallow  cup,  with  its  concavity 
towards  the  handle  of  the  instrument.  This 
part  serves  the  purposes  of  receiving  the 
little  pieces  of  bone,  when  detached,  keep- 
ing the  end  of  the  blade  from  hurting  the 
dura  mater,  and,  when  applied  under  the 
margin  of  the  opening,  enables  the  operator 
to  guide  the  edge  of  the  instrument  all  round 
it,  w ith  steadiness  and  security. 

LEUCOMA.  (from  \euxos,  white.)  Leu- 
comaand albugo  are  often  used  synonymous- 
ly, to  denote  a white  opacity  of  the  cornea. 
Both  of  them,  as  Scarpa  remarks,  are  essen- 
tially different  from  the  nebula  of  the  cornea  ; 
for,  they  are  not  the  consequence  of  chronic 
ophthalmy,  with  varicose  veins,  and  an 
effusion  of  a milky  serum  into  the  texture  of 
the  delicate  continuation  of  the  conjunctiva 
over  the  cornea  ; but,  are  the  result  of  vio- 
lent acute  ophthalmy.  In  this  state,  a dense 
coagulating  lymph  is  extravasated  from  the 
arteries ; sometimes  superficially,  at  other 
times  deeply  into  the  substance  of  the 
cornea.  On  other  occasions,  the  disease 
consists  of  a firm  callous  cicatrix  on  this 
membrane,  the  effect  of  an  ulcer,  or  wound, 
with  loss  of  substance.  The  term  albugo , 
Strictly  belongs  to  the  first  form  of  the  disease ; 
leucoma  to  the  last,  more  particularly  when 
the  opacity  occupies  the  whole,  or  the  chief 
part,  of  the  cornea. 

The  recent  albugo,  remaining  after  the 
cure  of  severe  acute  ophthalmy,  is  of  a clear 
milky  colour;  but,  when  of  ancient  date,  it 
becomes  pearl-coloured.  Some  cases,  which 
have  existed  a considerable  time,  do  not 
seem  to  have  any  connexion  with  the  vascu- 
larity of  the  cornea  ; for  they  continue  insu- 
lated in  the  middle  of  the  transparent  por- 
tion of  this  membrane,  withoul  occasioning 
the  least  uneasiness  to  the  patient,  the  least 
disturbance  of  the  rest  of  the  eye,  or  any 
attempt  of  the  absorbents  to  remove  them. 

The  recent  albugo,  provided*  the  organi- 
zation of  the  cornea  be  not  destroyed,  may 
generally  be  dispersed  by  the  means  em- 
ployed for  the  relief  of  the  first  and  second 
stages  of  acute  ophthalmy;  viz.  general  and 
topical  blood-letting  with  internal  antiphlo- 
gistic medicines,  and  topical  emollients  for 
the  first;  slightly  irritating  and  corroborant 
applications  for  the  second-  As  soon  as  the 
inflammation  has  subsided,  the  latter  ^should 
be  employed  ; for,  by  making  the  absorbents 
remove  the  coagulating  lymph,  deposited  in 
the  cornea,  they  restore  the  transparency  of 
this  membrane. 

But,  though  this  may  often  be  accomplish- 
ed in  the  recent  state  of  albugo,  it  is  more 
difficult  when  the  long  duration  of  the  dis- 
ease has  paralyzed  the  absorbents  of  the  af- 
fected part ; or  when  the  deposition  of  a 
dense  tenacious  substance  into  the  cornea 
has  subverted  its  organization-  (Scarpa.) 


The  recent  condition  of  the  disease,  with 
out  disorganization  of  the  structure  of  the 
cornea;  its  occurrence  in  young  subjects, 
whose  absorbents  are  readily  excited  by  ex- 
ternal  stimulants;  are  circumstances  favour- 
able to  the  cure.  In  children,  the  albugo, 
arising  from  severe  ophthalmy  after  the 
small  pox,  and  insulated  in  the  centre  of  the 
cornea,  very  often  disappears  of  itself  in  the 
course  of  a few  months.  Heister,  Langguth, 
and  Richter,  make  the  same  observation. 
The  event  can  only  be  imputed  to  the  vigor- 
ous action  of  the  lymphatics  in  children, 
and  to  the  organization  of  the  cornea  not 
being  destroyed.  For  promoting  the  absorp- 
tion, Scarpa  recommends  the  following  colly- 
rium  : 3,.  Ammon,  muriata*.  Qij.Cupri  acetati 
gr.  iv.  Aquae  Calcis^viij.  Misce,  The  fluid  is  to 
be  filtered,  after  standing  twenty-four  hours. 
He  praises  also  this  ointment : Tutiae 

praepar.  3j-  Aloes,  s.  p.  gr.  ij.  Hydrargyri 
submur.  gr.  ij.  Adipis  suillae.  55s.  Misce 
And  the  unguentum  ophthalmicuin  of  Janit?. 
He  mentions  the  gall  of  the  ox,  sheep,  pike, 
and  barbel,  applied  to  the  cornea,  two  or 
three  times  a day,  with  a small  hair  pencil,  if 
top  much  irritation  should  not  be  produced. 
In  some  subjects,  when  the  eyes  are  very  irri- 
table, and  cannot  bear  the  latter  applications, 
Scarpa  has  found  the  oil  of  walnuts  an  use 
ful  application.  But  it  is  generally  neces- 
sary to  persevere,  at  least  three  or  four 
months,  before  the  case  can  be  reckoned  in- 
curable. 

All  the  expedients,  proposed  for  the  inve 
terate  albugo  or  leucoma  from  a cicatrix, 
consisting  of  scraping  or  perforating  the 
layers  of  the  cornea,  and  exciting  ulceration 
there,  are  unavailing.  For,  though  the  en- 
largement of  the  cornea  should  be  lessened 
by  such  means,  its  diaphanous  state  could 
not  be  restored  ; or  should  the  patient  per- 
ceive a ray  or  two  of  light  immediately  after 
the  operation,  the  benefit  would  only  be 
transient;  for,  as  soon  as  the  wound  had 
healed,  the  opacity  would  recur.  The  for- 
mation of  an  artificial  ulcer  might  prove  use- 
ful, if  leucoma  depended  on  a mere  extrava- 
sation of  lymph  ; but,  the  fact  is,  the  disease 
arises  from  the  deposition  of  an  opaque  sub- 
stance, and  the  disorganization  of  the  tex- 
ture of  the  cornea,  conjointly  : in  this  lies 
the  difference  between  albugo  and  leucoma. 

See  Scarpa  suite  Malatlie  degli  Occhi ; 8 vo. 
Venezia,  1802.  Richter,  Anfangsgrunde  dec 
Wundarzn.  B.  3.  Essays  on  the  Morbid  Ana- 
tomy of  the  Eye,  by  J.  IV ar  dr  op ; Edinb.  1808  : 
chap.  11. 

LIGATURE.  In  the  article  Hemorrhage , 
it  has  been  explained,  that  the  immediate 
effect  of  a tight  ligature  on  an  artery,  is  to 
cut  through  its  middle  and  internal  coats,  a 
circumstance  that  tends  very  much  to  pro- 
mote the  adhesion  of  the  opposite  sides  ot 
the  vessel  to  each  other.  Hence,  1 think 
with  Dr.  Jones,  in  opposition  to  Scarpa,'  that 
the  form  and  mode  of  applying  a ligature  to 
an  artery  should  be  such,  as  are  most 
certain  of  dividing  the  above  coats  ot  tin*, 
vessel,  in  a regular  manner.  A broad  flat 
ligature  does  not  seem  likely  to  answer  H 1 > ■ 


LIGATURE. 


purpose  well ; because  it  is  scarcely  possible 
to  t:e  it  smoothly  round  the  artery,  which  is 
apt  to  be  thrown  into  folds,  or  to  be  puck 
ered  by  it,  and,  consequently,  to  have  an 
irregular  bruised  wound  made  in  its  middle 
and  internal  coats.  (Jones.)  A ligature  of 
an  irregular  form  is  likely  to  cut  through 
these  coats  more  completely  at  some  parts, 
than  others;  and  if.it  does  not  perfectly 
divide  them,  though  adhesion  may  yet  take 
place,  it  is  a slower  and  less  certain  event, 
and  secondary  hemorrhage  more  likely  to 
follow.  The  fear  of  tying  a ligature  too 
tight  may  often  lead  to  the  same  disadvan- 
tages. ihese,  and  many  other  important 
circumstances,  are  noticed  in  the  article 
Hemorrhage. 

Ligatures  are  commonly  made  of  inkle, 
and  rubbed  with  white  wax.  They  should 
be  round,  and  very  firm,  so  as  to  allow  being 
tied  with  some  force,  without  risk  of  break- 
ing. (See  Jones  on  Hemorrhage , p.  172.) 

The  principles,  which  should  guide  the 
surgeon  in  the  use  of  the  ligature,  were  not 
known  until  the  late  Dr.  Jones  published  his 
valuable  treatise  on  hemorrhage.  As  an 
able  surgeon  has  observed,  “ he  has  banished 
(at  least  in  this  country)  the  use  of  thick  and 
Ibroad  threads,  of  tapes,  of  reserve  ligatures, 
of  cylinders  of  cork  and  wood,  linen  coin 
presses, and  all  tLi€5  contrivances, 'which,  em- 
ployed as  a security  against  bleeding,  only 
served  to  multiply  the  chances  of  its  occur- 
rence.” ( Lawrence , in  Med.  C/iir.  Trans. 
Vol.  6,  p.  162.) 

In  the  article  Amputation , l have  noticed 
the  method  of  cutting  off  both  ends  of  the 
ligature  close  to  the  knot,  on  the  face  of  the 
stump,  with  the  view  of  lessening  the  quan- 
tity of  extraneous  matter  in  the  wound,  and 
promoting  a complete  union  of  the  divided 
parts,  without  suppuration 

This  plan  has  been  tried  by  Mr.  Lawrence  : 
u The  method  I have  adopted  (says  this 
gentleman)  consists  in  tying  the  vessels  with 
fine  silk  ligatures,  and  cutting  off  the  ends  as 
close  to  the  knot  as  is  consistent  with  its 
security,  Thus  the  foreign  matter  is  reduced 
to  the  insignificant  quantity,  which  forms 
the  noose  actually  surrounding  the  vessel, 
and  the  knot,  by  which  that  noose  is  fastened. 
Of  the  silk,  which  i commonly  employ,  a 
portion  sufficient  to  tie  a large  artery,  when 
the  ends  are  cut  off,  weighs  between  one- 
fiftieth  and  one-sixtieth  of  a grain  : a similar 
portion  of  the  thickest  kind  I have  tried, 
weighs  one-twentieth  of  a grain,  and  of  the 
slenderest  one-eightieth.” 

Mr.  Lawrence  states,  that  the  kind  of  silk 
twist  which  is  commonly  known  in  the 
shops  by  the  name  of  dentist’s  silk,  and 
which  is  used  in  making  fishing  lines,  is  the 
strongest  material,  in  proportion  to  its  size, 
and  therefore  the  best  calculated  for  our 
purpose,  which  requires  considerable  force 
in  drawing  the  thread  tight  enough  lo  di- 
vide the  fibrous  and  internal  coats  of  the 
arteries.  This  twist  is  rendered  very  hard 
and  stiff  by  means  of  gum,  which  may  be 
removed  by  boiling  it  in  soap  and  water ; 
but  the  twist  then  loses  a part  of  its  strength. 


ina 

The  stoutest  twist  which  Mr.  Lawrence  has 
used,  is  a very  small  thread  comp  red  with 
ligatures  made  of  inkle.  The  quantity  of 
such  a thread,  necessary  for  the  noose  and 
knot  on  the  iliac  artery,  weighs  one-twenti- 
eth of  a grain  ; or,  if  the  gum  has  been 
removed,  about  one-twenty-sixth.  But  the 
finest  twist,  kept  in  the  silk  shops,  is  strong 
enough  in  iTS  hard  slate  for  any  surgical 
purpose  ; and  the  noose  and  knot,  accord- 
ing to  Mr.  Lawrence’s  statement,  would  not 
weigh  one-fortieth  of  a grain. 

It  anther  appears,  from  the  report  of  this 
gentleman  on  the  subject,  that  there  is  no 
danger  ot  these  ligatures  cutting  completely 
through  the  vessel,  as  some  surgeons  have 
apprehended;  and  that,  although  he  has 
not  yet  ascertained  what  becofnes  of  the 
piece  of  ligature  after  the  wound  is  united, 
he  has  never  seen  abscess  nor  any  other  bad 
symptom  occasioned  by  them.  At  the  time 
when  Mr.  Lawrence  wrote,  he  had  employ- 
ed this  method  of  securing  the  arteries  in 
ten  or  eleven  amputations,  in  six  operations 
Oil  the  breast,  and  in  the  removal  of  two 
testicles.  The  cases  all  did  well,  excepting 
a man  w ho  lost  his  thigh,  and  who  died  of 
an  affection  of  tne  Sungs.  (See  Lawrence  on 
a JYew  Method  of  Tying  the  Arteries  in  Aneu  - 
rism, 4’C.  in  Medico-  Chit.  Trans.  Vol.  6,  p. 
156,  Hfc.) 

The  foregoing  method  was  tried  by  myself 
in  several  amputations,  which  1 performed 
in  1815  at  Brussels,  and  in  a larger  number 
of  cases  by  my  friend,  Mr.  Collier.  Our 
ligatures,  however,  though  small,  were  not 
so  small  as  those  judiciously  recommended 
by  Mr.  Lawrence  ; and,  on  this  account,  no 
accurate  inferences  can  be  drawn  from  our 
examples,  which,  however,  as  far  as  I could 
learn,  were  not  unfavourable  to  the  practice. 

This  subject  was  mentioned  by  Mr.  Gu- 
thrie, as  follows  : — Some  military  surgeons, 
both  French  and  English,  have  lately  adopt- 
ed the  practice  of  cutting  off’  both  ends  of 
the  ligatures  close  to  the  knot  on  the  artery, 
uniting  the  parts,  if  possible,  over  them,  and 
allowing  the  knots  to  find  their  way  out  as 
they  can.  The  edges  of  the  wound,  in  some 
instances,  have  united  thoroughly  in  a few 
days,  and  when  the  knots  have  come  off  the 
ends  of  the  arteries,  they  have  caused  small 
abscesses  to  be  formed,  which  point  at  the 
nearest  external  surface,  and  are  discharged 
with  little  uneasiness.  1 know  that  many 
cases,  treated  in  tills  manner,  in  the  cam- 
paign of  1813,  ended  successfully,  and  heal- 
ed in  as  short  a time  as  the  most  favourable 
ones  by  the  usual  method  ; and  at  Montpel- 
lier, in  June,  1814,  Motis.  Delpech,  Professor 
of  Surgery  in  that  university,  showed  ine  at 
least  twenty  cases  in  which  he  had,  and  was 
still  practising  this  method  with  success.  1 
have  seen,  however,  in  two  or  three  instan- 
ces, some  ill-looking  abscesses  formed  by 
them,  and  I suspect  some  disagreeable  con- 
sequences .will  ensue,  if  this  practice  be 
continued. 

“ I consider  this  improvement  as  very  va- 
luable in  all  cases,  that  will  not  unite  by  the 
first  intention.  The  ligatures,  if  there  he 


many,  form  into  ropes,  ano  the  cause  of  much 
irritation,  and  are  frequently  pulled  away 
with  the  dressings  ; by  cutting  them  off.  these 
evils  are  avoided,  and  the  knots  will  come 
away  with  the  discharge. 7 (See  Guthrie  on 
Gunshot  IVounds  of  the  Extremities,  p.  93, 
94.) 

With  respect  to  the  abscesses,  which  this 
gentleman  saw  produced  by  the  method,  it 
is  properly  observed  by  Mr.  Lawrence,  that 
as  this  statement  is  not  accompanied  by  any 
description  of  the  materials,  or  size  of  the 
ligature,  nor  by  any  details  of  the  unfavour- 
able cases,  we  cannot  judge,  whether  the 
events  alluded  to  are  to  be  attributed  to 
f.he  method  itself,  or  to  the  way  in  which 
it  was  executed.  (See  fifed.  Chir.  Trans. 
Vol.  6,  p.  171.) 

M.  Roux  has  tried  the  plan  in  three  ope- 
rations on  the  breast ; the  £ases  did  well  ; and 
no  ill  consequences  arose  from  the  presence 
of  the  bits  of  thread  under  the  cicatrix.  (See 
Relation  d'un  Voyage  faith  Londres  en  1814, 
ou  Parallele  dtla  Chiruraie  Angloise  avecla 
Chirurgie  Franchise;  Paris,  1815.  p.  134 — 
136.)  For  other  remarks,  connected  with 
the  foregoing  topics,  see  Amputation,  Aneu- 
rism,, and  Hemorrhage. 

LIMMENTUM  ACIpI  SULPHURICI. 
— Olei  Olivae  3 i -s.  Acid.  Sulph.  ~;s.  M. 
Recommended  by  Mr.  Bi  odie,  for  the  remo- 
val of  the  effects  left  by  inflammation  of  the 
synovial  membrane.  (See  Joints.) 

LIMMENTUM  AMMONIA  FORTIUS. 
- — 1^.  Liq.  ammou.  Zj.  Qlei  olivae  §iij.  Misce. 
Proper! ies  stimulai in g. 

LIMMENTU  VI  CALCIS  — ft.  Aquae  cal- 
cis,  Olei  olivae,  sing.  |viij.  Spirit,  vinosi  recti- 
fieati  Misce.  A common  application  to 
burns  and  scalds. 

LINI  vIENTUM  CAMPHORS  COMPO- 
S1TUM.  ft.  Camph.  ^ij.  Aq.  atnmon.  ^vj. 
Spirit,  lavend.  ^xvj  Sixteen  ounces  are  to 
be  distilled  of  the  two  last  ingredient-,  from 
a glass  retort,  and  the  camphor  then  dissolved 
in  the  distilled  fluid.  For  bruises,  sprains, 
rigidities  of  the  joints,  incipient  chilblains,  &e. 

LIMMENTUM  CAMPHOR/E  A FH E- 
I1EUM. — ft  Camphurae  drach.  j.  Atheris 
unc.  ss.  Olei.  viperarma  drach.  ij.  Misce 
The  camphor  is  to  be  dissolved  in  (lie  aedier, 
and  the  oil  afterw  rd  incorporated  with  it. 
The  lale  Mr.  Ware  sometimes  used  this  ap- 
plication, in  certain  obscure  affections  of  the 
eye,  in  which  it  was  not  easy  to  determine, 
whether  the  imperfection  of  the  sight  pro- 
ceeded from  an  incipient  cataract,  or  a defect 
of  sensibility  in  the  optic  nerve.  The  mode 
of  applying  it  is  to  moisten  the  finger  with  it, 
and  to  rub  it  for  two  or  three  minutes  toge- 
ther, morning  and  evening,  on  the  outside  and 
edges  of  the  eyelids.  (Pharm.  Chirurgica.) 

LIMMENTUM  HYDKARGYRI  CO.Vi- 
POSITUM — ft.  Ung.  hydrargyri  fortioris, 
Adipis  suillae,  sing.  §i.  Camph,  3 j Spirit, 
vinos,  rectif.  3>j-  Liq.  ammou.  ?j.  The 
camphor  being  dissolved  in  the  spirifof  wine, 
add  the  liq.  amtnon.  and  the  ointment  pre- 
viously blended  with  the  hog’s  lard.  (Pharm. 
Sancti.  Barlhol.)  An  excellent  formula  for 
all  surgical  cases,  in  which  the  object  is  to 


quicken  the  action  of  (lie  absorbents,  and 
gently  stimulate  the  surfaces  of  parts.  It  is 
a capital  application  for  diminishing  a chro- 
nic indurated  state  of  particular  muscles, 
every  now  and  then  met  with  in  practice  • 
and  it  is  particularly  well  calculated  for  les- 
sening the  stiffness  and  chronic  thickening 
often  noticed  in  the  joints. 

LIMMENTUM  POTASSA  SULPHU- 
RETI. — Saponis  Albi...  ^iv.  Olei  Amyg- 
dalae |viij.  Potassae  Sulphureti  3vj-  Olei 
Thy  mi  gr.  xv.  vel  3j.  This  liniment,  used 
twice  a day,  will  cure  the  itch  in  five  days, 
or,  at  latest,  in  eight.  It  has  very  little  un- 
pleasant smell,  and  would  be  preferable  to 
sulphur  ointment,  if  equally  efficacious.  (See 
London  Medical  Repository,  Vol.  3,  p.  242  and 
Cross's  Sketches  of  the  Medical  Schools  of  Pa- 
ris,p.  176.) 

L1NMENTUM  SAPONIS  COMPOSi- 
TU.*j. — ft.  Sapon.  ?iij.  Camph.  ^j.  Spi- 
rit. rorismar.  iftj.  Dissolve  the  soap  in  the 
spirit,  and  then  add  the  camphor.  Uses  the 
same  as  those  of  the  iinimenturn  camph. 

LIMMENTUM  SAPONIS  CUM  OPIO, 
ft.  Lin.  sapon.  comp.  ^vj.  Tinct.  opii.  ^ij. 
Misce.  For  dispersing  indurations  and  swell- 
ings attended  with  pain,  but  no  acute  inflam- 
mation*. 

LIMMENTUM  TEREBINTHINA.— ft. 
Ung.  resinse  fiavae  ^iv.  01  terebinthina?, 
q.  s.  Misce.  The  well-kno&n  application  for 
burns,  recommended  by  Kentish. (See  Barns.) 

LIMMENTUM  TEREBINTHINA  SUL- 
PHURICUM. — ft.  Olei  oiivee  3X.  01.  te 
rebinth.  3iv.  Acidi  Sulph:  3 * *« j - Misce.  Said 
to  be  efficacious  in  chronic  affections  of  the 
joints,  and  in  the  removal  of  the  old  effects 
of  sprains  and  bruises.  (Pharm.  Chirurgica .) 

LIP,  CANCER  OF.  The  lips  are  subject 
to  ulcers,  which  put  on  a very  malignant  as- 
pect, although  some  of  them  are  not  in  re- 
ality malignant ; and  many  occurring  just  on 
the  inside  of  these  parts,  will  be  found  to 
depend  on  the  bad  state  of  the  constitution, 
and  the  irritation  and  disturbance  which  the 
sores  are  continually  suffering  from  the  inces- 
sant motion  of  the  parts,  and  their  rubbing 
against  a projecting,  or  rough  tooth. 

Arsenic  is  frequently  useful  in  subduing  the 
obstinacy  and  malignity  of  certain  ulcers  and 
diseases  of  the  lip,  reputed  to  lie  cuncerous. 
(Stark,  Dc  Cancro  Labii  Inferioris.)  Ot  this 
essay.  P otessor  Langenbeck  speaks  in  high 
terms.  Tue  following  formula  is  recom- 
mended. ‘‘  ft.  Arsenici  Albi  drachm  dimid. 
Aq.  comm  stfflaticiai  unc.  sex.  M.  Digeranlur 
vase  vitreoclauso  in  balueo  arenas  justi  ca- 
loris  ope  per  boras  sex,  turn  adde  Potassai 
Carbon)  is  pura?  drachm,  dimid.  antea  soluf. 
in  aq.  Cinnamon,  sjmpl.  unc.  duab.  M.  Dige- 
rantur  denuo  per  aliquot  horas  in  loco  tem 
perato.  Mac  solutione  bis  terve  quotidie  ad 
guttas  8 — 10 — 15,  utimur.” 

When  cancer  takes  place,  it  is  usually  in 
the  lower,  and  very  seldom  in  the  upper  lip. 

The  disease  sometimes  puts  on  the  appear- 
ance of  an  ulcerated,  wart-like  excrescence, 
occasionally  acquiring  a considerable  size. 
Sometimes  it  is  seen  in  the  form  of  a very 
destructive  ulcer,  which  consumes  the  stir- 


LIQUOR. 


185 


rounding  substance  of  the  lip  ; and,  in  other 
examples,  the  disease  resembles  a hard  lump, 
which,  at  length,  ulcerates.  The  disease,  in 
its  infancy,  is  often  no  more  than  a pimple, 
which  gradually  becomes  malignant.  When- 
ever there  is  reason  to  believe,  that  the  dis- 
ease is  of  an  unyielding  cancerous  nature, 
and  it  does  not  soon  give  way  to  arsenic, 
hemlock,  and  mercurials,  the  sooner  it  is  ex- 
tirpated the  better.  For  this  purpose,  some 
surgeons  admit  the  propriety  of  using  caus- 
tic, when  the  whole  disease  can  he  com- 
pletely destroyed  by  one  application.  But  as 
the  action  of  caustic  is  not  capable  of  being 
regulated  with  so  much  precision  as  the  ex- 
tent of  a wound  can  be,  and  as  caustic  will 
not  allow  the  parts  to  be  united  again,  the 
knife  is  the  only  justifiable  means,  especially 
as  it  occasions  also  less  pain.  Two  incisions 
are  to  be  made,  meeting  at  an  angle  below 
(supposing  it  to  be  the  lower  lip,)  and  inclu- 
ding the  whole  of  the  disease.  The  sides  of 
the  wound  are  then  to  be  united  by  the 
twisted  suture.  (See  Hare-Up.)  When  the 
affection  is  extensive,  however,  the  surgeon 
is  frequently  necessitated  to  remove  the 
whole  of  the  lip,  or  too  much  of  it  to  admit 
of  the  above  plan  being  followed.  This 
circumstance  is  particularly  unpleasant,  as 
the  patient's  spittle  can  only  be  prevented 
from  continually  running  over  his  chin  by 
some  artificial  contrivance.  The  deformity 
also  is  very  great,  and  pronunciation  and 
swallowing  can  only  be  imperfectly  per- 
formed. 

LIPPITUDO.  (from  lippus,  blear-eyed.) 
Blearedness.  The  ciliary  glands,  and  lining 
of  the  eyelids,  only  ^secrete,  in  the  sound 
state,  a mere  sufficiency  of  a sebaceous  fluid 
to  lubricate  the  parts  in  their  continual  mo- 
tions. But,  it  sometimes  happens,  from  dis- 
ease, that  this  sebaceous  matter  is  secreted 
in  too  great  a quantity,  and  glues  the  eye- 
lids together  during  sleep,  so  that,  on  waking, 
they  cannot  be  easily  separated.  Hence, 
the  margin  of  the  eyelids  becomes  red  all 
round,  and  the  sight  itself  even  weakened. 

The  best  remedies  are  the  unguentum  liy- 
drargyri  nitrati,  smeared,  at  night,  on  (lie 
edges  and  inside  of  the  eyelid  with  a hair 
pencil,  after  being  melted  in  a spoon  ; the 
unguentum  tutiae,  applied  in  the  same  way  ; 
and  a collyrium,  composed  of  3j.  of  the 
sulphate  of  zinc  in  v^iij.  of  rosewater. 

"When  alterative  medicines  are  requisite, 
a grain  of  calomel  may  be  exhibited  daily, 
or  the  compound  calomel  pill,  containing 
one  grain  of  calomel,  one  of  sulphur  anti- 
monii  preecipitatum,  and  two  of  guaiacum, 
put  together  with  soap. 

Persons  who  have  lippitudo  and  cataracts 
together,  bear  couching  much  better  than 
one  would  expect  from  the  appearance  of 
the  eyes  in  that  disease  ; and  Mr.  Hey  never 
rejects  a patient  on  this  account,  provided 
such  state  is  habitual.  ( Practical  Observa- 
tions, p.  51.)  Scarpa,  however,  recommends 
the  lippitudo  to  be  removed  before  the 
operation  is  undertaken. 

LIQUOR  AMMON.  ACET.  (L.  P.)— 
This  is  given  in  the  dose  of  half  an  ounce  in 

Vol.  II.  24 


many  surgical  cases,  in  which  the  object  is 
to  keep  up  a gentle  perspiration. 

LIQUOR  ARSEN1CALIS.— ft.  Arsenic! 
Oxydi  pneparati  in  pulverem  subtilissimuni 
triti,  Potassa?  Subcarbonatis  ex  tartaro,  sin- 
gulorum  gr.  64.  Aq.  distill,  jfej  coque  si.mul 
in  vase  vitreo,  donee  arsenicum  omne  lique- 
tur.  Liquori  frigefacto  adjice  Spiritfts  Lavan- 
dulae com.  3iv.  Denique  adjice  insuper  Aq. 
distil,  quantum  satis  sit,  ut  inensurarn  octarii 
accurate  impleat.  For  internal  use  the  dose 
is  iv.  drops  gradually  increased  to  xx.  twice 
a day.  It  is  frequently  given  in  cases  of 
anomalous  ulcers,  and  cancerous  affections 
of  the  lip.  It  is  also  used  as  an  external 
application  in  similar  cases,  and  especially 
in  hospital  gangrene.  (See  Arsenic , and 
Hospital  Gangrene,) 

LIQUOR  CALCIS  (L.  P.)— Sometimes 
used  as  an  astringent  injection,  or  lotion,  in 
cases  of  gonorrhoea,  gleet,,  psora,  porrigo, 
abscesses,  &c. 

LIQUOR  CUPRI  SULPHATIS  CAM- 
PHORATA. — 1^,  Cupri  sulphatis.  Boli  Gal- 
lici  sing.  une.  ss.  Camphorm  drach.j.  Aquas 
ferventis  lib.  iv.  Boiling  water  is  to  be 
added  to  the  other  ingredients,  and  the  liquor 
filtered  when  cold.  It  is  chiefly  employed 
in  a diluted  state,  as  a collyrium  ; hopit  may 
also  prove  of  service  as  an  application  to 
foul  ulcers. 

When  used  for  the  cure  of  the  purulent 
ophthalmy,  the  lotion  is  to  be  injected  under 
the  eyelids,  by  means  of  a blunt  syringe, 
and,  if  necessary,  the  application  may  be 
repeated  once  or  twice  every  hour.  (See 
Ophthalmy.) 

LIQUOR  POTASSES  SUBCARBONATIS 
(L.  P.) — This  remedy  is  principally  deserving 
of  notice  on  account  of  its  having  been 
given  with  a view  of  dissolving  calculi  in 
the  bladder,  so  as  to  remove  the  necessity 
of  performing  the  dangerous  and  painful 
operation  of  lithotomy.  The  principle,  on 
which  the  liquor  potassm  subcarbonatis  acts, 
is  by  the  potassa  attracting  and  combining 
with  the  uric  acid  of  the  calculus.  The 
medicine  may  be  exhibited  in  doses  of  20 
or  40  drops,  or  of  a dram,  in  a basin  of 
gruel.  Experience  does  not  seem  to  justify 
the  indulgence  of  much  hope,  with  regard 
to  the  complete  efficacy  of  the  medicine  in 
dissolving  urinary  calculi,  and  on  some  kinds 
it  is  not  calculated  to  act  at  all,  even  ou 
chymieal  principles  ; but,  it  would  appear, 
from  the  reports  of  writers,  that  it  has  often 
materially  palliated  the  pain  which  attends 
the  presence  of  a stone  in  the  bladder. 
Some  practitioners  place  more  confidence 
in  the  liquor  potassae. 

LIQUOR  KALI  ARSENIC  ATI, ■ — ]J.  Kali 
Arsenicati  grana  duo.  Aquae  Menthae  Sativa^ 
uncias  quatuor.  Spiritus  Vinosi  tenuiori^l 
unciam.  Misce  et  cola.  Two  drams  of  this 
may  be  given  thrice  a day  in  cases  of  cancer. 
My  friend,  Mr.  Barnes,  oi  Exeter,  when  for- 
merly a student  at  St.  Bartholomew's,  show- 
ed me  a case  of  lupus,  or  noli  me  tangere, 
which  was  greatly  benefited  by  this  remedy 
externally  applied.  Mr.  Barnes  was  using 
the  lotion  with  double  the  proportion  of 


LITHOTOMY 


arsenic.  There  are  many  ulcerations  round 
the  roots  of  the  nails  of  the  (ingers  and  toes, 
to  which  Plunket’s  caustic  is  sometimes 
applied  ; but,  the  liquor  kali  arsenicati 
would,  in  all  probability,  be  <|uite  as  effica- 
cious, and,  certainly,  it  is  a neater  applica- 
tion. 

LIQUOR  TOTASS^E  (L.  P.)  This  has 
been  given  with  a view  of  dissolving  urinary 
calculi,  in  considerable  doses>  for  a length 
of  time.  The  trials,  however,  have  not  pro- 
ved so  successful  as  could  have  been  wish- 
ed, nor  is  the  exhibition  of  so  active  a re- 
medy unattended  with  disadvantageous 
consequences  to  the  system;  for  which 
reason,  soda  water  and  other  alkaline  wa- 
ters, supersaturated  with  fixed  air,  have  of 
late  been  much  substituted. 

The  proper  dose  of  the  liquor  potassse  at 
first,  is  from  ten  to  twenty  drops  twice  a 
day,  in  some  linseed  tea.  At  St.  Thomas’s 
Hospital,  the  following  is  the  way  in  which 
the  liquor  potasssk  is  prescribed  : — Liq. 
Potass;e  §i.  Aquae  Distillatae  %\j.  Misce. 
Dosis  Drachma  una  bis  die  ex  unciis  quatuor 
infusi  liui. 

LIQUOR  PLUMB!  ACETATJS  (L.  P.) 
— Is  extensively  used,  largely  diluted  with 
water,  as  an  application  to  inflamed  parts. 
(See  Inflammation.)  One  dram  to  a quart 
of  water  is  quite  strong  enough  for  common 
purposes.  Mr.  Justamond  and  Dr.  Cheston 
used  to  apply  it,  mixed  with  an  equal  pro- 
portion of  a spirit  resembling  the  tinctura 
lerri  muriati,  to  the  edges  of  cancerous 
sores. 

k LITHONTRIPTICS.  (from  wfloc,  a stone  ; 
and  d-gv7rra>,  to  break.)  Medicines  for  dis- 
solving stone  in  the  bladder.  (See  Urinary 
Calculi.) 

^'LITHOTOMY,  (from  xtSog,  a stone; 
and  <rs(MV&),  to  cut.)  The  operation  of  cutting 
into  the  bladder,  in  order  to  extract  a stone. 

It  has  been  correctly  remarked,  that  no 
single  operation  of  surgery  has  attracted  so 
much  notice,  or  had  so  much  written  upon 
it,  as  lithotomy.  A full  and  minute  account 
of  the  sentiments  of  every  writer,  who  has 
treated  of  the  subject,  and  a detail  of  the 
infinite  variety  of  particular  modes  of  ma- 
king an  opening  into  the  bladder,  would 
occupy  as  many  pages  as  are  allotted  to  the 
whole  of  this  dictionary.  It  must  be  my 
endeavour,  therefore,'  rather  to  describe 
what  is  most  interesting  anil  important, 
than  pretend  to  offer  an  article  which  is  to 
comprehend  every  thing. 

May  I be  allowed  to  premise,  that  through- 
out the  following  columns,  l suppose  the 
reader  to  be  already  well  informed  of  all 
that  relates  to  the  anatomy  of  the  bladder 
and  adjacent  parts,  and  that  of  the  perinai- 
urn  ? Without  correct  knowledge  of  this 
kind,  a man  must  be  presumptuous  indeed, 
to  set  himself  up  for  a good  lithotomist  ; 
and  if  he  were  to  distinguish  himself  at  all, 
it  would  only  be  by  the  murders  which  he 
committed,  while  his  successful  feats,  if  he 
achieved  any,  could  redound  little  to  his 
honour,  since  every  young  student  would 
soon  find  ouf,  that  they  vrere  not  the  effect 


of  science,  but  ot  mechanical  habit  and  inn 
tation.  I would  particularly  recommend 
every  one,  who  wishes  to  understand  well 
the  anatomy  of  the  pelvic  viscera  and  peri 
namm,  with  a view  to  lithotomy,  in  the. 
first  place  to  dissect  those  parts  himself,  and 
then  avail  himself  of  the  valuable  instruc 
t ions  to  be  derived  on  the  subject  from 
Winslow’s  Anatomy  ; Le  Dran’s  Parallele 
de  Tailles ; Le  Cat’s  Deuxieme  Recueil  , 
planche  5 et  f> ; Haller’s  Inst.  Med.  of  Bo- 
erhaave,  and  Elem.  Physiol.  T.  5 ; Mor- 
gagni, Adversar.  Anat.  3,  p.  82,  97  ; Cam- 
per’s plates  ; Sabatier’s  Anatomy  ; John 
Bell's  Principles  of  Surgery  ; Deschamp’s 
Trailts  Historique,  fee.  de  [’Operation  de  la 
Taille,  T.  1,  p.  7,  fee.;  and  Langenbeck’s 
description  of  the  parts,  and  the  matchless 
plate  which  he  has  given  of  them  in  his 
valuable  work  on  lithotomy,  cited  at  the 
end  of  this  article. 

/V  few  subjects  which  are  closely  connect- 
ed with  the  present,  will  be  found  in  other 
parts  of  this  dictionary.  For  instance,  the 
nature  of  stones  in  the  bladder  will  be  consi- 
dered under  the  head  of  Urinary  Calculi , 
where  also  will  be  seen  some  observations 
on  lithontriptics.  The  manner  of  searching 
for  the  stone,  or,  as  it  is  now  more  common 
ly  expressed,  of  sounding,  will  be  explained 
in  the  article  Sounding. 

Here  I shall  principally  confine  myself  to 
the  symptoms  of  the  disease,  and  the  chief’ 
methods  of  executing  the  much  diversified 
operation  of  lithotomy. 

SYMPTOMS  OF  THE  STOKE. 

The  symptoms  of  a stone  in  the  bladder 
are,  a sort  of  itching  along  the  penis,  parti- 
cularly at  the  extremity  of  the  glans  ; and 
hence  the  patient  often  acquires  a habit  of 
pulling  the  prepuce,  vvhich  becomes  very 
much  elongated  ; frequent  propensities  to 
make  water,  and  go  to  stool ; great  pain  in 
voiding  the  urine,  and  difficulty  of  retaining 
it,  and  often  of  keeping  the  feces  from  being 
discharged  at  the  same  time  ; the  stream  of 
urine  is  liable  to  stop  suddenly,  while  flow- 
ing in  a full  current,  although  the  bladder  is 
not  empty,  so  that  the  fluid  is  expelled  bv 
fits,  as  it  w^ere  ; the  pain  is  greatest  towards 
the  end  of,  and  just  after,  the  evacuation  ; 
there  is  a dull  pain  about  the  neck  of  the 
bladder,  together  with  a sense  of  weight,  or 
pressure,  at  the  lower  part  of  the  pelvis  ; and 
a large  quantity  of  mucus  is  mixed  with  the 
urine  ; and,  sometimes,  the  latter  is  tinged 
with  blood,  especially  after  exercise.  ( Sharpy 
Earle , Sabatier.) 

Frequently  (says  Deschamps)  a patient 
will  have  a stone  in  his  bladder  a long  while 
without  the  occurrence  being  indicated  by 
any  symptom  or  accident.  Most  commonly, 
however,  the  presence  of  the  stone  is  an- 
nounced by  pain  in  the  kidneys,  more  espe- 
cially in  adults  and  old  persons,  children 
scarcely  ever  suffering  in  this  way,  because 
in  them  the  stone  is  hardly  at  all  detained 
in  the  kidneys  and  ureters,  but  descends  im- 
mediately into  the  bladder,  the  preceding 


LITHOTOMY  - 


18V 


tubes  being  in  them  more  dilatable,  and  the 
rudiment,  or  nucleus  of  the  stone  smaller. 

It  seldom  happens,  that  calculous  patients 
void  blood  with  their  urine,  before  the  symp- 
toms and  accidents,  usually  caused  by  the 
stone,  have  taken  place.  It  is  not  till  after 
the  foreign  body  has  descended  into  the 
bladder,  acquired  some  size,  and  presented 
itself  at  the  orifice  of  that  viscus,  that  pain  is 
occasioned,  particularly  when  the  surface  of 
the  stone  is  unequal.  The  patient  then  ex- 
periences frequent  inclination  to  make  wa- 
ter, attended  with  pain.  The  jolting  of  a 
carriage,  riding  on  horseback,  and  much 
walking,  render  the  pain  more  acute.  The 
urine  appears  bloody,  and  its  course  is  fre- 
quently interrupted,  and  sabulous  matterand 
particles  of  stone  are  sometimes  discharged 
with  it.  The  want  to  make  water  becomes 
more  frequent  and  more  insupportable.  The 
bladder  is  irritated,  and  infiames  ; its  parietes 
become  thickened  and  indurated  ; and  its 
diameter  is  lessened.  A viscid,  more  or 
less,  tenacious  matter  is  observed,  in  greater 
or  lesser  quantity,  in  the  urine,  and  is  pre- 
cipitated to  the  bottom  of  the  vessel.  The 
urine  becomes  black  and  putrid,  and  exhales 
an  intolerable  alkalescent  smell,  which  is 
perceived  at  the  very  moment  of  the  evacua- 
tion, and  is  much  stronger  a little  while  af- 
terward. The  patient  can  no  longer  use 
any  exercise,  without  all  his  complaints  be- 
ing redoubled.  Whenever  he  walks  in  the 
least,  the  urine  becomes  bloody  ; the  pain 
about  the  hypochondria,  which  was  dull  in 
the  beginning,  grows  more  and  more  acute  ; 
the  ureters  and  kidneys  participate  in  the  ir- 
ritation with  the  bladder;  they  inflame  and 
suppurate,  and  very  soon  the  urine  brings 
away  with  it  purulent  matter.  The  fever 
increases,  and  changes  into  one  of  a slow 
type  ; the  patient  loses  his  sleep  and  appe- 
tite ; becomes  emaciated  and  exhausted  ; 
and  death  at  length  puts  a period  to  his  mise- 
ry. (See  Traits  Historique  et  Dogmatique  de 
/.'Operation  de  la  Taille  par  J.  F.  L.  Des- 
ehamps,  T.  I,  p.  163,  Paris , 1796.) 

It  is  acknowledged  by  the  most  experien- 
ced surgeons,  that  the  symptoms  of  a stone 
in  the  bladder  are  exceedingly  equivocal, 
and  may  be  produced  by  several  other  dis- 
orders. “ Pain  in  making  water,  and  not 
being  able  to  discharge  the  urine  without 
the  feces,  are  common  consequences  of  ir- 
ritation of  parts  about  the  neck  of  the  blad- 
der, from  a diseased  prostate  gland,  and 
other  causes.  The  urine  stopping  in  a full 
stream  is  frequently  caused  by  a stone  alter- 
ing its  situation,  so  as  to  obstruct  the  pas- 
sage; but  the  same  thing  may  happen  from 
a tumour,  or  fungus  in  the  bladder.  I have 
seen  an  instance  of  this,  where  a tumour, 
hanging  by  a small  pedicle,  would  sometimes 
cause  obstruction,  and  by  altering  the  pos- 
ture, would  retire,  and  give  a free  passage. 
The  dull  pain  at  the  neck  of  the  bladder,  and 
the  sensation  of  pressure  on  the  rectum,  are 
frequently  owing  to  the  weight  of  the  stone, 
&c. ; but  these  may  proceed  from  a diseased 
enlargement  of  the  prostate  glan^.  Children 
generally,  and  grown  persons  frequently,  are 


subject  to  a prolapsus  ani,  from  the  irritation 
of  a stone  in  the  bladder;,  but  it  will  like- 
wise be  produced  by  any  irritation  in  those 
parts.”  (Earle.)  The  rest  of  the  symptoms 
are  equally  fallacious  ; a scirrhous  enlarge- 
ment of  the  os  tincae,  and  disease  of  the  kid- 
neys may  occasion  a copious  quantity  of 
mucus  in  the  urine,  with  pain,  irritation,  &c. 
“ The  least  fallible  sign  (says  Sir  James 
Earle)  which  I have  remarked,  is  the  patient 
making  the  first  portion  of  urine  with  ease, 
and  complaining  of  great  pain  coming  on 
when  the  last  drops  are  expelled.  This  may 
readily  be  accounted  for,  from  the  bladder 
being  at  first  defended  from  contact  with  the 
stone  by  the  urine,  and,  at  last,  being  pressed 
naked  against  it.  But,  to  put  the  matter  out 
of  all  doubt,  and  actually  to  prove  the  exist 
ence  of  a stone  in  the  bladder,  we  must 
have  recourse  to  the  operation  of  sounding.' 

A stone  in  the  ureter,  or  kidneys,  or  an  in- 
flammation in  the  bladder  from  any  other 
cause,  will  sometimes  produce  the  same  ef 
fects  ; but  if  the  patient  cannot  urine,  ex- 
cept in  a certain  posture,  it  is  almost  a sure 
sign  that  the  orifice  of  the  bladder  is  ob- 
structed by  a stone.  If  he  finds  ease  by 
pressingagainstthe  perinaeum  with  his  fingers, 
or  sitting  with  that  part  upon  a hard  body, 
there  is  little  doubt  the  ease  is  procured  by 
taking  off  the  weight  of  the  stone  ; or,  lastly, 
if,  with  the  other  symptoms,  he  thinks  he 
can  feel  it  roll  in  his  bladder,  it  is  hardly  pos- 
sible to  be  mistaken  ; however,  the  only  sure 
judgment  is  to  be  formed  from  searching. 
(Sharp  on  the  Operations.) 

An  enlarged  prostate  gland  is  attended 
with  symptoms  resembling  those  of  a stone 
in  the  bladder ; but  with  this  difference,  that 
the  motion  of  a coach,  or  horse,  does  notin- 
crease  the  grievances,  when  the  prostate  is 
affected,  while  it  does  so  in  an  intolerable 
degree  in  cases  of  stone.  It  also  generally 
happens,  that  the  fits  of  the  stone  come  on  at 
intervals  ; whereas,  the  pain  from  a disea- 
sed prostate  is  neither  so  unequal,  nor  so 
acute.  ( Sharp  in  Critical  Inquiry , p.  165, 
Edit.  4.) 

Though,  from  a consideration  of  all  the 
circumstances  above  related,  the  surgeon 
may  form  a probable  opinion  of  there  being 
a stone  in  the  bladder,  yet  he  must  never 
presume  to  deliver  a positive  one,  nor  ever 
be  so  rash' as  to  undertake  lithotomy,  with- 
out having  greater  reason  for  being  certain 
thatthere  is  a stone  to  be  extracted.  Indeed, 
all  prudent  surgeons,  for  centuries  past,  have- 
laid  it  down  as  an  invariable  maxim,  never 
to  deliver  a decisive  judgment,  nor  under- 
take lithotomy,  without  having  previously- 
introduced  a metallic  instrument  called  a 
sound,  into  the  bladder,  and  plainly  felt  the 
stone. 

Within  the  last  five  years,  at  least  seven 
cases  have  corne  to  my  knowledge,  and  at 
two  of  them  I was  present,  where  the  pa- 
tients were  subjected  to  all  the  torture  and 
perils  of  this  operation,  without  there  being 
any  calculi  in  their  bladders.  The  maxim, 
therefore,  cannot  be  too  strictly  enforced, 
that  the  operation  ought  never  to  be  at- 


188 


UthotomY. 


tempted,  unless  the  stone  can  be  distinctly 
felt  with  the  sound  or  staff.  In  one  of  the 
examples,  of  which  I was  a spectator,  not 
only  the  symptoms,  but  the  feel,  which  the 
sound  itself  communicated  when  in  the 
bladder,  made  the  surgeons  imagine,  that 
there  was  a calculus,  or  some  extraneous 
body  in  this  organ.  Mostof  the  above  cases, 
I understand,  recovered,  which  may  be  con- 
sidered fortunate  ; because  when  the  stone 
cannot  be  found,  the  disappointed  operator 
is  apt  to  persist  in  roughly  introducing  his 
fingers,  and  a variety  of  instruments,  so  long, 
in  the  hope  of  catching  what  cannot  be  got 
hold  of,  that  inflammation  of  the  bladder  and 
peritoneum  is  more  likely  to  follow,  than 
when  a stone  is  actually  present,  soon  taken 
out,  and  the  patient  kept  only  a short  time 
upon  the  operating  table. 

In  a valuable  practical  work  is  recorded 
an  instance,  in  which  what  is  called  a horny 
cartilaginous  state  of  the  bladder,  made  the 
sound  communicate  a sensation,  like  that 
arisingfrotn  the  instrument  actually  touching 
a stone,  and  the  surgeon  attempted  lithoto- 
my. This  patient  unfortunately  died  in 
twenty-four  hours.  (See  Desault's  Parisian 
Chir.  Journal , Vol.  2 ,p.  125.) 

However,  were  the  symptoms  most  une- 
quivocal, there  is  one  circumstance  which 
w ould  always  render  it  satisfactory  to  touch 
the  stone  with  an  instrument,  just  before 
venturing  to  operate  ; I mean  the  possibility 
of  there  actually  being  a stone  in  the  bladder 
to-day,  and  not  to-morrow.  It  is  said,  that 
stones  are  occasionally  forced,  by  the  vio- 
lent contractions  of  the  bladder,  during  fits 
of  the  complaint,  between  the  fasciculi  of 
the  muscular  coat  of  this  viscus,  together 
xvith  a portion  of  the  membranous  lining  of 
the  part,  so  as  to  become  what  is  termed 
encysted.  The  opening  into  the  cyst  is 
frequently  very  narrow,  so  that  the  stone  is 
much  bigger  than  the  orifice  of  the  cyst,  in 
consequence  of  which  it  is  impossible  to 
lay  bold  of  the  extraneous  body  with  the 
forceps,  and  the  operation  would  necessa- 
rily become  fruitless.  ( Sharp's  Critical  In- 
quiry, p.  228,  Edit.  4.) 

In  the  article  Urinary  Calculi,  I have  no- 
ticed the  probability  of  this  having  occur- 
red in  some  of  the  instances  in  which  Mrs. 
Stevens’s  medicine  was  supposed  to  have 
actually  dissolved  the  stone  in  the  bladder; 
lor  an  encysted  stone  is  not  likely  to  be  hit 
with  the  sound,  nor  to  cause  any  inconve- 
nience, compared  with  what  u calculus, 
rolling  about  in  the  bladder,  usually  oc- 
casions. 

It  is  remarked  by  Deschamps,  that  when 
the  stone  is  lodged  in  an  excavated  corner 
of  the  bladder,  in  a particular  cyst,  or  de- 
pression ; when  it  projects  hut  very  little  ; 
when  it  cannot  shift  its  situation  in  the  blad- 
der, so  as  to  fall  against  the  orifice  of  this 
viscus  ; and  when  it  is  also  smooth,  polished, 
and  light;  the  patient  may  then  have  it  a 
long  while  without  experiencing  any  afflict- 
ing symptoms.  He  may  even  live  to  an 
advanced  age,  if  not  without  some  degree  of 
-uffering,  at  all  events,  with  such  pain  as  is 


very  supportable.  Daily  experience  prove*, 
that  persons  may  live  a considerable  time, 
with  one,  two,  or  even  three  stones  in  the 
bladder,  and,  during  the  whole  of  their  lives, 
have  not  the  least  suspicion  of  the  existence 
of  these  foreign  bodies. 

According  to  Deschamps,  this  must  have 
been  the  case  of  M.  Portaiieu,  a tailor.  This 
individual,  eighty  years  old,  was  frequently 
attacked  with  a retention  of  urine  from  pa- 
ralysis, and  Deschamps  introduced  a sound 
several  times,  and  distinctly  felt  a stone  in 
the  bladder.”  The  patient,  however,  never 
had  any  symptom  of  the  disorder,  nor  even 
at  the  end  of  two  years  from  the  time  when 
Deschamps  was  first  consulted.  Very  large 
and  exceedingly  rough  stones  have  also 
been  found  in  the  dead  bodies  of  persons 
who  had  never  complained  of  the  symp- 
toms of  the  disease.  Thus,  at  the  anatomi- 
cal Theatre  of  La  Charit6,  Richerand  found 
an  enormous  mulberry  stone  in  the  bladder 
of  a person  who  died  altogether  of  another 
disease,  and  never  had  any  symptoms  that 
led  to  the  suspicion  of  the  stone.  ( JVoso - 
graphic  Chir.  T.  3,  p.  530,  Edit.  4.)  But 
cases  of  this  kind  must  be  rare,  because  it 
is  rvell  known  that  the  pain,  which  a stone 
produces,  is  less  in  a ratio  to  its  size  than 
to  its  shape  and  situation.  A small  stone, 
owing  to  its  situation,  may  be  more  painful 
than  an  enormous  calculus  which  fills  the 
bladder,  as  is  proved  by  the  following  case, 
by  Deschamps. 

Pechet,  a watchmaker,  until  the  age  of 
forty-five,  had  never  had  any  infirmity,  ex- 
cept that  of  not  being  able  to  retain  his  wa- 
ter a long  while.  One  day,  while  he  W’as 
carrying  a very  heavy  clock,  he  made  some 
exertions  which  probably,  by  changing  the 
situation  of  the  calculus,  caused  at  the  in- 
stant an  acute  pain  in  the  hypogastric  re- 
gion. Symptoms  of  the  stone  soon  came 
on ; the  pain  became  intolerable,  and  the 
patient  went  into  the  tlopital  de  la  Charite. 
He  was  sounded  ; the  stone  wras  felt,  and 
judged  to  be  of  considerable  size.  The  in- 
cision in  the  neck  of  the  bladder  not  suffi- 
cing for  its  extraction,  the  patient  was  put 
to  bed  again.  The  next  morning  he  was 
operated  upon  above  the  pubes  by  Frere 
Come,  who  extracted  an  oval  calculus  that 
weighed  twenty -four  ounces.  The  patient 
died  four  and  twenty  hours  after  this  second 
operation.  This  case  proves,  then,  that 
very  large  stones  may  lie  in  the  bladder 
without  occasioning  any  serious  complaints, 
since  the  preceding  patient  apparently  had 
had  such  a calculus  a long  time  without 
suffering  inconvenience  from  it,  and  it 
seems  likely  that  he  might  have  continued 
well  still  longer,  had  it  not  been  for  the  acci- 
dental effort  which  first  excited  the  symp- 
toms. ( Deschamps , in  Traitc  Hislorique , 
dc  la  Traille , Tom.  1,  p.  166,  167.) 

A priest,  in  whom  Morand  had  ascertain 
ed  the  presence  of  a stone  by  sounding, 
could  not  be  persuaded  that  his  case  was  of 
this  nature.  However,  he  bequeathed  his 
body  at  hi^decease  to  the  surgeons,  and  the 
tycsnnluatiol  of  the  bladderfully  justified  Me- 


LITHOTOMY. 


189 


rand's  prognosis.  Tne  celebrated  D'Alem- 
bert also  died  with  a stone  in  his  bladder, 
having  always  refused  to  be  sounded.  ( Ri - 
chcrand,  Op.  cit.  T.  3,  p.  538.) 

A question  may  here  suggest  itself : ought 
lithotomy  to  be  practised  where  calculi  are 
under  a certain  size  ? Certainly  not,  be- 
cause they  frequently  admit  of  being  dis- 
charged with  the  urine,  without  any  opera- 
tion at  all,  even  from  the  male  subject,  and 
how  much  more  likely  this  is  to  happen  in 
females,  must  be  plain  to  every  body  who 
recollects  the  direct  course,  the  shortness, 
ample  size,  and  dilatability  of  the  meatus 
urinarius.  On  this  subject,  various  facts 
will  be  adverted  to  in  considering  the  ope- 
ration of  lithotomy  in  women.  Sometimes, 
also,  when  a calculus  is  too  large  to  pass 
completely  through  the  male  urethra,  it 
lodges  in  this  passage,  where  it  may  be 
more  safely  cut  upon  and  removed,  than 
from  the  bladder;  and  sometimes  it  is  actu- 
ally discharged  by  an  ulcerative  process. 
Thus,  Dr.  R.  A.  Langenbeck  has  published 
an  example  in  which  a stone  made  its  way 
out  by  ulceration,  and  was  discharged  im- 
mediately behind  the  testes.  (See  J.  C. 
Langenbeck,  Bibl.  ftir  die  Chir.  Gott.  1809.) 
And  G.  Coopmans  has  recorded  an  almost 
incredible  case,  in  which  a calculus,  weigh- 
ing five  ounces,  one  drachm  and  a half, 
when  being  dried-,  was  discharged  on  the 
left  side  of  the  urethra  of  an  elderly  man,  a 
little  below  the  glans  penis.  In  fact,  with- 
out some  further  explanation,  this  case 
would  be  pronounced  impossible  , but  it 
should  be  recollected,  that  after  a small  cal- 
culus has  made  its  way  out  of  the  urethra 
by  ulceration,  if  the  urine  have  still  access 
to  it,  it  will  continue  to  increase  in  size  in 
its  new  situation  ; and  this  is  what  happen- 
ed in  the  present  example  ; for  the  extrane- 
ous body,  when  first  felt  externally,  was 
not  larger  than  a pea.  The  calculus  is  now 
preserved  in  Camper’s  museum.  ( G . Coop- 
r nans , Keurologia , Svo.  Franequerx,  1795.) 
I am  not  meaning,  however,  to  recommend 
surgeons  to  let  the  patient  encounter  all  the 
sufferings  which  must  inevitably  attend  lea- 
ving the  business  to  be  completed  by  ulcera- 
tion, because,  as  soon  as  the  nature  of  the 
, case  is  known,  an  incision  should  be  made 
into  the  swelling,  and  the  foreign  body  taken 
out.  In  many  cases,  also,  small  calculi  may 
be  voided  by  dilating  the  male  urethra  with 
elastic  gum  catheters  of  very  large  diameter, 
and  then  desiring  the  patient  to  expel  his 
urine  with  considerable  force,  a plan  which 
Baron  Larrey  has  found  repeatedly  answer. 
Of  late,  Mr.  Weiss,  surgical  instrument  ma- 
ker, in  the  Strand,  has  invented  a kind  of 
sound,  the  end  of  which,  when  in  the  blad- 
der,  admits  of  being  opened,  like  a pair  of 
forceps,  and  closed  again,  so  as  to  grasp 
calculi  under  a certain  size,  and  draw  them 
out  through  the  urethra.  The  instrument 
has  been  tried  with  great  success  by  Mr.  A. 
Cooper,  who  removed  with  it  from  one  pa- 
tient at  different  times  84  calculi.  And, 
even  when  the  stone  cannot  be  drawn  com- 
pletely out  of  the  urethra,  but  only  into  this 


passage,  it  is  a great 'advantage,  because, 
then  it  may  easily  be  cut  down  to,  and  ex- 
tracted, without  any  w ound  or  injury  of  the 
bladder.  (See  A.  Cooper  in  Med.  Chir . 
Trans.  Vol.  11.) 

I shall  next  describe  the  various  methods 
of  cutting  for  the  stone,  beginning  with  the 
most  ancient,  called  the  apparatus  minor , 
and  ending  with  the  modern  proposal  of 
employing  a knife  in  preference  to  a gorget. 

OF  THE  APPARATUS  MINOR,  CUTTING  ON 
THE  GRIPE,  OR  CELSUS’S  METHOD. 

The  most  ancient  kind  of  lithotomy  was 
that  practised  upwards  of  two  thousand 
years  ago  by  Ammonius,  at  Alexandria,  in 
the  time  of  Heropbilus  and  Erasistratus,  and 
by  Meges,  at  Home,  during  the  reign  of  Au- 
gustus; and.  being  described  by  Celsus,  is 
named  Litholhomia  Celsiana.  From  cutting 
directly  on  the  stone,  fixed  by  the  pressure; 
of  the  fingers  in  the  anus,  it  has  been  called 
cutting  on  the  gripe,  a knife  and  a hook  be- 
ing the  only  instruments  used.  The  appel- 
lation of  the  lesser  apparatus  was  given  to 
it  by  Marianus,  to  distinguish  it  from  a me- 
thod which  he  described,  called  the  appara- 
tus major,  {com  the  many  instruments  em- 
ployed. 

The  operation  was  done  in  the  following 
way.  The  rectum  wTas  emptied  by  a clys- 
ter a few  hours  previously ; and,  immedi- 
ately before  cutting,  the  patient  was  desired 
to  walk  about  his  chamber,  to  bring  the 
stone  down  to  the  neck  of  the  bladder;  he 
was  then  placed  in  the  lap  of  an  assistant, 
or  secured  in  the  manner  now  practised  in 
the  lateral  operation.  The  surgeon  then  in- 
troduced the  fore  and  middle  fingers  of  his 
left  hand,  well  oiled,  into  the  anus  ; while 
he  pressed  with  the  palm  of  his  right  hand 
on  the  lower  part  of  the  abdomen  above  the 
pubes,  in  order  to  promote  the  descent  of 
the  stone.  With  the  fingers  the  calculus 
was  next  griped,  pushed  forward  toward  the 
neck  of  the  bladder,  and  made  to  protrude, 
and  form  a tumour  on  the  left  side  of  the 
perinaeum.  The  operator  then  took  a scat- 
pel,  and  made  a lunated  incision  through 
the  skin  and  cellular  substance,  directly  on 
the«tone,  near  the  anus,  down  to  the  neck 
of  the  bladder,  with  the  horns  towards  the 
hip.  Then,  in  the  deeper  and  narrower 
part  of  the  wound,  a second  transverse  inci- 
sion was  made  on  the  stone  into  the  neck 
of  the  bladder  itself,  till  the  flowing  out  of 
the  urine  showed  that  the  incision  exceeded 
in  some  degree  the  size  of  the  stone.  The 
calculus  being  strongly  pressed  upon  with 
the  fingers,  next  started  out  of  itself,  or  was 
extracted  with  a hook  for  the  purpose. 
( Celsvs , lib.  7,  cap.  26.  J.  Bells  Principles, 
Vol  2,  p.  42.  Allan  on  Lithotomy,  p.  10.) 

The  objections  to  cutting  on  the  gripe, 
are;  the  impossibility  of  always  dividing  the 
same  parts;  for  those  which  are  cut  will 
vary,  according  to  the  degree  of  force  em- 
ployed in  making  the  stone  project  in  the 
perinEeum.  When  little  exertion  is  made, 
if  the  incision  be  begun  just  behind  the  scro 


LITHOTOMY. 


190 


turn,  the  urethra  maybe  altogether  detach- 
ed from  the  prostate:  if  the  stone  be  much 
pushed  out,  the  bladder  may  be  entered 
beyond  the  prostate,  and  both  the  vesiculas 
serninales  and  vasa  deferentia  inevitably 
suffer.  Lastly,  if  the  parts  are  just  suffi- 
ciently protruded,  the  bladder  will  be  cut 
upon  its  neck,  through  the  substance  of  the 
prostate  gland.  (Allan  on  Lithotomy.  Burns , 
in  Edinb.  Surg.  Journal,  No.  XIII.  J.  Bell , 
Vol.  2,  p.  59.) 

The  preceding  dangers  were  known  to 
Fabricius  Hildanus,  who  attempted  to  obvi- 
ate them  by  cutting  on  a staff,  introduced 
through  the  urethra  into  the  bladder.  He 
began  his  incision  in  the  perinaeum,  about 
half  an  inch  on  the  side  of  the  raphe  ; and 
he  continued  the  cut,  inclining  the  knife  as 
he  proceeded  towards  the  hip.  He  continu- 
ed to  divide  the  parts  till  lie  reached  the 
staff ; after  which  he  enlarged  the  wound  to 
such  an  extent,  as  permitted  him  easily  with 
a hook  to  extract  the  sione,  which  he  had 
previously  brought  into  the  neck  of  the 
bladder,  by  pressure  with  the  fingers  in  the 
rectum.  (Burns.)  In  this  way  Mr.  C.  Bell 
has  operated  with  success.  (J.  Bell.) 

The  apparatus  minor,  as  practised  by 
Fabricius,  with  the  aid  of  a staff,  is  certainly 
a very  simple  operation  on  children,  and 
some  judicious  surgeons  doubt  the  propriety 
of  its  present  neglected  state.  You  cut,  says 
an  eminent  writer,  upon  the  stone,  and  make 
of  course,  with  perfect  security,  an  incision 
exactly  proportioned  to  its  size.  There  is 
no  difficult  nor  dangerous  dissection;  no 
gorget,  nor  other  dangerous  instrument, 
thrust  into  the  bladder,  with  the  risk  of  its 
passing  betwixt  that  and  the  rectum  ; you 
are  performing,  expressly,  the  lateral  inci- 
sion of  Raw  and  Cbeselden,  in  the  most 
simple  and  favourable  \yay.  The  prisca  sim- 
plicity instrumentorum  seems  here  to  have 
been  deserted,  for  the  sake  of  inventing 
more  ingenious  and  complicated  operations. 
(J.  Bell.) 

Celsus  has  delivered  one  memorable  pre- 
cept in  his  description  of  lithotomy,  ul  pla- 
ga  paulo  major  qurnn  calculus  sit ; and  he 
seems  to  have  known  very  well,  that  there 
was  more  danger  from  lacerating,  than  cut- 
ting the  parts. 

The  simplicity  of  the  apparatus  minor, 
however,  formerly  emboldened  every  quack 
to  undertake  its  performance  ; and  as  this 
circumstance  was  necessarily  followed  by 
the  evils  and  blunders,  unavoidably  origina- 
ting from  ignorance,  and  also  diminished  the 
emolument  of  regular  practitioners,  it  be- 
came the  grand  cause  of  the  downfall  of 
this  operation.  (See  Heister  on  this  subject.) 
It  was  longer  practised,  however,  than  all 
the  other  methods,  having  been  continued 
to  the  commencement  of  the  16th  century  ; 
and  it  was  performed  at  Bourdeaux,  Paris, 
and  other  places  in  France,  on  patients  of 
all  ages,  by  Raoux,  even  as  late  as  150 
years  ago.  Frere  Jacques  occasionally  had 
recourse  to  it ; and  it  was  successfully  exe- 
cuted by  Ileister.  ( Part  2,  clftip.  140.)  A 
modern  author  recommends  it  always  to  be 


preferred  on  boys  under  fourteen.  (Allan, 
V • 12.) 

APPARATUS  MAJOR, 

So  named  from  the  multiplicity  of  instru- 
ments employed;  or  the  Marian  method, 
from  having  been  first  published  by  Ma- 
rianus  Sanctus,  in  1524,  as  the  invention  of 
his  master,  Johannes  de  Romanis.  (See 
Marianus  de  lapide  Vesiccc  per  mcisionem  ex 
trahendo.) 

This  operation,  which  came  into  vogue, 
as  we  have  noticed,  from  avaricious  causes, 
was  rude,  and  painful  in  its  performance, 
and  very  fatal  in  its  consequences.  The 
apology  for  its  introduction  was  the  decla- 
ration of  Hippocrates,  that  wounds  of  mem- 
branous parts.are  mortal.  It  was  contended, 
however,  that  such  parts  might  be  dilated 
with  impunity  ; and  on  this  principle  of  di- 
latation, Romanis  invented  a complex  and 
dangerous  plan  of  operating ; one  very  in- 
competent to  fulfil  the  end  proposed  ; one, 
which,  though  supposed  only  to  dilate,  really 
lacerated  the  parts.  (Burns.) 

The  operator,  kneeling  on  one  knee,  made 
an  incision  with  his  razor  along  the  peri- 
naeum,  on  one  side  of  th»*  raphe  ; and  feel 
ing  with  his  little  finger  for  the  curve  of  the 
staff,  he  opened  the  membranous  part  of  the 
urethra  ; and  fixing  the  point  of  the  knife  in 
the  groove  of  his  staff,  gave  it  to  an  assistant 
to  hold,  while  he  passed  a probe  along  the 
knife  into  the  groove  of  the  staff,  and  thus 
into  the  bladder.  The  urine  now  flowed 
out.  and  the  staff  was  withdrawn.  The 
operator  next  took  two  conductors,  a sort 
of  strong  iron  probes ; one.  named  the  fe- 
male conductor,  having  in  it  a groove,  like 
one  of  our  common  directors ; the  other 
the  male  conductor,  having  a probe  point, 
corresponding  with  that  groove.  The  groov- 
ed, or  female  conductor,  being  introduced 
along  the  probe  into  the  bladder,  the  probe 
was  withdrawn,  and  the  male  conductor 
passed  along  the  groove  of  the  female  one, 
into  the  bladder.  Then  commenced  the 
operation  of  dilating.  The  lithotomist  took 
a conductor  in  each  hand,  and  by  making 
their  shafts  diverge,  dilated,  or,  in  plain  lan- 
guage, tore  open  (he  prostate  gland.  (J.Bell.) 

It  would  be  absurd  in  me  to  trace  the 
various  dilating  instruments  contrived  for 
the  improvement  of  this  barbarous  operation , 
by  the  Colots,  Marechal,  Le  Dran,  Parfe,  be. 
Among  the  numerous  glaring  objections  to 
(he  apparatus  major,  we  need  only  notice 
the  cutting  the  bulb  of  the  urethra,  not  di- 
viding the  membranous  part  of  the  urethra, 
nor  the  transversalis  perinaii  musele,  which 
forms  a kind  of  bar  across  the  place  where 
the  stone  should  be  extracted  ; violent  dis- 
tention of  the  membranous  part  of  the  ure- 
thra and  neck  of  the  bladder ; laceration  of 
these  latter  parts;  large  abscesses,  extrava- 
sation of  urine,  and  gangrene ; frequent 
impotency  afterward,  and  extensive  fatali- 
ty. Bertraudi  even  saw  the  urethra  and 
neck  of  the  bladder  torn  from  the  prostate 
by  the  violerme  employed  in  tins  vile  nv- 


LITHOTOMY. 


191 


hot]  of  operating.  ( Operations  de  Chir.  p. 
169.)  Pare,  Le  Dran,  Le  Cat,  Mery,  Mo- 
rand,  Mareschal,  Raw,  and  all  the  best  sur- 
geons in  Europe,  most  strangely  practised 
this  rash  method,  for  two  hundred  years, 
till  Fr&re  Jaques,  in  1697,  taught  at  Paris 
the  original  model  of  lithotomy,  as  com- 
monly adopted  at  the  present  day. 

OF  THE  HIGH  OPERATION'. 

This  method  of  cutting  for  the  stone  was 
first  published  in  1556,  by  Pierre  Franco, 
wbo,  in  his  Treatise  on  Hernia,  Ed.  1,  says, 
he  once  performed  it  on  a child  with  suc- 
cess, but  discourages  the  farther  practice  of 
it.  After  him,  Rossetus  recommended  it, 
with  great  zeal,  in  his  book  entitled  Partus 
Cwsarius,  printed  in  1591  ; but  he  never 
performed  the  operation  himself.  Tolet 
mentions  its  having  been  tried  in  the  H6lel 
Dieu,  but  without  entering  into  the  particu- 
lar causes  of  its  discontinuance,  merely  says, 
that  it  was  found  inconvenient.  About  the 
year  1719,  it  was  first  done  in  England,  by 
Mr.  Douglas ; and  after  him,  practised  by 
others.  ( Sharp’s  Operations.) 

The  patient  being  laid  on  a square  table, 
with  his  legs  hanging  off,  and  fastened  to 
the  sides  of  it  by  a ligature,  passed  above 
the  knee,  his  head  and  body  lifted  up  a little 
by  pillows,  so  as  to  relax  the  abdominal 
muscles,  and  his  hands  held  steady  by  some 
assistants  ; as  much  barley-water  as  be  could 
bear,  w'hich  was  often  about  eight  ounces, 
and  sometimes  twelve,  was  injected  through 
a catheter,  into  the  bladder. 

The  bladder  being  filled,  an  assistant,  in 
order  to  prevent  the  reflux  of  the  water, 
must  grasp  the  penis,  the  moment  the  cathe- 
ter is  withdrawn,  bolding  it  on  one  side,  in 
such  a manner  as  not  to  stretch  the  skin  of 
^he  abdomen  ; then,  with  a round-edged 
knife,  an  incision,  about  four  inches  long, 
was  made  between  the  rfl(kti  and  pyramidal 
muscles,  through  the  membrana  adiposa, 
as  deep  as  the  bladder,  bringing  its  extremity 
almost  down  to  the  penis;  after  this,  with  a 
crooked  knife,  the  incision  was  continued 
into  the  bladder,  and  carried  a little  under 
the  os  pubis;  and  immediately  upon  the 
water’s  flowing  out,  the  forefinger  of  the  left 
band  was  introduced,  which  directed  the 
forceps  to  the  stone.  ( Sharp's  Observations.) 
Sabatier  condemns  making  the  cut  in  the 
bladder  from  below  upward,  lest  the  knife 
injure  the  peritonaeum.  {Med.  Operatoire , 
, T.  3,  p.  160.) 

Although  this  is  one  of  the  easiest,  and 
to  all  appearance,  the  safest  method  of 
operating,  several  objections  soon  brought 
it  into  disuse.  1.  The  irritation  of  a 
stone  often  causes  such  a thickened  and 
contracted  state  of  the  bladder,  that  this 
viscus  will  not  admit  of  being  distended  so 
as  to  rise  above  the  p?ibes.  2.  If  the  ope- 
rator should  break  the  stone,  the  fragments 
cannot  be  easily  washed  away,  and  remain- 
ing behind  will  form  a nucleus  for  a future 
stone.  3.  Experience  has  proved,  that  the 
high  operation  is  very  commonly  followed 


by  extravasation  of  urine,  attended  with 
suppuration  and  gangrenous  mischief  in  the 
cellular  membrane  of  the  pelvis.  This  hap- 
pens because  the  urine  more  readily  escapes 
out  of  the  wound  in  the  bladder,  than 
through  the  urethra  ; and  also  because  when 
the  bladder  contracts,  and  sinks  behind  the 
os  pubis,  this  wound  ceases  to  be  parallel 
to  that  in  the  linea  alba  and  integuments, 
and  becomes  deeper  and  deeper.  For  the 
prevention  of  these  ill  consequences,  says 
Sabatier,  it  will  be  in  vain  to  make  the  pa- 
tient lie  in  a horizontal  posture,  and  keep  a 
catheter  introduced,  as  Roussetand  Morand 
recommended : experience  evincing,  that 
the  bad  efFects  are  neither  less  frequent,  nor 
less  fatal  (See  Medecine  Operatoire,  T.  3, 
p.  161,  Edit.  2.)  And  Sir  Everard  Home 
confesses,  that  while  the  high  operation  for 
the  stone  had  no  other  channel  but  the 
wound  for  carrying  off  the  urine,  it  seemed 
to  him  a method  which  ought  never  to  be 
adopted  ; “ the  urine  almost  always  insinu- 
ating itself  into  the  cellular  membrane  be- 
hind the  pubes,  producing  sloughs,  and  con- 
sequently abscerses.”  (On  Strictures , Vol. 
3.  p.  359,  8vo.  Land.  1S2I.)  4.  The  danger 

of  exciting  inflammation  of  the  peritonaeum. 
5.  The  injection  itself  is  exceedingly  pain- 
ful, and  however  slow  the  fluid  be  injected, 
the  bladder  can  seldom  be  dilated  enough 
to  make  the  operation  absolutely  secure  : 
and  when  hastily  dilated  (to  say  nothing  of 
the  possibility  of"  its  bursting,)  its  tone  may 
be  destroyed.  (See  Sharp,  Bilan , Sabatier , 
4'C.) 

In  many  men,  however,  we  know  by 
searching,  that  the  bladder  is  very  large,  so 
that  there  is  no  risk  <4  meeting  with  it  in  a 
contracted  state,  and  the  objection  is  of  no 
weight,  when  the  bladder  extends  a consider- 
able way  above  the  pubes,  and  will  admit  a 
large  quantity  of  injection.  Stones  are  some- 
times known  to  be  of  large  size,  and  they  arc 
less  likely  to  be  btoken  in  this,  than  any  other 
mode  of  lithotomy,  so  that  the  objection  of 
the  difficulty  «>f  extracting  small  calculi  and 
fragments  is  less  forcible.  Mr  Carpue  even 
declares,  that  if  the  stone  should  break,  the 
particles  can  be  extracted  with  much  greater 
certainty,  in  less  time,  and  with  considerably 
less  pain,  than  in  the  lateral  operation, 
(History  of  the  High  Operation , p.  154.) 

I may  add,  that  some  judicious  surgeons 
of  the  present  day  are  decidedly  of  opinion, 
that  when  a stone  in  the  bladder  is  known 
to  be  very  large,  no  attempt  ought  ever  to 
be  made  to  extract  it  from  the  perinaeum. 
Professor  Scarpa  also  declares,  that  the 
lateral  operation  should  not  be  practised, 
when  the  calculus  exceeds  twenty  lines  in 
its  small  diameter.  (See  Memoir  on  the  Cut- 
ting Gorget  of  Hawkins,  p.  8,  transl.  by  Briggs.) 
In  such  cases,  it  is  true,  the  surgeon  might 
do  the  lateral  operation,  and  try  to  break  the 
stone.  But  it  is  a question  whether  one 
ought  not  to  prefer  to  this  unpleasant,  un- 
satisfactory proceeding,  the  high  operation. 
I speak  particularly  ot  cases,  in  which  the 
stone  is  known  to  be  of  very  large  dimen- 
sions before  any  operation  is  begun  Were 


LITHOTOMY 


192 


the  lateral  operation  commenced,  the  stone, 
•f  too  large  for  extraction,  must  of  course  be 
broken  ; for,  it  is  then  too  late  to  adopt  the 
high  operation  with  advantage.  That  such 
things  have  been  done,  however,  arid  yet 
the  patients  escaped,  is  a truth,  which  cannot 
be  denied.  Deschamps  mentions  an  in- 
stance, initwhich  M.  Lassus,  after  using 
Hawkins’s  gorget,  could  not  draw  out  the 
calculus,  and  he  therefore  immediately  did 
the  high  operation,  and  the  patient  recover- 
ed. Indeed,  the  first  example  of  the  . high 
operation  on  record  was  done  by  Franco 
under  similar  circumstances,  and  the  patient 
was  saved.  I have  also  heard  of  a modern 
French  surgeon,  who  began  with  the  lateral 
operation,  but,  finding  a large  calculus,  end- 
ed with  performing  the  high  operation,  with- 
out the  least  delay  or  hesitation  : the  patient 
died. 

Mr.  Samuel  Sharp,  an  excellent  practical 
surgeon  in  his  time,  after  noticing  with  great 
impartiality  the  objections  which  were  then 
urged  against  the  high  operation  says,  that 
he  should  not  be  surprised,  if  hereafter  it 
were  revived  and  practised  with  success;  an 
observation,  which  implied,  that  Mr.  Sharp 
himself  foresaw,  that  the  method  was  capa- 
ble of  being  so  improved,  as  to  free  it  from 
its  most  serious  inconveniences.  In  fact, 
since  his  time,  various  attempts  have  been 
made  to  introduce  the  high  operation  anew, 
and  upon  improved  principles.  Frere  Come, 
i s particular,  knew  very  well,  that  there 
were  circumstances,  as  for  instance,  a calcu- 
lus above  a certain  size,  disease  of  the  ure- 
thra, or  prostate  gland,  &lc.,  where  the  late- 
ral operation  was  liable  to  great  difficulties 
and  disadvantages,  and  where  the  high 
operation,  if  it  could  be  perfected,  would 
be  a fitter  and  safer  mode  of  proceeding. 
However,  it  was  only  in  such  cases,  and 
not  in  all,  that  Frere  C6me  thought  the 
method  better  than  the  lateral  operation. 
He  had  also  discernment  enough  to  perceive, 
that  it  was  extremely  desirable  to  invent 
some  means,  whereby  the  painful  and  hurt- 
ful distention  of  the  bladder,  for  the  purpose 
of  making  this  organ  rise  behind  the  pubes, 
would  be  rendered  unnecessary;  fit  the 
same  time,  that  some  measure  was  adopted 
for  letting  the  urine  have  a more  depending 
outlet,  than  the  wound  in  the  hypogastric 
region.  In  the  former  editions  of  this 
dictionary,  the  error  was  committed  of 
representing  C6me  to  have  cut  the  neck  of 
the  bladder,  as  well  as  its  fundus ; a mistake, 
which  I first  became  aware  of  upon  the 
perusal  of  Mr.  Carpue’s  interesting  work  on 
lithotomy.  The  fact  is,  that  Come  did  not 
wound  the  bladder  in  two  places  ; but  ope- 
rated after  the  following  .way  : he  first  intro- 
duced through  the  urethra  into  the  bladder 
a staff,  which  was  then  held  by  an  assistant. 
An  incision,  an  inch  in  length,  was  now 
made  in  the  perinteum  in  the  same  direction, 
as  in  the  lateral  operation.  Another  incision 
was  made  in  the  membranous  part  of  the 
urethra  along  the  groove  of  the  stalf,  as  fur 
as  the  prostate  gland.  A very  deeply 
grooved  director  was  then  passed  along  the 


staff  into  the  bladder,  and  the  latter  instru- 
ment was  withdrawn.  By  means  of  the 
director,  a sonde  a dard , or  kind  of  catheter 
furnished  with  a stilette,  was  now  introduced 
into  the  bladder,  and,  when  this  had  Ufeeu 
done,  the  director  was  taken  out.  An  in- 
cision was  then  made,  about  three  or  four 
inches  in  length,  just  above  the  symphysis 
of  the  pubes,  down  to,  and  in  the  direction 
of  the  linea  alba.  A trocar,  in  which  there 
was  a concealed  bistoury,  was  next  passed 
into  the  linea  alba,  close  to  the  pubes,  and 
the  blade  of  the  knife  then  started  from  its 
sheath  towards  the  handle  of  the  instrument, 
while  its  other  end  remained  stationary.  In. 
this  manner,  the  lower  part  of  the  linea  alba 
was  cut  from  below  upwards,  and  an  aper- 
ture was  made,  which  was  now  enlarged 
with  a probe-pointed  curved  knife,  behind 
which  a finger  was  kept  so  as  to  push  the 
peritonaeum  out  of  the  way.  Come  then 
took  hold  of  the  sonde  a dard  with  his  right 
baud,  and  elevating  its  extremity,  lifted  up 
the  fundus  of  the  bladder,  while  with  the 
fingers  of  his  left  hand  he  endeavoured  to 
feel  its  extremity  in  the  wound.  As  soon 
as  the  end  of  the  instrument  was  perceived, 
it  was  taken  hold  of  between  the  thumb  and 
middle  finger,  the  peritoneum  was  carefull }/ 
kept  up  out  of  the  way,  and  the  stilette  was 
pushed  by  an  assistant  from  within  outwards, 
through  the  fundus  of  the  bladder.  The 
bladder  being  thus  pierced,  the  operator  in- 
troduced into  a groove  in  the  stilette  a 
curved  bistoury,  with  which  he  divided  the 
front  of  the  bladder, from  above  downwards, 
nearly  to  its  neck.  He  then  passed  his  fin- 
gers into  the  opening,  and  keeping  up  the 
bladder  with  them,  withdrew  the  sonde  a 
dard  altogether.  But,  as  it  was  useful  that 
both  his  hands  should  be  free,  the  bladder 
was  prevented  from  slipping  away  by  means 
of  a suspensory  hook  held  by  an  assistant 
as  soon  as  the  opening  was  found  to  be 
already  ample  enough,  or  had  been  enlarged 
to  the  necessary  extent.  Cdme  next  intro- 
duced the  forceps,  took  out  the  stone,  and 
passed  a cannula,  or  elastic  gum  catheter 
through  the  wound  in  the  perineeum  into 
the  bladder,  so  as  to  maintain  a ready  outlet 
for  the  urine,  and  divert  this  lluid  from  the 
wound  in  the  bladder.  In  women,  of  course, 
the  catheter  was  passed  through  the  meatus 
urinarius.  And,  1 ought  here  to  observe, 
that  C6me  thought  the  high  operation  espe- 
cially adviseable  for  females,  because  his 
experience  had  taught  him,  that  the  division, 
or  dilatation , of  the  meatus  urinarius  was 
generally  followed  by  an  incontinence  of 
urine.  (See  JYouvclle  Mbthode  d'exlraire  la 
Pierre  de  la  Vessie  par  dessus  le  Pubis , fyc. 
S vo.  Bruxelles , 1779.) 

Another  modification  of  the  high  operation 
was  suggested  by  Deschamps,  who,  instead 
of  opening  the  membranous  part  of  the 
urethra  as  C6me  did,  perforated  the  bladder 
from  the  rectum,  and  through  the  cannula 
of  the  trocar  effected  the  same  objects, 
which  the  latter  lithotomist  accomplished  by 
means  of  the  incision  in  the  membranous 
part  of  the  urethra.  Of  the  two  plans,  that 


LITHOTOMY 


Revised  by  Gome  is  unquestionably  the  best, 
because  not  attended  with  a double  wound 
of  the  bladder  ; a thing  which,  I conceive, 
must  always  be  highly  objectionable. 

Dr.  Souberbielle,  who  practices  Come’s 
method,  introduces  a silver  wire  hrough  the 
cannula  of  the  sonde  a dard , and  passes  it 
through  the  wound  made  in  the  tinea  alba. 
The  wire  is  then  held  while  the  sonde  a dard 
is  withdrawn,  and  a flexible  gum-catheter  is 
passed  by  means  of  the  wire  into  the  blad- 
der through  the  wound  in-the  membranous 
part  of  the  urethra.  The  wire  is  now  with- 
drawn, and  the  catheter  is  fixed  with  tapes, 
passed  round  the  thighs  and  pelvis,  and  a 
bladder  is  tied  to  it  for  the  reception  of  the 
urine.  “ A piece  of  soft  linen,  half  an  inch 
wide,  and  six  or  eight  inches  long,  is  to  be 
introduced,  by  means  of  a pair  of  forceps 
into  the  bottom  of  the  bladder;”  the  object 
of  which  slip  of  linen  is  to  carry  off  such 
urine,  as  may  not  escape  through  the  cathe- 
ter. Lint  and  light  dressings  are  applied, 
and  a bandage  round  the  abdomen.  Great 
care  is  to  be  taken  to  keep  the  catheter  per- 
vious, and,  usually  on  the  third  day,  the  slip 
of  lirftn  may  be  taken  out,  and  the  wound 
closed  with  adhesive  plaster.  (See  Carpue’s 
Hisiory  of  the  High  Operation , p.l 71,  172.) 

Sir  Everard  Home  made  trial  of  Dr.  Sou- 
berbielle’s  method  in  St.  George’s  Hospital, 
and  though  some  difficulty  and  delay  occur- 
red in  the  operation,  on  account  of  the  stone 
.being  encysted,  the  result  was  successful. 
Subsequently  to  this  case,  however.  Sir 
Everard  has  invented  and  practised  another 
method,  which,  as  far  as  I can  judge,  is 
better  than  that  of  Come,  or  Souberbielle, 
though  its  principles  are  the  same.  When  it 
is  considered,  that  in  the  operation  of  these 
last  lithotomists,  the  neck  of  the  bladder  is 
not  opened,  and  the  catheter  enters  that  re- 
ceptacle through  the  prostatic  portion  of  the 
urethra,  it  must  be  immediately  obvious,  that 
the  incision  in  the  perinaeum  cannot  answer 
any  material  object,  because  a tube  may  be 
placed  in  the  same  position  by  passing  it 
through  the  urethra  from  the  orifice  in  the 
glans.  The  retainer,  or  bracelet,  invented 
for  keeping  the  catheter  in  the  bladder,  in 
cases  of  enlargement  of  the  prostate  gland, 
seemed  to  Sir  Everard  Home  peculiarly  ap- 
plicable to  the  high -operation,  since  it  keeps 
the  tube  steadily  in  the  natural  canal,  and  * 
renders  the  wound  in  the  perinaeum  unneces- 
sary. Bracelets,  for  this  purpose,  extremely 
elastic,  and  producing  no  irritation,  are 
sold  by  Mr.  Weiss,  of  the  Strand.  They  are 
furnished  with  small  rings,  to  which  the 
outer  end  of  the  catheter  is  fixed  by  means 
of  string. 

Sir  Everard  Home  performed  his  new 
operation,  for  the  first  time,  in  St.  George’s 
Hospital,  on  the  26th  of  May,  1820.  An  in- 
cision was  made  in  the  direction  of  the  linea 
alba,  between  the  pyramidales  muscles,  be- 
ginning at  the  pubes,  and  extending  four 
inches  in  length  : it  was  continued  down  to 
the  tendon.  The  linea  alba  was  then  pierced 
close  to  the  pubes,  and  divided  by  a probe- 
pointed  bis  tour  v to  the  extent  of  three 

Vol.  I Ft  25 


inches.  Tfle  pyramidales  muscles  had  a por- 
tion of  their  origin  at  the  symphysis  pubis 
detached,  to  make  room.  When  the  finger 
was  passed  down  under  the  linea  alba,  the 
fundus  of  the  bladder  was  felt  covered  with 
loose,  fatly,  cellular  membrane.  A silver 
catheter,  open  at  the  end,  was  now  passed 
along  the  urethra  into  the  bladder,  and  when 
the  point  was  felt  by  the  finger  in  the  wound, 
pressing  up  the  fundus,  a stilet,  that  had 
been  concealed,  was  forced  through  the 
coats  of  the  bladder,  and  followed  by  the 
end  of  the  catheter.  The  stilet  was  then 
withdrawn,  and  the  opening,  through  the 
fundus  of  the  bladder,  enlarged  towards  the 
pubes,  by  a probe-pointed  bistoury,  suffi- 
ciently to  admit  two  fingers,  and  then  the 
catheter  was.  withdrawn.  The  fundus  of  the 
bladder  was  held  up  by  one  finger,  and  the 
stone  examined  by  the  forefinger  of  the  right 
hand.  A pair  of  forceps,  with  a net  attached, 
was  passed  down  into  the  bladder,  and  the 
stone  directed  into  it  by  the  finger : the  sur- 
face being  very  rough,  the  stone  stuck  upon 
the  opening  of  the" forceps,  and  being  re- 
tained there  by  the  finger,  was  extracted.  A 
slip  of  linen  had  one  end  introduced  into  the 
bladder,  and  the  other  was  left  hanging  out 
of  the  wound,  the  edges  of  which  were 
brought  together  by  adhesive  plaster.  A 
flexible  gum  catheter,  without  the  stilet,  was 
passed  into  the  bladder  by  the  urethra,  and 
kept  there  by  an  elastic  retainer  surrounding 
the  penis.  The  patient  was  put  to  bed,  and 
laid  upon  his  side,  in  which  position  the 
urine  escaped  freely  through  the  catheter.” 
As  no  blood  had  been  lost  i:i  the  operation, 
twelve  ounces  were  taken  from  the  arm. 
iup  next  day  the  slip  of  linen  was  with- 
drawn, as  useless  and  irritating,  the  catheter, 
while  pervious,  preventing  any  urine  from 
escaping  by  the  wound-  Sir  Everard  thinks, 
that  in  future  the  linen  nbed  only  be  left  in 
the  external  wound,  so  as  to  prevent  col- 
lections of  matter,  and  carry  off  any  urine, 
which  may  issue  from  the  opening  in  the 
bladder,  when  the  catheter  happens  to  be 
stopped  up.  For  this  operation,  Sir  Eve- 
rard particularly  recommends  catheters,  with 
their  insides  polished  like  their  outsides,  in 
order  that  they  may  better  resist  the 
effects  of  the  urine.  Suffice  it  to  add,  with, 
respect  to  the  above  case,  that  the  boy  soon 
recovered,  the  bladder  having  resumed  its 
healthy  functions  in  ten  days,  although  the 
calculos  was  of  the  roughest  possible  kind. 

Sir  Everard  Home  has  repeated  his  new 
method  on  a gentleman,  who  went  out  in  his 
carriage,  with  the  external  wound  con  - 
pletely  healed,  on  the  14th  day  after  the  ope- 
ration. The  only  particulars,  which  need 
here  be  noticed,  in  regard  to  the  latter  case, 
are,  that  some  difficulty  was  experienced  in 
bringing  the  point  of  the  catheter  forwards 
toward  the  pubes,  and  the  slit  in  the  front  of 
the  instrument  made  it  so  incapable  of  bear- 
ing lateral  -motion,  that  the  two  sides  were 
twisted  over  one  another.  (On  Strictures, 
Vol.  3,  p.  359, Svo.  Load.  1820.) 

Whoever  follows  this  method  of  ooeratin*** 
should  always  be«  .provided  with 1 severed 


LITHOTOMY 


T94 


tubes  and  stilets,  of  different  lengths  and 
curvatures ; for,  in  the  only  case,  in  which  I 
have  seen  the  operation  attempted,  the  ex- 
tremity of  the  catheter  could  not  be  made 
to  project  the  fundus  of  the  bladder  towards 
the  pubes,  and,  after  long-protracted  endea- 
vours had  been  made  to  bring  the  end  of  the 
instrument  upwards  and  forwards,  the  tube 
broke,  and  the  operation  was  left  unfinished. 
The  impression  upon  my  mind  was,  that  no 
resistance  of  the  bladder  could  account  for 
what  happened,  and  that  the  fault  lay  in  the 
instrument  itself,  which  should  have  been 
exchanged  for  anotherof  more  suitable  form, 
as  soon  as  it  was  found  to  be  inapplicable. 
And, l believe, that  if  attention  be  paid  to  this 
suggestion  of  always  having  at  hand  a suf- 
ficient number  of  tubes  and  stilets  of  differ- 
ent lengths  and  curvatures,  Sir  Everard 
Home’s  new  method  will  be  the  best  modifi- 
calion  of  the  high  operation  yet  proposed. 
The  slip  of  linen,  however,  I think  is  more 
likely  to  do  harm  by  its  irritation,  than  any 
good,  as  a conductor  of  the  urine  or  matter 
out  the  wound.  At  all  events,  as  Sir  Eve- 
rard has  observed,  it  should  never  be  passed 
into  the  bladder  itself.  Whenever  I am 
asked  my  opinion,  respecting  the  preference, 
which  should  be  given  to  the  high  operation, 
as  a general  practice,  I venture  no  further 
than  to  express  a favourable  opinion  of  it  for 
cases,  in  which  the  calculus  is  known  be- 
forehand to  be  of  very  large  size,  or  the 
urethra  and  prostate  gland  are  diseased. 
The  reasons  urged  by  Mr.  Carpue,  in  favour 
of  a preference  to  the  high  operation  in 
most  cases,  are  : 1.  Because,  it  is  generally 
performed  in  less  time;  a point,  which  may  be 
disputed,  though  it  is  perhaps  not  worth  con- 
testing, since  the  danger  of  an  operation  can- 
not always  be  truly  estimated  by  the  length 
of  time,  which  the  patient  remains  in  the 
operating  room,  slow  and  gentle  proceedings 
sometimes  contributing  to  his  safety.  2.  There 
is  less  pain  ; a remark,  the  justness  of  which 
must  depend,  perhaps,  upon  the  manner  in 
which  each  operation  is  done.  3.  There  is  no 
fear  of  a fatal  hemorrhage  ; a consideration, 
which  I admit  is  one  good  reason  in  favour 
of  the  high  operation ; though  the  lateral  ope- 
ration is  only  subject  to  risk  of  hemorrhage, 
when  the  incisions  are  directed  in  a manner 
not  sanctioned  in  this  dictionary.  4.  There 
is  no  division  of  the  prostate  and  inferior 
part  of  the  bladder : no,  but  there  is  one 
of  the  fundus,  so  that  perhaps  on  this  point 
the  two  operations  stand  upon  an  equality, 
As  for  ‘there  being  no  danger  in  the  high 
operation  of  wounding  the  rectum,  it 
is  undoubtedly  an  advantage,  though  the 
accident,  as  far  as  L have  seen,  is  not 
followed  by  any  serious  consequences,  and 
can  only  happen  from  inattention  to  rules 
easily  followed.  5.  The  stone,  if  of  a cer- 
tain size,  cannot  be  extracted  by  the  lateral 
operation,  but  admits  of  being  so  by  the  high 
operation.  Of  all  the  reasons  for  the  latter 
practice,  this  appears  to  me  the  strongest, 
with  the  exception  perhaps  of  disease  in  the 
urethra  and  prostate.  6.  A small  stone  is 
more  readily  discovered  ifi  this  method,  than 


in  the  lateral  operation  : a point  which  i 
consider  questionable,  and  at  all  events,  not 
sufficiently  important  to  form  a ground  for 
the  high  operation.  7.  If  a stone  breaks, 
the  particles  can  be  extracted  with  more 
certainty,  than  in  the  lateral  operation  : on 
this  question  authors  differ.  8.  The  high 
operation  enables  the  surgeon  to  remove 
encysted  calculi  with  greater  ease  : a reason 
which  may  perhaps  be  generally  true,  but 
which  is  somewhat  weakened  by  the  consi- 
deration that  encysted  calculi  are  not  very 
frequent.  Mr.  Carpue  allows,  that  the  high 
operation  should  not  be  selected  when  the 
patient  is  corpulent,  and  the  bladder  is  thick- 
ened and  diseased,  so  that  its  fundus  cannot 
be  raised  above  the  pubes.  (See  Hist,  of 
the  High  Operation,  p.  173,  8 vo.  Lond.  1819.) 

As  it  is  not  my  object  to  discourage  the 
practice  of  the  high  operation,  under  the  par- 
ticular circumstances  which  have  been  speci- 
fied, I decline  entering  into  any  strict  con 
sideration  of  the  inconveniences  to  which 
this  method  is  exclusively  subject,  especially, 
the  greater  vicinity  of  the  wound  to  the 
peritoneum  and  small  intestines,  and  the 
division  of  that  membrane  and  protrusion  of 
the  viscera  ; accidents,  which  w ill  be  found 
by  any  body,  who  chooses  to  look  over  the 
cases  on  record,  not  to  have  been  unfre- 
quent. On  the  contrary,  as  I believe  this 
method  is  advantageous  in  certain  cases,  the 
recent  attempts  to  bring  it  to  greater  perfec- 
tion give  me  sincere  pleasure. 

In  December,  1818,  Mr.  Kirby,  of  Dublin, 
performed  the  high  operation  for  the  extrac- 
tion of  an  elastic  gum  catheter,  which  had 
slipped  into  the  bladder  through  the  cannula 
of  a trocar,  with  which  paracentesis  had  been 
performed.  No  contrivance  was  found 
necessary  for  lifting  up  the  fundus  of  the 
bladder.  The  puncture,  already  made,  was 
enlarged,  and  after  the  operation  was  fin- 
ished, a catheter  was  placed  in  the  wound, 
but  was  withdrawn  on  the  4th  day,  as  the 
urine  passed  out  by  the  side  of  it.  The  case 
terminated  well.  (See  Kirby's  Cases,  p.  92, 
tyc.  8 vo.  Dublin , 1819.) 

LATERAL  OPERATION. 

So  named  from  the  prostate  gland,  and 
neck  of  the  bladder,  being  laterally  cut. 

From  some  quotations  made  by  Mr.  Car- 
pue from  the  works  of  Franco,  it  appears 
clear  enough,  that  the  latter  wras  not  only 
the  inventor  of  the  lateral  operation,  but 
that  he  placed  his  patients  in  the  position 
adopted  at  the  present  time,  used  similar  in- 
struments to  those  now  employed,  (except- 
ing that  his  gorget  bad  no  sharp  side)  and 
made  the  same  incisions.  Now,  as  this  claim 
of  Franco  to  an  invention  of  such  import- 
ance had  been  nearly,  or  quite  forgot,  when 
Mr.  Carpue’s  work  made  its  appearance,  the 
latter  gentleman  deserves  much  praise  for 
reminding  (he  profession  of  what  may  be 
due  to  the  memory  of  an  old  surgeon,  whose 
name  must  flourish,  as  long  as  the  history  of 
the  rise  and  progress  of  surgery  isinterestingto 
mankind.  But,  though  Franco  appears  proba- 
bly to  havej*ractiscd  the  lateral  operation,  or 


LITHOTOMY. 


J95 


something  very  much  like  it,  he  never  esta- 
blished the  method  as  a permanent  improve- 
ment of  surgery, which  measure  was  left  to  be 
completed  long  afterward  by  ari  ecclesiastic, 
who  called  himself  Frere  Jacques  : he  came 
to  Paris  in  1697,  bringing  with  him  abun- 
dance of  certificates  of  his  dexterity  in  ope- 
rating ; and  making  his  history  known  to  the 
court  and  magistrates  of  the  city,  he  got  an 
order  to  cut  at  the  H6tel  Dieu,  and  the  Cha- 
rity, where  he  performed  this  operation  on 
about  fifty  persons.  His  success  did  not 
answer  the  promises  which  he  had  made, 
and  from  that  time  his  reputation  seems  to 
have  declined  in  the  world,  if  we  may  give 
credit  to  Dionis,  who  has  furnished  us  w ith 
these  particulars. — ( Sharp's  Operations.) 

Frere  Jacques  used  a large  round  staff  With- 
out a groove,  and  when  it  was  introduced 
into  the  bladder,  be  depressed  its  handle, 
with  an  intention  of  making  the  portion  of 
this  viscus,  which  he  wished  to  cut,  approach 
the  periuaeum.  He  then  plunged  a long 
dagger-shaped  knife  into  the  left  bip,  near 
the  tuber  ischii,  two  finger-breadths  from  the 
periuaeum,  and  pushing  it  towards  the  blad- 
der, opened  it  in  its  body,  or  as  near  the 
neck  as  he  could,  directing  his  incision  up- 
ward from  the  anus.  He  never  withdrew 
his  knife,  till  a sufficient  opening  bad  been 
made  for  the  extraction  of  the  stone.  Some- 
times he  used  a conductor  to  guide  the  for- 
ceps, but  more  commonly  directed  them 
with  his  finger,  which  he  passed  into  the 
wound  after  withdrawing  the  knife.  When 
he  had  hold  of  the  stone,  he  used  to  draw  it 
out  in  a quick  rough  manner,  heedless  of  the 
bad  coiisequences.  His  only  object  was  to 
get  the  stone  extracted,  and  he  disregarded 
every  thing  else  ; all  preparatory  means,  ail 
dressings,  all  after-treatment.  (Allan,  p.  23.) 

Totally  ignorant  of  anatomy,  and  thus 
rude  and  indiscriminate  in  practice,  Frere 
Jacques  soon  sunk  into  disrepute.  However, 
there  were  several  eminent  surgeons,  who 
conceived,  from  considering  the  parts  which 
be  cut,  that  his  method  might  be  converted 
into  a most  useful  operation.  ( Sharp's  Ope- 
rations.) 

The  principal  defect  in  his  first  manner  of 
cutting,  was  the  want  of  a groove  in  his  staff, 
which  made  it  difficult  to  carry  the  knife  into 
the  bladder.  At  length,  Frere  Jacques  was 
prevailed  upon  to  study  anatomy,  by  which 
his  judgment  being  improved,  he  readily 
embraced  several  improvements,  which  were 
suggested  to  him.  Indeed,  we  are  informed 
that  he  now  succeeded  better,  and  knew 
more,  than  is  generally  imagined.  Mr.  Sharp 
says,  that  when  he  himself  was  in  France 
in  1702,  he  saw  a pamphlet,  published  by 
this  celebrated  character,  in  which  his  me- 
thod of  operating  appeared  so  much  impro- 
ved, that  it  scarcely  differed  from  the  practice 
of  that  time.  Freire  Jacques  had  learnt  the 
necessity  of  dressing  the  wound  after  the 
operation,  and  had  profited  so  much  from 
the  criticisms  of  Mery,  Fagon,  Felix,  and 
Hunauld,  that  he  then  used  a staff  with  a 
groove,  and  what  is  more  extraordinary,  had 


cut  thirty-eight  patients  successively,  without 
losing  one.  (Sharp's  Operations.) 

In  short,  as  a modern  writer  has  observed, 
he  lost  fewer  patients  than  we  do  at  the  pre- 
sent day,  in  operating  with  a gorget.  He  is 
said  to  have  cut  nearly  5000  patients  in  the 
course  of  his  life,  and  though  persecuted  by 
the  regular  lithotomists,  he  was  imitated  by 
Marechal  at  Paris,  Raw  in  Holland,  and  by 
Bamber  and  Cheselden  in  England,  where 
his  operation  was  perfected.  (Allan.) 

For  a particular  history  of  Frere  Jacques, 
and  his  operations,  Allan  refers  us  to  Bus- 
siere's  Letter  to  Sir  Hans  Sloane , Philos. 
Trans.  1699.  Observations  sur  la  Mani&re  de 
tailler  dans  Us  deux  Sexes,  pour  V Extraction 
de  la  Pierre , praiiqu6e  par  F.  Jacques , par  J. 
Mery.  Lister's  Journey  to  Paris  in  1693. 
Cours  d'  Operations  de  Chirurgie , par  Dionis. 
Garengeot  Traiti  des  Operations,  T.  3,  Ma- 
raud, Opuscule  Chirurgie,  Part  2. 

Among  the  many  who  saw  Fre  e Jacques 
operate,  was  the  famous  Professor  Raw,  who 
carried  his  method  into  Holland,  and  practi- 
sed it  with  amazing  success.  He  never  pub- 
lished any  account  of  it  himself,  though  he 
admitted  several  to  his  operations;  but  after 
his  death,  his  successor  Albums,  gave  the 
world  a very  circumstantial  detail  of  all  the 
processes,  and  mentions,  as  one  of  Raw’s 
improvements,  that  he  used  to  open  the  blad- 
der, between  its  neck  and  the  ureter.  But 
either  Albinus,  in  his  relation,  or  Raw  him- 
self in  his  supposition,  w’as  mistaken  ; since 
it  is  almost  impossible  to  cut  the  bladder  in 
that  part  upon  the  common  staff,  without 
also  wounding  the  neck.”  (Sharp  in  Opera- 
tions and  Critical  Inquiry.) 

Raw’s  method  was  objectionable,  even 
when  accomplished,  as  the  urine  could  not 
readily  escape,  and  became  extravasaied 
around  the  rectum,  so  as  to  produce  terrible 
mischief.  There  is  little  doubt,  that  Raw’s 
really  successful  plan  was  only  imitative  of 
Frere  Jacques’s  second  improved  one,  though 
he  was  not  honourable  enough  to  confess  it, 
(See  Ferhius  de  Culculo  Vcsicce .) 

Dr.  Bamber  was  the  first  man  in  England, 
who  made  a trial  of  Raw’s  method  on  the 
living  subject,  which  he  did  in  St.  Bartholo- 
mew’s Hospital.  Cheselden,  who  had  been 
in  the  habit  of  practising  the  high  operation, 
giadly  abandoned  it,  on  receiving  the  ac- 
count of  Raw’s  plan  and  success,  and  a few 
days  after  Bamber,  he  began  to  cut  in  tin’s 
way  in  Si.  Thomas’s  Hospital. 

Cheselden  used  at  first  to  operate  in  -the 
following  manner.  The  patient  being  pla- 
ced, and  tied  much  in  the  same  way,  as  is 
done  at  this  day,  the  operator  introduces  a 
hollow  grooved  steel  catheter  into  the  blad 
der,  and  with  a syringe,  mounted  with  an 
ox’s  ureter,  injects  as  much  warm  water  into 
it,  as  the  patient  can  bear  without  pain.  The 
water  being  kept  from  running  out  by  a slip 
of  fiannel  tied  round  the  penis,  the  end  of 
the  catheter  is  to  be  held  f»y  an  assistant, 
whose  principal  care  is  to  keep  it  from  rising, 
but  not  at  all  to  direct  the  groove  to  the 
place  where  the  incision  is  to  be  made. 

With  a pointed  convex-edged  knife,  the 


LITHOTOMY 


operator  beginning  about  an  inch  above  the 
anus,  on  1 he  left  side  of  the  raphe,  between 
the  accelerator  u rinse,  and  erector  penis, 
makes  an  incision  downwards,  by  the  side  of 
the  sphincter  ani,  a little  obliquely  outward.*? 
ns  it  descends,  from  two  and  a half  to  four 
inches  in  length,  according  to  the  age  of  the 
patient,  or  size  and  structure  of  the  parts. 
This  incision  he  endeavours  to  make  aii  at 
one  stroke,  so  as  to  cut  through  the  skin,  tut, 
and  all,  or  part  of  the  levator  ani,  which  lies 
in  his  way.  This  done,  he  passes  his  left 
fore-finger  into  the  middle  of  he  wound,  in 
order  to  press  the  rectum  to  one  side,  that  it 
may  be  in  less  danger  of  being  cut ; and 
taking  a crooked  knife  in  his  other  hand, 
with  the  edge  on  the  concave  side,  he  thrusts 
the  point  of  it  through  the  wound,  close  by 
his  linger,  into  (he  bladder,  between  the  ve- 
sicula  setninalis  and  os  ischium  of  the  same 
side.  This  second  incision  is  continued  up- 
wards, till  the  point  of  the  knife  comes  out  at 
the  upper  part  of  the  first.  The  incision  be- 
ing completed,  the  operator  passes  his  left 
fore-finger  through  the  wound  into  the  blad- 
der, and  having  felt,  and  secured  the  stone, 
he  introduces  the  forceps,  pulls  out  his  finger, 
and  extracts  the  stone. 

As  the  bladder  was  distended,  Cheselden 
thought  it  unnecessary  to  cut  on  the  groove  of 
the  staff,  and  that,  as  this  viscus  was  suffi- 
ciently pressed  down  by  the  instrument,  the 
forceps  could  be  very  well  introduced  with- 
out the  use  of  any  director,  except  the  finger. 
( Postscript  to  Douglas's  History  of  the  Lateral 
Operation , 1726.) 

With  respect  to  this  first  of  Cheselden’s 
plans,  Sharp  says,  the  operations  were  ex- 
ceedingly dexterous ; but  the  wound  of  tile 
bladder  retiring  back,  when  it  was  empty, 
did  not  leave  a ready  issue  for  the  urine, 
which  insinuated  itself  among  the  neighbour- 
ing muscles  and  cellular  substance,  and  four 
out  of  the  ten  patients  on  whom  the  operation 
was  done  perished,  and  some  of  the  others 
narrowly  escaped.  ( Sharp's  Operations.) 

Cheselden,  finding  that  he  lost  .-<>  many 
patients  in  imitating  Raw*,  according  to  the 
directions  given  by  Albinus,  began  a new 
manner  of  operating,  which  he  thus  de- 
scribes : “ I first  make  as  long  an  incision  as 
1 well  can,  beginning  near  the  place  where 
the  old  operation  ends,  and  cutting  down 
between  the  rnusculus  accelerator  urina?  and 
erector  penis,  and  by  the  side  of  the  intesti- 
num  rectum  : 1 then  feel  for  the  staff,  and  cut 
upon  it  the  length  of  the  prostate  gland 
straight  on  to  the  bladder,  holding  down  the 
gut  all  the  while  with  one  or  two  fingers  of 
my  left  hand.”  {Anatomy  of  the  Human 
Body , Edit.  1730.) 

Jt  deserves  remark,  that  it  was  Cheselden’s 
second  manner  of  cutting,  which  ivasdescri 
bed  in  the  Opuscules de  Chirurgie , of  Morand, 
who  was  deputed,  and  had  Ins  expenses  de 
frayed  by  the  Royal  Academy  of  Sciences  in 
Paris,  to  come  over  to  England,  and  learn 
from  Mr.  Cheselden  himself,  his  way  of  ope- 
rating for  the  stone  ; and,  accordingly,  we 
find, that  most  French  authors,  taking  their  ac- 
count from  Morand,  describe  Cheselden ’s  se- 


cond, not  his  third  operation,  as  that  which 
he  invented,  and  bears  his  name.  But,  that 
Mr  Cheselden  never  resumed  his  second 
manner  of  cutting  may  be  inferred  from  his 
continuing  to  describe  the  third  only  in  all 
(he  editions  of  his  anatomy  published  after 
1730.  {See  anote  by  J.  Thomson , M.  D.  an- 
nexed to  his  new  edition  of  Douglas's  Appen- 
dix. Edinb  1808.) 

The  insirumenis  which  Cheselden  employ- 
ed in  his  third,  and  most  improved  mode  of 
cutting  for  the  stone,  were  a stall',  an  incision 
knife,  a gorget,  a pair  of  forceps,  and  ga 
crooked  needle  carrying  a waxed  tiiread.  The 
patient  being  placed  on  a table,  his  wrists  are 
brought  down  to  the  outsides  of  his  anklesp 
and  secured  there  by  proper  bandages,  his 
knees  having  first  been  bent,  and  his  heels 
brought  back  near  his  buttocks. 

Cheselden  used  then  to  take  a catheter, 
first  dipped  in  oil,  and  introduce  it  into  the 
bladder,  where  having  searched  for,  and 
discovered  the  stone,  he  gave  the  instru- 
ment to  one  of  his  colleagues,  whom  he  de- 
sired to  satisfy  himself,  whether  there  was  a 
stone,  or  not.  The  assistant,  standing  on  his 
right  hand,  held  the  handle  of  the  staff  be- 
tween his  fingers  and  thumb,  inclined  it  a 
little  towards  the  patient's  right  thigh,  and 
drew  the  concave  side  close  up  to  the  os  pu- 
bis, in  order  to  remove  the  urethra  as  far  as 
possible  from  the  rectum. 

The  groove  of  the  staff  being  thus  turned 
outwardly  and  laterally,  Cheselden  sat  down 
in  alow  chair,  and  keeping  the  skin  of  the 
perinaeum  steady  with  the  "thumb  and  fore- 
finger of  his  left  hand,  he  made  the  first  or 
outward  incision,  through  the  integuments, 
from  above  downwards,  beginning  on  the 
left  side  of  the  raphe,  between  the  scrotum 
arid  verge  of  the  anus,  almost  as  high  up  as 
where  the  skin  of  the  perinaeum  begins  to 
form  the  bag  containing  the  testicles.  Thence 
he  continued  the  wound  obliquely  outwards, 
as  low  down  as  the  middle  of  the  margin  of 
the  anus,  at  about  half  an  inch  distant  from  itr 
and  consequently,  beyond  the  tuberosity  of 
the  ischium.  He  was  always  careful  to  make 
this  outward  wound  as  large  as  he  could  with 
safety.  Having  cut  (he  fat  rather  deeply, 
especially  near  the  rectum,  he  used  to  put  his 
left  fore-finger  info  the  wound,  and  keep  it 
there  till  the  internal  incision  was  quite  finish- 
ed ; first  to  direct  the  point  of  his  knife  into 
the  groove  of  the  staff,  which  he  now  felt 
with  the  end  of  his  finger  • and  secondly,  to 
hold  and  prevent  the  rectum  from  being 
wounded,  by  the  side  of  which  his  knife  was 
to  pass.  This  inward  incision  Cheselden 
made  with  more  caution,  than  the  former. 
H is  knife  first  entered  the  groove  of  the  ros- 
trated, or  straight  part  of  the  staff,  through 
the  side  of  the  bladder,  immediately  above 
the  prostate,  and  its  point  was  afterward 
brought  along  the  same  groove  in  the  direc- 
tion downwards,  and  forwards,  or  towards 
himself.  Cheselden  thus  divided  that  part 
of  the  sphincter  of  the  bladder,  which  lay 
upon  the  prostate  gland,  of  which  he  next 
cut  the  outside  of  one  half  obliquely,  accord- 
ing to  the  direction  and  whole  length  of  the 


tlTHOIOMY. 


197 


urethra  within  it,  and  finished  tlie  internal  in- 
cision, by  dividing  the  membranous  portion 
of  the  urethra,  on  the  convex  part  of  his  staff’. 

A sufficient  opening  being  made,  Che- 
selden  used  to  rise  from  his  chair,  bis  finger 
still  remaining  in  the  wound.  Next  he  put 
the  beak  of  his  gorget  in  the  groove  of  the 
staff',  and  then  thrust  it  into  the  bladder. 
The  staff  was  now  withdrawn,  and  while  he 
held  the  gorget  with  his  left  hand,  lie  intro- 
duced the  forceps  with  the  Hat  side  upper- 
most, with  great  caution  along  the  concavity 
of  the  gorget.  When  the  forceps  was  in  the 
bladder,  he  withdrew  the  gorget,  and  taking 
hold  of  the  two  handles  of  the  forceps  with 
both  his  hands,  he  searched  gently  for  the 
stone,  while  the  blades  were  still  kept  shut. 
As  soon  as  the  calculus  was  felt,  the  forceps 
Was  opened,  and  an  attempt  made  to  get  the 
lower  blade  under  the  stone,  in  order  that 
it  might  be  more  conveniently  laid  hold  of. 
This  being  done,  the  stone  was  extracted 
with  a very  slow  motion,  in  order  to  give 
the  parts  time  to  dilate,  and  the  forceps  was 
gently  turned  in  all  directions. 

When  the  stone  was  very  small,  and  did 
not  lie  well  in  the  forceps,  Cheselden  used 
to  withdraw  this  instrument,  and  introduce 
his  finger  into  the  bladder,  for  the  purpose 
of  turning  the  stone,  and  disengaging  it  from 
the  folds  of  the  lining  of  the  bladder,  in 
which  it  was  sometimes  entangled.  Then 
the  gorget  w as  passed  in  again  on  the  upper 
side  of  his  finger,  and  turned  as  soon  as  the 
fatter  was  pulled  out.  Lastly  ; the  forceps 
was  introduced,  and  the  stone  extracted. 
With  the  view  of  hindering  a soft  stone 
from  breaking  during  its  extraction,  Chesel- 
den used  to  put  one  or  more  of  his  fingers 
between  the  branches  of  his  forceps,  so  as 
to  prevent  any  greater  pressure  upon  it, 
than  what  was  just  necessary  to  hold  it  to- 
gether. But  when  it  did  break,  or  there 
were  more  calculi  than  one,  he  used  to 
extract  the  single  stones,  or  fragments,  one 
after  another,  repeating  the  introduction  of 
his  fingers  and  forceps,  as  often  as  there 
was  occasion.  Cheselden  took  care  not  to 
thrust  the  forceps  so  far  into  the  bladder  as 
to  bruise  or  wound  its  opposite  side;  and  he 
was  equally  careful  not  to  pinch  any  folds 
of  its  inner  coat.  In  this  w ay,  Cheselden 
saved  50  patients  out  of  52,  whom  he  cut 
successively  in  St.  Thomas’s  Hospital.  (Ap- 
pendix to  the  History  of  the  Lateral  Opera- 
tion, by  J.  Douglas.  1731.) 

Cheselden,  with  all  the  enthusiasm  of  an 
inventor,  believed,  that  he  had  discovered 
an  operation,  which  was  not  susceptible  of 
improvement  ; yet,  he  himself  changed  the 
manner  of  his  incision  not  less  than  three 
times,  in  the  course  of  a few  years.  1st,  He 
cut  into  the  body  of  the  bladder,  behind  the 
prostate,  when  he  imitated  Raw.  2dly,  He 
cut  another  part  of  the  bladder,  viz.  the 
neck  and  the  thick  substance  of  the  pros- 
tate ; this  is  his  lateral  mode  of  incision. 
3dly,  He  changed  a third  time,  not  the  es- 
sential form  of  the  incision,  but  the  direc- 
tion, in  which  he  moved  the  knife  ; for  in 
his  first  operation,  when  imitating  the  sup- 


posed operation  of  Raw  and  Frcre  Jacques, 
he  struck  his  knife  into  the  body  of  the 
bladder,  betwixt  the  tuber  ischii  and  the 
vesiculac  seminales,  and  all  his  incision  lav 
behind  the  prostate  gland.  In  this  second 
operation,  he  pushed  his  knife  into  the 
membranous  part  of  the  urethra,  imme- 
diately behind  the  bulb,  and  ran  it  down 
through  the  substance  of  the  gland  ; but  his 
incision  shopped  at  the  membranous  *part, 
or  body,  of  the  bladder.  But  in  his  third 
operation,  after  very  large  external  inci- 
sions, he  passed  his  knife  deeply  into  the 
great  hollow  under  the  tuber  ischii,  entered 
it  into  the  body  of  the  bladder  immediately 
behind  the  gland,  and  drawing  it  towards 
himself,  cut  through  the  whole  substance  of 
the  gland,  and  even  a part  of  the  urethra, 
“ cutting  the  same  parts  the  contrary  way.” 
By  carrying  the  fore-finger  of  the  left  hand 
before  the  knife,  in  dissecting  towards  the 
body  of  the  bladder,  he  protected  the  rec- 
tum more  perfectly,  than  he  could  do  in 
running  the  knife  backwards  along  the 
groove  of  the  staff’;  and  by  striking  his 
knife  into  the  body  of  the  bladder  and 
drawing  it  towards  him,  through  the  whole 
thickness  of  the  gland,  he  was  sqre  to  make 
an  ample  wound.  (J.  Bell's  Principles  of 
Surgery,  Vol.  2,  Part  1,  p.  152.) 

LATERAL  OPERATION  AS  PERFORMED  AT  TUB 

PRESENT  DAV  WITH  CUTTING  GORGETS. 

The  gorget  has  the  same  kind  of  form  as 
one  of  the  instruments  used  by  F.  Colot 
and  others  in  the  performance  of  the  appa- 
ratus major,  and  the  common  opinion,  that 
the  conductor  of  Hildanus  was  the  first  mo- 
del of  it,  is  not  exactly  true  ; but  it  differs 
from  the  instruments  employed  by  these 
older  surgeons  in  having  a cutting  edge. 
Sir  Cesar  Hawkins  thought  that,  when  its 
right  side  was  sharpened  into  a cutting 
edge,  it  might  be  safely  pushed  into  the  blad- 
der, guided  by  the  staff,  so  as  to  make  the 
true  lateral  incision  in  the  left  side  of  the 
prostate  gland  more  easily,  and  with  less 
risk  of  injuring  the  adjacent  parts,  than 
Cheselden  could  do  with  the  knife  ; and 
surgeons  were  pleased  with  a contrivance, 
which  saved  them  from  the  responsibility 
of  dissecting  parts,  with  the  anatomy  of 
which  all  were  not  equally  well  acquainted. 
(J.  Bell.  Allan.) 

As  Scarpa  observes  : To  render  the  exe- 
cution of  the  lateral  operation  easier  to 
surgeons  of  less  experience  than  Chesel- 
den, was  the  motive  which  induced  Haw- 
kins to  propose  his  gorget.  He  thought, 
that  two  great  advantages  would  be  gained 
by  the  use  of  this  instrument ; one  of  exe- 
cuting invariably  the  lateral  incision  of 
Cheselden  ; the  other,  of  constantly  guard- 
ing the  patient  through  the  whole  course  of 
the  operation,  from  injury  of  the  rectum, 
and  of  the  arteria  pudica  profunda.  The 
utility  of  the  latter  object  (says  Scarpa) 
cannot  be  disputed,  as  it  is  evident,  that  the 
convexity  of  the  director  of  the  instrument  de- 
fends the  rectum  from  injury,  and  that  its 
cutting  edge  not  being  inclined  horizontally. 


198 


LITHOTOMY. 


inwards  iitc  tuberosity  and  ramus  of  the  ischi- 
urn,  but  turned  upwards  in  the  direction  of  the 
longitudinal  axis  of  the  neck  of  the  urethra , 
cannot  wound  the  pudic  artery.  But,  with 
respect  to  the  first  advantage,  or  that  of 
executing  precisely  the  lateral  incision  of 
Cheselden,  it  must  be  admitted  that  it  does 
not  completely  fulfil  the  intention  which  he 
|)roposed,  not  only  on  account  of  the  cutting 
edge  of  his  instrument  not  being  raised 
enough  above  the  level  of  the  staff,  to  pene- 
trate sufficiently  the  substance  of  the  pros- 
tate gland,  and  consequently  to  divide  it  to 
a proper  depth ; but,  because  being  too 
much  turned  upwards  at  that  part  of  it, 
which  is  to  lay  open  the  base  of  the  pros- 
tate gland,  it  does  not  divide  it  laterally, 
but  rather  at  its  upper  part,  towards  the 
summit  of  the  ramus  of  the  ischium,  and  the 
arch  of  the  pubes  ; an  opening,  of  all  others 
in  the  perinaDum,  the  most  confined,  and 
presenting  the  greatest  impediment  to  the 
passage  of  the  stone  from  the  bladder.  The 
breadth  of  the  point  of  the  director  is,  be- 
sides, so  disproportionate  to  the  diameter  of 
the  membranous  part  of  the  urethra,  that, 
from  the  great  resistance  with  which  it 
meets,  the  instrument  may  easily  slip  from 
the  groove  of  the  staff,  and  pass  between 
the  bladder  and  rectum,  a serious  accident, 
which  has  very  often  happened  even  in  the 
hands  of  experienced  surgeons. 

Scarpa  considers  all  the  modifications  of 
Hawkins’s  gorget,  proposed  by  B.  Bell, 
Desault,  Cline,  and  Cruikshanks,  as  deteri- 
orations of  the  original  instrument.  B.  Bell 
(he  observes)  has  diminished  the  breadth 
of  the  director,  but  has  given  the  cutting 
edge  an  horizontal  direction.  The  horiz  >n- 
tal  direction  of  the  cutting  edge  is  also  pre- 
ferred by  Desault,  Cline,  and  Cruikshanks  ; 
but  they  have  enlarged  the  director,  and 
flattened  the  part  which  was  previously 
concave.  Aware  of  the  danger  of  wound- 
ing the  pudic  artery,  by  the  horizontal  di- 
rection of  the  gorget,  they  direct  the  handle 
of  the  staff  to  be  inclined  towards  the  pa- 
tient’s right  groin,  and  the  gorget  to  be 
pushed  along  it,  inclined  in  such  a manner, 
that  its  obtuse  edge  may  be  directed  towards 
the  rectum,  and  its  cutting  edge  placed  at 
a sufficient  distance  from  the  tuberosity  and 
ramus  of  the  ischium  to  avoid  wounding 
the  artery.  Scarpa  contends,  however, 
that  it  is  difficult  to  give  a proper  degree  of 
obliquity  to  the  staff,  and  that  such  inclina- 
tion of  the  instrument  must  be  incommo- 
dious,arbitrary,  and  unstable,  in  comparison 
with  that  position  of  it,  in  which  the  handle 
of  the  staff  is  held  in  a line  perpendicular  to 
the  body  of  the  patient,  and  its  concavity 
placed  against  the  arch  of  the  pubes ; on 
which  stability  of  the  instrument  (says  Scar- 
pa) the  safety  and  precision  of  the  lateral 
operation  depend.  According  to  this  emi- 
nent professor,  the  defects  of  Hawkins’s 
original  gorget  arise  from  the  excessive 
breadth  of  the  director,  particularly  at  the 
point  ; the  want  of  sufficient  elevation  of 
the  cutting  edge,  above  the  level  of  the 
groove  of  the  staff,  and  the  uncertain  incli- 


nation of  the  edge  to  the  axis  of  the  urethra 
and  prostate  gland.  The  cervix  of  the  ure 
thra,  in  a man  between  thirty  and  forty 
years  of  age,  is  only  three  lines  in  diameter 
at  the  apex  of  the  prostate  gland,  four  lines 
in  its  centre,  and  five  near  the  orifice  of  the 
bladder.  The  apex  of  the  prostate  gland  is 
rather  more  than  two  lines  in  thickness,  the 
body  or  centre  four,  and  the  base  six,  and 
sometimes  eight,  which  surrounds  the  orifice 
of  the  bladder.  In  an  adult  of  middle  sta- 
ture, from  eighteen  to  twenty  years  of  age, 
the  thickness  of  the  base  of  the  prostate 
gland  is  about  two  lines  less,  compared  with 
that  of  a man  of  forty,  and  of  a large  size. 
The  precise  line  in  which  the  lateral  incision 
of  the  prostate  gland  should  be  made  in  an 
adult,  (says  Scarpa)  is  found  to  be  inclined 
to  the  longitudinal  axis  of  the  cervix  of  the 
urethra,  and  of  the  gland  itself,  at  an  angle 
of  69°.  Now,  from  these  data,  drawn  from 
the  structure  of  the  parts,  Scarpa  makes  the 
director  of  his  gorget  only  four  lines  broad, 
and  two  deep  ; the  breadth  decreasing  at 
the  beak.  The  cutting  edge  of  the  instru- 
ment is  straight  near  its  point,  but  gradu- 
ally rises,  and  becomes  convex  above  the 
level  of  the  staff,  so  that  its  greatest  con- 
vexity is  seven  lines  broad.  Lastly  ; the 
inclination  of  the  cutting  edge  to  the  lon- 
gitudinal axis  of  the  director,  is  exactly 
at  an  angle  of  69°  ; that  is  to  say,  the 
same  as  the  left  side  of  the  prostate  gland 
to  the  longitudinal  axis  of  the  neck  of  the 
urethra.  (See  Scarpa’s  Memoir  on  Haw- 
kins’s Gorget;  transl.  by  Mr.  Briggs , p. 
12,  17.) 

For  nearly  twenty  years  past,  the  instru- 
ment-makers in  London  have  been  in  the 
habit  of  selling  a gorget,  which  Mr.  Aberne- 
thy  first  had  constructed,  and  which  in  the 
particularity  of  having  its  cutting  edge  turn- 
ed up  at  an  angle  of  45°,  bears  much  analo- 
gy to  the  instrument  lately  recommended 
by  Scarpa.  The  cutting  edge  is  straight, 
and  that  useless  and  dangerous  part  of  a 
gorget,  sometimes  called  the  shoulder,  is  re- 
moved. Admitting  that  the  principles  of 
the  lateral  operation  as  inculcated  by  Scar- 
pa, are  correct,  and  of  which  1 shall  present- 
ly speak,  it  appears  to  me,  that  Mr.  Aberne- 
thy’s  gorget  is  far  preferable  to  that  very  re- 
cently proposed  by  Scarpa.  Its  edge  is  not 
so  immoderately  turned  up,  and  it  will  enter 
with  more  ease,  and  less  risk  of  slipping  from 
from  the  staff,  because  it  has  not  any  pro- 
jecting shoulder,  which,  while  the  staff  is 
firmly  held  with  the  beak  of  the  gorget  in  it, 
can  have  no  other  effect  but  that  of  obstruct- 
ing the  passage  of  the  last  instrument. 

Gorgets,  which  cut  on  both  sides,  have 
also  been  sometimes  employed  in  England, 
and  as  a larger  opening  can  be  obtained  by 
them,  even  without  trespassing  the  limits  of 
the  incision,  fixed  by  Scarpa,  that  is  to  say, 
without  cutting  any  part  of  the  body  of  the 
bladder,  they  appear  to  promise  utility,  es- 
pecially when  the  stone  is  suspected  to  be 
large.  However,  they  are  less  used  now, 
than  they  were  some  years  ago,  when  Sir 
Astley  Cooper  employed  them  in  Guv’s*  Hoi: 


LITHOTOMY. 


pital  ; but  I aui  unacquainted  with  the  par- 
ticular reasons  of  this  change. 

Some  criticisms  on  Scarpa’s  method  of 
operating,  and  a few  remarks  on  the  size  and 
direction  of  the  lateral  incision,  will  be 
found  in  a subsequent  section  of  the  present 
article. 

As  inflammation  of  the  bladder  and  peri- 
tonaeum is  the  principal  danger  of  this  ope- 
ration, and,  under  an  equal  degree  of  injury 
and  violence,  is  most  likely  to  happen  in  a 
plethoric  subject,  it  ha3  been  a question, 
whether  venesection  should  not  be  practised 
a day  or  two  before  the  patient  is  operated 
upon,  supposing  that  his  age  and  weakness 
form  no  prohibition.  The  chief  reason, 
which  prevents  the  common  observance  of 
this  practice  is,  that  a great  deal  of  blood  is 
sometimes  lost  in  the  operation  itself.  But 
when  this  has  not  happened,  and  the  patient 
is  young  and  strong,  and  particularly  when 
the  operation  has  been  tedious,  and  the 
bladder  has  suffered  a good  deal,  I am  dis- 
posed to  think  very  favourable  of  the  rule, 
which  is  followed  by  many  surgeons,  of 
bleeding  the  patient  as  soon  as  he  is  put  to 
bed,  and  recovered  from  the  first  depressing 
effects  of  the  operation.  An  opening  medi- 
cine should  also  be  given*the  day  before  the 
patient  is  cut,  and  a clyster  injected  a cou- 
ple of  hours  before  the  time  fixed  upon  for 
the  operation,  in  order  to  empty  the  rectum, 
and  thus  diminish  the  chance  of  its  being 
■wounded. 

As  it  is  advantageous  to  have  the  bladder 
somewhat  distended,  the  patient  should  be 
requested  to  retain  his  urine  a certain  time 
before  being  cut.  Formerly,  a jugum  penis 
was  sometimes  used  for  confining  the  urine 
in  the  bladder  ; but,  since  my  entrance  into 
the  profession,  I have  never  heard  of  this 
contrivance  being  employed. 

Before  the  operation,  the  following  instru- 
ments should  all  be  arranged  ready  on  a 
table  : a staff  of  as  large  a diameter  as  will 
easily  admit  of  introduction,  and  the  groove 
of  which  is  very  deep,  and  closed  at  the  ex- 
tremity. A sharp  gorget,  with  a beak  nicely 
and  accurately  adapted  to  the  deep  groove 
of  the  preceding  instrument,  so  as  to  glide 
easily  and  securely.  A large  scalpel  for 
making  the  first  incisions.  Forceps  of  va- 
rious sizes,  for  extracting  the  stone.  A 
blunt-pointed  curved  bistoury  for  enlarging 
the  wound  in  the  prostate,  if  the  incision  of 
the  gorget  be  not  sufficiently  large,  as  the 
parts  should  never  be  lacerated.  A pair  of 
Le  Cat’s  forceps  with  teeth  for  breaking 
the  stone,  if  too  large  to  come  through  any 
wound  reasonably  dilated.  A syringe  for 
washing  out  clots  of  blood,  or  particles  of 
the  stone.  A scoop  for  the  removal  of 
small  calculi  or  fragments.  Two  strong 
garters,  or  bands,  with  which  the  patient’s 
hands  and  feet  are  tied  together. 

The  curvature  of  the  staff  is  a matter  of 
considerable  importance  ; because  the  di- 
rection of  the  incision  through  the  prostate 
gland  and  neck  of  the  bladder  is  partly  de- 
termined by  it.  The  French  surgeons,  con- 
vinced of  the  advantage  of  introducing  the 


199 

gorget  in  the  direction  of  the  axi3  of  the 
bladder,  always  use  a staff,  which  is  much 
more  curved  than  what  English  surgeons 
employ.  (See  Roux,  Voyage  fait  a Londres 
en  IS  14,  ou  Par  allele  de  la  Chir.  Angloise , 
<£'C.  p.  319  ) But,  I am  inclined  to  believe 
with  Scarpa,  that,  upon  the  whole,  it  is  best 
to  let  the  curvature  of  the  staff  correspond 
exactly  to  that  of  the  axis  of  the  neck  of  the 
urethra  and  prostate  gland.  ( Memoir  on 
Hawkins's  Gorget,  <^c.  p.  17.) 

After  introducing  the  staff,  and  feeling  that 
the  stone  is  certainly  in  the  bladder,  the 
patient  is  to  be  secured  in  the  same  position, 
as  was  described  in  the  account  of  Chesel- 
den’s  latest  method  of  operating. 

The  assistant,  holding  up  the  scrotum 
with  his  left  hand,  is  with  his  right  to  hold 
the  staff,  inclining  its  handle  towards  the 
right  groin,  so  as  to  make  the  grooved  con- 
vexity of  the  instrument  turn  towards  the 
left  side  of  the  perinaeum.  Some  operators, 
also,  like  the  assistant  to  depress  the  handle 
of  the  staff  towards  the  patient’s  abdomen, 
in  order  to  make  its  convexity  project  ia 
the  perinaeum,  while  others  condemn  this 
plan,  asserting,  that  it  withdraws  the  instru- 
ment from  the  bladder.  {Allan,  fyc.) 

Professor  Scarpa  disapproves  of  inclining 
the  handle  of  the  staff  towards  the  patient’s 
right  groin,  ( p . 15.)  and  he  expressly  recom  - 
mends this  instrument  to  be  held  firmly 
against  the  arch  of  the  pubes,  in  a line  per- 
pendicular to  the  body  of  the  patient,  so 
that  the  convex  part  of  the  director  may  be 
placed  towards  the  rectum,  and  take  the 
exact  course  of  the  axis  of  the  neck  of  the 
urethra  and  prostate  gland.  (P.  20.)  This 
position  of  the  staff  is  the  firmest  and  most 
commodious  to  the  surgeon,  and  Scarpa 
maintains,  that  on  such  stability  of  the  instru- 
ment the  safety  and  precision  of  the  lateral 
operation  depend.  (P.  15.) 

The  first  incision  should  alwrays  com- 
mence belowf  the  bulb  of  the  urethra,  over 
the  membranous  part  of  this  canal,  at  the 
place,  where  the  operator  means  to  make  bis 
first  cut  into  the  groove  of  the  staff,  and  the 
cut  should  extend  at  least  three  inches,  ob- 
liquely downward,  to  the  left  of  the  raphe 
of  the  perinaeum,  at  equal  distance  from  the 
tuberosity  of  the  ischium  and  the  anus.  In  a 
large  man,  the  first  cut  should  pass  the  anus 
an  inch  and  a half  or  more  ; for  it  is  a 
general  rule  in  surgery  to  make  free  exter- 
nal incisions,  by  w hich  the  surgeon  is  ena- 
bled to  conduct  the  remaining  steps  of  his 
operation  with  greater  facility,  and  nowhere 
is  it  so  necessary,  as  where  a stone  is  to  be 
extracted.  {Allan.)  That  excellent  surgi- 
cal writer,  Callisen,  lays  it  dowrn  as  a rule 
to  be  observed  in  the  lateral  operation,  that • 
the  incision  ought  not  to  extend  to  such  parts 
as  can  make  no  impediment  to  the  extraction 
of  the  stone  ; and  therefore,  (says  he)  the  bulb , 
and  that  part  of  the  urethra,  vjhich  is  sur- 
rounded by  the  corpus  spongiosum,  should 
never  be  cut.  Only  those  parts  ought  to  be 
divided,  which  firmly  resist  the  safe  intro- 
duction of  instruments  into  the  bladder,  and 
the  extraction  of  the-  stone.  Hence,  the  in- 


LITHOTOMY. 


StJO 


teguments  must  be  opened  by  an  ample  in- 
cision, and  the  membranous  part  of  the  ure- 
thra, transversales  perinaei  muscles,  levater 
uni,  and  prostate  gland,  be  properly  divided. 
( Callisen , Systema  Chirurgiee  Ilodicrnce,  Pars 
2,  p.  655.)  Like  Scarpa,  however,  he  is 
fearful  of  making  a free  cut  through  the 
neck  of  the  bladder,  and  in  lieu  of  doing  so, 
prefers  a slow  and  cautious  dilatation  of  the 
parts.  When  the  external  cut  through  the 
integuments  has  been  executed,  the  next 
object  is  to  divide  the  transversales  perinsei 
muscles,  which  stand,  like  a bar,  across  the 
triangular  hollow,  out  of  which  alone  the 
stone  can  be  easily  extracted.  A part  of  the 
membranous  portion  of  the  urethra,  adjoin- 
ing the  prostate  gland,  is  next  to  be  laid 
open  ; but  an  extensive  cut  through  it,  as  far 
forward  as  the  bulb,  is  quite  unnecessary, 
because  it  will  not  at  all  facilitate  the  pas- 
N sage  of  the  stone  outward. 

Having  placed  the  beak  of  the  gorget  in 
the  groove  of  the  staff,  the  operator  takes 
firm  hold  of  the  latter  instrument  with  his 
left  hand,  raises  its  handle  from  the  abdo- 
men, so  that  it  may  form  nearly  a right  an- 
gle with  the  body,  and  stands  up.  Before 
attempting  to  push  the  gorget  into  the  blad- 
der, however,  he  should  slide  it  backwards 
and  forwards,  with  a wriggling  motion,  that 
he  may  first  be  sure  of  its  beak  being  in  the 
groove  of  the  staff.  The  bringing  forward  of 
the  handle  of  the  latter  instrument,  so  as  to 
elevate  its  point,  before  introducing  the  gor- 
get into  the  bladder,  is  also  considered  of 
great  importance  : for  it  is  by  this  means, 
that  the  gorget  is  introduced  along  the 
groove  of  l he  staff  in  the  axis  of  the  blad- 
der, the  only  direction  unattended  with  risk 
of  wounding  the  rectum.  In  fact,  the  gor- 
get should  be  introduced  nearly  in  a direc- 
tion, corresponding  to  a line  drawn  from 
the  os  coccygis  to  the  umbilicus.  It  is  ob- 
vious, however,  that  the  degree  in  which 
the  handle  of  the  staff' should  be  depressed, 
must  depend  very  much  upon  the  curvature 
of  i he  instrument. 

The  utmost  attention  to  the  ride  last  no- 
ticed is  especially  necessary,  when  a staff 
with  a groove  not  closed  at  the  end  is  em- 
ployed. The  neglect  of  it  in  this  case 
might  make  the  operator  cut  the  bladder 
with  the  gorget  in  several  places,  as  has 
actually  happened,  as  we  learn  from  the 
observations  of  Mr.  B.  Bell.  But  since  the 
gorget,  when  introduced  as  nearly  as  possi- 
ble in  the  axis  of  the  bladder,  may  transfix 
and  otherwise  injure  this  organ,  if  introdu- 
ced either  too  far,  or  at  all  beyond  the  ex- 
tremity of  the  staff,  I am  decidedly  of  opi- 
nion that  every  surgeon,  who  chooses  to 
perform  the  lateral  operation  with  a gorget, 
should  employ  a staff,  the  groove  of  which 
is  closed  at  the  extremity,  as  is  invariably 
done  in  France,  and  is  expressly  enjoined 
by  Professor  Scarpa.  (See  Sabatier's  Mt- 
ilecine  Optroioire,  T 3 ,p.  223.  Edit.  2;  and 
Scarpa's  Memoir  on  Hawkins's  Gorget,  p.  18, 
<^c.)  There  can  also  be  no  doubt  of  the 
prudence  of  endeavouring  to  have  only  a 
fixed  and  limited  length  of  the  stafLin  the 


bladder.  Scarpa  specifies  an  inch  and  a 
half  as  the  proper  distance  to  which  the  end 
of  the  staff’ should  enter  the  bladder.  How- 
ever, as  it  is  known,  that  this  distinguished 
Professor  is  an  advocate  for  a very  limited 
incision,  and  that  consequently,  he  would 
not  require  the  staff  to  extend  further  than 
an  inch  and  a half  into  the  bladder,  I infer 
that  operators,  who  prefer  making  a freer 
opening,  must  use  a staff'  that  reaches  into 
this  viscus  rather  further.  Much,  however, 
will  depend  upon  the  kind  of  gorget  em- 
ployed, particularly  its  breadth. 

As  soon  as  the  gorget  is  introduced,  the 
staff  is  to  be  withdrawn.  Some  operators 
next  pass  the  forceps  alopg  the  concave 
surface  of  the  gorget  into  the  bladder;  while 
others,  with  every  appearance  of  being  right, 
recommend  the  cutting  gorget  to  be  with- 
drawn immediately  it  has  completed  the 
wound  ; for  then  the  bladder  contracts,  and 
its  fundus  is  liable  to  be  cut.  The  gorget 
should  be  withdrawn  in  the  same  line  in 
which  it  entered,  pressing  it  towards  the 
right  side,  in  order  to  prevent  its  making  a 
second  wound.  If,  however,  the  operator 
should  prefer  passing  the  forceps  into  the 
bladder,  along  the  gorget,  the  latter  instru- 
ment must  be  kepf  quite  motionless,  lest  its 
sharp  edge  do  mischief;  and,  at  all  events, 
as  soon  as  the  forceps  is  in  the  bladder,  the 
cutting  gorget  is  to  be  withdrawn. 

Some  operators  withdraw  the  cutting  gor- 
get, and  introduce  a blunt  one  for  the  gui- 
dance of  the  forceps  ; a step  certainly  un- 
necessary, as  the  latter  instrument  will  ea- 
sily pass,  when  the  incision  into  the  bladder 
is  ample  and  direct,  as  it  ought  always  to  be. 

The  operator  has  next  to  grasp  the  stone 
with  the  blades  of  the  forceps ; for  which 
purpose,  he  is  not  to  expand  the  instrument 
as  soon  as  it  has  arrived  in  the  bladder  ; but 
he  should  first  make  use  of  the  instrument  as' 
a kind  of  probe,  for  ascertaining  the  exact 
situation  of  the  stone.  If  this  body  should 
be  lodged  at  the  lower  part  of  the  bladder, 
just  behind  its  neck,  the  operator  is  to  open 
the  forceps  immediately  over  the  stone,  and 
after  depressing  the  blades  a little,  is  gently 
to  shut  them,  so  as  to  grasp  it.  Certainly 
it  is  much  more  scientific  to  use  the  forceps 
at  first,  merely  for  ascertaining  the  position 
of  the  stone  : for  when  this  is  known,  the 
surgeon  is  much  more  able  to  grasp  the  ex- 
traneous body  in  a skilful  maimer,  than  if 
he  were  to  open  the  blades  of  the  instru- 
ment immediately,  without  knowing  where 
they  ought  next  to  be  placed,  or  when 
shut.  No  man  of  experience  can  doubt 
that  the  injury,  which  the  bladder  frequent- 
ly suffers  from  rough,  reiterated,  awkward 
movements  of  the  forceps,  is  not  an  unconr 
mon  cause  of  such  inflammation  of  this' 
viscus,  as  too  often  extends  to  the  perito- 
naeum, and  occasions  death 

If  the  surgeon  cannot  readily  take  hold 
of  the  stone  with  the  forceps,  he  should  in- 
troduce his  fore  and  middle  fingers  into  the 
rectum,  and  raise  up  the  extraneous  body, 
when  it  may  generally  be  easily  grasped. 
The  stone  should  be  held  with  sufficient 


LITHOTOMY. 


'2d  l 

instance,  however,  the  surgeon  should  gently 
examine  the  cavity  of  the  bladder  with  his 
fore-finger  ; for,  it  would  be  an  inexcusable 
neglect  to  put  the  patient  to  bed  with  ano- 
ther stone  in  his  bladder. 

After  the  operation,  a simple  pledget 
should  be  laid  on  the  wound,  supported  by 
a T bandage  ; the  patient  should  lie  in  bed 
on  his  back,  with  his  thighs  closed  ; a piece  of 
oil  cloth,  and  some  folded  napkins  should 
be  laid  under  him  for  the  reception  of  the 
urine,  and,  if  there  be  much  pain,  a large 
opiate  should  be  administered  ; but,  as  the 
latter  medicine  is  a stimulant,  if  it  can  be 
dispensed  with,  so  much  the  better. 

An  occasional  embarrassment  to  lithoto- 


iirmness  to  keep  it  from  slipping  away 
trom  the  blades,  but  not  so  forcibly  as  to 
incur  the  risk  of  its  breaking. 

Sometimes  the  extraction  of  the  stone  is 
attended  with  difficulty,  owing  to  the  ope- 
rator having  chanced  to  grasp  it  in  a trans- 
verse position,  in  which  circumstance,  it  is 
better  to  try  to  change  its  direction,  or  let 
it  go  altogether,  and  take  hold  of  it  in  ano- 
ther manner.  When  the  stone  is  so  large, 
that  it  cannot  be  extracted  from  the  wound 
without  violence  and  laceration,  the  surgeon 
may  either  break  the  stone  by  means  of  a 
strong  pair  of  forceps,  with  teeth  construct- 
ed for  the  purpose  ; or  he  may  enlarge  the 
■wound  with  a probe-pointed  crooked  bis- 
toury, introduced  under  the  guidance  of  the  mists  is  the  circumstance  of  stones  in  the 
tore-finger  of  the  left  hand.  The  latter  plan  bladder  not  being  always  free  and  detached  • 
is  generally  the  best  of  the  two  ; for,  break-  some  are  embraced  verv  tightly  bv  the  coats 
ing  the  stone  is  an  exceedingly  unpleasant  of  this  viscus ; others  are  partially  en^ed 
circumstance,  as  it  creates  serious  danger  of  in  the  ureters  : they  are  sometimes  fixed”  in 
calculous  fragments  remaining  behind.  the  neck  of  the  bladder;  and  are  not  uii- 
However,  as  nothing  can  justify  the  exer-  frequently  found  lodged  in  saccuii  accident- 
tion  of  force  m pulling  out  a stone,  if  the  ally  formed.  These  cysts  are  of  different 
operator  should  be  afraid  of  making  the  sizes:  some  are  small,  and  exist  in  a consi- 
wo.un.d  ra^re  ample,  (<t  being  already  large  derable  number;  some  are  deeper,  with  an 
and  direct)  he  must  break  the  stone  as  above  orifice  smaller  than  their  base.  They  appear 
described  As  many  of  the  fragments  are  to  be  formed  by  a prolongation  of  the  in- 
then  to  be  extracted  w ith  the  common  li-  ternal  coat  of  the  bladder.  ^ Other  saccuii  are 
thotomy  forceps,  as  can  be  taken  away  in  occasionally  found  which  seem  to  be  com- 
th.s  method,  after  which  the  surgeon  should  posed  of  all  the  tunics  of  the  bladder,  and 
introduce  his  finger,  in  order  to  feel  whether  they  are  sometimes  of  such  magnitude,  that 
any  pieces  of  the  stone  still  remain  behind,  the  bladder  appears  as  if  it  were  divided  into 
Perhaps  some  of  these  may  be  most  conve-  two  or  more  cavities  of  nearly  equal  size, 
mently  taken  out  with  the  scoop  ; but  if  Stones,  found  in  these  saccuii,  sometimes 
J yery  small,  it  is  best  to  inject  luKe-  present  depressions  and  irregularities,  in 
warm  water  with  moderate  force  into  the  which  fungi  of  the  bladder  have  been  re- 
wound for  the  purpose  of  washing  them  out.  ceived.  When  this  happens,  a portion  of 
e surgeon  however,  cannot  be  too  such  fungous  productions  is  often  extracted 

"e  abS°IUte  116  wilh  tbe  stone;  a circumstance  that  has 
cessit}  of  using  the  greatest  care  not  to  re-  deceived  some  practitioners,  and  led  them 


move  the  patient  from  the  operating  table, 
while  any  calculus,  or  fragment,  remains  in 
the  bladder.  For,  the  distressing  pain  of 
the  disorder  has  been  knowrn  to  recur  upon 
the  healing  of  the  wound,  and  a second 
operation  become  necessary.  It  is  a me- 
lancholy truth,  however,  that  a fresh  calcu- 
lus may  form  again  in  the  short  space  of  a 
few  months.  I have  seen  several  patients 
who  have  been  cut  for  the  stone,  more  than 
once ; and  Richerand  mentions  the  case 
of  a surgical  instrument  maker,  resident  at 
the  gate  of  La  CharTte,  in  Paris,  who  has 
undergone  the  operation  three  times  in  the 
course  of  a year  and  a half,  although  after 
each  operation  several  eminent  surgeons 
carefully  examined  the  bladder,  and  could 
not  find  any  calculus  remaining  in  it.  (See 
JYosogr.  Chir.  T.  3,  p.  549,  Edit.  4.) 

The  stone  should  always  be  attentively  ex- 
amined immediately  it  is  extracted  ; because 
its  appearance  conveys  some  information 


to  suppose,  that  the  calculi  actually  adhered 
to  the  coat  of  the  bladder.  (See  Desault's 
Parisian  Chirurgicale  Journal.  Vol.  2,  p.  386. 
387.)  ^ * 

Tne  extraction  of  encysted  stones  requires 
different  modes  of  proceeding  from  those 
which  have  been  related.  Littre  conceived 
that  they  might  be  removed  in  two  ways. 
Wneri  they  made  only  an  inconsiderable 
projection  into  the  bladder,  he  recommended 
the  introduction  of  a probe,  with  which 
the  membrane,  covering  the  calculus,  was 
to  be  rubbed,  a linger  being  put  into  the 
rectum,  in  order  to  keep  it  down,  and  facili- 
tate the  action  of  the  probe  in  opening  the 
cyst.  When  the  calculi  w’ere  very  prominent. 
Littre  recommended  taking  hold  of  them 
with  a pair  of  forceps,  and  contusing  and 
breaking  the  membranous  pouch,  with  the 
points  and  asperities  upon  the  inside  of  the 
blades  of  the  instrument.  He.  conceived 


that  suppuration  would  then  destroy  the  in- 

o7oi;;;r  and M the  rr 

surface,  „,e  smoo.buess  is  Se„era,,v US 

it  is  plain,  that  this  theory,  which  is  found- 
ed on  the  idea  entertained  bv  Littre  of  the 


to  arise  from  the  friction  of  other  stones 
still  in  the  bladder ; but,  when  it  is  uniformly 
rough,  it  is  a presumptive  sign,  that  there  is 
uo  other  one  remaining  behind  In  every 
Tot  U. 


*2  fi 


manner  in  which  stones  become  eficysted 
i?  totally  inadmissible  in  practice 


3Q3 


LITHOTOMY. 


Garengeol.  ventured  to  pass  a bistoury  into 
the  bladder  for  the  purpose  of  disengaging  a 
calculus  lodged  in  a particular  cyst  at  the 
fundus  of  this  organ,  behind  the  pubes.  The 
knife  had  some  tape  twisted  round  the  great- 
est part  of  its  length , and  was  introduced 
under  the  guidance  of  the  left  index  finger, 
which  was  passed  in  as  far  as  it  could  reach. 
The  patient  was  not  more  than  ten,  or  eleven 
years  old,  and  consequently  of  a size,  which 
favoured  the  operation.  The  stone  was 
oosened  and  taken  out,  and  the  child  re- 
covered However,  as  Sabatier  remarks, 
there  are  many  instances,  in  which  this  mode 
of  proceeding  cannot  be  imitated  ; for,  if 
the  calculus  should  be  in  a sort  of  cul-de- 
sac,  as  often  happens,  the  entrance  of  which 
is  narrower  than  its  bottom,  and  the  stone 
be  of  considerable  size,  the  incision  cannot 
be  made  large  enough,  without  risk  of  cut- 
ting through  the  whole  thickness  of  the  blad- 
der, and  producing  certain  death  by  the 
effusion  of  urine  in  the  abdomen. 

Other  practitioners  fancied,  that  the  cal- 
culus might  be  taken  hold  of  with  the  for- 
ceps, and  turned  about  in  different  directions 
so  as  to  lacerate  its  connexions,  or  even 
that  it  might  be  forcibty  extracted,  with  any 
serious  ill  consequences.  Houstet  mentions, 
(See  Mem.  de  VAcad.  de  Chir.  T.  2,  p.  307,  fyc. 
Edit.  12 mo*)  that  Peyronie  adopted  this  me- 
thod on  a patient,  thirty-one  years  of  age. 
The  calculus  did  not  resist  long,  and  its  sur- 
face was  found  covered  with  fleshy  substan- 
ces, which  formed  the  adhesions  to  the  blad- 
der. The  operation  was  painful,  follow- 
ed by  considerable  hemorrhage,  tension  of 
the  belly,  hiccough,  cold  extremities,  and 
death. 

There  are  some  examples,  however,  in 
which  this  bold  practice  had  better  success. 
In  1730,  Le  Drari  extracted  from  a woman 
an  enormous  stone,  adherent  to  that  part  of 
the.bladder  which  lies  upon  the  rectum. 
The  irritation  of  the  inequalities  of  the 
stone  had  produced  ulceration  of  the  blad- 
der, and  fungous  growths,  which  insinuated 
themselves  into  the  substance  of  the  extra- 
neous body.  The  adhesions  readily  yielded, 
and  the  excrescences  came  away  with  the 
calculus.  Ten  days  afterward,  some  thick 
membranous  sloughs  were  voided.  This 
calculus  is  engraved  in  Le  Dran’s  Treatise 
on  the  Operations. 

Le  Dran  afterward  extracted  similar 
stones,  which  adhered  by  a less  extensive 
surface ; and  he  relates  an  operation  done 
by  Mar&chal,  who,  in  1715,  extracted  with 
a pair  of  forceps  a stone  shaped  like  a cala- 
bash, and  having  its  narrow  part  surrounded 
by  a fungus.  In  one  case,  the  position  of 
the  calculus  led  Le  Dran  to  suspect  that  it 
was  fixed  in  the  extremity  of  the  ureter  ; he 
shook  it  occasionally  with  a pair  of  forceps  ; 
and,  lastly,  it  fell  into  the  bladder,  whence 
it  was  extracted  without  difficulty.  It  re- 
sembled a cucumber  in  shape,  and  its  large 
extremity  had  been  lodged  in  the  ureter, 
from  which  it  could  only  be  gradually  re- 
moved. Sabatier  believes,  that  a case  of 


this  description,  which  must  be  very  un- 
common, is  the  only  one  in  which  there  is 
any  prospect  of  removing  an  encysted  stone 
with  success.  In  other  examples,  he  con- 
ceives, that  it  is  more  prudent  to  leave  the 
stone,  and  let  the  wound  heal,  than  expose 
the  patient  to  an  almost  certain  death  by 
repeated  attempts  to  extract  it.  ( M6decine 
Opdraloire,  T.  3,  p.  190,  194,  Edit.  2.)  De- 
sault employed  a sort  of  concealed  knife, 
called  a coupe-bride,  for  opening  the  cavity 
or  cyst;  and  he  has  recorded  one  example, 
in  which  he  thus  successfully  extracted  from 
a woman,  aged  sixty-two,  a stone,  lodged 
at  the  insertion  of  the  ureter  into  the  blad- 
der. The  bistoury,  used  by  Garengeot,  De- 
sault did  not  consider  a safe  instrument,  as 
the  stones  are  round,  and  the  knife  may  slip 
and  pierce  the  bladder;  an  objection  to 
which,  he  says,  the  coupe-bride  is  not  liable. 
No  injury  can  be  received  from  its  point,  as 
the  blade  is  concealed,  nor  can  any  part  be 
divided,  except  what  the  surgeon  intends. 
If  the  incision  should  not  be  completed  at 
first,  the  blade  may  be  withdrawn,  the  semi- 
circular notch  of  the  instrument  pushed 
more  forward,  and  the  incision  prosecuted 
to  any  extent.  This  instrument  was  invent- 
ed for  the  express  purpose  of  dividing  mem- 
branous bands  in  the  rectum  ; but  it  was 
afterward  employed  with  the  greatest  suc- 
cess for  the  excision  of  diseased  tonsils  and 
fungous  tumours  situated  in  cavities.  The 
blade  is  so  contrived,  that  when  it  passes 
through  the  semicircular  notch,  it  firmly 
fixes  the  parts  which  are  to  be  divided  : a 
thing  that  cannot  be  done  either  with  the 
scissors  or  bistoury,  as  the  moveable  parts 
recede,  and  render  the  section  difficult.  (See 
Desault's  Parisian  Chirurgicale  Journal,  Vol. 

hp-  33,4*.) 

A stone  perfectly  encysted  would  not  be 
expected  to  produce  symptoms  equal  in 
severity  to  those  which  arise  from  an  extra- 
neous body  actually  in  the  cavity  of  the 
bladder.  And  yet,  in  Houstet’s  interesting 
dissertation,  several  cases  are  recorded, 
which  prove  that  encysted  stones  do  some- 
times cause  the  same  distressing  symptoms 
which  proceed  from  the  presence  of  a loose 
calculus  in  the  bladder.  Hence,  the  pa- 
tients were  sounded,  and  in  consequence  of 
the  sacs,  or  pouches,  in  which  the  stones 
lay,  not  being  entirely  closed,  the  calculi 
were  distinctly  struck  by  the  instrument, 
and  lithotomy  attempted.  It  deserves  par- 
ticular remark,  also,  that,  in  a large  propor- 
tion of  these  cases,  the  pouches,  or  cysts, 
were  not  single,  but  numerous,  occupying 
different  parts  of  the  bladder.  In  some  dis- 
sections, referred  to  by  Houstet,  cysts  ot 
this  kind  were  found,  not  containing  any 
stones  whatever  ; a circumstance  that  would 
rather  lead  one  to  suspect,  that,  in  general, 
the  formation  of  these  sacs  precedes  that  ot 
the  calculi  commonly  found  in  them.  (Sec 
Observations  sur  les  Pierres  EnkisUes  et  Ad- 
herent es  a la  Vessie  par  M.  Houstet,  in  M6ui. 
de  PAcad.  de  Chir.  T.  2,  p.  258,  Edit.  >'/■ 
I2/7J0.) 


LITHOTOMY'. 


203 


OF  SOME  PARTICULAR  METHODS  AND  IN- 
STRUMENTS. 

M.  Foubert,  a very  eminent  surgeon  at 
Paris,  devised  and  practised  a plan  of  his 
own,  which,  however,  has  not  been  consi- 
dered by  others  as  worthy  of  being  imitated. 
The  patient  having  retained  his  urine,  so  as 
to  distend  his  bladder,  an  assistant,  with  a 
convenient  bolster,  presses  the  abdomen  a 
little  below  tbe  navel  in  such  a manner, 
that,  by  pushing  the  bladder  forwards,  he 
inay  make  that  part  of  it  protuberant  which 
lies  between  the  neck  and  the  ureter.  The 
operator,  at  the  same  time,  introduces  the 
fore-finger  of  his  left  hand  up  the  rectum, 
and  drawing  it  down  towards  the  right  but- 
tock, pushes  in  a trocar  on  the  left  side  of 
the  perinasum,  near  the  great  tuberosity  of 
the  ischium,  and  about  an  inch  above  the 
anus.  Then  the  trocar  is  to  be  carried  on 
parallel  to  the  rectum,  exactly  between  the 
erector  penis  and  accelerator  urinae  muscles, 
so  as  to  enter  the  bladder  on  one  side  of  its 
neck.  As  soon  as  the  bladder  is  wounded, 
the  operator  withdraws  his  fore-finger  from 
the  anus. 

In  the  upper  part  of  the  cannula  of  the 
trocar,  there  is  a groove,  the  use  of  which  is 
to  allow  some  urine  to  escape,  immediately 
the  instrument  enters  the  bladder,  so  that 
the  trocar  may  not  be  pushed  in  any  fur- 
ther ; but  its  principal  use  is  for  guiding  the 
incision.  As  soon  as  the  urine  began  to 
flow,  Foubert,  retracting  the  trocar  a little, 
without  drawing  it  quite  out  of  the  cannula, 
introduced  the  point  of  a slender  knife  into 
the  groove  in  the  cannula  ; and  by  the  gui- 
dance of  this  groove  he  ran  it  onwards  into 
the  bladder,  and  was  aware  of  the  knife 
having  actually  entered  this  viscus,  by  the 
urine  flowing  still  more  freely.  Then  rai- 
sing the  knife  from  the  groove,  he  made  his 
incision  about  an  inch  and  a half  in  length, 
through  the  neck  of  the  bladder,  by  moving 
the  knife  from  that  point  at  which  it  had 
entered  upwards  towards  the  pubes.  And 
finally,  by  moving  the  handle  more  largely 
than  the  point  of  the  knife,  he  opened  the 
outer  part  of  the  w ound  to  whatever  extent 
the  size  of  the  stone  seemed  to  require,  and 
then,  withdrawing  the  knife,  he  introduced 
a blunt  gorget  to  guide  the  forceps. 

An  effort  was  made  by  Thomas  to  im- 
prove thi3  method  ; but  he  failed,  and  it 
was  never  much  adopted.  The  inability  of 
many  bladders  to  bear  being  distended,  is 
an  insuperable  objection  ; for,  without  this, 
the  trocar  is  liable  to  pass  between  the. blad- 
der and  rectum,  and  even  through  the  blad- 
der into  the  pelvis.  ( Memoires  de  l’ Acad.  de 
Chir.  663,  Vol.  1.  Le  Dran’s  Parallllt. 
Sharp's  Critical  Inquiry.  J.  Bell's  Princi- 
ples, Vol.  2.) 

In  the  year  174S,  Frere  Come’s  method 
of  performing  the  lateral  operation  began  to 
attract  considerable  notice.  The  operation 
was  done  with  a particular  instrument,  call- 
ed the  lithotome  cache , by  means  of  which 
the  prostate  gland  and  neck  of  the  bladder 
were  divided,  from  within  outwards#  The 


lithotome  cach6  is  entitled  to  much  atten- 
tion, because  it  is  still  generally  used  in 
several  parts  of  the  continent,  and  some- 
times in  this  country,  especially  by  the  sur- 
geons of  the  Westminster  Hospital.  “ In 
France  (says  M.  Roux)  if  there  is  any 
mode  of  operating  more  common  than 
others,  and  preferred  by  the  majority  of 
practitioners,  it  is  that  in  which  the  instru- 
ment, named  the  lithotome  cache , is  employ- 
ed.” (See  Parall&le  de  la  Chirurgie  Ang- 
loise , tyc.  P-  3 IS.  Frere  Come  does  not 
ascribe  the  invention  of  this  instrument  to 
himself ; but  acknowledges  that  it  resembles 
ihe  knife  for  operating  upon  hernia,  said  to 
have  been  devised  by  a French  surgeon-of 
the  name  of  Bienaise.  It  consists  of  a han- 
dle and  the  blade  part.  The  latter  is  slightly 
curved,  about  as  thick  as  a quill,  furnished 
with  a beak,  and  excavated  so  as  to  form  a 
sheath  for  a knife  of  its  own  length.  By 
means  of  a kind  of  lever,  the  knife  can  be 
made  to  pass  out  of  the  sheath,  and  the 
distance  to  which  the  blade  projects  also 
admits  of  being  regulated  with  precision. 
For  this  purpose,  the  handle  is  divided  into 
six  sides,  numbered  6,  7,  9,  11,  13,  and  15, 
and  which,  according  as  they  are  more  or 
less  elevated,  allow  the  lever  to  be  depress- 
ed in  different  degrees,  and  the  knife  to 
move  out  of  its  sheath  in  the  same  propor- 
tion. Thus  the  surgeon  can  at  his  option 
make  an  incision  through  the  prostate  gland 
and  neck  of  the  bladder  ot  six  different 
lengths. 

When  the  lithotome  cache  is  to  be  used, 
the  patient  must  be  placed  in  the  same  pos- 
ture as  in  every  other  mode  of  practising 
the  lateral  operation  ; and  after  a staff  has 
been  introduced,  an  oblique  incision  is  to  be 
made  from  the  raphe  of  the  perinajum,  to  a 
point  situated  rather  more  towards  the  anus, 
than  the  innermost  part  of  the  tuberosity  of 
the  ischium.  The  bulb  of  the  urethra  should 
not  be  cut,  and  not  too  much  of  the  mem- 
branous part  of  the  urethra  The  fat  and 
transverse  muscles  having  been  divided,  arid 
the  urethra  opened,  exactly  as  in  tbe  com- 
mon operation,  the  scalpel  is  to  be  put  down, 
and  the  beak  of  the  lithotome  introduced 
into  the  groove  of  the  staff.  Of  course,  the 
surgeon,  previously  to  the  operation,  will 
have  settled  the  distance,  to  which  the  blade 
of  the  instrument  is  to  pass  out  of  the  sheath, 
and  which  must  necessarily  depend  upon 
the  age  of  the  subject,  and  the  presumed 
size  of  the  calculus.  When  the  beak  of  the 
lithotome  has  been  inserted  in  the  groove  of 
the  staff,  the  surgeon  is  to  take  hold  of  the 
handle  of  the  latter  instrument  with  his  left 
hand,  and  bring  it  a little  towards  himself, 
at  the  same  time  pushing  the  lithotome  into 
the  bladder,  with  the  handle  depressed  as 
much  as  possible.  The  staff  is  now  to  be 
withdrawn,  and  the  surgeon  is  to  try  to  feel 
the  stone  with  the  sheath  of  the  other  in- 
strument, in  order  to  be  able  to  judge  of  the 
size  of  the  calculus,  and  whether  the  dis- 
tance, to  which  the  blade  of  the  knifs  is  in- 
tended to  move  out  of  the  sheath,  is  such  as 
Tc  likely  to  make  an  opening  of  due.  but  net. 


2.0/t 


LITHOTOMY 


unnecessary  magnitude.  Things  being  pro 
perly  determined,  the  lithotorne  is  to  be  held 
in  a position  calculated  to  make  a division 
of  the  parts  which  is  parallel  to  the  cut  in  the 
integuments,  and,  by  means  of  the  lever,  the 
cutting  blade  of  the  instrument  is  then  to  be 
disengaged  from  its  sheath.  The  surgeon  is 
next  to  draw  the  opened  lithotorne  towards 
himself,  in  a perfectly  horizontal  manner,  so 
as  to  make  the  requisite  division  of  the  pros- 
tate gland  and  orifice  of  the  bladder. 

As  Sabatier  observes,  Frere  Come’s  me- 
thod undoubtedly  possesses  all  the  advanta- 
ges of  the  lateral  operation,  besides  being 
more  easy  than  Cheselden’s  plan,  and  most 
of  the  other  modes,  subsequently  proposed, 
for  cutting  the  neck  of  the  bladder  with  per- 
fect smoothness,  and  to  a sufficient  extent  to 
allow  the  calculus  to  be  removed,  without 
any  laceration  of  the  parts.  ( Mtdecine  Ope- 
ratoirc,  T.  3,  p.  199.) 

There  have  been  several  objections  urged 
against  the  use  of  the  lithotorne  cache. 

1.  ft  is  said  that  the  size  of  the  incision 
is  not?  always  proportioned  to  the  distance, 
to  which  the  knife  moves  out  of  the  sheath, 
and  that  the  instrument,  when  opened  to 
No.  13  or  15,  sometimes  makes  a smaller  in- 
cision, than  when  opened  only  to  No.  5 or 
f7.  This  uncertainty  is  said  to  depend  upon 
the  greater  or  less  contraction  of  the  bladder 
in  different  subjects. 

For  my  own  part,  I confess,  that  I am  not 
inclined  to  put  much  credit  in  the  accuracy 
of  this  last  explanation,  and  suspect  the  dif- 
ference sometimes  observed  must  depend 
upon  the  operator  not  taking  care  to  draw 
out  the  instrument  in  a horizontal  direction, 
a thing  which  is  always  easy  to  be  done. 

2.  Frere  Come  himself  made  his  incision 
too  high,  so  that  an  extravasation  of  urine  in 
the  scrotum  followed  some  of  his  opera- 
tions ; but  the  above  method  of  operating  is 
free  from  any  objection  of  this  kind. 

3.  Some  surgical  writers  have  exaggera 
ted  the  danger  of  cutting  the  body  of  the 
bladder  too  extensively  with  the  lithotorne, 
and  thus  producing  internal  hemorrhage. 
However,  this  cannot  happen,  unless  the 
surgeon  raise  the  handle  of  the  instrument 
improperly  at  the  moment  of  withdrawing 
it,  and  as  Sabatier  himself  allows,  it  is  rather 
the  fault  of  the  operator  than  of  the  opera- 
tic n. 

4.  The  arteria  pudica  profunda  and  the 
rectum,  which  some  authors  conceive  to  be 
endangered,  must  always  he  in  absolute 
safety,  if  the  edge  of  the  knife  of  the  litho- 
tome  be  turned  in  the  direction  above  re- 
commended. 

I think  that  for  a surgeon,  who  under- 
stands the  right  principles  of  lithotomy,  this 
is  one  of  the  best  ways  of  performing  the 
operation. 

When  I was  at  Paris  in  1815,  I saw  Dr. 
Souberbielle  operate  very  skilfully  with  the 
lithotorne  cache.  A stone  of  considerable 
size  was  extracted  from  a,  gentleman,  who 
was,  I should  think,  not  less  than  70.  No 
apprehensions  were  entertained  of  ill  suc- 


cess, as  I understood  that  this  operator  hard- 
ly ever  lost  a patient. 

M.  Roux,  when  he  visited  England,  seems 
not  to  have  been  informed,  that  at  the  West- 
minster Hospital,  the  lithotorne  cache  has 
been  commonly  employed  for  many  years 
past.  It  has  also  been  sometimes  used  at 
Guy’s  Hospital  by  Sir  A.  Cooper.  When 
M.  Roux  likewise  finds  fault  with  the  bad 
construction  of  this  instrument,  as  made  in 
London,  I suspect,  that  he  cannot  have  seen 
those  which  are  made  and  sold  by  Mr. 
Evans.  (See  Voyage  fait  a Londres,  ou  Pa- 
ralltle  de  la  Chirurgie  Angloist , fyc.  p . 318.) 

Le  Cat,  a surgeou  of  Rouen,  in  Norman- 
dy, devised  a mode  of  lithotomy  which 
would  be  too  absurd  to  be  described,  were 
it  less  renowned.  He  thought  the  neck  of 
the  bladder  might  be  dilated,  like  the  wound, 
and  his  operation  was  deformed  with  all  the 
cruelty  of  the  Marian  method,  and  every  er- 
ror attendant  on  the  infant  state  of  the  late- 
ral operation.  He  first  introduced  a long 
wide  staff;  he  cut  forward  with  a common 
scalpel,  through  the  skin  and  fat,  till  he  could 
distinguish  the  bulb,  the  naked  urethra,  and 
the  prostate  gland.  Secondly,  with  another 
knife,  the  urethrotome,  having  a groove  on 
one  side,  he  opened  the  urethra,  just  before 
the  prostate,  and  fixing  the  urethrotome  in 
the  groove  of  the  staff,  and  holding  it  steady, 
rose  from  the  kneeling  posture,  in  which  he 
performed  the  outward  incision.  Thirdly, 
holdingthe  urethrotome  in  the  left  hand,  he 
passed  another  knife,  the  cystotome,  along 
the  groove  of  the  urethrotome,  and  the  beak 
of  the  cystotome  being  lodged  in  the  groove 
of  the  urethrotome,  it  was  pushed  forwards, 
through  the  substance  of  the  prostate  gland 
into  the  bladder.  Fourthly,  drawing  the 
cystotome  a little  backwards,  he  gave  the 
staff  to  an  assistant  to  be  held  steadily,  and 
lifting  a blunt,  gorget  in  the  fight  hand,  he 
placed  the  beak  of  it  in  the  groove  of  the 
cystotome,  and  pushed  it  onwards,  till  it 
glided  from  the  groove  of  the  cystotome., 
along  the  groove  of  the  staff  into  the  bladder. 
Then,  true  to  the  principles  of  the  apparatus 
major,  and  never  forgetting  his  own  pecu- 
liar theory,  little  incision,  and  much,  dilate 
lion,  he  forced  his  fingers  along  the  gorget, 
dilated  the  neck  of  the  bladder,  and  so  made 
way  for  the  forceps.  (J.  Bell's  Principles , 
Vol.  2 ) 

In  1741,  Le  Dran  described  an  operation, 
the  introduction  of  which  has  been  claimed 
by  several  since  his  time.  A staff  being  in- 
troduced, and  two  assistants  keeping  open 
the  patient’s  knees,  while  a third  stands  on 
one  side  of  him  on  a chair,  (Le  Dran  says,) 
“ l then  raise  up  the  scrotum,  and  directing 
the  last  assistant  to  support  it  with  both 
hands,  so  as  to  avoid  bruising  it,  by  pressing 
it  either  against  the  staff,  or  the  os  pubis,  I 
place  his  two  fore-fingers  on  each  side  of 
the  part,  where  the  incision  is  to  be  made  ;, 
one  of  the  fingers  being  laid  exactly  along 
that  branch  of  the  ischium,  which  rises  to- 
wards the  pubes,  and  the  other  pressed  upon 
the  raphe,  that  the  skin  may  be  kept  fixed 
and  tight.  While  1 thus  place  the  fingers  of 


LITHOTOMY. 


205 


the  assistant,  who  supports  the  scrotum,  I 
still  keep  hold  of  the  handle  of  the  staff,  and 
direct  it  so  as  to  form  a right  angle  with  the 
patient’s  body ; at  the  same  time  taking 
care  that  the  end  of  it  is  in  the  bladder. 
This  position  is  the  more  essential,  as  all  the 
other  instruments  are  to  be  conducted  along 
the  groove  of  this.  If  the  handle  of  the 
staff  were  kept,  inclined  towards  the  belly, 
the  end  of  it  would  come  out  of  the  bladder, 
and  the  gorget,  missing  its  guide,  would  slip 
between  that  and  the  rectum. 

“ The  staff  being  rightly  placed,  I take 
the  knife  from  the  assistant,  who  holds  the 
instruments,  and  put  it  into  my  mouth  ; 
then  pressing  the  beak  of  the  staff  against 
the  rectum,  I feel  the  curvature  of  it  through 
the  perinaeum.  The  incision  ought  to  ter- 
minate an  inch  and  a hall  below  where  we 
feel  the  bottom  of  the  curvature.  If  we  do 
not  carry  this  incision  sufficiently  low,  it  may 
happen  not  to  be  of  a size  to  allow  the  ex- 
traction of  a large  stone,  and  might  lay  us 
under  the  necessity  of  extending  it  further 
afterward, for  the  skin  will  not  lacerate  here, 
nor  easily  give  way  for  the  passage  of  the 
stone.  1 therefore  begin  the  incision  from 
the  lower  part  of  the  os  pubis,  continuing  it 
down  to  the  place  that  I before  directed  for 
its  termination  ; after  which  I pass  the  point 
of  the  knife  into  the  groove  of  the  staff,  and 
cutting  from  below-  upwards,  without  taking 
the  point  out  of  the  groove,  I open  the  an- 
terior part  of  the  urethra  as  far  as  the  inci- 
sion that  is  in  the  skin. 

“ The  Leak  of  the  staff,  which  wTas  press- 
ed upon  the  rectum,  must  now  be  raised 
and  pressed  against  the  os  pubis.  At  the 
same  time,  I turn  the  handle  towards  the 
right  groin,  that  the  groove,  which  is  at  the 
beak  of  the  staff,  may  face  the  space  be- 
tween the  anus  and  the  tuberculum  isehii  on 
the  left  sid.e.  Then  carrying  the  point  of 
the  knife  down  the  groove,  I slide  it  along 
the  beak,  turning  the  edge,  that  it  may  face 
the  space  between  the  anus  and  tuberosity 
of  the  ischium.  By  this  incision,  I exactly 
divide  the  bulb  of  the  urethra,  and  by  doing 
this  on  its  side,  we  are  sure  to  avoid  wound- 
ing the  rectum,  w hich  for  want  of  this  pre- 
caution has  been  often  cut.  This  first  inci- 
sion being  made,  I again  pass  the  point  of 
the  knife  into  the  curvature  of  the  staff  to 
the  part  where  it  bears  against  the  peri- 
nseum,  and  direct  it  to  be  held  there  by  the 
assistant  who  supports  the  scrotum.  This 
done,  I take  a large  director,  the  end  of 
which  is  made  with  a beak,  like  that  of  a 
gorget,  and  conveying  this  beak  upon  the 
blade  of  the  knife,  into  the  groove  of  the 
staff.  I draw1  the  knife  out.  1 then  slide  the 
beak  of  this  director,  along  the  groove  of  the 
staff,  into  the  bladder,  and  I withdraw  the 
staff,  by  turning  the  handle  towards  the  pa- 
tient’s belly.  The  following  circumstances 
will  sufficiently  satisfy  us,  that  the  director  is 
introduced  into  the  bladder;  first,  if  itstrikes 
against,  the  end  of  the  staff,  which  is  closed  ; 
secondly,  if  the  urine  runs  along  the  groove. 
I next  feel  for  the  stone  with  this  director, 
and  having  found  it,  endeavour  to  distin- 


guish its  size  and  surface,  in  order  to  make 
choice  of  a proper  pair  of  forceps  ; that  is, 
one  of  a stronger  or  weaker  make,  or  of  a 
large  or  small  size,  agreeably  to  that  of  the 
stone  ; after  which  I turn  the  groove  towards 
the  space,  between  the  anus  and  tuberosity 
of  the  ischium,  and  resting  it  there,  convey  a 
bistoury  along  the  groove,  the  blade  of 
which  is  half  an  inch  broad,  and  about  three 
quarters  of  an  inch  long.  I continue  the  in- 
cision made  by  the  knife  in  the  urethra,  and 
entirely  divide  the  prostate  gland  laterally, 
as  also  the  orifice  of  the  bladder;  and,  I am 
very  certain,  that  the  introducing  the  use  of 
these  two  instruments,  which  are  not  em- 
ployed by  other  lithotomists,  does  not  pro- 
long the  operation  a quarter  of  a minute, 
but  rather  shortens  the  time,  both  by  facili- 
tating the  dilatation,  that  is  afterward  to  be 
made  with  the  finger,  and  by  rendering  the 
extraction  of  the  stone  more  easy.  The  bis- 
toury being  withdrawn,  the  groove  of  the 
director  serves  to  guide  the  gorget  into  the 
bladder.  I then  introduce  my  fore-finger 
along  the  gorget,  (which  is  now  easily  done, 
as  the  urethra  and  prostate,  being  divided, 
do  not  oppose  its  entrance)  and  with  it  I di- 
late the  passage  for  the  stone,  in  proportion 
to  the  size,  of  w'bich  I discover  it  to  be 
This  dilatation  being  made,  I withdraw  my 
finger,  and  use  the  proper  forceps.”  (Le 
Dran's  Operations,  Edit.  5,  1784,  London .) 

Professor  Pajola,  of  Venice,  was  the  pupil 
of  Le  Cat,  and  his  method  resembles  that  of 
his  master  He  is  stated  to  have  cut  for  the 
stone  650  patients  with  success  ; which  de- 
serves notice,  because  his  operation  has  for 
its  principles,  dilatation,  and  no  division  of 
any  part  of  the  bladder.  He  makes  an  inci- 
sion into  the  groove  of  the  staff,  with  a lan- 
cet-pointed, double-edged  knife,  called  an 
urethrotome,  the  blade  of  which  has  upon  its 
centre  a groove,  that  is  continued  to  its  very 
point,  and  serves  to  guide  the  beak  of  ano- 
ther instrument,  called  the  eystotome,  into 
the  groove  of  the  staff.  As  the  professed  in- 
tention of  the  eystotome  is  only  to  cut  the 
prostate  gland,  its  name  is  ridiculous.  It 
consists  of  a handle,  and  very  slender  blade, 
which  is  not  connected  with  the  handle,  but 
with  its  sheath,  by  means  of  a little  joint, 
close  to  the  beak  of  the  instrument.  When 
the  eystotome  is  opened  as  far  as  possible, 
the  end  of  the  blade  furthest  from  the  beak, 
is  twelve  lines  from  the  sheath.  In  this  po- 
sition, it  is  held  by  a transverse  piece  of  steel, 
which  admits  of  being  pushed  more  or  less 
out  at  the  option  of  the  surgeon,  and  can  be 
fixed  by  means  of  a screw.  Pajola,  like 
Scarpa,  considers  cutting  the  neck  of  the 
bladder  dangerous,  and  he  merely  divides  the 
prostate,  after  which  he  introduces  a blunt 
gorget,  and  along  this  a species  of  forceps  for 
dilating  the  neck  of  the  bladder  in  all  direc- 
tions. (X.  F.  Rudtorffer  uber  die  Operation 
des  Blasensleins  nach  Pajola' s Methode.)  As 
Langenbeck  observes,  great  as  the  success  of 
this  lithotomist  has  been,  his  method  of  ope- 
rating has  little  to  recommend  it ; and  every- 
thing must  be  ascribed  to  his  individual  skill, 
and  intimate  knowledge  of  the  parts.  Lan- 


LITHOTOMY. 


206 

genbeck  even  prefers  Le  Cat’s  method,  in 
which  there  is  no  need  of  such  a multiplicity 
of  instruments.  The  blunt  gorget  and  dila- 
tor are  perfectly  unnecessary,  as  the  finger 
would  do  the  purpose  of  both. 

In  the  former  editions  of  this  Dictionary,  I 
have  not  taken  any  notice  of  what  has  been 
termed  by  the  French,  “ Operation  a deux 
temps,"  and  which  was  first  mentioned  by 
Franco.  If,  by  this  plan,  it  be  intended,  that 
the  incision  should  be  made  at  one  period,  and 
the  extraction  of  the  stone  not  attempted  till 
u subsequent  period,  I cannot  too  strongly  re- 
probate the  practice.  But,  if  I am  to  under- 
stand, that  the  postponement  of  the  comple- 
tion of  the  operation  is  only  to  be  adopted, 
as  a matter  of  necessity,  when  the  patient 
cannot  bear  the  longer  continuance  of  the 
unsuccessful  efforts  to  extract  the  stone,  of 
course,  I can  only  say,  that  every  endeavour 
should  be  used  to  avoid  this  very  disagreeable 
dilemma,  by  making  in  the  first  instance  an 
adequate  opening, and  (if  this  cannot  be  done) 
by  breaking  the  calculus,  and  carefully  remo- 
ving all  the  fragments.  Some  further  consi- 
derations against  delaying  the  completion  of 
the  operation  will  be  found  in  the  2d  vol.  of 
the  First  Lines  of  Surgery. 

The  danger  of  the  beak  of  the  gorget  slip- 
ping out  of  the  groove  of  the  staff,  is  one  of 
the  chief  objections  urged  agtiinst  the  em- 
ployment ot  the  first  of  these  instruments, 
in  order  to  obviate  this  inconvenience,  Sir 
Charles  Blicke  bud  the  groove  of  the  staff, 
and  the  beak  of  the  gorget,  so  constructed 
that  they  locked  into  each  other,  and  conti- 
nued fixed  till  near  the  extremity  of  ttie  staff. 
The  contrivance,  though  plausible  and  inge- 
nious, is  not  much  used  : the  point  of  con- 
tact of  the  beak  and  body  of  the  instrument 
is  necessarily  so  small,  that  it  is  liable  to  break. 
It  is  allowed,  however,  that  this  objection 
might  be  removed  ; but  another  one  is  still 
urged,  viz.  the  beak  and  groove  catching  on 
each  other,  so  as  to  resist  the  efforts  made  to 
introduce  the  gorget  into  the  biuddei.  Every 
operator  knows,  that  much  of  the  satety  of 
the  lateral  operation,  as  performed  at  present, 
depends  on  the  ease  with  which  the  beak  of 
the  gorget  slides  along  (he  groove  of  the  staff. 
Le  Cat,  in  1747,  is  said  to  have  devised  a si- 
milar intention. 

Some  operators  have  a good  deal  of  trou- 
ble in  dissecting  into  the  groove  of  the  staff. 
Sir  James  Earle  invented  an  instrument  to 
render  this  part  of  the  operation  more  easy. 
It  consists  ot  a short  staff,  with  an  open 
groove,  connected  by  a hinge  with  the  han- 
dle of  another  staff,  ot  the  usual  size,  shape, 
curvature,  and  length,  which  may  be  called 
the  long  staff.  The  hinge,  by  means  ot  pm, 
is  capable  ot  being  disjointed  at  pleasure. 
Tbe  short  staff  is  sufficiently  curved  to  go 
over  the  penis  and  scrotum,  and  long  enough 
to  reach  to  that  part  ot  the  long  staff  winch  is 
just  below  llte  beginning  ot  its  curvature. 
The  end  of  the  short  staff,  made  somewhat 
like  a pen,  with  the  sides  sharpened  and  finely 
pointed,  is  adapted  to  shui  into  tbe  gioove  of 
the  long  staff,  and  its  cutting  edges  are  de- 
fended from  being  injured  by  a proper  recep- 


tacle which  is  prepared  for  it  in  the  groove 
of  the  long  staff.  When  the  instrument  is 
shut,  the  groove  of  the  short  staff  leads  into 
that  of  the  long  one,  so  as  to  form  one  con- 
nect and  continued  groove.  The  short  staff' 
is  rendered  steady  by  the  segment  of  an  arch 
projecting  from  the  long  one  through  it. 

The  long  staff,  separated  from  the  short 
one,  is  first  introduced  in  the  usual  rnanuer, 
and,  the  stone  having  been  felt,  the  short  staff' 
is  to  be  put  on  tbe  other  at  the  hinge.  Tbe 
incision  is  then  to  be  made  in  the  usual  man- 
ner, through  the  skin  mid  cellular  membrane, 
and  a second  incision  through  the  muscles, 
so  as  nearly  to  lay  bare  the  urethra.  The 
operator  then  being  perfectly  convinced  that 
(lie  extremiiy  of  (he  long  staff  is  sufficiently 
within  the  bladder,  must  bring  the  end  of  the 
short  staff  down,  and  press  it  against  the 
urethra,  which  it  will  readily  pierce,  and  pass 
into  the  cavity  prepared  for  it  in  the  groove 
of  the  long  staff.  The  two  pieces  being  now 
firmly  held  together  by  the  operator’s  left 
hand,  nothing  remains  to  be  done,  except 
applying  the  beak  of  the  gorget  to  the  groove 
of  the  short  staff*,  and  pushing  it  on  till  it  is 
received  in  the  groove  of  the  long  one  ; and 
if  this  latter  be  made  with  a contracted 
groove,  it  will  just  enter  where  the  contrac- 
tion begins,  and  thus  must  be  saiely  conduct- 
ed into  the  bladder.  ( Earle  on  the  Stone  ; 
Appendix;  Edit.  2,  1796.)  Deschamps  des- 
cribes an  instrument,  invented  by  Jardaa, 
surgeon  of  Montpelier,  which  bears  a resem- 
blance to  Earle’s  double  staff,  but  was  more 
complicated,  being  designed  to  support  the 
scrotum,  and  also  press  the  rectum  out  of  the 
way. 

The  late  Mr.  Dease,  of  Dublin,  and  Mr. 
Muir,  of  Glasgow,  considering  that  the  gor- 
get was  more  apt  to  slip  from  the  staff’  in  con- 
sequence of  the  latter  being  curved,  and  that 
its  beak  never  slips  from  tbe  groove  of  the 
staff  in  operating  on  women,  proposed,  like 
Le  Dran,  to  convert  the  male  into  the  temale 
urethra.  They  introduce,  as  usual,  a curved 
grooved  staff'  into  the  bladder,  make  the 
common  incisions,  and  open  the  membra- 
nous part  of  the  urethra  ; but  -instead  of  in- 
troducing a gorget  on  the  curved  staff,  they 
conduct  along  the  groove  a straight  director, 
or  staff’,  into  the  bladder,  and  immediately 
withdraw  the  other.  The  gorget  is  then  in- 
troduced. In  this  manner  the  operation  may 
be  very  well  performed  with  a narrow  bis- 
toury, as  was  advised  by  Mr.  A.  Burns. 

LITHOTOMY,  AS  PERFORMED  WITH  A KNIFE, 

INSTEAD  OF  A CUTTING  GORGET,  LY  SE- 
VERAL OF  THE  MODERNS. 

We  have  alreidy  described,  bow  Fr^re 
Jacques  and  Chesclden,  used  to  operate  with 
a knife,  without  any  cutting  gorget,  in  the 
early  state  of  the  lateral  operation.  The 
success  which  attended  Uie  excellent  prac- 
tice of  ihe  latter  surgeon,  certainly  far  ex- 
ceeds what  attends  the  present  employment 
of  the  gorget,  for,  out  of  52  patients  whom 
he  cut  successively  for  the  stone,  he  only 
lost  two;  and  out’of  213,  of  all  age?,  cm,- 


LITHOTOMY. 


207 


stitutions,  (co . only  20.  These  facts  are 
strongly  in  favour  of  abandoning  the  use  of 
the  gorget,  and  doing  its  office  with  a knife. 

The  objections  to  the  gorget  are  nume- 
rous and  well  founded.  In  the  hands  of 
many  skilful  operators,  its  beak  has  slipped 
out  of  the  groove  of  the  staff,  and  the  in- 
strument has  been  driven  either  betvveen  the 
rectum  and  the  bladder,  or  into  the  intestine 
instead  of  the  latter  viscus.  Sir  James  Earle 
remarks  : (l  I have  more  than  once  known  a 
gorget,  though  passed  in  the  right  direction, 
pushed  on  so  far,  and  with  such  violence,  as 
to  go  through  the  opposite  side  of  the  blad- 
der.” Bromfield,  even  when  operating  with 
a blunt  gorget,  perforated  the  bladder  and 
peritonaeum,  so  that  the  abdominal  viscera 
came  out  of  the  wound.  (P.1270.)  I now  know 
of  at  least  three  instances,  in  which  the  gor- 
get, slipping  from  the  staff,  completely  sever- 
ed the  urethra  from  the  bladder  ; the  stone 
was  not  taken  out ; and  the  patients  died. 

We  will  suppose,  however,  that  the  pre- 
ceding dangers  of  the  gorget  are  surmounted, 
as  they  certainly  may  be,  by  particular  dex- 
terity, seconded  by  the  confidence  of  expe- 
rience. The  gorget  is  introduced,  but  what- 
ever kind  of  one  has  been  used,  the  wound 
is  never  sufficiently  large  for  the  easy  pass- 
age of  any  stone,  except  such  as  are  below 
the  ordinary  size.  Camper  has  noticed  this 
fact : “ Hawkensius  solo  conductore,  cujus 
margo  dexter  in  aciem  assurgit,  idem  praes- 
tat : omnts  plagam  dilatant,  ut  calculum  ex - 
trahant  : dilacerentur  igitur  semper  vesicce 
ostium  et  prostata .”  (P.  J 14.)  Dease  says  : 

ct  In  ail  the  trials  that  I have  made  with  the 
gorget  on  the  dead  subject,  l have  never 
found  the  opening  into  the  biadder  sufficient- 
ly lar^e  for  the  extraction  of  a stone  of  a 
middling  size,  without  a considerable  lacera- 
tion of  the  parts.  I have  frequently  taken 
the  largest-sized  gorget,  and  could  not  find, 
in  the  adult  subject,  I ever  entirely  divided 
the  prostate  gland,  if  it  was  any  way  large  ; 
and  in  the  operations  that  were  performed 
here  on  the  living  subject,  if  the  stone  was 
large,  the  extraction  was  painfully  tedious, 
and  effected  with  great  difficulty ,**•  and,  in 
some  cases,  not  at  all.” 

I shall  dismiss  this  part  of  the  subject  with 
referring  the  reader  to  the  spirited  and  cor- 
rect remarks  on  the  objections  to  the  gorget 
in  Mr.  John  Bell’s  Principles,  Vol.  2.  Part  2. 

The  latterauthor  recommends  the  external 
incision,  in  a large  man,  to  commence  about 
an  inch  behind  the  scrotum,  and  to  be  car- 
ried downwards  three  inches  and  a half, 
midway  between  the  anus  and  tuberosity  of 
the  ischium.  The  fingers  of  the  left  hand, 
which  at  first  kept  the  skin  tense,  are  now 
applied  to  other  purposes.  The  fore-finger 
now  guides  the  knife,  and  the  operator  pro- 
ceeds to  dissect  through  fat  and  cellular 
substance,  and  muscular  and  ligamentous 
fibres,  till  the  wound  is  free  and  open,  till  all 
sense  of  stricture  is  gone  ; for  it  is  only  by 
feeling  opposition  and  stricture  that  we  re- 
cognize the  transverse  muscle.  When  this 
hollow  is  fairly  laid  open,  the  external  inci- 
sion, which  relates  merely  to  the  free  extrac- 


tion of  the  stone,  is  completed.  If  it  were  the 
surgeon’s  design  to  operate  only  with  the 
knife,  he  would  now  push  his  fingers  deeply 
into  the  wound,  and,  by  the  help  of  the  fore- 
finger, dissect  from  the  urethra  along  the 
body  of  the  gland,  till  he  distinguished  its 
thickness  and  solidity,  and  reached  its  back 
part.  Then,  plunging  his  knife  through  the 
posterior  portion  of  the  gland,  and  settling  it 
in  the  groove  of  the  staff,  he  would  draw  it 
firmly  and  steadily  towards  him,  at  the  same 
time  pressing  it  into  the  groove  of  this  instru- 
ment, and  then  the  free  discharge  of  the 
urine,  assuring  him  that  the  prostate  and  neck 
of  the  bladder  were  divided,  he  would  lay 
aside  his  knife,  pass  the  left  fore-finger  into 
the  bladder,  withdraw  the  staff,  and  intro- 
duce the  forceps.  ( John  Bell , p.  197.) 

Mr.  Charles  Bell  describes  the  following 
method  of  operating  with  a knife,  instead 
of  a gorget.  A staff  grooved  on  the  right 
side,  a scalpel  with  a straight  back,  and  the 
common  lithotomy  forceps,  are  the  indis- 
pensable instruments.  The  staff  is  kept  in 
the  centre,  and  well  home  into  the  bladder. 
The  surgeon  making  his  incision  under  the 
arch  of  the  pubes,  and  by  the  side  of  the 
anus,  carries  it  deeper  towards  the  face  of 
the  prostate  gland  ; cutting  near  to  the  stall', 
but  yet  not  cutting  into  it,  and  avoiding  the 
rectum  by  pressing  it  down  with  the  finger. 
Now  carrying  the  knife  along  the  staff,  the 
prostate  gland  is  felt.  The  point  of  the  knife 
is  run  somewhat  obliquely  into  the  urethra, 
and  into  the  lateral  groove  of  the  staff^just 
before  the  prostate  gland.  It  is  run  on,  until 
the  urine  flows.  The  fore-finger  follows  the 
knife,  and  it  is  slipped  along  the  back  of  it, 
until  it  is  in  the  bladder.  Having  carried 
the  fore-finger  into  the  bladder,  it  is  kept 
there,  and  the  knife  is  withdrawn.  Then 
the  forceps,  directed  by  the  finger,  are 
introduced.  (C.  Bells  Operative  Surgery, 
Vol.  1,  p.  361.) 

Mr.  Allan  Burns,  of  Glasgow,  recommends 
the  following  method  : “ The  plan  (says  he) 
introduced  by  Cheselden,  and  revived  by 
Mr.  J.  Bell,  I would  assume,  as  the  basis  of 
the  operation  ; but  still,  along  with  their 
mode,  I would  blend  that  of  Mr.  Dease,  by 
which,  I imagine,  we  may  overcome  some 
of  the  disadvantages  attendant  on  each  con- 
sidered individually. 

u For  more  than  twelve  months,  I have 
been  in  the  habit  of  showing  such  an  ope- 
ration, which  is  as  simple  in  its  performance, 
as  the  one  in  general  use,  is  attended  with 
less  danger  to  the  patient,  permits  of  an  in- 
cision varying  in  size,  according  to  the  wish 
of  the  operator,  and  completely  prevents 
injury  of  the  rectum,  or  pudic  artery.  To 
perform  this  operation,  I introduce  into  the 
urethra  a common  curved  staff,  then  make 
the  usual  incision  into  the  perinaeum,  di- 
vide fully  and  freely  the  levator  ani,  so  as  to 
expose  the  whole  extent  of  the  membranous 
part  of  the  urethra,  the  complete  extent  of 
the  prostate  gland,  and  a portion  of  the 
side  of  the  neck  of  the  bladder.  When  this 
part  of  the  operation  is  finished,  I open  the 
membranous  part  of  the  urethra,  and  intro- 


L1TH0T0MV. 


2u3 


duce  through  the  slit  a straight  or  female 
staff,  with  which  l feel  the  stone,  and  then 
withdraw  the  curved  staff.  This  done,  I 
grasp  the  handle  of  the  staff  firmly  in  my 
left  hand,  and  with  the  right  lay  hold  of  the 
knife.  Having  ascertained  that  the  two  in- 
struments are  in  fair  contact,  l rest  the  one 
hand  upon  the  other,  pressing  them  together, 
and  then  by  a steady  extraction,  I pull  out 
the  knife  and  staff  together,  which  is  prefer- 
able to  drawing  the  knife  along  the  staff ; 
it  prevents  the  risk  of  the  one  slipping  from 
the  other  ; it  guards  the  bulb  of  the  urethra, 
and  every  other  part  from  injury ; for,  be- 
tween them  and  the  cutting  instrument, the 
staff  is  interposed  &c.  “ When  introdu- 

cing the  knife,  the  side  of  the  blade  must 
belaid  flat  along  the  fore-finger  of  the  right- 
hand  which  is  to  project  a little  beyond  the 
point.  In  this  state  the  finger  and  knife  are 
to  enter  the  wound,  opposite  the  tuber 
ischii ; but,  in  proportion  as  they  pass  along, 
they  are  to  be  inclined  forward,  till  at  last, 
with  the  point  of  the  finger,  the  staff  is  to  be 
felt  through  the  coats  of  the  bladder,  a little 
beyond  the  prostate,  and  rather  higher  than 
(he  orifice  of  the  urethra.  Here  the  knife  is 
to  be  pushed,  with  the  finger,  through  the 
bladder,  and  when  the  point  is  fairly  fixed 
in  the  groove  of  the  staff,  the  operation  is 


he  judges  the  incision  in  the  fneck  of  the 
bladder  to  be  too  small  for  the  easy  extrac- 
tion of  the  stone,  he  next  introduces  into 
the  bladder  a straight  probe-pointed  bistoury, 
with  its  side  close  to  the  forepart  of  his 
finger,  and  its  cutting  edge  upwards.  By 
turning  this  edge  towards  the  left  side,  and 
by  keeping  the  point  of  his  finger  always 
beyond  the  point  of  the  bistoury,  he  may 
safely  divide,  in  the  direction  of  the  first  in- 
cision, as  much  of  the  prostate  gland,  and 
neck  of  the  bladder,  as  he  shall  deem  neces- 
sary.” (See  Observations  on  Lithotomy , <^c. 
with  a Proposal  for  a new  Manner  of  Cutting 
for  the  Slone,  by  J.  Thomson , M.  D.  one  of  the 
Surgeons  of  the  Royal  Infirmary , $-c.  Edinb . 
1808.)  In  this  small  work,  the  reader  will 
find  additional  particulars. 

Mr.  Allan,  who  is  a strenuous  advocate  for 
using  the  knife  instead  of  the  gorget,  directs 
us,  after  laying  bare  the  urethra,  and  bring- 
ing the  staff  so  as  to  form  a right  angle  with 
the  patient’s  body,  to  feel  that  the  instru- 
ment is  fairly  lodged  in  the  bladder.  The 
operator  is  to  use  the  fore-finger  of  his  left- 
hand  as  a director  in  feeling  for  the  groove 
in  the  staff,  and  in  distinguishing  the  pros- 
tate eland  ; and,  with  this  finger,  he  is  to  de- 
press the  rectum,  and  direct  the  deeper  part 
of  his  dissection.  “ Feeling  the  gland,  with 


to  be  finished  by  the  steady  extraction  of  the  point  of  the  fore-finger  of  the  left-hand, 


both  instruments.”  (Man  Burns , in  Edin- 
burgh Surgical  Journal , No.  13.) 

The  knife  of  Cheselden  does  not  require 
so  much  violence  to  divide  the  parts  as  the 
gorget  does  ; cannot  slip  in  some  instances 
before,  in  others  behind  the  bladder ; and  it 
will  make  a wound  sufficiently  ample  for 
the  easy  extraction  of  the  stone,  without  the 
least  laceration.  The  possibility  of  its  wound- 
ing the  rectum,  Dr.  Thomson  thinks  might 
be  obviated  by  employing  it  as  follows 
“ After  having  made  the  external  incisions, 
and  divided  the  membranous  part  of  the 
urethra,  in  the  way  that  it  is  usually  done  for 
the  introduction  of  the  beak  of  the  gorget,  a 
straight-grooved  staff  is  to  be  introduced  into 
the  groove  of  the  curved  staff,  and  pushed 
along  it  into  the  bladder.  The  curved  staff 
is  then  to  be  withdraw  n,  and  the  surgeon, 


and  the  groove  of  the  staff  in  the  upper  part 
of  the  wound,  the  assistant  is  desired  to 
steady  his  hand,  and  the  operator,  holding 
his  knife  as  he  does  a writing  pen,  his  fin- 
gers an  inch  and  a half  from  the  point,  turns 
up  its  edge  towards  the  staff,  and  strikes  its 
point  through  the  membranous  part  of  the 
urethra  into  its  groove,  half  an  inch  before 
the  prostate  gland.  He  now  turns  the  back 
of  the  knife  to  the  staff,  slides  it  a little  back- 
wards and  forwards  in  the  groove,  that  he  may 
be  sure  he  has  fairly  entered  ; then  shifts  the 
fore-finger,  with  which  he  guidesthe  incision, 
places  it  under  the  knife,  and  carries  always 
before  the  point  of  it,  to  prevent  the  rectum 
being  wounded  ; he  then  lateralizes  the  knife, 
enters  the  substance  of  the  prostate,  is  con- 
scious ©f  running  the  scalpel  ihrough  its 
solid  and  fleshy  substance,  and  judges,  by  the 


laying  hold  of  the  handle  of  the  straight  staff  finger,  of  the  extent  of  the  incision  which  he 
with  his  left  hand,  and  turning  the  groove  now  makes.  The  urine  flow's  out  ; he  slips 
upwards  and  a little  outwards,  presses  the  his  finger  into  the  opening,  withdraws  the 
back  of  it  downwards  towards  the  right  scalpel,  and  gives  it  to  an  assistant,  who 
tuber  ischii,  and  holds  it  steadily  in  that  o-  hands  him  the  forceps,  which  he  passes  into 
sition.  The  point  of  a straight-backed  seal-  the  bladder,  using  the  fore-finger  of  his  left- 
pel  being  now  introduced  into  the  groove  of  hand,  which  is  still  within  the  wound,  as  a 
the  staff,  with  its  cutting  edge  inclined  up-  conductor.  The  forceps  instantly  encoun- 
wards  and  a little  outwards,  is  to  be  pushed  ter  the  staff,  w hich  serves  to  conduct  them 


gently  forwards  into  the  bladder.  The  size  of 
the  scalpel  need  only  be  such  as  will  make  a 
wound  in  the  prostate  gland  and  neck  of 
the  bladder,  sufficiently  large  to  admit  the 
fore-finger  of  the  left-hand.  The  scalpel 
being  removed,  this  finger  is  lo  be  introduced 
into  the  bladder,  through  the  wound  which 
has  been  made,  and  the  staff  may  then  be 
withdrawn.  With  the  finger  the  surgeon 
endeavours  to  ascertain  the  size  and  situa- 
tion of  the  stone.  If.  after  this  examination, 


safely  into  the  bladder,  while  the  finger  guides 
them  through  the  wound  ; &c.”  (Allan  on 
Lithotomy,  p.  48,  Edinb.  1808.) 

1 leave  the  reader  to  judge,  which  of  the 
foregoing  modesof  operating  with  a common 
knife  claims  the  preference.  Perhaps  Chesel- 
den’s  manner,  which  is  also  Mr.  John  Bell’s, 
is  as  deserving  of  recommendation  as  any. 

The  methods  of  operating  with  a knife,  as 
practised  by  Klein  and  Langenbcck,  I shall 
not  here  repeat,  as  they  were  described  in  tlw 


LITHOTOMY 


209 


last  edition  of  the  First  Lines  of  Surgery,  ac- 
companied with  many  valuable  practical 
observations  made  by  these  judicious  and 
skilful  surgeons. 

That  the  performance  of  lithotomy  with  a 
knife,  when  the  operator  has  ihe  assistance 
of  a proper  staff,  cannot  be  difficult,  may 
be  inferred  from  there  being  no  particular 
difficulty  in  the  method,  even  when  no  staff 
at  all  is  employed.  In  the  spring  of  the 
year  1814,  when  at  Oudenbosch  in  Holland, 
I was  requested  by  Sergeant  Ryan,  of  the 
1st  Foreign  Veteran  Battalion,  to  see  his 
little  boy,  about  four  years  old,  who  was 
troubled  with  symptoms,  which  made  me 
immediately  suspect,  that  there  was  a stone 
in  the  bladder.  As  I had  no  sound,  I in- 
troduced into  this  viscus  a small  silver  cathe- 
ter, which  distinctly  struck  against  a cal 
cuius.  Without  taking  the  instrument  out 
again,  I determined  to  perform  lithotomy 
with  a common  scalpel.  Indeed,  no  other 
mode  could  be  adopted,  as  we  had  neither 
staff,  gorget,  nor  lithotomy  instruments  of 
any  kind.  After  making  the  external  part 
of  the  incision  in  the  common  way,  I found 
that  the  catheter  afforded  me  no  guidance. 
I therefore  withdrew  it,  and  dissected  deeply 
by  the  side  of  the  prostate  gland,  till  the 
fore-finger  of  my  left  hand  passed  rather  be- 
yond it.  The  scalpel  was  then  plunged  into 
the  bladder,  behind  this  gland,  under  the 
guidance  of  my  left  fore-finger,  and  with  the 
edge  turned  towards  the  urethra.  The  ne- 
cessary division  of  the  prostate  and  neck  of 
the  bladder  was  then  made  by  cutting  in- 
wards and  upwards  in  the  direction  of  the 
rest  of  the  wound.  With  a small  pair  of 
ordinary  dressing  forceps,  a calculus,  rather 
larger  than  the  end  of  the  thumb,  was  easily 
extracted.  This  operation  was  done  at  the 
Military  Hospital,  in  the  presence  of  Dr. 
Shanks  of  the  56th  regiment,  and  several 
other  medical  officers.  Not  a single  bad 
symptom  ensued,  although  the  army  unex- 
pectedly moved  into  the  field  three  days 
afterward  and  the  child  travelled  about  for 
some  time  in  a baggage  cart,  in  an  exposed 
and  neglected  state.  The  wound  was  conse- 
quently rather  longer  in  healing  than  usual ; 
but,  this  was  the  only  ill  effect.  The  little 
boy  in  the  end  completely  recovered. 

Of  late  years,  many  surgeons  have  chosen 
to  perform  lithotomy  with  several  kinds  of 
beaked  scalpels.  The  practice,  indeed,  is 
still  gaining  ground.  Mr.  Thomas  Blizard’s 
knife  is  one  of  the  best.  Its  blade  is  long, 
straight,  and  narrow,  and,  like  the  gorget,  is 
furnished  with  a beak,  by  means  of  which  it 
admits  of  being  conducted  along  the  groove 
of  the  staff  into  the  bladder,  after  the  ex-  . 
ternal  incisions  have  been  made.  The  staff 
is  then  withdrawn,  and  the  operator  has  now 
the  power  of  making  the  incision  through 
the  prostate  and  neck  of  the  bladder  down- 
wards and  outwards  to  any  extent,  which 
the  parts  w'ill  allow,  or  the  case  require. 
This  is  one  of  the  principal  advantages 
which  beaked  long  narrrow  knives  have  over 
gorgets,  which,  after  their  introduction,  can- 
not be  further  used  for  the  enlargement  of  the 

Vojl  If  27 


wound.  The  narrow  knife  will  also  cut  more 
safely  dow  awards  and  outwards  than  any  gor- 
get ; nor  is  it  subject  to  the  serious  danger  of 
slipping  away  from  the  staff,  and  going  we 
know  not  where ; because  the  moment  its  beak 
and  extremity  have  entered  the  bladder,  the 
staff  is  no  longer  necessary,  as  the  proper 
extent  of  the  blade  will  then  readily  pass  in 
without  the  aid  of  any  conductor  at  all.  I 
need  hardly  observe,  also,  that,  in  this 
method,  we  have  nothing  like  the  perilous 
and  violent  thrust  of  the  gorget,  which,  in 
the  event  of  a lMle  unsteadiness  in  the  ope- 
rator’s hand,  or  of  any  fault  either  in  the 
position  of  the  staff,  or  the  direction  of  the 
gorget,  will  do  irremediable  and  fatal  mis- 
chief. 

A FEW  GENERAL  REMARKS  ON  THE  BEST 

MODE  OF  MAKING  THE  INCISION  IN, THE 

LATERAL  OPERATION  : AND  SOME  REFLEC- 
TIONS ON  THE  PRINCIPLES  INCULCATED  BV 

PROFESSOR  SCARPA. 

Perhaps  of  all  the  great  operations  in  sur- 
gery, lithotomy  is  that,  in  which  great  awk- 
wardness, mortifying  failures,  and  dangerous 
blunders,  are  most  frequently  observed. 
Many  a surgeon,  who  contrives  to  cut  off 
limbs,  extirpate  large  tumours,  and  even  tie 
aneurismal  arteries,  w'ith  eclat , cannot  get 
through  the  business  of  taking  a stone  out 
of  the  bladder  in  a decent,  much  less,  a 
masterly  style.  This  fact  is  so  familiarly 
known  in  the  profession,  and  its  truth  so  ofteii 
exemplified,  that  I may  well  be  excused  the 
unpleasant  task  of  relating  in  proof  of  it  all 
the  disasters,  which  have  come  to  my  own 
personal  knowledge.  But.  I must  take  the 
liberty  of  remarking,  that,  in  this  branch  of 
surgery,  a great  number  of  individuals  d» 
not  profit  by  these  instructive  lessons  of  ex- 
perience. The  more  they  see  of  lithotomy, 
the  more  they  are  convinced  of  its  dangers  ; 
yet,  too  often,  instead  of  studying  the  causes 
of  ill  success,  they  merely  derive  from  the 
examples  before  them,  a suspicion  of  the  un- 
skilfulness  of  the  operator,  or  some  dis- 
couraging conjectures  about  the  difficulties 
of  the  operation. 

The  establishment  of  certain  prineiplesto 
be  observed  in  lithotomy,  appears  the  most 
probable  way  of  diminishing  the  frequency 
of  the  accidents  and  failures  of  this  common 
operation.  If  these  principles  are  not  viola- 
ted, it  is  of  less  consequence  what  instru- 
ment is  employed,  for  the  surgeon  may  do 
nearly  the  same  thing  with  an  ordinary  dis- 
secting knife,  a concealed  bistoury,  a beaked 
Scalpel,  or  a well-made  gorget. 

After  the  very  opposite  principles,  and 
different  methods  of  cutting  for  the  stone, 
which  are  explained  in  the  preceding 
columns,  as  preferred  by  different  surgeons, 

I think  it  maybe  useful  to  offer  a few  gene- 
ral observations  on  the  proper  direction  and 
size  of  the  incision.  These  points,  which 
are  of  the  highest  practical  consequence,  in 
regulating  the  principles,  w hich  ought  to  be 
observed  in  lithotomy,  are  far  from  being 
Settled,  as  must  be  plain  to  every  body  wbo 


LITHOTOMY. 


210 


recollects  that  Desault,  Mr.  John  Bell,  Klein, 
and  Langdenbeek,  have  recommended  a 
free  opening  ; Scarpa,  Callisen,  and  others, 
a small  one  ; that  Mr.  Ahernetby  and  Scarpa 
employ  gorgets,  which  cut  upwards  and 
outwards,  at  angles  of  45°  and  69°  from  the 
axis  of  the  urethra  ; and  t hat  the  gorgets  of 
of  Cruickshank,  B.  Beil,  Desault,  Mr.  Cline, 
and  most  other  surgeons  arp  constructed  for 
cutting  either  directly  outwards,  or  outwards 
and  inwards. 

It  appears  to  tne,  that  the  incision,  through 
the  whole  of  the  parts  cut  in  lithotomy, 
should  always  be  made  in  a straight,  regular, 
direct  manner,  from  the  surface  of  the  skin 
in  the  perinasurn  to  the  termination  of  the 
wound  in  the  urethra  and  bladder.  In  an 
adult  subject,  trie  external  wound  should 
commence  about  an  inch  above  Ihe  anus. 
The  impropriety  of  beginning  it  higher  up 
has  been  duly  insisted  upon  bv  Sharp,  Ber- 
trandi,  Callisen,  and  every  g.fod  writer  on 
the  operation.  “ II  ne  faut  couper  I’uretre 
que  le  nioins,  qu’on  peut,  parcequ’on  obtient 
par  ce  moyen  one  meilleure  voie  pour  pene- 
trer  dans  la  vessie  sous  Tangle  du  pubis. 
C'est  avec  raison  que  Sharp  dit  que  I’incision 
de  1’uretre  faite  au  dessus  de  cet  angle  est  si 
peu  utile  pour  l’extraclion  de  la  pierre,  qu’on 
n’en  retireroit  pas  plus  d’avantage  en  le  r ou- 
pant  presque  dans  toute  sa  longueur.”  ( Ber - 
trandi,  TraiUdes  Operations,  p.  127.)  And 
Callisen  lays  it  down  as  a maxim  : “ Ut  pffl 
partes  baud  sectione  attingan'ur,  quae  pro 
calculi  egressu  nihil  faciunt ; adeoque  bulbus 
urethrae,  et  hujus  pars  norpore  spongioso  cir- 
cumdata  intacta  relinquatur.”  (Sy  sterna  Chi- 
rurgice  Ilodiernce ; Pars  Posterior ; p.655.) 

Extraordinary  as  it  may  seem,  it  i3  not  the 
less  true,  that  cutting  too  much  of  t ie  ure- 
thra is  one  of  the  most  common  faults  still 
committed  by  modern  surgeons.  The  inci- 
sion in  the  integuments  is  to  be  large,  that  is 
to  say,  at  least,  three  inches  in  length  in  an 
adult  subject,  because  a free  opening  in  the 
skin  is  not  only  exempt  from  danger,  but  at- 
tended with  many  advantages,  especially 
those  of  facilitating  the  other  steps  of  the 
operation,  and  preventing  any  future  lodg- 
ment and  effusion  of  urine.  The  external 
wound  ought  to  be  directed  towards  a point 
situated  a very  little  towards  the  anus,  from 
the  innermost  part  of  the  tuberosity  of  the 
ischium.  From  the  line,  thus  made,  the  in- 
cision should  he  carried  inward  and  upward, 
through  all  the  parts  between  it  and  the  side 
of  the  prostate  gland.  Another  line,  extend- 
ing from  the  inferior  angle  of  the  wound  to 
the  termination  of  the  cut  in  the  bladder, 
forms  the  precise  limits,  to  which  the  depth 
of  the  incisions  should  reach,  and  no  further. 

The  great  principle  of  making  the  axis  of 
the  wound  as  straight  and  direct  as  possible, 
should  always  be  kept  in  view,  whether  the 
surgeon  employ  a common  scalpel,  which 
cuts  into  the  bladder, from  without  inwards, 
or  other  instruments,  which  divide  the  pros- 
tate gland,  and  neck  of  the  bladder,  from 
within  outwards,  like  the  bistoire  cache, 
beaked  knives,  and  every  kind  of  cutting 
gorget  Tn  the  latter  circumstance,  the  only 


difference  consists  in  cutting,  from  the  blad- 
der and  urethra,  downwards  and  outwards 
towards  a point , situated  a little  way  more  in- 
wardly than  the  tuberosity  of  the  ischium, 
instead  of  carrying  the  incision  from  this 
point,  upwards  and  in  wards,  through  the  side 
of  the  prostate  gland  and  the  orifice  of  the 
bladder.  The  following  may  be  enumerated 
as  important  advantages  of  attending  to  the 
foregoing  principle  : 

1.  The  wound  is  made  in  that  direction, 
which  affords  the  greatest  room  for  the  ex- 
traction of  large  stones;  and  the  axis  of  the 
incision  being  also  as  nearly  straight  as  pos- 
sible, the  introduction  of  forceps,  and  the 
passage  of  the  calculus  outward,  are  mate- 
rially facilitated. 

Thai  these  are  important  advantages,  I 
think  every  surgeon  will  allow,  who  knows 
bow  much  the  pain  and  danger  of  lithotomy 
depend  upon  the  injury  which  the  parts 
suffer  from  the  force  sometimes  used  in  the 
extraction  of  the  stone,  and  the  repeated  in- 
troduction of  the  forceps.  Cheselden,  the 
most  successful  lithotornist  England  ever 
produced,  made  the  incision  in  the  direction 
here  recommended,  sometimes  inward  and 
upward  ; sometimes  outward  and  downward. 
The  following  remarks  of  another  excellent 
surgeon  merit  particular  attention  : — J’ai  vu 
plusieurs  fois  dans  les  H6spitaux  de  Paris, 
que  les  Chirurgiens,  coupant  tiop  en  haul 
vers  I’angle  du  pubis,  sentoient  une  grand 
resistance  au  perine,  quand  ils  vouloient  re- 
tirer  le  calcul  avec  les  lenettes  ; on  voyoit  le 
p6rin6  se  tum6!ier  par  la  pression,  qu’y  faisoit 
la  pierre  ; en  ce  cas,  quelques  operateurs 
plussages  abandonnoient  la  pierre,  introduis- 
oient  de  nouveau  le  gorgeret,  et  en  tournant 
en  dessous  la  cannelure  de  celui  ci, prolonged 
em  I’incision  obliquernent  vers  la  tuberosite 
de  l’os  isohion  ; et  erifin  a la  faveur  de  cetle 
plus  grande  ouverture,  retiroient  la  pierre 
sans  causer  de  deonirernens.”  ( Berirandi , 
Traiti  des  Operations , p.  133.)  Larger 
stones  may  likewise  be  thus  extracted,  with- 
out being  broken,  than  in  any  other  mode  of 
making  the  lateral  incision,  as  must  be  ob- 
vious to  every  practitioner,  who  recollects 
the  very  limited  room,  afforded  at  the  upper 
part  of  the  triangular  space,  between  the 
arch  of  the  pubes,  the  ramus  of  the  ischium, 
and  the  neck  of  the  bladder.  This  conside- 
ration cannot  fail  to  have  great  weight  with 
all  surgeons,  who  feel  duly  convinced,  how 
unsatisfactory  a method  it  is  to  break  a cal- 
culus, in  order  to  get  it  out  of  the  bladder 
The  measures  necessary  for  the  removal  of 
all  the  fragments  protract  the  completion  of 
the  operation,  and  seriously  increase  its  dan- 
ger; while  the  continuance  of  a single  part 
' of  the  stone  behind  may  cause  a renewal  of 
all  the  grievances,  for  the  cure  of  which  the 
patient  submitted  to  the  operation.  By  these 
remarks,  however,  I am  far  from  meaning  to 
say,  that  large  calculi  should  nut  be  broken  ; 
on  the  contrary,  my  only  wish  is,  that  the 
necessity  for  the  practice  may  be  avoided, 
as  much  as  possible,  by  making  a free  inci- 
sion into  the  bladder,  and  even  enlarging  the 
opening,  if  necessary,  as  far  ns  can  be  done 


LITHOTOMY. 


211 


with  safety,  in  snort,  instead  of  breaking 
the  stone,  I prefer  the  practice  of  Mr.  Marti- 
neau,  of  Norwich,  perhaps  the  most  success- 
ful lithotomist  now  living  in  this  country,  as 
out  of  84  patients,  whom  he  has  cut,  only 
two  have  died  ; a statement  highly  favourable 
to  operating  with  a knife,  and  making  an 
adequate  opening.  “ Should  the  stone  be 
large,  or  there  be  any  difficulty  in  the  ex- 
traction. rather  than  use  much  force,  while 
the  forceps  have  a firm  hold  of  the  stone 
(says  Mr.  Martineau,)  I give  the  handles  to 
an  assistant,  who  is  to  draw  them  outwards 
and  upwards,  while  the  part  forming  the 
stricture  is  cut  ; which  is  easily  done,  a3 
the  broad  part  of  the  blade  becomes  a 
director  to  the  l^nife  ; and  rather  than  lace- 
rate, I have  often  repeated  this  enlargement 
of  the  inner  wound  two  or  three  times.” 
(See  Med.  Ckir.  Trans.  Vol.  11,  jj.  411.)  The 
great  advantage  of  the  knife  over  the  gorget, 
and  even  the  necessity  of  employing  it  for 
adapting  the  size  of  the  opening  in  the  blad- 
der to  the  magnitude  of  the  stone,  or  its 
fragments,  are  most  convincingly  exemplified 
in  several  cases  recently  put  upon  record. 
Thus  Klein,  with  the  aid  of  a common 
scalpel,  extracted  a calculus,  which  weighed 
twelve  ounces,  thirty  grains  ; and  the  patient 
recovered.  ( Pract . Ansichten  Bedeutendsten 
Operationen , H.  1.)  In  1818,  M . Mayo,  of 
Winchester,  operated  with  a knite,  and 
extracted  a calculus,  which  broke  in  the  for- 
ceps,weighing  fourteen  ounces,  two  drachms, 
a voirdupoise,  and  the  patient  recovered. 
(See  Med.  Chir.  Trans.  Vol.  11,  p 54,  fyc.) 
Mr.  W.  B.  Dickenson,  of  Macclesfield,  aim 
succeeded  with  Mr.  Gibson's  knife,  in  taking 
out  of  the  bladder  a calculus,  the  fragments 
of  which  v\  eighed  eight  and  a half  ounces, 
and  the  patient  was  saved.  ( Vol.cit.p . 61.) 
An  I in  the  same  volume  may  be  seen  other 
instances,  in  which  immense  calculi  were 
removed  from  the  bladder  with  various  re- 
sults, but  particularly  one  which  weighed 
sixteen  ounces,  and  which  Sir  A.  Cooper 
could  not  succeed  in  breaking : he  was 
therefore  obliged  to  enlarge  the  wound,  first 
made  with  the  gorget  >l  to  the  sacro-sciatic 
ligament,”  when  with  the  aid  of  a hook 
applied  to  the  forepart  of  the  stone  behind 
the  pubes,  and  the  simultaneous  assistance 
of  the  forceps,  he  succeeded  with  consider- 
able difficulty  in  removing  thi  immense 
mass.  The  patient  lived,  however,  only  four 
hours  after  the  operation.  (See  Med  '.  Ckir. 
Trans.  Vol.  11,  p.  73.) 

2.  The  arteria  pudica  profunda  can  never 
be  injured, because  the  surgeon  does  not  let 
the  knite,  or  gorget,  approach  nearer  to  the 
ischium,  than  a point  which  is  situated  a lit- 
tle way  from  the  tuberosity  of  that  bone  to- 
wards the  anus;  and  consequently  the  edge 
of  the  instrument  cannot  come  into  contact 
with  the  inside  of  the  tuberosity  and  ramus 
of  the  ischium  where  the  great  pudic  artery 
is  situated. 

3.  The  rectum  will  not  be  wounded, 
because  the  direction  of  the  axis  of  the  inci- 
sion, either  downwards  and  outwards  to 
the  above-mentioned  point,  or  from  that 


point  inwards  and  upwards,  sufficiently 
removes  the  edge  of  the  knife,  or  gorget, 
from  the  intestine.  But,  the  rectum  will  be 
in  still  greater  safety,  if  it  be  pressed  down- 
ward with  the  fore-finger  of  the  left-hand  in 
the  wound,  and  the  prudent  custom  of  emp- 
tying it,  by  means  of  a clyster,  a short  time 
before  the  operation,  he  not  omitted  ; for,  no 
lithotomist  should  ever  forget,  that,  when 
this  bowel  is  considerably  distended  with 
feces,  it  rises  up  a little  way  on  each  side  of 
the  prostate  gland. 

4.  As  the  seminal  duct  penetrates  the  lower 
part  of  the  substance  of  the  prostate  gland, 
in  order  to  reach  the  urethra,  and  the  knife, 
or  other  instrument,  employed,  divides  the 
upper  portion  of  the  side  of  that  gland  in- 
ward and  upward,  or  outward  and  down- 
ward, it  is  obvious  that  the  duct  will  not  be 
in  the  least  danger  of.  being  cut. 

The  judicious  Callisen  is  well  aware  of 
the  advantages  of  making  a smooth,  even, 
direct  incision  into  the  bladder  ;*  but,  like 
Professor  Scarpa,  he  is  averse  to  making  a 
free  cut  through  the  neck  of  that  viscus.  In- 
deed, as  we  shall  presently  notice,  Scarpa 
does  not  sanction  cutting  any  portion  of 
the  bladder  at  all. 

Every  practitioner,  who  will  take  the 
trouble  to  look  ove  the  history  of  the  late- 
ral operation,  will  find,  that  the  greater  num- 
ber of  lithotomists,  who  have  particularly 
distinguished  themselves  by  their  unparallel- 
ed success,  as  Frere  Jacques,  Cheselden, 
Cosme,  Mr.  Martineau  Dr.  Souberbielle, 
&tc.  m tde  a free  incision  into  the  bladder. 
This  fact  alone  is  enough  to  r ise  doubts  of 
the  goodness  of  the  advice  delivered  upon 
this  subject  by  Callisen  and  Scarpa  ; espe- 
cially, as  neither  they,  nor  any  other  modern 
surgeon  (with  the  exception,  perhaps,  of 
Pajola,  who-e  individual  skill  is  said  by 
Langenb'wk  to  make  amends  for  the  disad- 
vantages of  his  method.)  can  boast  of  having 
cut  patients  for  the  stones  with  a degree  of 
success  at  all  equal  to  that  of  the  above-men- 
tioned operators.  The  extraordinary  success 
which  characterized  Cbeselden’s  practice  we 
1 ^ve  already  detailed  in  this  volume.  The 
accounts,  which  we  nave,  of  the  successful 
operation  done  by  Frere  Jacques  and  Cosme, 
are  equally  remarkable. 

Mr.  Martineau,  as  I have  noticed,  has  lost 
hut  two  patients  out  of  84,  on  whom  he  has 
operated,  and  this  without  making  any  se- 
lection, as  he  never  rejected  any  one  who 
was  brought  for  operation.  Mis  patients 
were  always  kept  a week  in  the  house  be- 
fore operating  ; and  this  precaution,  with  a 
regulated  diet,  and  perhaps  a dose  or  two  of 
opening  medicine,  was  the  only  preparatory 
treatment.  (Med.  Chir.  Trans.  Vol.  11,  p. 
409.) 

During  my  stay  at  Paris,  in  1815,  I saw 
Dr.  Souberbielle  extract  a stone  of  consider- 

*„Vulnus  sit  equate,  hand  angtilatum,  conicae  figu- 
vae.  apice  vesicam  respiciente,  externa  pla'ga  ampa  > 
et  quatuor  pollicum  longitudine,  mideeflluxus  sangui- 
nis, puris,  loth,  arena?,  facilitatur.  See  Systema  Ohi- 
rurp-iae  Hodiernse ; Pars  Posterior,  p 660.  fctafnias, 
1800. 


LITHOTOMY. 


a 2 


able  size,  on  the  plan  of  his  well-known  an- 
cestor. The  incision  was  ample  and  direct, 
so  that  the  calculus  was  taken  out  with  per- 
fect ease.  Now,  as  the  operations  of  this 
professed  lithotomist  are  very  numerous,  and 
lie  enjoys  the  reputation  of  scarcely  ever 
losing  a patient,  are  we  not  justified  in  in- 
ferring, that  the  advocates  for  a small  open- 
ing are  promulgating  the  worst  advice  which 
can  be  offered  to  the  practitioner?  My  own 
observations  certainly  tend  to  such  a con- 
clusion as  will  be  presently  explained.  The 
tract  recently  published  by  Scarpa  (Memoir 
on  the  Cutting  Gorget  of  Hawkins , tyc.  trans. 
by  Briggs ,)  has  for  its  main  objects  the  ie- 
commendation  of  a modification  of  Haw- 
kins’s gorget,  audit  he  inculcation  ol  the  pro- 
priety of  making  a small  limited  incision  in 
the  prostate  gland,  without  cutting  any 
part  of  the  bladder.  As  sufficient  room  can 
not  thus  be  obtained  for  the  extraction  of 
even  a stone  of  moderate  size,  he  is  an  ad- 
vocate for  the  gradual  dilatation  of  the  ure- 
thra and  orifice  of  the  bladder.  He  observes, 
that  the  lateral  operation,  though  executed 
with  the  greatest  precision,  does  not  exempt 
the  surgeon  from  dilating  in  a certain  degree 
the  orifice  of  the  bladder,  and  cervix  of  the 
urethra,  the  dilatation  of  those  parts,  how- 
ever moderate,  being  always  necessary  even 
where  the  calculus  is  of  middling  size.  He 
states,  that,  in  the  adult,  the  orifice  of  the 
bladder  dilates  almost  spontaneously  to  the 
diameter  of  five  lines  ; and  he  adds,  that  the 
lateral  incision,  within  proper  limits,  divides 
the  body  and  base  of  the  prostate  gland  to 
the  depth  of  four,  or,  at  most,  five  lines, 
forming  with  the  five,  to  which  the  orifice 
of  the  bladder  naturally  yields,  an  apertu/e 
of  ten  lines.  But,  says  Scarpa,  in  an  adult, 
a stone  of  ordinary  size  and  oval  figure  is 
sixteen  lines  in  the  small  diameter,  to  which 
must  be  added  the  thickness  of  the  blades  of 
the  forceps  : consequently,  even  after  the 
incision  has  been  made  with  the  most  scru- 
pulous exactness,  the  stone,  though  of  mode- 
rate size,  cannot  pass  out  of  the  bladder,  un- 
less the  dilatation  of  the  base  of  the  gland 
and  orifice  of  the  bladder  be  carried  to  the 
extent  of  nearly  eight  lines,  beyond  the  size 
of  the  aperture  made  with  the  knife.  But, 
says  Scarpa,  if,  in  order  to  avoid  distending 
the  parts  to  the  extent  of  eight  lines,  the  base 
oi  the  prostate  gland,  together  with  the 
orifice  of  the  bladder,  and  a part  of  its  lun- 
dus,  be  divided  to  a depth  equivalent  to  it, 
the  event  would  necessarily  be  an  effusion  of 
urine  into  the  cellular  membrane,  between  the 
rectum  and  bladder,  and  consequently  suppu- 
ration, gangrene,  Jislulce,  and  other  serious 
evils.  (Page  4,  5.) 

According  to  Scarpa,  the  apex  of  the 
prostate  gland  forms  the  greatest  resistance 
t.>  the  introduction  of  the  forceps  and  the 
extraction  of  the  stone,  and,  therefore, 
ought  to  be  completely  divided ; (P.  7 ) 
but,  he  contends,  that  two,  and  sometimes 
three,  lines  of  the  substance  of  the  base  of 
the  gland,  should  be  left  undivided  ; which, 
be  asserts,  is  a matter  of  great  importance, 
because  the  untouched  portion,  around  the 


orifice  of  the  bladder,  prevents  the  effusion, 
of  urine,  and  the  formation  of  gangrene,  or 
fistulae,  between  that  part  and  the  rectum 
(P.  22.) 

After  this  statement  of  one  of  the  great 
principles,  which  Scarpa  wishes  to  be  ob- 
served in  the  performance  of  the  lateral 
operation,  a question  or  two  naturally  arise. 
Are  we  then  to  conclude,  that  the  plan  of 
making  a free  and  direct  incision  into  the 
bladder  ought  to  be  abandoned  ? Must  we 
forget,  that  it  is  this  method,  which  has  an- 
swered so  well  in  the  hands  of  Cheselden 
and  the  several  renowned  lithotomists  al- 
ready enumerated  ? And  must  we  believe, 
that  the  advice  delivered  upon  this  point  by 
Bertrandi,  Desault,  Mr.  John  Bell,  and  all 
the  best  modern  surgeons  in  this  country,  is 
founded  only  upon  a capricious  partiality  to 
the  free  use  of  cutting  instruments  ? 

Earnestly  as  I respect  the  names  of  a Cal- 
Jisen  and  a Scarpa,  their  authority  cannot 
influence  me  further,  than  I find  it  coincide 
with  the  dictates  of  experience, — the  great 
arbitrator  of  every  disputed  point  in  practice. 

We  have  seen,  that  an  apprehension  of 
effusion  of  urine,  gangrene,  fistulae,  he.  is 
the  only  reason  assigned  by  Scarpa  for  his 
aversion  to  making  a complete  division  of 
the  side  of  the  prostate  gland,  and  orifice 
of  the  bladder.  But,  I would  inquire,  do 
we  find  extravasation  of  the  urine,  between 
the  rectum  and  bladder,  and  gangrene,  and 
fistulae,  so  frequent  after  lithotomy  in  Eng- 
land, as  to  render  it  probable,  that  these  ill 
consequences  can  ever  proceed  from  our 
usual  mode  of  dividing  completely,  not  only 
the  side  of  the  prostate  gland,  but  also  the 
adjoining  part  of  the  bladder?  Are  such 
bad  effects  so  often  experienced  in  this  coun- 
try, as  to  constitute  a material  source  of  un- 
easiness in  the  mind  of  a surgeon  about  to 
undertake  lithotomy  ? Do  they  form  a sub- 
stantial reason  for  abandoning  the  inaxim  of 
always  endeavouring,  as  far  as  circumstances 
will  allow,  to  make  an  incision  of  sufficient 
size  for  the  easy  removal  of  the  calculus  ? 
And,  would  not  Scarpa’s  method  of  stretch- 
ing and  dilating  the  wound,  in  order  to  get 
the  stone  out  of  the  bladder,  often  danger- 
ously prolong  the  operation;  lead  to  much 
mischief  from  the  repeated  use  of  the  for- 
ceps ; cause  serious  contusion  and  lacera- 
tions of  the  parts  ; and,  for  all  these  reasons, 
render  inflammation  of  the  bladder  and  pe- 
ritoneum very  likely  to  follow  ? 

In  the  course  of  the  twenty-four  years 
that  I have  been  in  the  profession  of  surge- 
ry, I have  seen  the  lateral  operation  perform- 
ed an  immense  number  of  times,  either 
with  various  kinds  of  gorgets,  beaked  knives, 
the  lithotomie  cache,  or  common  scalpels. 
In  all  these  examples  the  avowed  intention 
of  the  surgeon  was  to  make  a free  opening 
into  the  bladder.  1 do  not  mean,  however, 
to  say,  that  this  was  always  actually  accom- 
plished, since  the  bad  construction  of  the 
instruments  employed,  and  other  causes, 
sometimes  frustrated  the  wise  design  of  the 
operator.  But,  what  was  the  consequence  ? 
Generally  speaking,  those  surgeons  who 


LITHOTOMY. 


made  only  a small  incision  into  the  bladder, 
and  kept  their  patients  a long  while  upon 
the  operating  table,  ere  they  succeeded  in 
getting  out  the  stone,  by  the  repeated  and 
foicibleuse  of  the  forceps,  had  the  mortifi- 
cation to  see  very  few  of  their  patients  re- 
cover : a large  proportion  of  them  being 
carried  off  by  peritonitis,  on  the  third  or 
fourth  day  after  the  operation. 

On  the  contrary,  when  the  incision  was 
ample  and  direct,  so  that  the  calculus  could 
be  easily  and  gently  removed,  the  patients 
were  almost  always  saved. 

During  the  first  six  or  seven  years  of  the 
long  time  during  which  I have  enjoyed  fre- 
quent opportunities  of  seeing  lithotomy  per- 
formed in  St.  Bartholomew’s  Hospital,  gor- 
gets were  invariably  used,  most  of  which 
instruments  made  an  insufficient  opening. 
The  consequence  was,  that  many  of  the 
patients  were  detained  a long  while  upon 
the  operating  table,  before  the  stone  could 
be  extracted,  and  some  considerable  num- 
bers were  lost  by  peritonitis.  Of  late  years, 
however,  in  the  same  institution,  common 
scalpels  and  beaked  knives  have  been  often 
used  ; a freer  opening  has  been  generally 
made  ; and  the  proportion  of  deaths  from 
peritonitis  is  strikingly  lessened. 

The  following  observation,  made  by  Mr. 
Martineau,  is  also  worthy  of  particular  at- 
tention : — “ In  the  first  years  of  my  prac- 
tice,” says  he,  “ I was  not  very  successful ; 
and  often  witnessing  many  untoward  circum- 
stances in  myself  and  others,  which  appeared 
to  arise  from  the  use  of  the  cutting  gorget, 

1 determined  to  lay  that  instrument  aside, 
and  employ  the  knife  only,  and  the  blunt 
gorget  as  a conductor  for  the  forceps.”  (Med. 
Chir.  Trans,,  p.  405.) 

Now,  when  we  remember  that  this  gentle- 
man has  lost  only  two  out  of  eighty-four 
patients,  on  whom  he  has  operated,  his  re- 
marks are  of  great  importance ; and  his 
cases,  and  the  other  facts,  which  I have  spe- 
cified, strongly  impress  my  mind  with  the 
truth  of  all  that  I have  urged,  respecting 
the  advantages  of  making  the  opening  large, 
and  in  the  best  direction  for  the  easy  pas- 
sage of  the  stone  outward. 

In  Mr.  Martineau’s  manner  of  operating, 
it  is  true,  he  does  not  make  the  external 
wound  parallel  to  that  in  the  bladder,  as  I 
venture  to  recommend,  but  directs  it  nearly 
in  a line  with  the  raphe  ; a circumstance 
which  may,  perhaps,  account  for  his  continu- 
ing the  use  of  the  blunt  gorget  as  a conduc- 
tor for  the  forceps.  Neither  is  his  internal 
incision  carried  downwards  and  outwards, 
as  Bertrandi,  Desault,  and  many  other  judi- 
cious surgeons  consider  most  advantageous. 
But  these  defects  (if  I may  presume  to  call 
them  so)  are  i-endered  of  less  consequence 
by  the  rule,  which  Mr.  Martineau  observes, 
of  making  his  first  incision  long  and  deep , and 
avoiding  all  stretching  and  laceration  of  the 
parts.  Like  Langenbeck  (See  First  Lines  of 
Surgery,  Vol.  2,)  he  uses  a-staff,  the  groove  of 
which  is  much  wider  and  deeper  than  usual, 
and  therefore  more  easily  felt.  This  instru- 
ment his  assistant  holds,  in  the  way  preferred 


2io 

by  Scarpa,  nearly  in  an  upright  straight 
direction.  “After  the  first  incision  (says 
Mr.  Martineau)  I look  if  the  stall’ is  not  al- 
tered in  its  situation,  and  then  feeling  for  the 
groove,  I introduce  the  point  of  the  knife 
into  it,  as  low  down  as  I can,  and  cut  the  mem- 
branous part  of  the  urethra , continuing  my 
knife  through  the  prostate  into  the  bladder  .,* 
when , instead  of  enlarging  the  wound  down- 
wards, and  endangering  the  rectum,  I turn 
the  edge  of  the  blade  towards  the  ischium,  and 
make  a lateral  enlargement  of  the  wound  in 
withdrawing  the  knife."  (See  Med . Chir. 
Trans.  Vol.  11,  p.  409.)  This  description  is 
particularly  interesting,  as  coming  from  a 
gentleman,  who  has  had  so  much  experience 
and  success;  and  its  value  would  have  been 
increased,  had  the  direction  in  which  the 
edge  of  the  knife  was  turned  in  the  division 
of  the  prostate  gland,  been  exactly  speci- 
fied. 

With  respect  to  the  degree  of  importance* 
which  ought  to  be  attached  to  the  fear  of 
effusion  of  urine,  between  the  bladder  and 
rectum,  gangrene,  fistulae,  &c.,  I can  only- 
say,  that  they  are  inconveniences  which  are 
not  commonly  observed  after  lithotomy  in 
this  country.  In  two  or  three  instances  only 
I have  known  the  urine  come  through  the 
wound  longer  than  usual,  and  these  cases 
ended  well.  As  for  the  extravasation  of 
urine  and  sloughing,  I shall  merely  remark, 
that  although  there  cannot  be  a doubt  of 
their  occasional  occurrence,  they  have  not 
taken  place  after  any  of  the  numerous  ope- 
rations, with  the  results  of  which  1 have 
been  acquainted. 

All  these  facts  and  considerations,  there- 
fore, incline  me  to  doubt  whether  the  appre  - 
hension of  the  effusion  of  urine,  fistulae, 
&c.  be  sufficiently  serious  and  well-founded 
to  make  it  adviseable  for  surgeons  to  relin- 
quish the  plan  of  making  a complete  division 
of  the  side  of  the  prostate  gland,  and  neck  of 
the  bladder,  in  the  operation  of  lithotomy. 
Nor  is  it  at  all  clear  to  my  mind,  that  effusion 
of  urine  and  sloughing  are  likely  to  be  the 
effect  of  practising  a free  opening.  Indeed, 
whenever  they  do  happen,  I believe  they 
proceed  from  a totally  different  cause,  viz, 
from  the  incision  in  the  skin  being  too  small 
and  too  high  up,  and  from  the  axis  of  the 
internal  part  of  the  incision  not  correspond- 
ing with  that  of  the  external  wound.  Hence 
the  urine  does  not  readily  find  its  way  out- 
ward, and  some  of  it  passes  into  the  neigh- 
bouring cellular  membrane. 

In  confirmation  of  the  foregoing  remarks, 
I beg  leave  to  cite  the  sentiments  of  one 
of  the  greatest  and  most  experienced  of 
modern  surgeons.  Speaking  of  the  defects 
of  Hawkins’s  gorget,  Desault  observes,  “ La 
methode  de  l’enforcer  horizontalement  dans 
la  vessie  sur  la  catheter  tenu  h angle  droit 
avec  le  corps,  a deux  grands  desavantages  : 
d’un  cote  celui  de  p^netrer  par  l’endroit  le 
plus  retreci  du  pubis,  et  par  consequent  de 
ne  faire  que  difficilement  une  ouverture 
suffisante;  d’un  autre  cote,  celui  de  ne  pas 
etablir  de  parallelisme  entre  l’incision  exte- 
rieure  des  teguraens  qui  est  oblique  et  celle 


LITHOTOMY. 


214 

du  col  de  la  vessie  et  de  la  prostate,  qui  sc  perceptible  through  the  thin  parietes  ot  the 
trouve  alors  horizontale.  De-Ik  la  possibi-  rectum  and  bladder  While  the  latter  instru- 


lite  des  infiltrations  par  les  obstacles  qui  les 
urines  trouveront  k s’ecouler.” 

No  doubt  also  some  of  the  worst,  and  most 
dangerous  urinary  extravasations  after  li- 
thotomy. have  proceeded  from  another 
cause,  pointed  out  by  the  same  excellent 
surgeon.  “ Imprudemment  port6  dan:>  la 
vessie,  le  gorgeret  peut  alier  par  le  stylet 
beaueoup  trip  long  qui  le  term  ie,  heurier, 
dechirer,  perforer  merae  la  '/embrane  de  la 
vessi  -,  et  donner  iieukdes  infiltrations  d’au- 
tant  plus  daugereuses,  que  le  lieu  d’ou  elles 
partent  est  plus  inaccessible.  Cet  accident 
est  surtout  k craindre,  lorsque,  comtne  les 
Anglais,  on  se  sert  de  catheter  sans  cul-de- 
sac.”  (See  (Euvres  Cliir.  de  Desault  par  Bi- 
chat, T.  2,  p.  460,  461.) 

LITHOTOMY  THROUGH  THE  RECTUM. 

This  method  may  be  said  to  have  been 
first  suggested  in  a work  published  at  Bkle, 
in  the  16th  century,  by  an  author  who  assu- 
med the  name  of  Vegetius  : “ Jubet  per  vul- 
nus  recti  intestini,  et  vesicse  aculeo  lapidem 
ejicere,”  says  Haller,  in  speaking  of  this  wri- 
ter. (Bibl.  Chir.  Vol.  1,  p.  102.)  But  the 
proposal  never  received  much  attention  un- 
til the  year  1S16,  when  M.  Sanson,  in 
France,  gave  an  account  of  this  manner  of 
operating,  and  urged  several  considerations 
in  favour  of  the  practice.  In  that  country, 
however,  the  operation  has  been  performed 
only  by  Dupuytren,  and,  though  the  opera- 
tion proved  successful,  the  other  French 
surgeons  do  not  appear  »o  have  imitated 
him.  Nor  am  1 aware,  that  Dupuytren  him- 
self now  continues  the  practice.  Almost  as 
soon  as  this  method  was  heard  of  on  the 
other  side  of  the  Alps,  it  was  put  to  the  test 
of  experience  by  Barbantini,  in  a case  where 
every  other  plan  of  operating  appeared  hard- 
ly practicable.  The  connexion  of  the  ure- 
thra with  the  rectum,  prostate  gland,  and 
posterior  part  of  the  bladder,  (says  M.  San- 
son) made  me  easily  perceive,  that  by  divi- 
ding the  sphincter  ani  and  some  of  the  rec- 
tum near  the  root  of  the  penis,  I should  x 
pose,  not  only  the  apex  of  the  prostate 
gland,  but  a more  or  less  considerable  por- 
tion of  this  body,  and  that  I should  then  be 
able  to  penetrate  into  the  cavity  of  the  blad- 
der, either  at  the  neck  through  the  prostate, 
or  at  its  posterior  part,”  It  was  the  latter 
method,  which  M.  Sanson  first  tried  upon 
the  dead  subject.  The  body  was  placed  in 
the  position  usually  chosen  for  the  common 
ways  of  operating,  and  a staff  was  introdu- 
ced, and  held  perpendicularly  by  an  assist 
ant.  A bistoury,  with  its  blade  kept  flat  on 
the  left  fore-finger,  was  now  introduced  into 
the  rectum,  and  the  edge  being  turned  up- 
wards, M Sanson,  with  one  stroke,  in  the 
direction  of  the  raphe,  cut  the  sphincter  ani, 
and  the  lower  part  of  the  rectum.  The  bot- 
tom of  the  prostate  gland  being  thus  expo- 
sed, the  finger  was  next  passed  beyond  its 
solid  substance,  where  the  staff  was  readily 


ment  was  steadily  maintained  in  its  original 
osition,  M.  Hanson  here  introduced  the 
nife  into  the  bladder,  and,  following  the 
groove  of  the  staff,  made  an  incision  about 
an  inch  in  length  At  this  instant,  the  flow 
of  urine  from  the  wound  indicated  that  the 
bladder  liad  had  an  opening  made  in  it.  On 
examination,  the  parts  divided  were  found 
to  be  the  sphincter,  the  lower  part  of  the 
rectum,  the  back  part  of  the  prostate,  and 
the  adjacent  portion  of  the  bladder.  Ano- 
ther mode,  contemplated  by  M.  Sanson, 
was.  after  dividing  the  sphincter  ani,  to  cut 
the  termination  of  the  membranous  part  of 
the  urethra  along  the  groove  of  the  staff 
held  perpendicularly,  and  by  the  same  gui- 
dance to  expend  the  incision  in  the  median 
line  through  the  prostate  gland  and  neck  of 
the  bladder. 

In  Barbantini’s  case,  the  calculus  was  so 
large,  that  it  made  a considerable  promi- 
nence in  the  rectum,  where  it  was  felt  ex- 
tending across  from  one  tuberosity  of  the 
ischium  to  the  other.  On  account  of  its 
size,  its  extraction  by  the  lateral  operation 
was  considered  impracticable,  and,  as  it  was 
not  thought  adviseable  or  easy  to  break 
such  a mass,  and  Barbantini  regarded  the 
high  operation  as  more,  difficult  and  uncer- 
tain in  its  results  than  the  common  method, 
it  was  determined  to  operate  through  the 
rectum.  The  attempt  wTas  delayed  some 
days,  by  the  impossibility  of  introducing 
effectually  the  staff',  which  was  stopped  at 
its  entrance  into  the  bladderby  the  calculus. 
But,  as  a grooved  instrument  was  judged  to 
be  an  essential  guide,  Barbantini  caused  a 
long  director  to  be  constructed,  which  he 
thought  might  be  passed  more  conveniently 
than  the  staff,  into  the  first  incision.  He 
aho  provided  himself  with  long  forceps,  the 
blades  of  which  were  very  broad,  and  ad- 
m 1 ted  of  being  put  separately  over  the 
stone.  A staff  having  been  introduced,  the 
operation  was  done  after  M.  Sanson’s  man- 
ner, except  that  a wooden  gorget  was  intro- 
duced for  the  protection  of  the  rectum,  and 
the  prostate  gland  was  left  undivided  at  the 
forepart  of  the  wound.  When  the  bladder 
had  been  opened  at  the  lower  part  of  the 
rectum,  as  far  as  the  groove  of  the  stafF 
served  as  a guide,  the  latter  instrument  was 
withdrawn,  and  the  long  director  introdu- 
ced into  the  incision,  which,  under  its  gui- 
dance, was  then  enlarged  to  the  necessary 
extent.  With  some  difficulty  the  stone  was 
then  extracted,  and  found  to  weigh  nine 
ounces  and  a half.  For  about  eighteen  days 
the  urine  passed  away  bv  the  anus,  only  a 
a few  drops  occasionally  issuing  from  the 
urethra.  As  this  circumstance  gave  Barban- 
tini some  uneasiness,  he  introduced  hiS‘( 
finger  into  the  bladder,  the  inner  surface  of 
whicl),  near  the  wound,  he  found  covered  I 
with  encysted  calculous  mailer,  which  was  j 
very  adherent.  At  length,  however,  it  was  j 
gradually  removed,  with  a portion  of  new- 
formed  membrane,  by  attempts  repeated 


LITHOTOMY. 


-215 


with  the  linger  several  days  in  succession. 

A catheter  was  then  introduced,  through 
which,  at  first,  almost  the  whole  of  the 
urine  (lowed.  But  the  tube  being  after- 
ward obstructed  with  mucus,  it  became  ne- 
cessary frequently  to  clear  it  by  injecting 
tepid  water.  The  cure  now  seemed  to  pro- 
ceed with  rapidity.  When  the  feces  were 
hard,  none  of  them  passed  into  the  bladder  ; 
but  when  they  were  liquid,  a part  of  them 
were  voided  with  the  urine  through  the 
tube,  though  without  any  inconvenience. 
At  the  end  of  fifty  days,  s arcely  any  urine 
passed  out  of  the  wound  ; the  patient, 
therefore,  went  into  the  country,  where,  in 
the  course  of  another  month,  the  cure  was 
complete. 

About  a year  ago,  I saw  an  example,  in 
which  a calculus  had  made  its  way  through 
the  prostatic  portion  of  the  urethra,  and 
formed,  with  the  swelling  of  the  soft  parts, 
a considerable  prominence  within  the  rec- 
tum. If  the  patient  had  been  under  my 
care,  I should  certainly  have  made  an  inci- 
sion directly  on  the  tumour  just  within 
the  sphincter,  by  which  means  the  calculus 
might  have  been  removed  with  great  ease, 
and  less  risk  than  dividing  the  prostate. 
However,  the  latter  method  was  followed, 
and  the  case  had  a very  favourable  termina- 
tion. In  this  instance,  as  the  sound,  in  its 
passage,  only  occasionally  touched  a small 
point  of  the  calculus,  which  approached  the 
urethra,  and  this  just  at  the  instant  before 
its  entrance  into  the  cavity  of  the  bladder, 
the  exact  nature  of  the  case  was  for  some 
lime  a matter  of  doubt  to  several  skilful 
surgeons  who  were  consulted.  Respecting 
the  merits  of  lithotomy  through  the  rectum, 
'l  think  the  practice  well  deserving  the  con- 
sideration of  the  profession,  where  the  cal- 
culus is  known  beforehand  to  be  of  unusual 
size.  It  must  be  less  painful,  I apprehend, 
than  the  high  operation,  and,  perhaps,  more 
easy  of  execution.  But  it  is  difficult,  with 
the  scanty  experience  before  us,  to  offer  any 
very  decided  opinion  whether,  on  the  whole, 
it  ought  to  be  preferred  either  to  the  high 
or  the  lateral  operation,  by  which  last, 
stones  of  larger  size  than  that  extracted  by 
Barbantini,  have  been  successfully  taken  out 
by  Mr.  Mayo,  of  Winchester,  Dr.  Klein,  of 
Stuttgard,  and  others.  The  most  serious 
consideration  is,  whether  a large  incision, 
forming  a communication  between  the  blad- 
der and  rectum,  will  generally  heal  up,  as 
well,  or  even  more  favourably,  than  in  Bar- 
bantini’s  case.  This  is  a point  which  can 
only  be  decided  by  further  observation.  A 
smaller  wound  in  the  same  part,  it  appears, 
is  soon  cured  ; for  in  the  instance  reported 
by  Sanson,  the  boy  was  quite  well  on  the 
twentieth  day.  For  further  information, 
consult  Sanson,  DcsMoyens  de  Parvenir  a la 
Vessie  par  le  Rectum,  4to.  Paris , 1817  ; JV*. 
Barbantini  Obs.  relative  a.  Vextruction  d’un 
calcul  urinaire  ires  volumineux , operec  au 
moyen  de  la  taille  vesicoreclnle,  8 vo.  Lucques , 
1819  ; Journ.  Complem.  du  Did.  des  Sciences 
Med.  T.  6,  p.  79,  8vo.  Paris , 1820  ; Diet  des 
Sciences  Med.  T.  28,  p.  422, 


LITHOTOMY  IN  WOMEN. 

Women  suffer  much  less  from  the  stone 
than  men,  and  far  less  frequently  stand  in 
need  of  lithotomy.  It  is  not,  however,  that 
their  urine  will  not  so  readily  produce  the 
concretions  which  are  termed  urinarv  <-il- 
culi.  The  reason  is  altogether  owin  to  he 
shortness,  largeness,  and  very  dilatab  na- 
ture of  the  female  urethra  ; circumstances 
which  in  general  render  the  expulsion  of 
the  stone  with  the  urine  almost  a matter  of 
certainty.  The  records  of  surgery  present 
us  with  numerous  instances,  where  calculi 
of  vast  size  have  been  spontaneous ly  voided 
through  the  meatus  urinarius,  either  sud- 
denly without  pain,  or  after  more  or  less 
time  and  suffering.  Heister  mentions  seve 
ral  well-authenticated  examples.  Middle- 
ton  has  also  related  a case,  where  a stone, 
weighing  four  ounces,  was  expelled  in  a 
fit  of  coughing,  after  lodging  in  the  passage 
a week.  Coiot  speaks  of  another  instance, 
where  a stone,  about  as  large  as  a goose’s 
egg*,  after  lying  in  the  meatus  urinarius 
seven  or  eight  days,  and  causing  a retention 
of  urine,  was  voided  in  a paroxysm  of  pain. 
A remarkable  case  is  related  by  Dr.  Moli- 
neux  in  the  early  part  of  the  Philosophical 
Transactions  : a woman  voided  a stone,  the 
circumference  of  which  measured  the  long- 
est way  seven  inches  and  six-tenths,  and 
round  about,  where  it  was  thickest,  five 
inches  and  three  quarters  ; its  weight  neav 
two  ounces  and  a hall  troy.  And  Dr.  Yel- 
loly  has  related  an  interesting  example,  in 
which  a calculus,  weighing  three  ounces, 
three  and  a half  drachms  troy,  and  lodged  in 
the  meatus  urinarius,  was  easily  taken  out 
with  the  fingers.  (See  Med.  Chir.  Trans. 
Vol.  6,  p.  577.)  Dr.  Yelioly  also  refers  to 
several  very  remarkable  instances,  described 
in  the  Phil  Trans.  Vols.  12,  15,  17,  20,  34, 
42,  and  55,  proving  what  large  stones  will 
pass  out  of  the  female  urethra,  either  spon- 
taneously or  with  the  aid  of  dilatation  and 
manual  assistance.  Were  any  doubts  now 
left  of  this  fact,  they  would  be  immediately 
removed  by  other  histories,  especially  those 
contained  in  a paper  drawn  up  by  Sir  A, 
Cooper.  (See  Med.  Chir.  Trans.  Vol.  8,  p. 
427,  4 rC.) 

Sometimes,  after  the  passage  of  large 
calculi,  the  patient  has  been  afflicted  with  an 
incontinence  of  urine;  but,  in  general,  this 
grievance  lasts  only  a short  time. 

The  occasional  spontaneous  discharge  of 
very  large  calculi  through  the  meatus  uri- 
narius led  Frederic  de  Leauson  to  deliver 
the  advice  not  to  interfere  with  them,  as  he 
thought  they  would  all  present  themselves 
sooner  or  later  at  the  orifice  of  that  passage, 
and  admit  of  being  taken  away  with  the 
fingers.  (See  Trait 6 Nouveau  pour  ai seme  at 
parvenir  a la  'Vraie  Curation  de  plusieurs 
belles  Operations,  fyc.  Geneve.  1674.) 

When  surgeons  began  to  consider  what 
very  large  calculi  were  sometimes  sponta- 
neously voided,  and  the  large  size,  and  di- 
latable nature  of  the  female  urethra,  they 
suspected  that  it  would  be  a good  practice 


LITHOTOMY. 


210 


to  dilate  this  passage  by  mechanical  con- 
trivances, until  it  would  allow  the  stone  to 
be  extracted,  and  thus  all  occasion  for  cut- 
ting instruments  might  be  superseded.  With 
this  view,  Tolet  first  proposed  suddenly  di- 
lating the  passage  with  two  steel  instru- 
ments, called  a male  and  female  conductor, 
between  which  the  fingers,  or  forceps,  were 
passed  for  the  removal  of  the  calculus. 
(Traits  de  la  Lithotomie,  Paris , 1681.)  But 
as  it  was  afterward  rightly  judged,  that  the 
dilatation  would  produce  less  snffering  and 
injury,  if  more  gradually  effected,  Douglas 
suggested  the  practice  of  dilating  the  mea- 
tus urinarius  with  sponge  or  dried  gentian 
root. 

Mr.  Brom field  has  published  the  case  of 
a young  girl,  in  whom  he  effected  the  ne- 
cessary dilatation  by  introducing  into  the 
meatus  urinarius  the  appendicula  coeci  of  a 
small  animal  in  a collapsed  state,  and  then 
filling  it  with  water  by  means  of  a syringe  ; 
thus  furnishing  a hint  for  the  construction  of 
instruments  on  the  principle  of  Mr.  Arnott’s 
dilator.  The  piece  of  gut,  thus  distended, 
was  drawn  out  in  proportion  as  the  cervix 
vesicae  opened,  and,  in  a few  hours,  the  dila- 
tation was  so  far  accomplished,  that  the 
calculus  had  room  to  pass  out.  (See  Chir. 
Obs.  and  Cases,  Vol  2,  p.  276.) 

Mr.  Thomas  met  with  a case,  in  which, 
after  dilating  the  meatus  urinarius  with  a 
sponge  tent,  he  succeeded  in  extracting  an 
earpicker  which  lay  across  the  neck  of  the 
bladder.  The  passage  was  so  much  enlar- 
ged, that  the  left  fore-finger  was  most  easily 
introduced,  and  (says  this  gentleman)  “ 1 
believe  had  the  case  required  it,  both  thumb 
and  finger  would  have  passed  into  the  blad- 
der without  the  smallest  difficulty.”  After 
adverting  to  this,  and  other  facts,  proving 
the  ease  with  which  the  female  urethra  can 
be  dilated,  Mr.  Thomas  remarks  : “ If  these 
relations  can  be  credited,  and  there  is  no 
reason  why  they  should  not,  l can  hardly 
conceive  any  case,  in  a young  and  healthy 
female  subject,  and  where  the  bladder  is 
free  from  disease,  where  a very  large  stone 
may  not  be  extracted,  without  the  use  of 
any  other  instrument  tnan  the  forceps,  the 
urethra  having  first  been  sufficiently  dilated 
by  means  of  the  sponge  tents  For  this 
purpose,  the  blades  of  the  forceps  need  not 
be  so  thick  and  strong  as  those  commonly 
employed.  (See  Medico- Chir.  Trans.  Vol. 
1,  p.  123 — 129.)  Many  facts  of  a similar 
kind  are  on  record,  and  one  in  which  a large 
needlecase  was  extracted,  is  referred  to  in 
a modern  periodical  work.  (See  Quarterly 
Journ.  of  Foreign  Med.  Vol.  2,  p 331.) 

Some  surgeons  have  extracted  stones  from 
the  female  bladder  in  the  following  manner: 
the  patient  having  been  placed  in  the  posi- 
tion commonly  adopted  in  the  lateral  opera- 
tion, a straight  staff,  with  a blunt  end,  is  in- 
troduced into  the  bladder,  through  the  mea- 
tus urinarius.  The  surgeon  then  passes 
along  the  groove  of  the  instrument  the 
beak  of  a blunt  gorget,  which  instrument 
becoming  wider  towards  the  handle,  effects 
n part  of  the  necessary  dilatation.  The  staff 


being  withdrawn,  and  the  handle  of  the  gor* 
get  taken  hold  of  with  the  left  hand,  the 
right  fore-finger  with  the  nail  turned  down- 
wards, is  now  introduced  slowly  along  the 
concavity  of  the  instrument.  When  the 
urethra  and  neck  of  the  bladder  have  thus 
been  sufficiently  dilated,  the  finger  is  with- 
drawn, and  a small  pair  of  forceps  passed 
into  the  bladder.  The  gorget  is  now  remo- 
ved, and  the  stone  taken  hold  of,  and  ex- 
tracted. ( Sabatier , Medecine  Opdratoire,  T. 
2,  p.  103.) 

This  plan,  however,  is  liable  to  the  objec- 
tions arising  from  the  dilatation  being  too 
suddenly  effected  ; and  the  practice  now 
generally  preferred  is  that  of  gradually  ex- 
panding the  meatus  urinarius  with  sponge 
tent.  And,  as  the  retention  of  the  urine, 
during  the  continuance  of  the  sponge,  causes 
great  irritation,  I consider  Mr.  C.  Hutchin- 
son's suggestion  of  placing  a catheter  in  its 
centre,  as  mentioned  by  Sir  A.  Cooper,  as 
meriting  attention.  (See  Med.  Chir.  Trans. 
Vol.  8,  p.  433.) 

Notwithstanding  these  favourable  ac- 
counts of  the  practice  of  dilating  the  female 
urethra,  for  the  purpose  of  removing  cal- 
culi from  the  bladder,  there  are  very  good 
surgeons  who  deem  an  incision  the  best 
practice.  It  is  certain,  that  some  patients 
have  found  the  method  insufferably  tedious 
and  painful.  But  the  strongest  objection  is 
the  incontinence  of  urine,  which  occasion- 
ally follows  any  great  distention  of  the  ure- 
thra and  neck  of  the  bladder.  Klein,  one 
of  the  most  experienced  operative  surgeons 
in  Germany,  states  that  he  has  tried  both 
plans,  and  that  the  use  of  the  knife  is  much 
less  frequently  followed  by  incontinence  of 
urine.  On  the  other  hand,  Mr.  Thomas  be 
lieves,  that  this  unpleasant  symptom  is  quite 
as  often  a consequence  of  the  operation  of 
lithotomy,  as  now  usually  performed.  (Med. 
Chir.  Trans.  Vol.  1,  p.  127.)  When  the  stone 
is  not  very  large,  perhaps  dilatation  should 
be  preferred  ; and,  in  other  cases,  an  inci- 
sion. 

In  females,  lithotomy  is  much  more  easy 
of  execution,  and  less  dangerous,  than  in. 
male  subjects.  It  may  be  done  in  various 
ways  ; but  the  surgeons  of  the  present  time 
constantly  follow  the  mode  of  making  the 
requisite  opening  by  dividing  the  urethra 
and  neck  of  the  bladder.  Louis  employed 
for  this  purpose  a knife  which  cut  on  each 
side,  and  was  contained  in  a sheath;  Le 
Blanc,  a concealed  bistoury,  which  had  only 
one  cutting  edge  ; Le  Cat.  his  gorgeret-cys- 
titome  ; Frere  Come,  his  lithotome  cache ; 
and  Fleurant  a double-bladed  lithotome 
cache.  Of  these  instruments,  the  best,  I 
think,  is  that  of  Frere  Come.  But,  at  pre- 
sent, every  surgeon  knows,  that  the  opera 
tion  may  be  done,  as  conveniently  as  possi- 
ble, with  a common  director  and  a knife, 
that  has  a long,  narrowr,  straight  blade.  A 
straight  staff,  or  director,  is  introduced 
through  the  mealus  urinarius  ; the  groove  is 
turned  obliquely  downwards  and  outwards, 
in  a direction  parallel  to  the  ramus  of  tin- 
left  os  pubis  ; and  the  knife  is  thus  conduct* 


LITHOTOMY. 


217 


ed  into  (lie  bladder, and  makes  the  necessary 
incision  through  the  whole  extent  of  the 
passage,  and  neck  of  the  bladder. 

Louis  and  Fleurant,  as  I have  said,  were 
the  inventors  of  particular  bistouries  for  di- 
viding both  sides 'of  the  female  urethra  at 
once.  The  instrument  of  the  former  effect- 
ed this  purpose,  in  passing  from  without 
inwards;  that  of  the  latter,  in  passing  from 
within  outwards.  Fleurant’*  bistoury  bears 
some  resemblance  in  principle  to  Frere 
Gome’s  lithotome  cache  or  to  the  cutting 
forceps,  with  which  Franco  divided  the 
neck  of  the  bladder.  The  reason  assigned 
in  recommendation  of  these  bistouries  is, 
that  they  serve  to  make  a freer  opening  for 
the  passage  of  large  stones,  than  can  be  safe- 
ly made  by  cutting  only  in  one  direction. 
When  the  calculus  is  large,  it  is  certainly  dif- 
ficult to  procure  a free  opening,  without  cut- 
ting the  vagina,  in  front  of  which  passage, 
there  is  but  little  space  under  the  pubes  for 
the  removal  of  the  stone.  Hence,  Dubois 
invented  a new  method,  which  consists  in 
dividing  the  meatus  urinarius  directly  up- 
wards towards  the  symphisis  of  the  pubes, 
dilating  the  wround  and  keeping  the  vagina 
out  of  the  way  by  means  of  a blunt  gorget, 
and  then  taking  out  the  calculus  with  the 
forceps.  This  method  seems  to  me  better 
devised  for  the  protection  of  the  vagina,  than 
the  acquirement  of  more  room  for  the  cal- 
culus, and  whatever  space  is  gained,  is  only 
gained  by  the  distention  of  the  parts,  and 
the  propulsion  of  them  downwards.  The 
plan  is  acknowledged  to  be  very  painful,  yet 
generally  successful,  and  not  followed  by 
any  serious  symptoms  or  incontinence  of 
urine.  (See  Did.  des  Sciences,  Med.  T.  28, 
p.  43b.)  When  the  stone  is  known  to  be 
very  large,  Sabatier  and  some  other  modern 
surgeons  prefer  the  apparatus  altus. 

A case  may  present,  itself,  in  which  the 
posterior  part  of  the  bladder,  drawn  down- 
wards by  the  weight  of  the  stone,  may  dis- 
place a portion  of  the  vagina,  and  make  it 
protrude  at  the  vulva  in  the  form  of  a swell- 
ing. Here,  there  wrould  be  no  doubt  of  the 
propriety  of  cutting  into  the  tumour,  and 
taking  out  the  foreign  body  contained  in  it. 
Rousset  performed  such  an  operation,  and 
Fabricius  Hildanus  in  a case,  where  the 
stone  had  partly  made  its  way  into  the  va- 
gina, enlarged  the  opening,  and  successfully 
extracted  the  foreign  body. 

Mery  proposed  to  cut  into  the  posterior 
part  of  the  bladder  through  the  vagina,  after 
introducing  a common  curved  staff  ; but  the 
apprehension  of  urinary  fistulae  made  him 
abandon  the  project. 

The  existence  of  extraordinary  circum- 
stances may  always  render  a deviation 
from  the  common  modes  of  operating  not 
only  justifiable,  but  absolutely  necessary. 
Thus,  Tolet  met  with  a case,  where  a wo- 
man had  a prolapsus  of  the  uterus,  with 
which  the  bladder  was  also  displaced.  In 
the  latter  viscus,  several  calculi  were  felt: 
an  incision  was  made  into  it,  and  the  stones 
extracted,  after  which  operation,  the  dis- 
placed parts  were  reduced,  and  a speedy 

Voi,.  If  28 


cure  followed.  (Sabatier,  Medecine  0p6ra - 
loirt , T.  2,  p.  i07.) 

The  incontinence  of  urine,  consequent 
to  lithotomy  in  women,  is  by  no  means  an 
unlrequent  occurrence.  Mr  Hey  cut  two 
female  patients  for  the  stone,  both  of  whom 
were  afterward  unable  to  retain  their  urine, 
and  were  not  quite  well  when  discharged 
from  the  Leeds  Infirmary.  These  cases  led 
Mr.  Hey  in  a tliifd  example  lo  endeavour  to 
prevent  the  evil,  by  introducing  into  the  va- 
gina a cylindrical  linen  tent,  two  inches 
long  and  one  broad  with  a view  of  bring- 
ing the  edges  of  the  incision  together,  with- 
out obstructing  the  passage  of  urine  through 
the  urethra.  The  plan  answered,  if  it  be 
allowable  to  make  such  an  inference  from 
a single  trial.  (See  Hep's  Practical  Obs.  in 
Surgery,  p.  560.  Ed.  1810.) 

TREATMExf  AFTER  THE  OPERATION. 

If  the  interna]  pudendal  artery  should  be 
wounded,  and  bleed  profusely,  the  best  plan 
is,  .f  possible,  first  to  take  out  the  stone,  and 
then  introduce  into  the  wound  a piece  of 
firm  sponge,  with  a large  cannula  passed 
through  its  centre.  The  expanding  property 
of  the  sponge,  on  its  becoming  wet,  will 
make  the  necessary  degree  of  compression 
of  the  vessel,  which  lies  too  deeply  to  be 
tied.  When  there  is  much  coagulated  blood 
lodged  in  the  bladder,  it  is  customary  to 
wash  it  out  by  injecting  lukewarm  water. 

I cannot  say  that  it  has  fallen  to  my  lot 
to  see  any  cases  (out  of  the  great  number 
which  I have  seen  in  Bartholomew’s  Hos- 
pital,) in  which  death  could  be  imputed  to 
hemorrhage,  notwithstanding  the  bleeding 
has  often  been  so  profuse,  and  from  so  deep 
a source,  jus!  after  the  operation,  as  to  cre- 
ate suspicion  that  it  proceeded  from  the  in- 
ternal pudendal  artery.  Such  hemorrhage 
generally  stopped  before  the  patient  was  put 
to  bed. 

The  majority  of  patients  who  die  after 
lithotomy  perish  of  peritoneal  inflammation. 
Hence,  on  the  least  occurrence  of  tender- 
ness over  the  abdomen,  copious  veuesection 
should  be  put  in  practice.  At  the  same  time, 
eight  or  ten  leeches  should  be  applied  to  the 
hypogastric  region  The  belly  should  be  fo- 
mented, and  the  bowels  kept  open  with  the 
oleum  ricini.  The  feebleness  of  the  pulse 
should  not  deter  the  practitioner  from  using 
the  lancet  ; this  symptom  is  only  fallacious; 
and  it  is  generally  attendant  on  all  inflam- 
mation within  the  abdomen.  It  is  a curious 
fact,  that  Mr.  Martineau,  who  has  lost  only  2 
out  of  84  patients,  whom  he  has  operated  upon 
for  the  stone,  should  never  have  found  it  re- 
quisite to  bleed  ; but  it  appears  to  me,  that, 
it  is  a much  better  argument  in  favour  of  the 
superior  safety  of  operating  with  the  knife 
and  making  a f: ee  opening,  than  reason  for 
discouraging  venesection,  when  inflamma- 
tion of  the  peritoneum  has  come  on,  which, 
however,  may  not  be  this  gentleman’s  mean- 
ing, as  he  says,  “ I believe,  it  will  be  found 
in  adults,  that  death  follows  oftener  from  ex- 
haustion, after  a tedious  operation,  or  from 


despondency,  &tc.  than  from  acute  disease  ; 
(Med.  Chir.  Trans.  Vol  11,  />.  412.)  a senti- 
r merit,  which  1 am  sure  this  gentleman  would 
not  have  entertained,  had  he  been  present 
with  me  at  the  opening  of  tbd  many  unfor- 
tunate cases,  which  used  formerly  to  occur 
in  the  practice  with  badly  made  gorgets  in 
St.  Bartholomew’s  Hospital.  Together  with 
the  above  measures,  the  wajjrn  bath,  a blister 
on  the  lower  part  of  the  abdomen,  and 
emollient  glysters,  are  highly  proper  I have 
seen  several  old  subjects  die  of  the  irritation 
of  a diseased  thickened  bladder,  continuing 
after  the  stone  was  extracted.  They  had 
not  the  acute  symptoms,  the  inflammatory 
fever,  the  general  tenderness  and  tension  of 
the  abdomen,  as  in  cases  of  peritonitis  ; but 
they  referred  their  uneasiness  to  the  lower 
part  of  the  pelvis  ; and  instead  of  dying  in  the 
course  of  two  or  three  days,  as  those  usually 
do,  who  perish  of  peritoneal  inflammation, 
they,  for  the  most  part,  lingered  for  two  or 
three  weeks  after  the  operation.  In  these 
cases,  opiate  glysters,  and  blistering  the  hy- 
pogastric region,  are  the  best  measures.  In 
some  instances  of  this  kind,  abscesses  form 
about  the  neck  of  the  bladder. 

Whoever  wishes  to  acquire  a perfect 
knowledge  of  the  history  of  lithotomy 
should  consult  the  following  works  : Ctlsus 
de  Re  M edict). , lib.  7,  cap.  26.  Remarques 
sur  la  Chirurgie  de  Chauliac , par  M.  Simon 
de  Mingelouzeaux,  tom.  2. ; Bourdeaux.  1663. 
La  legende  du  Gascon  par  Drelincourt ; Paris, 
1665.  Van  Horne's  Opuscul a Marianus  de 
Lapide  Vesicce  par  Incisionem  exlrahendo ; 
1552.  G.  Fair.  Hildanus,  Lilhotomia  Vesicce, 
S vo.  Lond.  1640.  M.  S.  Baroliianus , De  Lapide 
Renum.  Ejusdem  de  Lapide  Vesicce  per  Inci- 
sionem exlrahendo,  4lo.  Paris,  1540.  Lc  Dr  an , 
Par  allele  des  Dfferenles  Manic  res  de  lirer  la 
Pierre  hors  de  la  Vessie,  2 Vol.  8 ro.  1730. 
Sharp's  Operations.  Sharp's  Critical  Inqui- 
ry. Le  Bran's  Operations,  Edit.  5 ; London, 
1781.  Franco's  Trail6  des  Ilernies,  1561. 
Roselus  de  Partu  Ccesario.  Traitt  de  la  Lilho- 
tomie,  par  F.  Tolet,  Paris , 5 me  Ed.  1708. 
Heister’s  Surgery,  Part  2.  Lilhotomia  Doug- 
lassiana,  1723.  J.  Douglas , Ilislory  of  the 
Lateral  Operation , 4 to.  Lond.  1726.  Er.  M. 
Colot , Trade  de  V Operation  de  la  Taille,  fyc. 
12 mo  Paris,  1727.  Murand,  Traiti  dc  la 
Taille  au  haul  appareil,  12 mo.  Paris,  1728  ./. 
Mery,  Observations  sur  la  Maniere  de  Tailler, 
$-e.  pratiqu6e  par  Frere  Jacques,  12wo.  Pari. , 
1700.  Cours  d'  Operations  de  Chirurgie  por 
Dionis.  Trade  des  Operations  par  Garengeot , 
Tom.  2.  Morand  Opuscules  de  Chirurgie. 
Bertrand i.  Trait6  des  Operations.  Index  Su- 
pellectihs  Analomicw  Ravi  once  ; Leidce,  1725. 
,/.  G.  Lsemann,  De  Lilhotomia  Celsiance 
Freest antice  ; Helmst.  1745.  Le  Cat,  Recueil 
de  Pieces  sur  V Opdration  de  la  Taille  Part  1 ; 
Rouen , 1749.  Cosme,  Recueil  de  Pieces  Ana- 
tomiques  import  antes  sur  l'  Operation  de  la 
Taille ; Paris,  1751 — 1753.  J.  Douglas, 

Postscript  to  Hist,  of  the  Lateral  Operation ; 
1726.  J.  Douglas , Appendix  to  Hist,  of  the 
Lateral  Operation  ; 1731.  A short  Historical 
Account  of  Cutting  for  the  Stone,  by  IV.  Che- 
widen,  in  his  own  last  edition  of  his  Anatomy . 


Falconet  in  Thes.  Chirurg.  HaVtn ; the.'. 
103,  T.  4,  p.  196.  Hartinkeil ; Tract  at  us  de 
Vesicce  Urinaria:  Calculo,  fye.  1785.  Trditc 
Historique  et  Dogmatiquc  de  V Operation  de  la 
Taille,  par  J.  F.  L.  Deschamps,  4 Tom.  8 vo. 
Paris,  1796.  This  last  work  is  a very  Com- 
plete amt  full  account  of  the  subject  up  to  the 
time  of  its  publication,  arid  well  merits  a care- 
ful perusal.  Richerand  s Nosogr.  Chir.  T.  3, 
p.  538 , fyc.  Ed.  4.  Leviillt,  J\ouvelle  Doc- 
trine Chir  T.  3,  p.  533.  John  Bell's  Princi- 
ples of  Surgery . Vol.  2,  Part  1.  A.  Burns , 
in  Edinb.  Med  and  Surg.  Journal,  January, 
1808  C.  Bell's  Operative  Surgery,  Vol.  1, 

1807.  Sabatier,  de  la  Medecint  Ophaloire , 
Tom.  3.  Edit.  2,  1810.  Dr  John  Thomson'i. 
Observations  on  Lithotomy ; Edinb.  1808. 
Also  an  Appendix  to  a.  proposal  for  a new 
manner  of  catling  for  the  Slone,  8 vo.  Edinb. 
1810.  Allan's  Treatise  on  Lithotomy  ; Edinb. 

1808.  Earle's  Practical  Observations  on  Ope- 

rations for  the  Stone  ; 2d  Ed.  with  an  Appen- 
dix containing  a description  of  an  instrument 
calculated  to  improveihal  operation , 8ro.  Lond. 
1803.  Wm.  Dense . Ohs.  on  the  different  me- 
thods for  the  radical  cure  of  the  Hydrocele,  fyc. 
Tojwhich  is  added  a comparative  view  of  the 
different  methods  of  cutting  for  the  Stone , fyc. 
8 vo.  Load.  1798.  ( Euvres  Chir.  de  Desault 

par  Bichat ; Tom.  2.  Wm.  Simmons,  Cases 
and  Obs.  on  Lithotomy,  8 vo.  Manchester,  1808. 
C.  B.  Trye , Essay  on  some  of  the  Stages  of  the 
Operat  ion  of  cutting  for  the  Stone,  8 vo.  Loud. 
1811  Roux,  Voyage  fail  a Londres  en  1814, 
ou  Par  allele  de  la  Chirurgie  Angloise  avec 
la  Chirurgie  Francoise,  p 315,  fyc.  Paris, 
1815.  Schregtr,  Chirurgisihe  Versnche,  B. 
2.  von  Steinschnitlen  an  Weibern,  p.  135,  fyc. 
8v o.  Number”,'  1S18.  C.  J.  M.  Langenbeck, 
iiber  tine  einfache  und  sichcre  methodcdcs 
Steinschnittes , 4 to.  Wurzburg,  1802.  F.  X. 
Rudtorjfer,  Ablmndluvg  iiber  die  Operation 
des  Blasensteines  nach  Pajolu's  Methods,  4 to. 
Leipz.  1S08.  A.  Scarpa,  A Memoir  on  the 
Cutting  Gorget  of  Hawkins,  §-c.  Trunsl.  by 
J.  II.  Wishart,  8 vo.  Edinb.  1816.  If.  Mayo, 
IV.  Dickenson,  II.  Earle,  and  P.  M.  Marli- 
neau  in  Med.  Chir.  Trans.  Vol.  11.  Klein, 
Tract.  Ansichten  bedeutendsten  Operalioner, 
4 to.  Stulgart,  IS  16.  J.  S.  Carpue,  Hist,  of 
the  High  Operation,  and  An  Account  of  the 
various  Methods  of  Lithotomy,  8 vo.  Lond. 
1819.  Sir  E.  Home  on  Strictures , tyc.  Vol  3, 
8 vo.  Lond.  1821  For  a minute  description 
and  delineations  of  the  parts  concerned  in 
the  operation,  see  Camper's  Demonslrationes 
Anatomico-palhologirce , lib.  2.  Also  L.  F Von 
Froriep  iiber  die  Lage  der  Eingcweide  un 
Becken , nebsl  enter  Darstellung  dcrselben , 4lo. 
Weimar,  1815. 

LOTIOA  LUMINIS. — ft.  Aluminis  purif- 
^ss.  Aquas  distillatae  Jftj.  Misce. — Some- 
times used  as  an  astringent  injection;  some- 
times as  an  application  to  inflamed  parts. 

LOTH)  AMMONLE  ACETATE.— ft. 
Liq.  nimnon.  acetaia}  ; Spirit,  vin.  rectil.  ; 
Aqua}  distillata};  sing.  3*v-  Misce. — Proper- 
ties disculient. 

LOTIO  AMMONITE  MURIATE.— ft. 
Ammon,  muriata}  3 j.  Spirit,  rorismarini  H>j. 
— Has  the  same  virtues  as  the  preceding 


LOT 


LUM 


Justamond  recommended  it  in  the  early 
stage  of  the  milk-breast. 

LOTIO  AMMONIA  MURIATE  CUM 
ACETO. — R.  Ammon.  Mur.  Zss.  Aceti, 
Spirit,  vinos,  rectif.  sing.  fbj.  Misce.  This 
is  one  of  the  most  efficacious  discutient  lo- 
tions. it  is,  perhaps,  the  best  application 
tor  promoting  the  absorption  of  extravasa- 
tcd  blood,  in  cases  of  eechymosis,  contu- 
sions, sprains,  &.c. 

LOTIO  AMMONLE  OPIATA. — R.  Spi- 
ntusammon.  comp.  3'*iss.  Aqua;  distilla'ae 
^iv.  Tinct.  Opii.  ^ss.  Misce.  Applied  by 
Kirkland  to  some  suspicious  swellings  in  the 
breast,  soda  and  bark  being  also  given  inter- 
nally. 

LOTO  CALCIS  COMPOSlTA.— -R. 

Aquae  calcis  R>j.  Hydrargyri  oxymuriatis 
3j  Misce. — Properties  strongly  astringent. 
Ringworms,  tetters,  and  some  other  cutane- 
ous affectionsyield  to  this  application,  which 
however,  should  generally  be  diluted.  In 
the  latter  state,  it  may  occasionally  be  used 
as  an  injection  for  various  purposes. 

LOTIO  GALLvE. — R.  Gallarum  contusa- 
rum  3 U-  Aquae  ferventis  ibj.  To  be  ma- 
cerated one  hour,  and  strained. — This 
astringent  lotion  is  sometimes  used  with  a 
view  of  removing  the  relaxed  state  of  the 
parts,  in  cases  of  prolapsus  ani,  prolapsus 
uteri,  &.c. 

LOTIO  HYDRARGYRI  AMYGDALINA. 
— R.  Amygdalurum  amararum  ^ j.  Aquas 
distil  fRj.  Hydrar^.  oxymuriatis  ^j.  Rub 
down  me  almonds  with  the  water,  which  is 
to  be  gradually  poured  on  them  ; strain  the  li- 
quor , then  add  the  oxymuriute  of  mercury. 
Tib-  will  cure  several  cutaneous  affections. 

LOTIO  HYDRARGYRI  OXYMURIATIS. 
— R.  Hydrargyri  oxymuriatis  gr.  ij-s.  Ara- 
bic! gurnmi  ^;s.  Aquae  distillptae  R,j-  Misce. 
— This  is  the  injection  of  corrosive  sublimate 
in  u*e  ai  St.  Bartholomew’s  Hospital. 

LOTIO  HYDRARGYRI  OXYMURIATIS 
COMPOSITA — R.  Hydrarg.  oxyinur.  gr.  x. 
Aq.  distillat.  bullientis  giss.  Tinct.  canthar. 
^ss.  Misce. — This  was  ordered  by  Dr.  H. 
Smith,  to  be  applied  every  night  to  scrofu- 
lous swellings. 

LOTIO  HELLEBORI  ALB!. — R.  Decoct i 
hellebori  albi  R,j.  Potassae  sulphured  ^ss. 
Misce. — This  is  occasionally  employed  as  an 
application  for  curing  tinea  capitis,  and 
some  other  cutaneous  diseases. 

LOTIO  PLUM  BI  ACE  TAT  IS. — R.  Liq. 
plumbi  acet  3 j-  Aq.  distill.  JRj-  Spirit  vinos, 
tenuioris  3u-  The  first  and  last  ingredients 
are  to  be  mixed  before  the  water  is  added. 

This  is  the'common  whitewash,  an  appli- 
cation universally  known. 

LOTIO  POTASSjE  SULPHURETI  — 
R.  Potassse  sulph.  3'j-  Aqua;  distill.  jRj. 
Misce. — It  is  used  in  the  same  cases  as  the 
preceding  application. 

LOTIO  OPII. — R.  Opii  ptirif.  3jss.  Aquae 
dislillatae  R>j  Misce. — A very  excellent  ap- 
plication to  irritable  painful  ulcers  of 
every  description.  It  is  best  to  dilute  it,  es- 
pecially at  first. 

LOTIO  PICJS. — R.  Picis  liquids;  ^iv. 
Calcis  Zvj.  Aqua;  ferventis  fb>ij. — To  be 


2i9 

boiled  till  half  the  water  is  evaporated.  The 
rest  is  then  to  be  poured  off  for  use.  This 
application  is  sometimes  employed  tor  the 
cure  of  tinea  capitis  ; it  is  also  of  singular 
service  in  removing  an  extensive  scorbutic 
redness,  frequently  seen  on  the  legs,  accom 
panying  old  ulcers. 

LOTIO  ZIJNCI  SULPH  ATI  >. — R.  Zinci 
sulphatis  3j.  Aq.  ferventis  Ibj.  Misce.  This 
is  sometimes  used  by  practitioners  in  lieq  of 
the  lotio  plumbi  acet.  It  forms  a good  as- 
tringent application  fora  variety  of  cases. 
When  diluted,  by  adding  two  pints  more 
water,  it  forms  the  common  injection,  so 
much  recommended  in  cases  of  gonorrhoea. 

LUES  VEIN  ERE  A.  See  V EX  ERE  A L 
DISEASE. 

L UM  B A K A BSC  ES  5.  Psoas  Mscess.  By 
these  terms  are  understood  chronic  collec- 
tions of  matter,  which  form  in  the  cellular 
substance  of  the  loins,  behind  the  peritone- 
um, and  descend  in  the  course  of  the 
psoas  muscle.  Patients,  in  the  incipi- 
ent stage  of  the  disease,  cannot  walk  so 
well  as  usual ; they  feet  a degree  of  uneasi- 
ness about  the  lumbar  region  ; but  in  gene- 
ral, there  has  been  no  acute  pain,  even  when 
the  abscess  has  acquired  such  a size  as  to 
form  a large  tumour,  protruding,  externally. 
In  short,  the  psoas  abscess  is  the  best  in- 
stance, which  can  possibly  be  adduced,  in 
order  to  illustrate  the  nature  of  those  collec- 
tions of  matter,  which  are  called  chronic, 
and  which  form  in  an  insidious  manner, 
w ithout,  serious  pain,  or  any  other  attendant 
of  acute  inflammation. 

The  abscess  sometimes  forms  a swelling 
above  Poupart’s  ligament  ; sometimes  below 
it  ; and  frequently  the  matter  glides  under 
the  fascia  of  the  thigh.  Occasionally  it 
makes  its  way  through  the  sacro-ischiatic 
foramen,  and  assumes  rather  the  appearance 
of  a fistula  in  ano.  When  the  matter  gravi- 
tates into  the  thigh,  beneath  the  fascia,  Mr. 
Hunter  would  have  termed  it  a disease  in, 
not  of,  the  part.  The  uneasiness  in  the 
loins,  and  the  impulse  communicated  to  the 
tumour  by  coughing,  evince,  that  the  di  ease 
arises  in  the  lumbar  region  ; but,  i-t  must  be 
confessed,  that  we  can  hardly  ever  know  the 
existence  of  the  disorder,  before  the  tumour, 
by  presenting  itself  externally,  leads  11s  to 
such  information.  The  lumbar  abscess  is 
sometimes  connected  with  diseased  verte- 
brae, which  may  either  be  a cause,  or  an 
effect,  of  the  collection  of  matter. — The 
disease,  however,  is  frequently  unattended 
with  this  complication. 

The  disease  of  the  spine,  we  may  infer,  is 
not  of  the  same  nature  as  ihat  treated  of  by 
Pott,  as  there  is  usually  no  paralysis.  When 
the  bodies  of  patients  with  lumbar  abscesses 
are  opened,  it  is  found,  that  the  matter  is 
completely  enclosed  in  a cyst,  which,  in 
many  cases,  is  of  course  very  extensive. 
If  the  contents  of  such  abscesses  were  not 
circumscribed  by  a membranous  boundary 
in  this  manner,  we  should  have  them  spread- 
ing among  the  cells  of  (he  cellular  substance, 
just  like  the  water  in  anasarca.  The  cysts 
are  both  secreting  and  absorbing  surfaces  as 


LITHOTOMY. 


is  proved  by  the  great  quantity  of  matter, 
which  soon  collects  again  alter  the  abscess 
has  been  emptied,  and  by  the  occasional  dis- 
appearance of  large  palpable  collections  of 
matter  of  this  kind,  either  spontaneously,  or 
in  consequence  of  means  which  are  known 
to  operate  by  exciting  the  action  of  the  ab- 
sorbents. In  slx.rt,  the  cyst  becomes  the 
suppurating  surface,  and  suppuration  is  now 
well  ascertained  to  be  a process,  similar  to 
glandular  secretion.  While  the  abscess  re- 
mains unopened,  its  contents  are  always  un- 
dergoing a change;  fresh  mailer  is  continu- 
ally forming,  and  a portion  of  what  was  pre- 
viously in  the  cyst  is  undergoing  t lie  neces- 
sary removal  by  the  absoi  bents.  This  is  not 
peculiar  to  lumbar  abscesses ; it  is  common 
to  all,  both  chronic  and  acute,  buboes  and 
suppurations  in  general.  It  is  true,  that,  in 
acute  abscesses,  there  often  has  not  been 
time  for  the  formation  of  so  di  tinct  a mem- 
brane as  the  cyst  of  a large  chronic  abscess  ; 
hut  their  matter  is  equally  circumscribed  by 
the  cavities  of  the  cellular  sub  lance  being 
filled  with  a dense  coagulating  lymph  ; and 
though  it  generally  soon  makes  its  way  tothe 
surface,  it  also  is  occasionally  absorbed. 

The  best  modern  surgeons  make  it  a com- 
mon maxim  to  open  very  few  acute  ab- 
scesses ; for  the  matter  natural!)  tends  with 
great  celerity  to  the  surface  of  the  body, 
where  ulceration  allows  it  to  escape  sponta- 
neously ; alter  which,  the  case  generally 
goes  on  better,  than  if  it  had  been  opened 
by  art.  But,  in  chronic  abscesses,  the  matter 
has  not  that  strong  tendency  to  make  its 
way  outward  ; its  quantity  is  continually  in- 
creasing; the  cyst  is,  of  course,  incessantly 
growing  larger  and  larger;  in  short,  the 
matter,  from  one  ounce,  often  gradually  in- 
creases to  the  quantity  of  a gallon.  When 
the  disease  is  at  length  opened,  or  bursts  by 
ulceration,  the  surface  oi  the  cyst,  irritated 
by  the  change,  inflames  ; and  its  great  ex- 
tent, in  this  circumstance,  is  enough  to  ac- 
count for  the  terrible  constitutional  disorder, 
and  fatal  consequences,  which  too  frequently 
soon  follow  the  evacuation  of  the  contents 
of  such  an  abscess.  Hence,  in  cases  of 
chrOnic  suppurations  of  every  kind,  and  not 
merely  in  lumbar  abscesses,  it  is  the  sur- 
geon’s duty  to. observe  the  opposite  rule  to 
that  applicable  to  acute  cases;  and  he  is 
called  upon  to  open  (he  collection  of  matter, 
as  soon  as  he  is  aware  of  its  existence,  and 
its  situation  will  allow  it  to  be  done. 

Certainly,  if  would  be  highly  advanta- 
geous to  have  some  means  of  a-certaining 
whether  the  vertebrae  are  also  diseased  ; for, 
as  in  this  instance,  the  morbid  bones  would 
keep  up  suppuration,  until  their  affection  had 
ceased,  and  there  would  be  no  reasonable 
hope  of  curing  the  ab-cess  sooner,  it  might 
be  better  to  avoid  puncturing  it  under  such 
circumstances.  The  propriety  of  this  con- 
duct seems  the  more  obvious,  as  issues,  which 
are  the  means  most  likely  tostop  and  remove 
the  disease  of  the  spine,  are  also  such  as 
afford  most  chance  of  bringing  about  the  ab- 
sorption of  the  abscess  itself.  However,  if 
the  collection  cannot  be  prevented  from  dis- 


charging itself,  and  ulceration  is  at  Land,  it 
is  best  to  meet  the  danger,  make  an  opening 
with  the  lancet,  in  a piace  at  some  distance 
from  where  the  pointing  threatens,  and  after- 
ward heal  it,  in  the  way  which  will  be  pre- 
sently detailed. 

Though  we  have  praised  the  prudence  of 
opening  all  chronic  abscesses  while  small,  the 
deep  situation  of  the  lumbar  one,  and  the 
degree  of  doubt  always  involving  its  early 
state,  unfortunately  prevent  us  from  taking 
this  beneficial  step  in  the  present  case.  But 
still  the  principle  is  equally  praiseworthy, 
and  should  urge  us  to  open  the  tumour  as  soon 
as  the  fluctuation  of  the  matter  is  distinct, 
ami  the  nature  of  the  case  is  evident.  For 
this  purpose,  Mr.  Abernethy  employs  an  ab- 
scess lancet.  which  will  make  an  opening 
large  enough  for  the  discharge  of  those  flaky 
substances  so  frequently  found  blended  with 
the  matter  of  lumbar  abscesses,  and  by  some 
conceived  to  be  an  emblem  of  the  disease 
being  scroiulous.  Such  flakes  seem  tocon- 
sist  of  a part  of  the  coagulating  matter  of 
the  blood,  and  are  very  commonly  secreted 
by  the  peculiar  cysts  of  scrofulous  ab- 
scesses. The  puncture  must  also  be  of  a cer- 
tain fize,  in  order  to  allow  the  clots  of  blood, 
occasionally  mixed  with  the  matter,  to 
escape.  Mr.  Abernethy  considers  the  open- 
ing of  a lumbar  abscess  a very  delicate  ope- 
ration. Former  surgeons  used  to  make  large 
openings  in  these  cases;  let  out  the  con- 
tents; leaye  the  wound  open:  the  usual 
consequences  of  which  were,  great  irritation 
and  inflammation  of  the  cyst  ; immense  dis- 
turbance 6f  the  constitution  ; putrefaction 
of  the  contents  of  the  abscess,  in  conse- 
quence of  the  entrance  of  air  into  its  cavity; 
anil,  too  often,  death.  While  such  practice 
prevailed,  very  few,  afflicted  with  lumbar 
abscesses,  were  fortunate  enough  to  escape. 
The  same  alarming  effects  resulted  from 
allowing  the  abscess  to  attain  its  utmost 
magnitude,  and  then  burst  by  ulceration  - If 
then  a more  happy  train  of  events  depend 
upon  the  manner,  in  which  lumbar  abscesses 
are  punctured,  the  operation  is  certainly  a 
matter  of  great  delicacy. 

Until  the  collection  is  opened,  or  bursts, 
the  patient’s  health  is  usually  little,  or  not  at 
all  impaired  ; indeed,  we  see  in  the  faces  of 
many  persons  with  such  abscesses,  what  is 
usually  understood  by  the  picture  of  health, 
lleuce,  how  likely  our  professional  conduct 
is  to  be  arraigned,  when  great  changes  for 
the  worse,  and  even  death  occur  very  soon 
after  we  have  let  out  the  matter,  seemingly, 
and  truly,  in  consequence  of  the  operation. 
Every  plan,  therefore,  which  is  most  likely 
to  prevent  these  alarming  effects,  is  entitled 
* to  infinite  praise;  and  such,  I conceive,  is 
the  practice  recommended  by  Mr.  Aber- 
nethy. 

This  gentleman’s  method  is  to  Jet  out  the 
matter,  and  heal  the  wound  immediately 
afterward  by  the  first  intention.  He  justly 
condemns  all  introductions  of  probes,  and 
other  instruments,  which  only  irritate  the 
edges  of  the  puncture,  and  render  them  un- 
likely to  grow  together  again.  The  wound 


LUMBAR  ABSCESS 


is  to  be  caret ul ly  closed  with  sticking  plaster, 
and  it  will  almost  always  heal. 

These  proceedings  do  not  put  a stop  to 
the  secretion  of  matter  within  the  cavity  of 
the  abscess.  Of  course,  a fresh  accumula- 
tion takes  place  ; but,  it  is  obvious  that  the 
matter,  as  fast  as  it  is  produced,  will  gravitate 
to  the  lowest  part  of  the  cyst,  and,  conse- 
quently, the  upper  part  will  remain  tor  a 
certain  time  undistended,  and  have  an  oppor- 
tunity of  contracting. 

When  a certain  quantity  of  matter  has 
again  accumulated,  and  presents  itself  in  the 
groin,  or  elsewhere,  which  may  be  in  about 
a fortnight  after  the  first  puncture,  the  ab- 
scess is  to  be  punctured  again,  in  tire  same 
manner  as  before,  and  the  w ound  healed  in 
the  same  way.  The  quantity  of  matter  will 
now  be  found  much  less,  than  what  was  at 
first  discharged.  Thus  the  abscess  is  to  be 
repeatedly  punctured  at  intervals,  and  the 
wounds  as  regularly  healed  by  the  first 
intention,  by  which  method,  irritation  and 
inflammation  of  the  cyst  will  not  be  induced, 
the  cavity  of  the  matter  will  never  be  allow- 
ed to  become  distended,  audit  will  be  ren- 
dered smaller  and  smaller,  till  the  cure  is 
complete.  * 

In  a few  instances,  the  surgeon  may,  per- 
haps, be  unable  to  pers  vere  in  healing  the 
repeated  punctures  which  it  may  be  neces- 
sary to  make  ; but,  after  succeeding  once 
or  twice,  the  cyst  will  probably  have  had 
sufficient  opportunity  to  contract  so  much, 
that  its  surface  will  not  now  be  of  alarming 
extent.  It  is  also  a fact,  that  the  cyst  loses 
its  irritability  and  becomes  more  indolent, 
and  less  apt  to  inflame,  after  the  contents 
have  been  once  or  twice  evacuated,  in  the 
above  way.  Its  disposition  to  absorb  be- 
comes also  stronger. 

The  knowledge  of  the  fact,  that  the  cysts 
of  all  abscesses  are  absorbing  surfaces, 
should  lead  us  never  to.neglect  other  means, 
which  Mr.  Abernethy  suggests,  as  likely  to 
promote  the  dispersion  of  the  abscess  by 
quickening  the  action  of  the  absorbents. 
Blisters  kept  open  with  savine  cerate,  issues, 
electricity,  occasional  vomits  of  the  sulphate 
of  zinc,  are  the  means  in  st  conducive  to 
this  object.  When  the  vertebrae  are  diseased, 
issues  are  doubly  indicated 

In  the  latter  complication,  the  case  is 
always  dangerous.  If  an  opening  be  made 
in  the  abscess,  the  cyst  is  at  first  more  likely 
to  be  irritated,  than  when  the  bones  are  not 
diseased,  and  the  affection  of  the  spine  is 
rendered  much  less  likely  to  undergo  any 
improvement,  in  consequence  of  the  mere 
formation  of  an  outward  communication. 
The  same  bad  effect  attends  necrosis  ; in 
which  case,  the  absorption  of  the  dead  bone* 
is  always^  retarded  by  the  presence  of  un- 
healed fistulas  and  sores,  which  lead  down 
to  the  disease. 

Mr.  Crowther  succeeded  , in  dispersing 
some  large  lumbar  abscesses  without  opening 
them.  Large  blisters,  applied  to  the  integu- 
ments covering  the  swelling,  and  kept  open 
with  the  savine  cerate,  effected  the  cure. 


s&l 

When  this  gentleman  punctured  such  collec 
tions  of  matter,  he  used  a small  trocar,  which 
he  introduced  at  the  same  place  as  often  as 
necessary.  He  observes,  that  the  aperture 
so  made  does  not  ulcerate,  and  allows  no 
matter  to  escape  after  being  dressed.  I 
cannot,  however,  discover  any  reason  for 
his  preferring  the  trocar  to  the  abscess  lan- 
cet, except  that  the  cannula  enables  the 
surgeon  to  push  back  with  a probe  any 
flakes  of  lymph,  &c.  which  may  obstruct  its 
inner  orifice.  But,  this  is  scarcely  a reason, 
when  Mr.  Abernethy  informs  us,  that  the 
opening,  made  with  an  abscess  lancet,  is 
large  enough  to  allow  such  flakes  to  be  dis- 
charged ; arid  when  they  stop  up  the  aper- 
ture, a probe  might  also  be  employed  to 
push  them  back.  A wound  made  vvi  h a 
cutting  instrument  will,  cceteris  paribus, 
always  unite  more  certainly  by  tne  first 
intention,  than  one  made  with  such  an  in- 
strument as  a trocar.  Mr,  t rowther  may 
always  have  succeeded  in  healing  the  aper- 
ture ; but,  I do  not  believe,  that  other  prac- 
titioners would  experience  equal  success. 
Were  the  tumour  not  very  prominent,  from 
the  quantity  ol  matter  being  small,  suddenly 
plunging  in  a trocar  might  even  endanger 
parts,  which  should,  on  no  account,  be  in- 
jured. 

Some  writers  recommend  opening  lumbar 
abscesses  with  a seton.  The  matter  being 
made  to  form  as  prominent  a swelling  as 
possible,  by  pressing  the  abdomen,  and 
putting  the  patient  in  a position,  which  will 
make  the  contents  of  the  abscess  gravitate 
towards  the  part  where  the  seton  is  to  be 
introduced,  a transverse  cut  is  first  to  be 
made  in  the  integuments  down  to  the  fascia. 
A flat  trocar  is  next  to  be  introduced  within 
the  incision,  which  should  only  be  just  large 
enough  tp  allow  the  instrument  to  pass 
freely  up  under  the  skin,  for  at  least  three 
quarters  of  an  inch  ; when  the  hand  is  to  be 
raised,  and  the  trocar  pushed  obliquely  and 
gently  upwards,  till  the  cannula  is  within 
tile  lower  part  of  the  sac.  The  trocar  must 
now  be  withdrawn,  and  the  matter  allowed 
to  flow  out  gently,  stopping  it  every  now 
and  then  for  some  minutes.  The  assistant 
must  now  withdraw  his  hand,  to  take  away 
the  pressure,  and  the  thumb  of  his  left  hand 
upon  the  opening  of  the  cannula,  holding  it 
between  his  fore  and  middle  fingers.  It 
must  then  be  pushed  upward,  nearly  to  the 
top  of  the  tumour,  where  its  end  may  be 
distinctly  fell  with  the  fore-finger  of  the 
right  hand.  As  soon  as  it  can  be  plainly  felt, 
it  must  be  held  steadil}  in  the  same  position, 
and  the  trocar  is  to  be  introduced  into  it 
again,  and  pushed  through  the  skin,  at  the 
place  where  it  is  felt  and  the  cannula  along 
with  it.  The  trocar  being  next  withdrawn, 
a probe  with  a skein  of  fine  soft  silk,  dipped 
in  oil,  must  be  passed  through  the  cannula, 
which  being  now  taken  away,  leaves  the 
seton  in  its  place.  A pledget  of  mild  oint- 
ment is  then  to  be  applied  over  the  two 
openings,  the  more  completely  to  exclude 
the  air.  A fresh  piece  of  the  silk  is  to  he 


<>.)  I 


MAMMA. 


drawn  into  the  abscess,  ami  that  which  was 
in  before  cut  off,  as  often  as  necessary.  (See 
Latta's  System  of  Surgery,  Vol.  3,  p.  307.) 

Mr.  Crowther  states,  that  Deckers,  who 
wrote  in  1696,  discharged  a large  abscess,  in 
a gradual  manner,  with  a trocar,  the  cannula 
of  which  was  not  withdrawn,  but  was 
stopped  up  with  a cork,  and  the  latter  let 
out  at  intervals.  B.  Bell  also  advises  the 
cannula  not  to  be  taken  out. 

I cannot  quit  this  subject  without  mention- 
ing a remarkable  case  of  lumbar  abscess, 
which  1 once  saw  in  Christ’s  Hospital,  under 
the  care  of  the  late  Mr.  Ramsden.  The 
tumour  extended  from  the  ilium  and  sacrum 
below,  as  high  up  as  the  ribs.  The  diameter 
of  the  swelling  from  behind  forward,  might 
be  about  six  or  eight  inches.  It  was  attended 
with  so  strong  a pulsation,  corresponding 
with  that  of  the  arteries,  that  several  emi- 
nent surgeons  in  this  city  considered  the 
case  as  an  aneurism  of  the  aorta.  After 
some  weeks,  as  the  tumour  increased  in  size, 
the  throbbing  of  the  whole  swelling  gradu- 
ally became  fainter  and  fainter,  and  at 
length,  could  not  be  felt  at  all.  The  tumour 
was  nearly  on  the  point  of  bursting.  Mr. 
Ramsden  suspected  that  it  was  an  abscess, 
and  determined  to  make  a small  puncture 
in  it.  The  experiment  verified  the  accuracy 
of  his  opinion  ; a large  quantity  of  pus  was 
evacuated  as  intervals  ; but  the  boy’s  health 
suffering,  he  went  to  his  friends  at  Newbury, 
and  I did  not  afterward  hear  the  event.  1 


have  never  seen  any  popliteal  aneurism, 
whose  pulsations  could  be  more  plainly 
seen,  and  strongly  telt,  than  those  of  the 
abscess  we  have  just  been  describing.  A 
singular  case  is  related  by  Mr.  Wilmot  of  a 
psoas  abscess,  the  matter  of  which  was  at 
length  absorbed,  and  its  cavity  filled  with 
air,  attended  with  a considerable  increase  in 
the  size  of  the  tumour,  a conical  elongated 
shape,  and  elastic  feel,  instead  of  a fluctua- 
tion, previously  quite  evident,  and  the  subsi- 
dence of  all  the  hectical  symptoms.  A 
complete  dispersion  of  the  swelling  was 
effected  by  a bandage  and  compress  wet 
with  a strong  decoction  of  oak  bark  and 
alum.  (See  Trans,  of  the  King's  and  Queen's 
College  of  Physicians  in  Ireland,  Vol.2,p. 
26, tyc.  8co.  Dublin,  lbIS.  F.  Schoenmczel, 
Obs.  de  Musculis  Psoa  et  lliaco  suppurntis , 
Frank.  Del.  Op.  V.  R.  Beckwith  de  Morbo 
Psoadico.  Edinb.  1784.  Abernethy's  Surgical 
and  Physiological  Essays,  Part  1 and  2. 
Crowther' s Observations  on  White- Swelling, 
^c.  1808.  Latta's  System  of  Surgery , Vol.  3. 
Callisen's  Syslema  Chirurgioe  Hodi  ernes,  Vol. 
1 ,p.  370.  Pearson's  Principles  of  Surgery, 
p.  102,  Edit.  2.  Richter's  Anfangsgrunde 
der  Wundarzneykunst,  B.  5,  1 13;  Gottingen , 
1801.) 

LUNAR  CAUSTIC.  (See  Argentum  ni- 
tratum.) 

LUPUS.  See  Noli  me  tangere. 

LUXATION.  See  Dislocation. 


Ifc/TAMMA,  REMOVAL  OF.  The  opera- 
ill.  ration  of  cutting  away  a diseased 
breast,  is  done  nearly  in  the  same  manner 
as  the  removal  of  tumours  in  general,  and  is 
indicated  whenever  the  part  is  affected  with 
an  incurable  disease,  which  admits,  how- 
ever, of  being  entirely  removed  with  the 
knife.  When  the  breast  is  affected  with 
scirrhus,  or  ulcerated  cancer,  the  impru- 
dence of  tampering  with  the  disease  cannot 
be  too  severely  censured.  Were  the  disor- 
der unattended  with  a continual  tendency 
to  increase,  some  time  might  properly  be 
dedicated  to  the  trial  of  the  internal  reme- 
dies, and  external  applications,  which  have 
acquired  any  character  for  doing  good  in 
these  unpromising  cases.  But,  unfortunately, 
by  endeavouring  to  cure  the  disease  by 
medicine,  we  only  afford  time  for  it  to  in- 
crease in  magnitude,  and,  at  length,  attain  a 
condition,  in  which  even  the  knife  cannot 
be  employed  so  as  to  take  away  the  whole 
of  the  diseased  parts.  When  the  case  is 
marked  by  the  characteristic  features  of 
scirrhus,  noticed  in  the  article  Cancer,  the 
soouer  the  tumour  is  cut  out,  fb^ietter. 
There  are  also  some  malignant  kiYra's*5.f,sar 
coma,  to  which  the  female  breast  is  subject, 
(as  will  be  explained  in  the  article  Tumour,) 
which  cannoi  be  removed  at  loo  early  a 
period  after  their  nature  is  suspected,  or 


i/i 


known.  Indeed,  though  there  is  not  equal 
urgency  for  the  operation  when  the  tumour  is 
only  an  indolent,  simple,  fatty,  or  sarco- 
matous disease,  yet  as  all  these  tumours  are 
continually  growing  larger,  and  little  success 
attends  the  attempt  to  disperse  them,  the 
practitioner  should  never  devote  much  time 
to  the  trial  of  unavailing  medicines  and 
applications,  and  let  the  swelling  attain  a 
size,  which  would  require  a formidable 
operation  for  its  excision.  Besides,  many 
simple,  fleshy,  indolent  tumours,  are  accom- 
panied with  a certain  degree  of  hazard  of 
changing  into  very  malignant  forms  ol 
disease. 

It  is  not  meant  to  be  denied,  however, 
there  are  many  swellings  and  indurations  of 
the  breast,  which  it  would  be  highly  injudi- 
cious and  unnecessary  to  extirpate,  because 
they  generally  admit  of  being  discussed. 
Such  are  many  tumours,  which  are  called 
scrofulous,  from  their  affecting  patients  of 
this  peculiar  constitution  ; such  are  nearly 
all  those  indurations  which  remain  after  a 
sudden  and  general  inflammatory  enlarge- 
ment of  the  mamma  ; such  are  most  other 
tumours,  which  acquire  their  full  size  in  a 
few  days,  attended  with  pain,  redness,  Lc.  ; 
and,  of  this  kind,  also,  are  the  hardnesses 
in  the  breast,  occasioned  bv  the  mammary 
abscess. 


'MAMMA. 


2iid 


to  the  removal  ot'  all  malignant  or  cance- 
rous tumours,  their  nature  makes  it  neces 
sary  to  observe  one  important  caution  in 
the  operation,  via.  not  to  rest  satisfied  with 
cutting  away  the  tumours  just  at  their  cir- 
cumference ; but  to  take  away  also  a con- 
siderable portion  of  the  substance  in  which 
they  lie,  and  with  which  they  are  surrounded. 
In  cutting  out  a cancerous  breast,  if  the  ope- 
rator were  to  be  content  with  merely  dissect- 
ing out  the  disease,  just  where  his  eyes  and 
lingers  might  equally  lead  him  to  suppose 
its  boundary  to  be  situated,  there  would 
still  be  left  behind  white  diseased  bands, 
which  radiate  from  the  tumour  into  the  sur- 
rounding fat,  and  which  would  inevitably 
occasion  a relapse.  In  a vast  proportion  of 
the  cases  also,  in  which  cancer  of  the  breast 
unfortunately  recurs  after  the  operation,  it  is 
found  that  the  skin  is  the  part,  in  which  the 
disease  makes  its  reappearance.  Hence  the 
great  prudence  of  taking  away  a good  deal 
of  it  in  every  case  suspected  to  be  a truly 
scirrhous  or  cancerous  disease.  This  may 
also  be  done  so  as  not  to  prevent  the  impor- 
tant objects  of  uniting  the  wound  hy  the  first 
intention,  and  covering  the  whole  of  its  sur- 
face with  sound  integuments.  So  frequent- 
ly does  cancer  recur  in  the  nipple,  whenever 
it  does  recur  any  where,  that  many  of  the 
best  modern  operators  always  make  a point 
of  removing  this  part  in  every  instance,  in 
which  it  is  judged  expedient  to  take  away 
any  portion  of  the  skin  at  all.  The  surgeon, 
indeed,  would  be  inexcusable,  were  he  to 
neglect  to  take  away  such  portion  of  the  in- 
teguments covering  scirrhous  tumours,  as  is 
evidently  affected,  appearingto  bediscolour- 
ed,  puckered,  and  closely  attached  to  the 
diseased  lump  beneath.  Nor  should  any 
gland,  in  the  axilla,  at  all  diseased,  nor  any 
fibres  of  the  pectoral  muscle,  in  the  same 
state,  be  ever  left  behind.  There  is  no  doubt, 
that  nothing  has  stamped  operations  for  can- 
cers with  disrepute,  so  much  as  the  neglect 
to  make  a free  removal  of  the  skin,  and 
•parts  surrounding  every  side  of  the  tumour. 
Hence,  the  disease  has  frequently  appeared 
to  recur,  when,  in  fact,  it  has  never  been 
thoroughly  extirpated  ; the  disease,  though 
entirely  a local  affection,  has  been  deemed 
a constitutional  one  ; and  the  operation 
frequently  rejected  as  ineffectual  and  use- 
less. 

But,  strongly  as  I have  urged  the  pru 
dence,  the  necessity  of  making  a free  remo- 
val of  the  skin  covering,  and  of  the  parts 
surrounding,  every  cancerous  or  malignant 
tumour,  the  same  plan  may  certainly  be  re- 
garded as  unnecessary,  and  therefore,  unsci- 
entific, in  most  operations  for  the  removal 
of  simple,  fatty,  fleshy,  or  encysted  tumours, 
to  which  the  breast  and  almost  every  other 
part  are  liable.  However,  even  in  the  lat- 
ter cases,  when  the  swelling  is  very  large, 
it  is  better  to  take  away  a portion  of  skin  •, 
for,  otherwise,  after  the  excision  of  the  tu- 
mour, there  would  be  a redundance  of  in- 
teguments, the  cavity  of  which  would  only 
serve  for  the  lodgment  of  matter.  The 
loose  superfluous  skin  also  would  lie  in 


folds,  and  not  apply  itself  evenly  to  the 
parts  beneath,  so  as  to  unite  favourably  by 
the  first  intention  ; nor  could  the  line  of  the 
cicatrix  itself  be  arranged  w ith  such  nice 
evenness  as  it  might  be,  were  a part  of  the 
redundant  skin  taken  auray  at  the  time  of 
operating. 

The  best  method  of  removing  a diseased 
breast  is  as  follows  : The  patient  is  usually 
placed  in  a sitting  posture,  well  supported 
by  pillows  and  assistants  ; but  the  operator 
will  find  it  equally  convenient,  if  not  more 
so,  to  remove  the.  tumour  with  bis  patient 
in  a recumbent  position  ; and  this  posture 
is  best  whenever  the  operation  is  likely  to 
be  long,  or  much  blood  to  be  lost,  which 
circumstances  are  very  apt  to  bring  on 
fainting.  I remember  that  Mr.  Abernethy, 
in  his  lectures,  used  to  recommend  the  latter 
plan  ; which,  however,  without  the  sanction 
of  any  great  name,  or  authority,  possesses 
such  obvious  advantages,  as  will  always  en- 
title it  to  approbation. 

The  arms  should  be  confined  back,  by 
placing  a stick  between  (hem  and  the  bo'dy, 
by  which  means,  the  fibres  of  the  great 
pectoral  muscle  will  he  kept  on  the  stretch, 
a state  most  favourable  for  the  dissection  of 
the  tumour  off  its  surface  The  stick  also 
prevents  the  patient  from  moving  her  arm 
about,  and  interrupting  the  progress  of  the 
operation. 

When  the  tumour  is  not  large,  and  only 
a simple  sarcoma,  free  from  malignancy,  it 
will  be  quite  unnecessary  to  remove  any  of 
the  skin,  and,  of  course,  this  need  only  be 
divided  by  one  incision,  of  a length  propor- 
tionate to  the  tumour.  The  cut  must  be 
made  with  a common  dissecting  knife;  and 
as  the  division  of  the  parts  is  chiefly  accom- 
plished with  the  part  of  the  edge  towards 
the  point,  the  instrument  will  be  found  to 
do  its  office  best  when  the  extremity.of  the 
edge  is  made  of  a convex  shape,  and  this 
part  of  the  blade  is  turned  a little  back,  in 
the  way  in  which  dissecting  knives  are  ’now 
often  constructed.  1 he  direction  of  the 
incision  through  the  skin  should  be  made 
according  to  the  greatest  diameter  of  the 
tumour  to  be  removed,  by  which  means  it 
will  be  most  easily  dissected  out. 

The  direction  of  the  incision  is  various 
with  different  practitioners ; some  making 
it  perpendicular,  others  transverse.  In  ge- 
neral, the  shape  of  the  tumour  must  deter- 
mine which  is  the  best.  In  France,  it  has 
been  said,  that  when  the  incision  follows 
the  second  direction,  it  heals  more  expedi- 
tiously, because  the  skin  is  more  extensible 
from  above  downward,  than  laterally,  par- 
ticularly towards  the  sternum,  and  conse- 
quently allows  the  sides  of  the  wound  the 
more  readily  to  be  placed  in  contact ; and 
that  the  action  of  the  pectoral  muscle  tends 
to  separate  the  edges  of  the  wound  when  it 
is  perpendicular.  On  the  other  hand,  it  is 
allowed  that  the  wound,  made  in  the  latter 
manner,  is  the  most  favourable  for  the 
escape  of  the  discharge,  if  suppuration 
should  occur.  (See  (Euvres  (h  Desault  var 
Bichat , p,  312.  T.  2.Y 


MAMMA. 


sm 


The  cut  through  the  skin  should  always 
be  somewhat  longer  than  the  tumour ; and 
as  it  is  perhaps,  the  most  painful  part  of  the 
operation,  and  one  attended  with  no  danger 
whatever,  it  should  be  executed  with  the 
utmost  celerity,  pain  being  more  or  less 
dreaded,  according  to  its  duration,  as  well 
as  its  degree.  The  fear,  however,  of  giving 
pain,  has  probably  led  many  operators  to 
err,  in  not  making  their  first  incision  through 
the  integuments  large  enough,  the  conse- 
quence of  which  has  often  been  that  there 
was  not  sufficient  room  for  the  dissection  of 
the  tumour  with  facility ; the  patient  has 
been  kept  nearly  an  hour  in  the  operating 
room,  instead  of  five  minutes,  and  the  sur- 
geon censured  by  the  spectators,  as  awk- 
ward and  tedious.  It  is  clear  also,  that, 
besides  the  great  deal  more  blood  lost,  from 
this  error,  than  would  otherwise  happen, 
the  vessels  being  commonly  not  tied  till  all 
the  cutting  is  finished,  the  avoidance  of 
pain,  that  fear,  which  led  to  the  blunder,  is 
not  effected,  and  the  patient  suffers  much 
more,  and  for  a much  longer  time,  in  conse- 
quence of  the  embarrassment  and  obstacles 
in  the  way  of  the  whole  operation. 

When  the  disease  is  of  a scirrhous  or  ma- 
lignant nature,  the  skin  covering  the  tu- 
mour should  at  all  events,  be  in  part  remo- 
ved. As  I have  said  before,  all  that  portion 
which  is  discoloured,  puckered,  tubercula- 
ted,  or  otherwise  altered,  should  be  taken 
away.  Some  must  also  be  removed,  in 
order  to  prevent  a redundance,  in  all  cases 
in  which  the  tumour  is  large.  We  have 
said  too,  that  in  cases  of  scirrhus  and  cancer 
of  the  breast,  the  nipple  is  considered  a 
dangerous  part  to  be  left  behind.  For  the 
purpose  of  removing  the  necessary  portion 
of  skin,  the  surgeon  must  obviously  pursue 
a different  mode  from  that  above  described; 
and,  instead  of  one  straight  incision,  he  is  to 
make  two  semicircular  cuts,  one  immedi- 
ately after  the  other,  and  which  are  to  meet 
at  their  extremities.  The  size  of  these 
wounds  must  be  determined  by  that  of  the 
disease  to  be  removed,  and  by  the  quantity 
of  skin,  which  it  is  deemed  prudent  to  take 
away  ; for  the  part,  which  is  included  in  the 
two  semicircular  cuts,  is  that  which  is  not 
to  be  separated  from  the  upper  surface  of 
the  swelling,  but  taken  away  with  it.  The 
shape  of  the  two  cuts  together  may  approach 
that  either  of  a circle  or  oval,  as  the  figure 
of  the  tumour  itself  may  indicate,  as  most 
convenient.  The  direction  of  the  incisions 
is  to  be  regulated  by  the  same  consideration. 

In  the  above  ways,  (he  first  division  of  the 
integuments  is  to  be  made  in  removing  tu- 
mours of  every  description,  covered  with 
skin.  The  same  principles  and  practice 
should  prevail  in  all  these  operations;  and, 
whether  the  swelling  is  the  mamma,  or  any 
other  diseased  mass,  whether  situated  on  the 
chest,  the  back,  the  head,  or  extremities,  the 
same  considerations  should  always  guide  the 
operator’s  hand 

The  incision,  or  incisions,  in  the  skin 
having  been  made,  the  next  object  is  to 
detach  every  side  of  the  tumour  from  its 


connexions,  and  the  separation  of  its  ba3e 
will  then  be  the  last  and  only  thing  remain- 
ing to  be  done.  When  the  tumour  is  a 
scirrhus,  or  other  malignant  disease,  the 
operator  must  not  dissect  close  to  the  swell- 
ing, but  make  his  incisions  on  each  side,  at 
a prudent  distance  from  it,  so  as  to  be  sure 
to  remove,  with  the  diseased  mass,  every 
atom  of  morbid  mischief  in  its  vicinity.  But 
when  the  tumour  is  only  a mere  fatty,  or 
other  mass,  perfectly  free  from  malignancy, 
the  cellular  bands  and  vessels  forming  its 
connexions,  may  be  divided  close  to  its 
circumference.  It  is  astonishing  with  what 
ease  fatty  tumours  are  removed,  after  the 
necessary  division  is  made  in  the  skin  ; they 
may  almost  be  turned  out  with  the  fingers, 
without  any  cutting  at  all.  When  they  have 
been  inflamed,  however,  they  are  then  more 
adherent  to  the  surrounding  parts. 

Thus  we  see,  that  the  first  stage  of  the 
operation  of  removing  a tumour,  is  the  divi- 
sion of  ttfe  skin  ; the  second,  the  separation 
of  the  swelling  from  the  surrounding  parts 
on  every  side  ; the  third  and  last  stage  is  the 
division  of  the  parts  to  which  its  under 
surface,  or  base,  is  attached.  The  latter 
object  should  be  accomplished  by  cutting 
regularly  from  above  downward,  till  every 
part  is  divided. 

It  is  a common  thi«g  to  see  many  opera- 
tors constantly  embarrassed  and  confused, 
whenever  they  have  to  remove  a large  tu- 
mour, on  account  of  their  having  no  parti- 
cular method  in  their  proceedings.  They 
first  cut  a few  fibres  on  one  side,  then  on 
another  ; and,  turning  the  mass  of  disease 
now  to  this  side,  now  to  that,  without  any 
fixed  design,  they  both  prolong  the  opera- 
tion very  tediously,  and  present  to  the 
bystanders  a complete  specimen  of  surgical 
awkwardness.  On  the  contrary,  when  the 
practitioner  divides  the  cutting  part  of  the 
operation  into  the  three  methodical  stages 
above  recommended,  in  each  of  which  there 
is  a distinct  object  to  be  fulfilled,  he  pro- 
ceeds with  a confidence  of  knowing  what 
he  is  about,  and  soon  effects  what  is  to  be 
done,  with  equal  expedition  and  adroitness. 

Having  taken  out  the  tumour,  the  operator 
is  immediately  to  tie  such  large  vessels  as 
may  be  pouring  out  their  blood  ; indeed, 
when  the  removal  of  the  swelling  will  ne- 
cessarily occupy  more  than  three  or  four 
minutes,  it  is  better  to  tie  all  the  large  arte- 
ries as  soon  as  they  are  divided,  and  then 
proceed  with  their  dissection.  This  was  the 
celebrated  Desault’s  plan,  and  it  is  highly 
deserving  of  imitation  in  this  country,  not 
only  because  many  subjects  cannot  afford 
to  lose  much  blood,  but  also  because  the 
profuse  effusion  of  this  fluid  keeps  the  ope- 
rator from  seeing  what  parts  he  is  dividing. 

The  largest  arteries  being  tied,  the  surgeon 
should  not  be  immediately  solicitous  about 
tying  every  bleeding  point  which  may  be 
observed.  Instead  of  this,  let  him  employ 
a little  while  in  examining  every  part  of  (he 
surface  of  the  wound,  in  order  to  ascertain 
that  no  portion  of  the  swelling,  no  hardened' 
lump,  nor  diseased  fibres  remain  behind. 


MAMMA. 


!Evcn  if  any  part  of  the  surface  of  the  pec- 
toral muscle  should  present  a morbid  feel, 
or  appearance,  it  must  on  every  account 
be  cut  away.  Also,  if  any  of  the  axillary 
glands  are  diseased,  the  operator  should  now 
proceed  to  remove  them.  After  the  time 
.spent  in  such  measures,  many  of  the  small 
vessels,  which  bled  just  after  the  excision 
of  the  swelling,  will  now  have  stopped,  the 
necessity  for  several  ligatures  will  be  done 
away,  and,  of  course,  the  patient  saved  a 
great  deal  of  pain,  and  more  of  the  wound 
be  likely  to  heal  by  the  first  intention. 

Some  information  may  be  derived,  res- 
pecting whether  any  of  tbe  tumour  is  left 
behind,  by  examining  its  surfaces,  when 
taken  out,  and  observing  whether  any  part 
of  them  is  cut  off ; for,  if  it  is,  it  may  always 
be  found  in  the  corresponding  part  of  the 
wound. 

The  axillary  glands  may  invariably  be 
taken  out  without  the  least  risk,  if  the  plan 
pursued  by  Desault  in  France,  and  the  late 
Sir  Charles  Blicke,  and  other  eminent  sur- 
geons in  this  country,  be  adopted.  The 
method  alluded  to  is,  after  dividing  the  skin 
covering  the  gland,  and  freeing  the  indura- 
ted part  from  its  lateral  connexions,  to  tie 
its  root,  or  base,  by  which  it  is  connected 
with  the  parts  on  the  side  towards  the  cavity 
of  the  axilla  Then  the  indurated  gland 
itself  may  be  safely  cut  off,  just  above  the 
ligature.  Were  the  gland  cut  off  in  the  first 
instance,  the  artery  which  supplies  it  with 
blood  would  be  exceedingly  difficult  to  tie, 
on  account  of  its  deep  situation  ; and  by 
reason  of  its  shortness  and  vicinity  to  tbe 
heart,  it  would  bleed  almost  like  a wound  of 
tbe  thoracic  artery  itself.  In  this  way,  there 
is  also  not  the  least  hazard  of  injuring  the 
latter  vessel.  It  would  be  a great  improve- 
ment in  the  mode  of  operating  for  tbe  re- 
moval of  these  glands,  if  surgeons  were 
always  to  make  the  patient  lie  down,  with 
the  arm  placed  in  such  a position  as  would 
let  the  light  fall  into  the  axilla.  How  much 
the  steps  of  the  operation  would  be  facili- 
tated in  this  way,  I need  not  attempt  to 
explain. 

The  above  directions  will  enable  a sur- 
geon to  remove  tumours  in  general.  They 
apply  also  in  a great  measure  to  encysted  tu- 
mours ; but,  a few  particular  rules  how  to 
operate  in  the  latter  cases,  will  be  found  in 
the  article  Tumours.  One  half  of  each  liga- 
ture is  always  to  be  cut  off  before  dressing 
the  wound.  The  edges  of  the  incision  are  to 
be  brought  together  with  strips  of  adhesive 
plaster  ; and,  before  this  can  be  done  with 
ease,  the  stick  confining  the  arm  back  must 
be  removed,  and  the  os  brachii  brought  for- 
ward, so  as  to  relax  the  pectoral  muscle,  and 
integuments  of  the  breast.  No  sutures  should 
ever  be  employed,  as  they  are  useless,  pain- 
ful, and  irritating.  The  wound  being  closed 
with  sticking  plaster,  and  a pledget  of  simple 
cerate,  a compress  of  folded  linen,  or  flan- 
nel, may  be  put  over  the  dressings  ; these 
are  to  be  secured  with  a broad  piece  of  linen, 
which  is  to  encircle  tbe  chest,  be  fastened 
with  pins,  or  stitches,  and  kept  from  slipping 
VoL.  II  29 


down  by  two  tapes,  one  of  which  is  to  go 
from  behind  forward,  over  each  shoulder, 
and  be  stitched  to  the  upper  part  of  the 
bandage,  both  in  front  and  behind.  The 
arm  on  the  same  side  as  that,  on  which  the 
operation  has  been  done,  should  be  kept 
perfectly  motionless  in  a sling;  for,  every 
motion  of  the  limb  must  evidently  disturb  the 
wound,  by  putting  the  great  pectoral  muscle 
into  action,  or  rendering  its  fibres  sometimes 
tense,  sometimes  relaxed.  It  is  scarcely  ne- 
cessary to  say,  that,  after  so  considerable  an 
operation  as  the  removal  of  a large  breast, 
or  any  other  tumour  of  magnitude,  the  pa- 
tient should  be  given  about  thirty  drops  of 
the  tinctura  opii.  A smaller  dose  always 
creates  restlessness,  headach,  and  fever,  af- 
ter operations,  instead  of  having  the  desi- 
red effect. 

Here  it  becomes  me  to  state,  that  as  I 
could  not  find  in  any  surgical  book  with 
which  I am  acquainted,  what  I conceived  to 
be  a proper  description  of  the  mode  of  re- 
moving a diseased  breast,  and  tumours  in 
general,  the  foregoing  remarks  are  given 
chiefly  on  my  own  authority.  Whetherthey 
are  just,  or  not,  must  he  decided  by  the  pro- 
fession. 

The  removal  of  a diseased  breast  rarely 
proves  fatal  of  itself,  unless  the  parts  cut 
away  extend  to  a considerable  depth,  and 
occupy  a very  large  space,  or  the  patient  is 
much  reduced  before  the  operation.  How- 
ever, about  two  years  ago,  a patient  in  St. 
Bartholomew’s  Hospital  died,  without  any 
very  apparent  cause,  very  soon  after  being 
operated  upon  ; and  Schmucker  has  record- 
ed an  instance,  in  which  the  operation  was 
followed  by  tetanus.  ( Wahmehmungen.  B. 
2,  p.  SO.) 

W ith  respect  to  the  average  success,  fol- 
lowing the  removal  of  cancerous  diseases, 
this  is  a topic,  which  has  been  noticed  in  the 
article  Cancer.  The  statement  lately  made 
by  Baron  Boyer  is  exceedingly  unfavoura- 
ble ; for,  in  one  hundred  cases,  in  which  he 
has  removed  the  diseased  parts,  only  four  or 
five  of  the  patients  continued  radically  cu- 
red. ( Traile  des  Mai.  Chir.  T.  7 p.  237,  8 ro. 
Paris,  1821.) 

The  principal  writers  on  the  removal  of 
the  mamma  are,  Garengeot,  Dionis,  Le  Dran, 
Bertrandi,  Sharp,  and  Sabatier,  in  their  res- 
pective treatises  on  the  operations.  B.  Bell, 
Latta,  &,c.  have  also  treated  on  the  subject 
in  their  Systems  of  Surgery  ; and  there  is  a 
memoir  Sur  V Operation  du  Cancer  au  Sciiiy 
in  Les  (Euvres  de  Desault  par  Bichat.  T.  2. 

MAMMARY  ABSCESS.  Milk' Mscess. 
With  regard  to  inflammations  of  the  mamma, 
as  my  friend,  Mr.  James  has  observed,  there 
is  “ either  simple  phlegmon,  or  mammary 
abscess,  which,  as  it  depends  upon  a peculi- 
arity of  state  and  function,  ought  to  stand 
alone.  Mr.  Hey  alsp  describes  a deep-seat- 
ed abscess,  to  which  this  gland  is  liable,  of 
rather  a chronic  character,  and  is  the  same, 
perhaps,  as  that  which  Dr.  Kirkland  has  de- 
scribed as  the  encysted.  Dr.  K.  describes 
also  two  others,  under  the  titles  of  chronic 
and  encysted.”  Certain  cases  most  frequent* 


MAMMA. 


226 


ly  occurring  in  unmarried  females,  and  ha- 
ving very  little  tendency  to  suppuration, 
Mr.  James  suspects,  are  the  result  of  inflam- 
mation of  the  gbmdular  part  of  the  breast 
from  disorder  in  the  digestive  organs,  uterine 
system,  or  both.  (On  Inflammation,  p.  171.) 

Women  who  suckle  are  particularly  sub- 
ject to  inflammation  and  suppuration  in  the 
breast.  The  part  enlarges,  becomes  tense, 
heavy,  and  painful.  The  integuments  of  the 
breast  sometimes  assume  an  uniform  red- 
ness ; sometimes  they  are  only  red  in  parti- 
cular places.  The  inflammation  may  affect 
the  mammary  gland  itself,  or  be  confined  to 
the  skin  and  surrounding  cellularsubstar.ee. 
In  the  latter  case,  the  inflamed  part  is  equally 
tense  ; but,  when  the  glandular  structure  of 
the  breast  is  also  affected,  the  enlargement  is 
irregular,  and  seems  to  consist  6f<  one  or 
more  large  tumours,  situated  in  the  sub- 
stance of  the  part.  The  pain  often  extends 
to  the  axillary  glands.  The  secretion  of  the 
milk  is  not  always  suppressed,  when  the  in- 
flammation is  confined  to  the  integuments, 
and  suppuration  is  said  to  come  on  more 
quickly,  than  in  the  affections  of  the  mam- 
mary gland  itself  When  the  symptoms  of 
inflammation  continue  to  increase  for  four 
or  five  days,  suppuration  may  be  expected  ; 
unless  the  progress  of  the  inflammation  be 
slow,  and  its  degree  moderate,  in  which  cir- 
cumstances, resolution  may  often  be  obtain- 
ed, even  as  late  as  a fortnight  after  the  first 
attack.  Inflammations  of  the  breast  are 
almost  always  attended  with  symptoms  of 
the  sympathetic  inflammatory  fever.  (See 
Fevers,  Surgical .)  1 think  authors  err,  who 

describe  the  febrile  disorder  as  generally 
preceding  the  local  complaint 

Women  are  most  liable  to  mammary  ab- 
scesses within  the  first  three  months  after 
parturition  , but  they  are  also  very  much 
exposed  to  the  disorder  as  long  as  they  con- 
tinue to  suckle. 

The  most  common  causes  occasioning  the 
mammary  abscess,  as  enumerated  by  writers 
in  general,  are,  repressing  the  secretion  of 
milk  at  an  early  period,  mental  disturbance, 
fright,  &c. ; exposure  to  cold,  moving  the 
arms  too  much  while  the  breasts  are  very 
large  and  disteuded,  bruises,  and  other  ex- 
ternal injuries.  The  causes  are  not  always 
obvious. 

The  matter  is  sometimes  contained  in  one 
cyst,  or  cavity  ; sometimes  in  several  ; but 
the  abscess  generally  breaks  near  the  nipple. 

As  all  inflammations  of  the  mamma  are 
attended  with  considerable  induration,  these 
cases  should  be  carefully  distinguished  from 
other  swellings  of  a more  incurable  kind. 
Jt  is  said,  that  scrofulous  tumours  of  the 
mamma,  which  have  existed  a long  while, 
often  disappear  after  the  occurrence  of  a 
milk  abscess.  Women  who  have  never 
been  pregnant  are  sometimes  affected  with 
suppuration  in  the  breast,  supposed  by  Mr. 
James,  of  Exeter,  to  be  connected  with  ute- 
rine, or  gastric  disorder.  Even  men  are 
suiti  to  be.  liable  to  similar  complaints. 

In  the  early  period  of  the  affection,  reso- 
lution should  be  attempted.  The  following 


are  the  principal  means  for  this  purpose  : — 
topical  blood-letting,  saline  purges,  low 
diet,  keeping  the  inflamed  breast  from  hang- 
ing down,  gentle  friction  of  the  breast,  w ith 
a soft  sponge,  wet  w itb  some  w arm  emollient 
liquor  ; having  the  milk  tenderly  sucked  out 
at  proper  intervals  ; saturnine  applications, 
or  lotions  containing  the  muriate  of  am- 
monia 

VY  hen  matter  cannot  be  prevented  from 
forming,  an  emollient  poultice  is  the  best 
application,  and  the  abscess  should  in  gene- 
ral be  allowed  to  break  of  itself  unless  of  a 
somewhat  chronic  nature,  in  . hich  case  it 
should  be  opened  in  a depending  part  with 
a lancet.  Sinuses  sometimes  form,  in  con- 
sequence of  abscesses  in  the  breast,  and  will 
not  heal  till  freely  opened  with  a director 
and  curved  bistoury.  When  the  cavity  of 
the  abscess  begins  to  fill  up  with  granula- 
tions, the  poultice  may  be  left  oft',  and  su- 
perficial dressings  applied. 

The  indurations,  often  remaining  in  the 
breast,  in  consequence  of  acute  inflamma- 
tion and  abscesses,  generally  yield  to  fric- 
tions with  camphorated  mercurial  ointment, 
the  application  of  a piece  of  soap  plaster, 
and  the  exhibition  of  calomel,  cicuta,  and 
other  alteratives. 

Mr.  Hey  describes  a very  deep-seated  ab- 
scess of  the  breast,  not  of  frequent  occur- 
rence, and  not  confined  to  pregnant  nor 
suckling  women.  Its  situation  renders  all 
superficial  applications  ineffectual.  The 
inflammatory  stage  is  tedious ; and  when 
the  matter  has  made  its  way  outward,  the 
discharge  continues,  and  there  is  no  ten- 
dency to  healing.  Sometimes  the  matter 
lodges  behind  the  mamma,  as  well  as  in  the 
substance  of  the  gland,  and  breaks  out  in 
different  places,  the  intermediate  parts  of  the 
breast  feeling  as  if  affected  with  a scirrhous 
hardness.  There  are  numerous  sinuses  run- 
ning in  different  directions,  and,  when 
opened,  a soft  purple  fungus  appears  w ith- 
in them.  The  disease  goes  on  in  this  state 
for  a long  while,  keeping  up  hectic  symp- 
toms. 

Mr.  Hey’s  practice  is  to  trace  the  course 
of  all  the  numerous  sinuses,  and  lay  them 
open,  and,  unless  this  be  done,  with  respect 
to  every  one  of  them,  the  cure  cannot  be 
accomplished.  If  he  finds  any  two  sinuses 
running  in  such  directions,  that  when  fully 
opened,  they  leave  a small  part  of  the  mam- 
ma in  a pendulous  state,  be  removes  such 
part  entirely.  As  the  sinuses  are  filled  with 
fungus,  their  continuations  present  no  visi- 
ble cavity,  and  can  only  be  detected  by  the 
greater  softness  of  parts  of  the  w ouud, 
w here,  on  breaking  down  the  fungus,  the 
orifice  of  the  collateral  sinus  may  be  found. 
Mr.  Hey  has  found,  that  even  in  the  most  un- 
favourable subjects  the  wounds  heal  quickly, 
and  the  natural  shape  of  the  breast  is  pre- 
served. 

Consult  Pearson's  Principles  of  Surgery , 
chap  3.  Iiey's  Practical  observations,  p. 
604.  Kirkland  has  also  treated  of  several 
kinds  of  abscesses  of  the  breast,  in  his  Inquiry 
into  Hit  present  State  oj  Medical  Surgery , Vol 


MERCURY. 


227 


2,  p.  161.  Callisen's  Syslema  Chirurgicc  IIo- 
ditrrue , Vol.  1,  p.  332.  Gibbons , De  Mulie- 
brum  Alain  mis  tt  Morbis  quibus  obnoxice  sunt, 
St’o.  Edinb.  1775.  «/.  Clubbe , Treatise  on  the 

Inflammation  of  the  Breasts,  peculiar  to  Ly- 
ing-in Women,  fyc.  8 vo.  Ipsivich,  1799.  M. 
Under  wood,  Treatise  upon  Ulcers , fyc.  and  on 
the  Mammary  Abscess,  fyc.  8ro.  Land  1783. 
J.  H.  James,  on  the  Principles  of  Inflamma- 
tion, p.  171,  8vo.  Lond.  1821.  Boyer,  Traiti 
des  Mai.  Chir.  T.  7,  p.  211,4-c.  8vo.  Par<s, 
1821.  The  German  reader  may  refer  to 
Richters  An fangsgr.  der  Wundarzn.  B.  4, 
chap.  16. 

[*M  AXILLA  INFERIOR.  Byareference 
to  the  article  Osteo  Sarcoma,  in  the  Appen- 
dix, will  be  found  recorded  three  instances 
wherein  portions  of  the  lower  jaw  were  ex- 
tirpated by  Professor  Mott,  of  New-York, 
for  the  removal  of  this  disease;  the  carotid 
artery,  in  the  several  instances,  having  been 
previously  tied. — Am.  Ed.] 

MELICERIS.  (from  /u&j,  honey,  and 
xnpoc,  wax.  A tumour  of  the  encysted  kind, 
filled  with  a substance  resembling  wax,  or 
honey,  in  consistence.  (See  Tumours,  En- 
cysted.) 

MENINGOPHYL  \X.  (from  /Amy%,  a 
membrane,  and  to  guard.)  An  in- 

strument used  by  the  ancients  for  guarding 
the  dura  mater  and  brain  from  injury,  in 
their  mode  of  trepanning.  It  seems  to  have 
been  something  like  the  lenticular,  only  its 
blade  was  completely  round  without  an 
edge.  It  ended  in  a lentiform  cup,  like  the 
latter.  ( Encyclopedic  Methodique,  Partie 
Chirurgicale.)  Pott  gives  an  engraving  of 
a meningophylax,  which  resembles  a com- 
mon elevator.  (See  Vol.  1.  of,  his  Works.) 

MERCURY".  ( Quicksilver . Mercurius. 

Hydrargyrus.)  The  medicinal  virtues  of 
this  mineral  were  almost  totally  unknown 
to  the  ancients,  who  considered  it  as  a poi- 
son It  was  first  employed  for  purposes  of 
medicine  by  the  Arabians,  who  made  use  of 
it  in  the  form  of  ointments  for  the  cure  of 
certain  diseases  of  the  skin  and  the  killing 
of  vermin.  In  modern  times  mercury  is 
one  of  the  most  important  articles  of  the 
materia  medica;  arid  though  pe  haps  recent 
investigations  will  not  strictly  allow  it  to 
be  regarded  as  a specific  for  the  venereal 
disease,  which  may  be  cured  by  other 
means,  or  sometimes  even  spontaneously, 
while  mercury,  so  far  from  being  always  a 
certain  cure,  is  sometimes  highly  detrimen- 
tal, yet  notwithstanding  these  facts,  mercury 
still  retains  the  character  of  being  generally 
the  most  expeditious  means  of  relief.  The 
possibility  of  curing  the  venereal  disease 
without  mercury,  by  no  means  establishes 
the  propriety  of  abandoning  this  remedy, 
any  more  than  its  unfitness  for  certain  states 
of  the  same  disease  is  a reason  for  not  avail- 
ing ourselves  of  its  superior  utility  in  others. 

Mercury,  taken  into  the  stomach  in  its 
metallic  state,  has  no  action  on  the  body, 
except  what  arises  from  its  weight  or  bulk. 
It  is  not  poisonous,  as  was  vulgarly  suppo- 
sed, but  perfectly  inert.  But,  in  its  various 
state*  of  combination,  it  produces  certain 


sensible  effects.  Tt  is  a powerful  and  gene- 
ral stimulant,  quickening  t lie  circulation, 
and  increasing  all  the  secretions  and  excre- 
tions. According  to  circumstances,  the 
habit  of  the  patient,  the  temperaturd'  in 
which  he  is  kept,  the  nature  of  the  prepara 
tion,  and  the  quantity  in  which  it  is  exhibit- 
ed, its  effects  are,  indeed,  various.  Some- 
times, it  more  par'icularly  increases  one 
secretion;  sometimes  another ; but  its  most 
characteristic  etfect  is  the  increased  flow  of 
saliva,  which  it  generally  excites,  if  given 
in  sufficient  quantity.  (Edinb.  Dispensatory.) 

From  the  writings  of  Theodoric,  it  appears 
that  mercury  was  employed  in  the  practice 
of  medicine  aad  surgery  as  early  as  the  13th 
century.  But,  its  use  in  venereal  cases  was 
first  mentioned  in  a tract  by  Almeriar,  pub- 
lished in  1516'  (See  Thompson's  Dispensatory , 
p.  205,  Edit.  2.) 

it  has  been  said,  that  the  efficacy  of  mer- 
cury in  curing  the  venerea!  disease  was  an 
accidental  discovery ; but  it  seems  more 
probable,  that  the  good  effects,  which  it  pro- 
duced in  cutaneous  diseases,  first  led  to  the 
trial  of  it  in  venereal  cases,  which  being 
frequently  attended  with  eruptions  on  the 
skin,  ulcers,  &c.  seemed  to  present  an 
analogy  to  the  affections,  in  which  mercury 
had  already  been  found  successful. 

In  the  times,  immediately  following  the 
origin  of  the  venereal  disease,  practitioners 
only  ventured  to  employ  this  remedy  with 
timorous  caution,  so  that,  of  several  of  their 
formulae,  mercury  scarcely  composed  a 
fourteenth  part,  and  either  on  this  account, 
or  some  difference  in  the  disease  itself  at  that 
period  from  what  is  now  remarked,  few 
cures  were  effected.  On  the  other  hand,  the 
empirics,  who  noticed  the  little  efficacy  of 
these  small  doses,  ran  into  the  opposite  ex- 
treme, and  exhibited  mercury  in  quantities 
so  large,  and  with  such  liitle  care,  that  most 
of  their  patients  were  suddenly  attacked 
with  violent  salivations,  frequently  attended 
with  very  dangerous,  and  even  fatal  symp- 
toms; or  such  as  after  making  them  lose 
their  teeth,  left  them  pale,  emaciated,  ex- 
hausted, and  subject,  for  the  rest  of  their 
lives,  to  tremblings,  or  other  more  or  less 
dangerous  affections.  From  these  two  very 
opposite  modes  of  practice,  there  originated 
such  uncertainty,  respecting  what  could  be 
expected  from  mercury,  and  such  fears  of 
the  consequences,  which  might  result  from 
its  employment,  that  every  plan  was  eagerly 
adopted,  which  offered  the  least  chance  of 
cure,  without  havingrecourse  to  this  mineral 

A medicine,  however,  so  powerful,  and 
whose  salutary  effects  had  been  watched  by 
attentive  practitioners  amidst  all  its  incon- 
veniences, could  not  sink  into  oblivion. 
After  efforts  had  been  made  to  discover  an 
equally  efficacious  substitute  for  it,  and  it 
had  been  seen,  how  inferior  other  means 
were,  on  which  the  highest  praises  had  been 
lavished,  the  attempts  to  extend  its  utility 
were  renewed.  A medium  was  pursued, 
between  the  too  timid  methods  of  those 
physicians,  who  had  first  administered  it, 
and  the  inconsiderate  boldness  of  the  empL 


MERCURi . 


l ies.  Thus  the  causes,  from  which  both  par- 
ties failed,  were  avoided  ; the  character  of 
the  medicine  was  revived  in  a more  durable 
way,  and  from  this  period,  its  reputation  has 
always  been  maintained. 

The  renowned  Paracelsus  first  taught  practi- 
tioners that  mercury  might  be  given  internal- 
ly with  safety  ; for,  before  he  set  the  exam- 
ple ; it  had  only  been  externally  employed, 
in  three  manners.  The  first  was  in  the 
form  of  an  oiniment  or  liniment ; the  second 
as  a plaster  ; and  the  third,  as  a fumigation. 

The  basis  of  the  ointment,  or  liniment,  was 
quicksilver,  which  was  blended,  by  means  of 
trituration,  with  hog  s lard,  goose’s  fat,  &c. 
and  composed  scarcely  one-sixth  or  one- 
eighth  of  the  whole  ; a proportion,  however, 
much  greater,  than  what  had  been  at  first 
employed.  But  from  a fear,  that  the  mi- 
neral might  prove  hurtful  to  the  nerves,  by 
the  cold  property  which  they  fancied  it 
possessed,  and  that  it  might  occasion  numb- 
ness, tremblings,  or  palsies,  they  combined 
with  it  a multitude  of  ingredients  of  a warm, 
aromatic  nature,  or  supposed  to  possess  such; 
for  example,  oil  of  camomile,  sesame-seeds, 
aniseeds,  the  roots  of  zedoary,  and  the  floren- 
tine  iris,  and  a thousand  other  substances, 
which  were  incorporated  with  the  ointment. 
The  members,  joints,  and  the  whole  of  the 
body,  except  the  head,  belly,  and  chest, 
were  rubbed  with  this  composition  ; and  the 
frictions  were  repeated,  at  suitable  intervals, 
until  obvious  signs  of  salivation  appeared. 

The  ingredients  of  the  plasters  resembled 
those  of  the  ointments  ; only  they  contained 
less  fat,  for  which  was  substituted  a sufficient 
quantity  of  wax,  to  give  them  a proper  con- 
sistence. This  composition  was  applied  to 
the  skin,  and  the  whole  body  was  covered 
with  it,  excepting  the  parts  on  which  it  was 
not  usual  to  put  ointment.  The  plasters 
were  kept  on,  till  salivation  began. 

The  fumigations  were  made  with  quick- 
silver, triturated  with  turpentine,  or  saliva, 
or  else  with  cinnabar.  These  substances 
were  mixed  with  fatty,  or  resinous  ones, 
such  as  myrrh,  nutmeg,  &c.  and,  all  the  in- 
gredients being  reduced  to  powder,  were 
made  into  a paste,  with  a sufficient  quantity 
of  turpentine,  or  gum  tragacantb.  The  pa- 
tient was  then  placed  in  a box  made  on  pur- 
pose, or  under  a little  kind  of  tent,  out  of 
which  the  head  was  generally  allowed  to 
protrude.  A chafing-dish,  containing  burn- 
ing coals,  was  placed  near  his  feet,  and 
every  now  and  then,  bits  of  mercurial  paste 
were  thrown  into  the  vessel.  The  patient 
was  left  exposed  to  the  fumes,  which  arose, 
until  he  broke  oulinto  a profuse  perspiration, 
which  they  took  great  pains  to  keep  up  and 
increase,  by  putting  him  into  a warm  bed, 
loading  him  with  bedding,  for  about  two 
hours,  after  which  he  was  rubbed  t^ite  dry, 
and  given  some  food.  This  plan  was'  persist- 
ed in  every  day,  till  a salivation*  W'eIS.  pro- 
duced, which  was  kept  up  as  long  as  neces- 
sary. The  method  of  fumigation  is,  described 
by  Astriic,  and  particular  preparations,  and 
apparatuses  for  the  purpose,  have  been  since 


recommended  by  La'lonette  in  France,  and# 
more  recently,  by  Abernethy  in  England. 

Of  the  three  methods,  which  we  have  just 
described,  only  the  first  is  at  present  much  in 
use,  and  even  this  is  considerably  altered.  It 
was  found,  not  only  that  mercurial  plasters 
caused  heat,  redness,  itching,  and  disagree- 
ble  eruptions,  but,  that  the  method  was  ex- 
ceedingly slow  and  uncertain.  Hence, 
plasters  are  now  only  used  as  topical  discu- 
tient  applications. 

Fumigations,  considered  as  the  only  means 
of  cure,  fell  also  into  discredit,  because, 
although  they  formed  a method  of  applying 
mercury  in  a very  active  manner,  they  were, 
as  anciently  managed,  liable  to  several  ob- 
jections.  In  this  way,  it  was  next  to  impos- 
sible to  regulate  the  quantity  of  mercury 
used,  which  varied  according  to  the  greater 
or  lesser  activity  of  the  fire,  the  position  of 
the  patient,  and  other  circumstances.  The 
effect  of  the  vapour  on  the  organs  of  respira- 
tion also  frequently  proved  very  oppressive 
and  mercury,  applied  in  the  way  of  fumiga- 
tion, more  frequently  occasioned  tremblings, 
palsies,  &lc.  than  in  any  other  manner.  In 
Mr.  Abernethy’s  mode,  however,  fumigation 
is,  under  certain  circumstances,  not  only  an 
eligible,  but,  the  very  best  way  of  affecting 
the  constitution. 

f rictions  with  ointment  have  always  been 
regarded  as  the  most  efficacious.  They  have 
undergone  considerable  change,  and  by 
being  rendered  more  simple,  have  been 
greatly  perfected.  All  the  warm  aromatic 
substances  have  been  retrenched  from  the 
ointment,  not  only  as  useless,  but  as  irritating 
and  inflaming  to  the  skin.  In  modern  times, 
the  proportion  of  mercury  to  the  fat  has 
also  been  very  much  increased. 

GENERAL  REMARKS  ON  THE  ADMINISTRA- 
TION OF  MERCURY,  ITS  OCCASIONAL  CON- 
SEQUENCES, &C. 

With  regard  to  the  preparations  of  the 
medicine,  and  the  modes  of  applying  it,  we 
are  to  consider  two  things  ; first,  the  prepa- 
ration and  mode  attended  with  the  least 
trouble  or  inconvenience  to  the  patient : 
and  secondly,  the  preparation,  and  mode  of 
administering  it,  that  most  readily  conveys 
the  necessary  quantity  into  the  constitution. 
Mercury  is  carried  into  the  constitution  in 
the  same  way  as  other  substances,  either  by 
being  absorbed  from  the  surface  of  the  body, 
or  that  of  the  alimentary  canal.  It  cannot, 
however,  in  all  cases,  be  taken  into  the  con- 
stitution in  both  ways;  for,  sometimes  the 
absorbents  of  the  skin  will  not  readily 
receive  it,  at  least,  no  effect  is  produced, 
either  on  the  disease  or  constitution,  from 
this  mode  of  application.  In  this  circum- 
stance, mercury  must  be  given  by  the  mouth, 
although  the  plan  may  be  very  improper  in 
other  respects,  and  often  inconvenient.  On 
the  other  hand,  the  internal  absorbents  some 
dimes  will  not  take  up  the  medicine,  or,  at 
Toast,  no  effect  is  produced  on  the  disease, 
or  the  constitution. 

In  such  cases,  all  the  different  preparation; 
of  the  medicine  should  be  tried  for  some 


MERCURY. 


229 


.iiaes  oue  succeeds,  when  another  will  not. 
In  some  cases,  mercury  seems  to  have  no 
effect,  either  applied  outwardly,  or  taken  in- 
to the  stomach.  Many  surfaces  seem  to  ab- 
sorb mercury  better  than  others : such  are 
probably  all  internal  surfaces  and  sores. 
Thirty  grains  of  calomel,  rubbed  in  on  the 
skin,  have  not  more  effect,  than  three,  or 
four,  taken  by  the  mouth.  Dressing  small 
ulcers  with  red  precipitate  sometimes  causes 
a salivation.  (See  Hunter  on  the  Venereal 
Disease,  p.  335,336.) 

Besides  the  practicableness  of  getting  tiie 
medicine  into  the  constitution  in  either  way, 
it  is  proper  to  consider  the  easiest  for  the 
patient,  each  mode  having  its  convenience 
and  inconvenience,  depending  on  the  nature 
of  the  parts  to  which  it  is  applied,  or  on 
certain  situations  of  life  at  the  time.  Hence, 
it  should  be  given  in  the  way  most  suitable 
to  such  circumstances. 

In  many,  the  bowels  can  hardly  bear  mer- 
cury at  ail,  and  it  should  then  be  given  in 
the  mildest  form  possible,  conjoined  with 
such  medicines  as  will  lessen  or  correct  its 
violent  local  effects,  although  not  its  specific 
ones  on  the  constitution. 

When  mercury  can  be  thrown  into  the 
constitution  with  propriety  by  the  external 
method,  it  is  preferable  to  the  internal  plan, 
because  the  skin  is  not  nearly  so  essential  to 
life  as  the  stomach,  and  therefore,  is  capable 
in  itself  of  bearing  much  more  than  the  sto- 
mach. The  constitution  is  also  less  injured. 
Many  courses  of  mercury  would  kill  the  pa- 
tient, if  the  medicine  were  only  given  inter- 
nally, because  it  proves  hurtful  to  the 
stomach  and  intestines,  when  given  in  any 
form,  or  joined  with  the  greatest  correctors. 
Every  one,  however,  has  not  opportunities 
of  rubbing  in  mercury,  and  is  therefore 
obliged,  if  possible,  to  take  it  by  the  mouth. 
(Hunter,  p.  338.) 

Mercury  has  two  effects  ; one  as  a stimu- 
lus on  the  constitution  and  particular  parts; 
the  other  as  a specific  against  a diseased  ac- 
tion of  the  whole  body,  or  of  parts,  ihe 
latter  action  can  only  be  computed  by  the 
disease  disappearing. 

In  giving  mercury  in  the  venereal  disease, 
the  first  attention  should  be  to  the  quantity, 
and  its  visible  effects  in  a given  time,  which, 
when  brought  to  a proper  pitch,  are  only  to 
be  kept  up,  and  the  decline  of  the  disease 
to  be  watched  ; for  by  this  we  judge  of  the 
invisible,  or  specific  effects  of  the  medicine, 
and  know  what  variation  in  the  quantity 
may  be  necessary.  The  visible  effects  of 
mercury  affect,  either  the  whole  constitu- 
tion, or  some  parts  capable  of  secretion.  In 
the  first,  it  produces  universal  irritability, 
making  it  more  susceptible  of  all  impres- 
sions. It  quickens  the  pulse,  increases  its 
hardness,  and  occasions  a kind  of  temporary 
fever.  In  some  constitutions,  it  operates 
like  a poison  ; whife,  in  others,  it  produces  a 
kind  of  hectic  fever,  that  is,  a small  quick 
pulse,  loss  of  appetite,  restlessness,  want  of 
sleep,  and  a sallow  complexion,  with  a num- 
ber of  consequent  symptoms;  but,  sucli 
effects  commonly  diminish,  on  the  patient 


becoming  a little  accustomed  to  the  medi- 
cine. Mercury  often  produces  pains  like 
those  of  rheumatism,  and  nodes  of  a scro- 
fulous nature.  ( Hunter , p.  339,  340.) 

The  quantity  of  mercury  to  be  thrown 
into  the  constitution,  for  the  cure  of 
any  venereal  complaint,  must  be  propor- 
tioned to  the  violence  of  the  disease.  How- 
ever, we  are  to  be  guided  by  two  cir- 
cumstances, namely,  the  time  in  which 
any  given  quantity  is  to  be  thrown  in,  and 
the  effec  ts  it  has  on  some  parts  of  the  body, 
as  the  salivary  glands,  skin,  or  intestines. 
For,  mercury  may  be  thrown  into  the  same 
constitution  in  very  different  quantities,  so  as 
to  produce  the  same  ultimate  effect , but  the 
two  very  different  quantities,  must  also 
be  in  different  times . for  instance,  one 
ounce  of  mercurial  ointment,  used  in  two 
days,  will  have  more  effect  upon  the  consti- 
tution, than  two  ounces  used  in  ten.  The 
effects  of  one  ounce,  used  in  two  days,  on 
the  constitution  and  diseased  parts,  are  con- 
siderable. A small  quantity,  used  quickly, 
w II  have  equal  effects,  to  those  of  a large 
one  employed  slow  ly  ; but,  if  these  effects 
are  principally  local,  that  is,  upon  the  glands 
of  the  mouth,  the  constitution  at  large  not 
being  equally  stimulated,  the  effect  upon  the 
diseased  parts  must  be  less,  which  may  be 
known  by  the  local  disease  not  giving  way 
in  proportion  to  the  effects  of  mercury  on 
some  particular  part.  If  it  is  given  in 
very  small  quantities,  and  increased  gradual  - 
ly, so  as  to  steal  insensibly  on  the  constitu- 
tion, a vast  quantity  at  a time  may  at  length 
be  used  without  any  visible  effect  at  all. 
( Hunter , p.  341 .) 

Tiie  ecircumstances  being  known,  mercu- 
ry becomes  a much  more  efficacious,  ma- 
nageable, and  safe  medicine,  than  it  was 
f rmerly  thought  to  be  ; but,  unluckily,  its 
visible  effects  upon  the  mouth  and  the  intes- 
tines are  -ometimes  much  more  violent,  than 
its  general  effect  upon  the  constitution  at 
lar^e.  Ihese  parts  must  therefore  not  be  sti 
mulated  so  quickly  as  to  hinder  the  necessary 
quantity  of  mercury  from  being  used. 

The  constitution,  or  parts,  are  more  sus- 
ceptible of  mercury  at  first,  than  afterward. 
If  the  mouth  is  made  sore,  and  allowed  to 
recover,  a much  greater  quantity  may  be 
thrown  iu,  a second  time,  before  the  same 
soreness  is  produced.  However,  anomalous 
cases  occur,  in  which,  from  unknown  causes, 
mercury  cannot  at  one  time  be  made  to  pro- 
duce any  visible  effects  ; but,  afterward,  tho 
m mth  Hid  intestines  are  all  at  once  affected. 
( Hunter , p.  342.) 

Mercury  occasionally  attacks  the  bowels, 
and  causes  violent  purging,  even  of  blood. 
This  effect  is  remedied  by  discontinuing  the 
use  of  the  medicine,  and  exhibiting  opium. 
Ai  otl^er times,  it  is  suddenly  determined  to 
the  mouth, eand  produces  inflammation,  ulce- 
ration, and  ari  excessive  flow  of  saliva.  To 
obtain  relief  in  this  circumstance,  purga- 
tives, nitre, sulphur,  gum-arabic,  lime-wTater, 
camphor,  bark,  the  sulphuret  of  pot  isb, 
blisters,  &ic.  have  been  advised.  Mr.  Pear- 
son, however,  does  not  seem  to  place  ranch 


MERCURY. 


230 

confidence  in  the  efficacy  of  such  means, 
and  the  mercury  being  discontinued  for  a 
time,  he  recommends  the  patient  to  be  freely 
exposed  to  a dry  cold  air,  with  thp  occa- 
sional use  of  cathartics,  peruvian  bark,  and 
mineral  acids,  and  the  assiduous  application 
of  astringent  gargles.  “ The  most  material 
objection,  (says  Mr.  Pearson,)  which  I fore- 
see against  the  method  of  treatment  I have 
recommended,  is  the  hazard  to  which  the 
patient  will  be  exposed,  of  having  the  saliva 
suddenly  checked,  and  of  suffering  some 
other  disease,  in  consequence  of  it. 

{{  That  the  hasty  suppression  of  a ptyalism 
may  be  followed  by  serious  inconveniences, 
has  been  proved  by  Dr.  Silvester,  {Med.  Obs. 
and  Inq.  Vol.  3.)  who  published  the  cases  of 
three  persons,  who  had  been  under  his  own 
care  ; two  of  whom  were  afflicted  with  vi- 
olent pains;  and  the  third  scarcely  retained 
any  food  in  her  stomach  for  the  space  of 
three  months.  I have  seen  not  only  pains, 
but  even  general  convulsions  produced  from 
the  same  cause.  But,  this  singular  kind  of 
metastasis  of  the  mercurial  irritation  does 
not  appear  to  me  to  owe  its  appearance  to 
simple  exposure  to  cold  and  dry  air  ; be- 
cause I have  known  it  occur  in  different 
forme,  where  patients  continued  to  breathe 
a warm  atmosphere,  but  used  a bath,  the 
water  of  which  was  not  sufficiently  heated. 
Cold  liquids,  taken  in  a large  quantity  info 
the  stomach,  or  exposure  of  the  body  to  cold 
and  moisture,  will  also  prove  extremely  in- 
jurious to  those,  who  are  fully  under  the 
influence  of  mercury  ; whereas  breathing  a 
cool  air,  while  the  body  is  properly  covered 
with  apparel,  has  certainly  no  tendency  to 
produce  any  distressing,  or  dangerous  con- 
sequences. 

“ If,  however,  a suppression  of  the  ptya- 
lism should  be  occasioned  by  any  act  of  in- 
discretion, the  remedy  is  easy  and  certain  ; 
it  consists  only  in  the  quick  introduction  of 
mercury  into  the  body,  so  as  to  produce  a 
soreness  of  the  gums,  with  the  occasional 
use  of  a hot  bath.”  ( Pearson  on  the 

Effect  of  various  Articles  in  the  Cure  of  Lues 
Venerea,  Edit.  2,  p.  163,  164.) 

Mercury,  when  it  falls  on  the  mouth,  pro- 
duces, in  many  constitutions,  violent  inflam- 
mation, which  sometimes  terminates  in 
mortification.  In  these  habits,  great  caution 
is  necessary.  The  ordinary  operation  of 
mercury  does  not  permanently  injure  the 
constitution  ; but  occasionally,  the  impair- 
ment is  very  material ; mercury  may  even 
produce  local  disease,  and  retard  the  cure  of 
chancres,  buboes,  and  certain  effects  of  the 
lues  venerea,  after  the  poison  has  been  des- 
troyed. ( Hunter , p.  342.) 

From  mercury  occasionally  acting  on  the 
system,  as  a poison,  quite  unconnected  with 
its  agency  as  a remedy,  and  neither  propor- 
tionate to  the  inflammation  of  the  mouth, 
nor  the  actual  quantity  of  the  mineral  ab- 
sorbed, Mr.  Pearson  noticed  that  one,  or  two 
patients  in  general  died  suddenly  every  year 
in  the  Lock  Hospital.  The  morbid  state  of 
the  system,  which  tends  to  the  fatal  event, 
during  a mercurial  course  is  named  by  Mr 


Pearson  ereihismus,  and  is  characterized  by 
great  depression  of  strength,  a sense  of 
anxiety  about  the  prascordia,  Irregular  ac- 
tion of  the  heart,  frequent  sighing,  trem- 
bling, a small,  quick,  and  sometimes  an  in- 
termitting pulse,  occasional  vomiting,  a 
pale  contracted  countenance,  a sense  of 
coldness ; but  the  tongue  is  seldom  furred, 
and  neither  the  vital,  nor  natural  functions 
are  much  disordered.  They,  wrho  die  sud- 
denly of  the  mercuiial  ereihismus,  have 
frequently  been  making  some  little  exertion 
just  before.  To  prevent  the  dangerous  con- 
sequences of  this  state  of  the  system,  the 
use  of  mercury  must  be  discontinued,  what- 
ever may  be  the  stage,  extent,  or  violence  of 
the  venereal  symptoms.  The  patient  should 
be  directed  to  expose  himself  freely  to  a dry 
and  cool  air,  in  such  a manner,  as  shall  be 
attended  w ith  the  least  fatigue,  and  he  should 
have  a generous  diet.  In  this  manner,  pa- 
tients often  recover  sufficiently  in  ten  or 
fourteen  days,  to  resume  the  use  of  mercu- 
ry with  safety.  In  the  early  stage,  the  mercu- 
rial erethismus  may  often  be  averted  by 
leaving  off  the  mercury,  and  giving  the  mis- 
tura  camphorata  with  large  doses  of  ammo- 
nia. When  the  stomach  is  unaffected,  sar- 
saparilla sometimes  does  good.  ( Pearson , 
p.  164,  <^c.) 

Occasionally,  the  use  of  mercury  brings 
on  a peculiar  eruption,  which  has  received 
the  several  names  of  hydrargyria,  mercurial 
rash,  eczema  mercuriale,  eczema  rubrum, 
lepra  niercurialis,  mercurial  disease,  and 
erythema  mercuriale. 

“ Eruptions  of  various  kinds  are  very 
common  symptoms  of  syphilis,  but  a very 
unusual  effect  of  mercury.  Therefore,  until 
the  real  nature  of  this  erythema  was  lately 
discovered,  whenever  it  occurred  in  patients 
undergoing  a mercurial  course  for  syphilitic 
complaints,  it  was  naturally  enough  consi- 
dered, as  an  anomalous  form  of  lues  venerea. 
The  mercury  was  consequently  pushed  to  a 
greater  extent,  in  proportion  to  the  violence 
of  the  symptoms,  and,  from  the  cause  of  the 
disease  being  thus  unconsciously  applied  for 
its  removal,  it  could  not  fail  to  be  aggrava- 
ted, and  hurried  on  to  a fatal  termination. 
The  observation  of  this  fact,  conjoined  with 
another,  of  less  frequent  occurrence,  name- 
ly, that  a similar  eruption  did  sometimes  ap- 
pear in  patients  using  mercury  for  other  com- 
plaints, and  in  whom  no  suspicion  of  syphilis 
could  be  entertained,  at  last  led  some  judi- 
cious practitioners  in  Dublin  to  the  impor- 
tant discovery,  that  the  eruption  was  entire- 
ly an  effect  of  mercury,  and  not  at  all  con- 
nected with  the  original  disease.  This  dis 
covery  was  not  published  till  1804.”  ( M‘Mul 
lin  in  Edinburgh,  Medical  and  Surgical  Jour- 
nal, No.  5.1  Mr.  Pearson  states,  however, 
that  he  has  been  acquainted  with  the  disease 
ever  since  1781,  and  has  always  described 
its  history  and  treatment  i«i  his  lectures,  since 
1783. 

The  eruption  is  attended  with  more  or 
less  indisposition,  is  not  confined  to  either 
sex,  or  any  particular  constitution,  and  seems 
to  be  equally  prodneed  by  mercury  applied 


MERCURY. 


231 


externally,  and  by  any  of  its  preparations 
taken  inwardly.  Mr.  Pearson  has  never 
seen  it  in  subjects  above  50 ; and  he  says, 
its  occurrence  is  more  common  about  eight, 
or  ten  days  after  beginning  a mercurial 
course.  ( P . 166.) 

Dr.  M'Mullin  has  described  three  distinct 
stages  ot  the  erythema  mercuriale.  “ The 
■ first  stage  commences  with  languOh  lassitude, 
and  cold  shiverin<s  ; these  symptoms  are 
succeeded  by  increased  temperature  of  tiie 
body  , quick  pulse,  nausea,  headacb,  and 
thirst.  The  patient  is  troubled  with  a dry 
cough,  and  complains  of  difficult  respiration, 
anxiety,  and  sense  of  stricture  about  the 
pnecordia.  The  tongue  is  usually  moist,  and 
covered  with  a white  glutinous  slime : it 
sometimes  appears  clean,  and  brightly  red 
in  the  centre,  whilst  the  margins  remain 
foul.  TheskifS  feels  unusually  hot  and  itchy, 
with  a sense  ot  prickling,  not  unlike  lie 
sensation  experienced  from  the  application 
of  nettles.  1‘lie  belly  is  generally  costive  ; 
but  a diarrhoea  is  often  produced  by  very 
slight  causes. 

“ On  tiie  first,  or  second  day,  an  eruption 
most  commomy  shows  itaelt,  the  colour  of 
which  is  either  dark  or  bright  red  : the  pa  - 
pulae  are  at  first  distinct  and  elevated,  re- 
sembling very  much  those  in  rubeola.  Some- 
times, but  rarely,  the  eruption  appears  like 
urticaria,  and  in  such  instances  the  disease 
is  observed  to  be  very  mild.  The  papma3 
very  speedily  run  together  in  such  a manner 
as  to  term  a suffused  redness,  which  disap- 
pears on  pressure.  In  most  cases,  it  begins 
first  on  the  scrotum,  inside  of  the  thighs, 
fore-arm,  or  where  mercurial  friction  has 
been  applied,  and  the  integuments  of  the 
parts  affected  become  much  swoln.  There 
have  also  been  observed  instances,  where 
an  eruption  of  a purplish  colour,and  unaccom- 
panied by  papulae, has  diffused  itself  suddenly 
over  the  entire  body  . Thi-,  however,  may  be 
considered  a5  uncommon.  la  every  instance, 
which  came  under  my  observation,  it  was 
confined  at  first  to  a few  places,  and  from 
thence  gradually  extended,  until  the  differ 
ent  portions  ot  the  eruption  bad  united,  and 
the  papulae  were  also  rough  to  the  feel.  But 
in  those  cases,  which  resemble  urticaria,  a 
number  ot  minute  vesicles,  which  contain  a 
serous  fluid,  appear  from  the  commence- 
ment, interspersed  among  the  papulm. 
Contrary  to  what  happens  in  most  diseases 
accompanied  with  cutaneous  affections,  the 
febrile  symptoms  are  much  aggravated,  and 
continue  to  increase  after  the  eruption  has 
been  completed.  The  pulse  in  genera!  beats 
from  120  to  130  in  a minute,  the  thirst  con- 
tinues urgent,  and  the  pauent  extremely 
restless,  seldom  enjoys  quiet  sleep.  When 
the  eruption  has  continued  in  this  in  timer 
fora  certain  period,  the  cuticle  begins  to 
peel  off  in  thin,  whiti>h,  scurfy  exfoliations, 
not  unlike  those  observed  in  rubeola.  This 
desquamation  has  not  been  attended  to  by 
Dr.  Moriarty  or  Mr.  Alley,  if  they  have  not, 
by  giving  the  same  naras  to  the  decrustation 
which  occurs  in  the  last  stage,  confounded 
both  together.  It  commences  in  those 


places  where  the  eruption  first  made  ils  ap- 
pearance, and  in  this  order  spreads  to  other 
parts.  About  this  period  the  fauces  become 
sore,  the  tongue  swells,  and  the  eyes  appear 
somewhat  inflamed. 

“The  duration  of  this  stage  is  very  va- 
rious; sometimes  it  continues  from  ten  to 
fourteen  days,  and,  in  oilier  cases,  it  termi- 
nates in  half  that  time.  When  she  disease 
has  appeared  in  ils  mildest  form,  the  patient 
recovers  immediately  after  the  desquamation, 
a new  cuticle  having  formed  underneath; 
but,  if  severe,  he  has  onty  experienced  the 
smallest  part  ot  his  sufferings,  and  the  skin 
now  assumes  a new  appearance,  which  I 
have  considered  as  the  second  stage. 

“ t he  skin  at  this  period  appears  as  if 
studded  with  innumerable  minute  vesicles, 
which  are  fi  led  with  a pellucid  fluid.  These 
vesicles  may  be  expected,  if  the  patient,  at 
the  close  ot  the  first  stage,  complains  ot  in- 
crease! itching,  and  sense  of  burning  heat, 
in  those  parts  Irom  which  the  cut icuiar  ex- 
foliations have  fallen.  They  rein  fin  some- 
times tor  a day  or  two,  but  ate  most  com- 
moidy  burst,  immediately  after  their  forma- 
tion, by  the  patient  rubbing  them,  in  order 
to  relieve  the  troublesome  iichiness  with 
which  these  parts  ate  affected.  They  dis- 
charge a serous,  acrimonious  fluid,  which 
possess  such  a very  disagreeable  odour  as  to 
induce  nausea  in  the  patient  himself,  and 
thuse  who  approach  near  his  bedside.  The 
odour  is  so  peculiar,  that  it  can  easily  be  re- 
cognized by  any  person  who  has  once  ex- 
perienceu  it. 

“This  fluid  is  poured  out  most  copiously 
from  the  scrotum,  groin,  inside  of  the  thighs, 
or  wherever  the  skin  forms  folds,  and  seba- 
ceous glands  are  most  numerous.  The 
serous  discharge  from  these  minute  vesicles 
forms,  with  the  cuticle,  an  incrustation, 
which  may  be  considered  as  the  third  or  last 
state. 

‘‘  These  crusts  are  generally  very  large, 
and,  when  detached,  retain  the  figure  of  the 
parts  from  which  they  have  lallen.  Their 
colour  is  yellowish;  but  sometimes  appears 
dark  and  dirty,  this  period  of  the  disease 
might  be  termed,  ! ;hink,  with  much  pro- 
priety, the  '.ta„e  61  decrustation,  in  order  to 
distinguish  n more  imiy  troui  the  desquama - 
tion,  which  has  been  a< ready  notic.d.  From 
the  u.-e  of  the  two  last  terms  indi-  runi- 
nately , tbos  who  have  described  the  d siase 
have  introduced  into  their  descriptions  a 
degree  ul  confusion  which  has  caused  its 
progress  not  to  be  well  understood.  When 
this  stage  appears,  the  fauces  become  more 
affected,  T>e  ey<  s intolerant  of  light,  end  the 
tarsi  tender,  inflamed,  and  sometimes  in- 
verted. The  crusts  torm<  d on  the  face,  as  in 
other  parts  ot  the  body,  before  tailing  off, 
divide  asunder,  so  as  to  leuv*-:  cracks  and 
fissures,  which  produce  an  hideous  expres- 
sion ot  countenance  ; and  the  eyelids  are 
also,  from  the  general  swelling  of  the  lace, 
completely  closed.  The  back  und  hairy 
scalp  are  last  affected,  and,  even  in  very 
severe  cases,  these  parts  are  sometimes  ob- 
served to  escape  entirely.  The  patient. 


MERCURY 


m 


whilst  in  this  state,  is  compelled  to  desist 
from  every  kind  of  motion,  on  account  of 
tile  pain  which  he  experiences  on  the  slight- 
est exertion,  and  which  he  describes  as  if  his 
flesh  were  cracking.  The  crusts  also  fall  off 
in  such  abundance,  that  the  bed  appears  as  it 
strewed  with  the  cones  of  hops.  Whilst  the 
eruption  is  only  making  its  appearance  in 
one  place,  another  part  may  have  arrived  at 
its  most  advanced  form  ; so  that  all  the  dif- 
ferent stages  ot  the  disease  may  he  present 
atone  lime  in  the  same  individual.  It  is 
attended  with  typhus  through  its  entire 
course } but  it  is  very  curious  to  observe, 
that  the  appetite  for  food,  in  most  cases,  re 
mains  unimpaired,  and  sometimes  is  even 
voracious.  This  circumstance  was  particu- 
larly remarkable  in  a patient  who  laboured 
under  the  disease,  in  its  worst  form. for  the 
space  of  three  months,  in  the  Royal  Infirm 
ary  of  Edinburgh  ; for  double  the  usual  hos- 
pital allowance  of  food  was  scarcely  suffi- 
cient to  satisfy  his  hunger.  When  the 
catarrhal  symptoms  have  continued  during 
the  progress  of  the  complaint,  they  are,  at 
this  advanced  period,  particularly  aggrava- 
ted : the  anxiety  and  pain  of  the  breast  are 
also  very  severe,  attended  with  cough,  and 
bloody  expectoration,  and  the  patient  always 
feels  languid  and  dejected.  The  pulse  be- 
comes frequent,  feeble,  and  irregular,  the 
tongue  black  and  parched,  and  at  length 
diarrhoea,  delirium,  convulsions,  gangrene  of 
the  surface  of  the  body,  and  death,  super- 
vene. In  its  mild  form,  it  only  goes  through 
the  first  stage,  and  terminates,  as  we  have 
already  stated,  in  a few  days,  by  a slight 
desquamation.  But,  when  severe,  it  is  often 
protracted  more  than  two  months,  every 
stage  of  the  eruption  continuing  proportion- 
abiy  longer}  and  when,  in  this  manner,  it 
has  run  its  course,  it  repeatedly  breaks  out 
on  the  new  surface,  and  passes  through  the 
same  stages.”  (M'Mullin  in  Edinb.  Med. 
and  Surg.  Journal,  No.  5.) 

With  respect  to  the  remote  cause,  this  is 
the  employment  of  mercury.  Dr.  M‘Mullin 
is  inclined  to  believe  with  Dr.  Gregory,  that 
the  application  of  cold  to  the  body,  while 
under  the  action  of  mercury,  is  absolutely 
necessary,  for  its  production;  an  opinion 
strengthened  by  the  constant  prevalence  of 
catarrhal  symptoms.  However,  Mr.  Pearson 
thinks,  that  cold  has  no  concern  in  bringing 
on  the  complaint  in  patients  under  the  influ- 
ence of  mercury.  At  the  same  time  it  merits 
particular  attention,  that  the  disease  is  not 
exclusively  occasioned  by  mercury  either  in 
its  general,  or  more  partial  attacks:  it  has 
been  observed  to  follow  exposure  to  cold, 
and  to  recur  in  the  same  individual,  at  irre- 
gular intervals,  without  any  obvious  or  ade- 
quate cause.  ( Bateman's  Synopsiq,  p.  256, 
Ed.  3 ; Rutter  in  Edin.  Med.  and  Surg.  Journ. 
Vol.  5,  p.  143 } Marcet  in  Med.  Chir.  Trans. 
Vol.  2,  art.  9.) 

In  the  early  stage,  Mr.  Pearson  recom- 
mends small  doses  of  antimonial  powder, 
with  saline  draughts,  or  the  ammonia  acetata. 
A genlle  purgative  should  be  given  every 
three  or  four  days,  and  opium  to  procure 


sleep.  The  latter  medicine  sometimes  dot  ■ 
most  good,  when  joined  with  camphor,  or 
Hoffman’s  anodyne  liquor.  Sarsaparilla  and 
bark  may  be  given,  when  the  discharge  is  no 
longer  ichorous,  and  the  tumefaction  has 
subsided.  Vitriolic  acid  lias  seemed  to  give 
relief.  The  diet  may  be  light  and  nutritive, 
without  fermented  liquors,  however,  till  the 
desquamation  has  somewhat  advanced.  Fre- 
quent use  of  the  warm  bath,  and  often  chan- 
ging the  patient’s  linen  and  sheets,  which 
soon  become  stiff  and  rough  with  the  dis- 
charge, afford  much  benefit.  If  the  warm 
bath  cannot  be  had,  Mr.  Pearson  advises 
washing  the  body  very  tenderly  with  warm 
water-gruel ; he  also  covers  parts,  from 
which  the  cuticle  is  detached,  with  a mild 
cerate,  and  renews  the  application  twice  a 
day.  (. P . 178.) 

Dr.  M‘Mullin  advises  the  immediate  dis- 
continuance of  mercury ; the  removal  of 
the  patient  from  wards,  where  this  mineral 
is  in  use  ; emetics  and  diaphoretics  ; but  on 
account  of  the  very  irritable  state  of  the 
bowels,  he  says  antimonials  are  hardly  ad- 
missible, and  that  when  purgatives  are  indi- 
cated, only  the  mildest  ones,  such  as  ol.  ri- 
cini,  sulphate  of  magnesia,  &c.  ought  to  be 
given.  He  advises  mucilaginous  draughts 
with  opium  for  relieving  the  soreness  of  the 
fauces.  In  the  second  stage,  the  cold  infu- 
sion of  bark  with  aromatics  and  opium,  or 
what  is  more  praised,  wine,  porter,  &c.  To 
relieve  the  ophthalmia  tarsi,  the  unguentum 
oxidi  zinci,  and  to  appease  the  painful  sensa- 
tion of  the  skin  cracking,  the  linimentum 
calcis,  which  should  be  liberally  applied  as 
soon  as  crusts  appear. 

Consult  Essay  on  a Peculiar  Eruptive  Dis- 
ease, arising  from  the  Exhibition  of  Mercury , 
by  G.  Alley , 8vo.  Dublin , 1804 ; also  Ubser- 
vaiions  on  the  Hydrargyria , or  that  Vesicular 
Disease  arising  from  the  Exhibition  of  Mer- 
cury, 4to.  Land.  1810.  A Description  of  the. 
Mercurial  Lepra,  by  Dr.  Moriarty , 12mo. 
Dublin , 1804.  SpensandJ WMullin,  in  Edin- 
burgh Med.  and  Surgical  Journal,  No.  1,  and 
5.  Pearson  on  Lues  Venerea,  Edit.  2.  Rate- 
man's  Synopsis,  p.  256,  fyc.  Ed.  3. 

Frictions  toith  Mercurial  Ointment. 

No  metal  acts  in  its  pure  metallic  state  ; 
it  must  first  be  more  or  less  combined  with 
oxygen.  The  mercury,  contained  in  the 
unguentum  hydrargyri,  becomes  in  a cer- 
tain degree  oxydated,  when  triturated  for 
the  purpose  of  blending  it  with  the  fat.  The 
metal,  however,  in. mercurial  ointment,  is  in 
the  most  simple,  and  least  combined  form, 
of  all  its  preparations,  and  hence,  it  not  ortly 
generally  operates  with  more  mildness  on 
the  system,  but  with  more  specific  effect  on 
the  disease.  Various  salts  of  mercury,  when 
given  internally,  operate  more  quickly  than 
mercurial  frictions  ; yet  there  are  many 
practitioners,  who  do  not  like  to  confide 
solely  in  any  internal  preparations  for  curing 
the  venereal  disease,  particularly,  when  the 
virus  has  produced  effects  in  consequence 
of  absorption.  We  shall  only  just  mention 
in  this  part  of  the  work,  that  rubbing  in 


MERCURY. 


233 


mercurial  ointment  is  the  mode  of  affecting 
the  system  with  mercury,  which  is  gene- 
rally considered  to  agree  best  with  most 
constitutions,  and  to  act  with  most  certainty 
on  the  venereal  disease. 

Mercurial  Fit migatio ns. 

We  have  mentioned  this  method,  as  being 
one  of  the  most  ancient  plans  of  affecting 
the  constitution  with  mercury,  and  Lalo- 
nette  and  Abernethy  have  stated  circum- 
stances in  its  favour,  which  certainly  render 
it  sometimes  a very  eligible  mode.  The 
latter  is  of  opinion,  that  if  the  peculiar  ad- 
vantages of  mercurial  fumigations  were  ge- 
nerally known  to  practitioners,  they  would 
be  much  more  frequently  employed.  The 
advantages  of  the  method  consist  in  its  af- 
fecting the  constitution,  when  other  means 
have  failed,  and  in  producing  its  effects  in  a 
much  shorter  time  than  any  other  mode  re- 
quires. How  desirable  this  celerity  of  ope- 
ration must  often  be,  when  venereal  ulcera- 
tion is  making  great  ravages  in  the  palate, 
throat,  &.c  it  is  needless  to  insist  upon.  In 
patients,  who  have  not  strength  to  rub  in 
ointment,  and  whose  bowels  will  not  bear 
the  internal  exhibition  of  mercury,  the  mode 
of  fumigation  may  prove  of  great  service. 

“ In  the  year  1776,  the  Chevalier  Lalo- 
nette,  a physician  at  Paris,  laid  before  the 
public  an  account  of  a new  mode  of  mercu- 
rial fumigation,  free  from  the  inconvenien- 
ces of  former  ones,  and  which  in  the  space 
of  thirty-five  years,  he  had  successfully  em- 
ployed in  more  than  four  hundred  cases, 
that  had  resisted  all  the  ordinary  methods 
of  cure.  His  method  consisted  in  enclosing 
the  patient,  previously  undressed,  in  a kind 
of  box  resembling  a sedan  chair,  with  an 
opening  at  the  top  to  let  out  the  head,  and 
another  at  the  bottom,  to  which  was  fitted  a 
small  grate  or  furnace,  having  in  it  a heated 
iron  for  converting  the  mercurial  remedy 
into  fume.  The  preparation  he  made  use  of 
was  a kind  of  calomel,  which  by  repeated 
sublimation  from  iron  filings,  was  so  far  de- 
prived of  its  muriatic  acid,  as  to  be  in  part 
reduced  into  running  quicksilver ; and,  while 
it  possessed  considerable  volatility,  was  per- 
fectly'unirritating.  Some  of  this  powder, 
being  strewed  upon  the  hot  iron  placed  be- 
low, was  immediately  converted  into  smoke, 
which  surrounded  the  patient’s  body,  and 
after  some  time  settled  on  his  skin  in  the 
form  of  a white  and  very  fine  calx  of  quick 
silver  : a complete  dress,  having  its  inner 
surface  fumigated  with  the  same  powder, 
was  then  put  on. — The  remedy  being  thus 
generally  applied  to  the  mouths  of  the  cu- 
taneous absorbents,  soon  got  admission  into 
the  circulating  fluids,  and  the  constitution 
became  thereby  more  speedily  affected  than 
by  any  other  process  known  before.”  {Aber- 
nethy's  Surgical  and  Physiological  Essays, 
Part  3.) 

As  the  fumigating  powder  used  by  M.  La- 
lonette  was  very  operose,  and  consequently 
a very  expensive  preparation,  and  appeared 
to  have  no  advantage  over  one  made  by 
abstracting  the  muriatic  acid  from  calomel 

Vor..  II  30 


by  means  of  ammonia.  Mr.  Abernethy  has 
always  employed  the  latter,  which  is  pre- 
pared at  the  hospital  in  the  following  man- 
ner: Two  drachms  of  liquor  ammoniae  are 
added  to  six  ounces  of  distilled  water,  and 
four  ounces  of  calomel  are  thrown  into  this 
liquor,  and  shaken  up  with  it;  the  powder 
is  afterward  separated  by  a filter,  and  dried. 

The  powder  th  is  obtained  is  of  a gray  co- 
lour, and  contains  a good  deal  of  quicksilver 
in  its  metallic  state,  which  of  course  is  ex- 
tremely volatile, but  becomes oxydated  when 
raised  into  fume,  and  afterward  condensed 
into  a white  subtile  powder. 

In  local  disease  of  the  joints,  such,  for  in- 
stance, as  frequently  takes  place  in  the  knee, 
and  in  sarcomatous  enlargements  of  the 
breast  in  women,  the  late  Mr.  Sharp  and  Sir 
C.  Blicke  were  accustomed  to  direct  fumi- 
gated stockings,  or  under- waistcoats,  to  be 
worn  ; by  which  these  complaints  were  re- 
lieved, and  the  constitutions  of  the  patients 
affected,  without  the  trouble  and  unplea- 
santness arising  from  the  use  of  the  common 
mercurial  ointment  (See  Abernethy's  Sur- 
gical and  Physiological  Essays,  Part  3.) 

Mr.  Pearson  procured  Lalonette’s  ma- 
chine, and  made  a considerable  number  of 
experiments  to  determine  the  comparative 
advantages  of  this  method,  and  mercurial 
frictions.  He  found,  that  the  gums  became 
turgid  and  tender  very  quickly,  and  that  the 
local  appearances  were  sooner  removed, 
than  by  the  other  modes  of  introducing 
mercury  into  the  system  ; but  that  it  soon 
brought  on  debility,  a rapid  and  premature 
salivation,  and,  of  course,  that  the  medicine 
could  not  be  steadily  continued.  This-  gen- 
tleman concludes,  that  where  checking  the 
progress  of  the  disease  suddenly  is  an  object 
of  great  mo  ment,  where  the  body  is  covered! 
with  venereal  ulcers,  or  where  the  eruptions 
are  large  and  numerous,  so  that  there  scarce- 
ly remains  a surface  large  enough  to  absorb 
the  ointment,  the  vapour  of  mercury  will 
be  advantageous.  But  he  thinks  it  extreme- 
ly difficult  thus  to  introduce  a sufficient 
quantity  of  mercury  into  the  system  to  se- 
cure the  patient  from  a relapse,  and  there- 
fore the  plan  by  no  means  eligible  as  a ge- 
neral practice.  The  vapour  of  mercury,  he 
says,  is  singularly  efficacious,  when  applied 
to  venereal  ulcers,  fungi,  and  excrescences; 
but  this  plan  requires  an  equal  quantity  of 
mercury  to  be  given  in  other  ways,  as  if  the 
local  application  itself  were  not  a mercurial 
one.  ( Pearson  on  Lues  Venerea , p.  145,  fyc.) 

For  the  purpose  of  fumigating  sores,  the 
hydrargyri  sulphuretum  rubrum  is  common- 
ly used.  Ulcers  and  excrescences  about  the 
pudendum  and  anus  in  women  are  said  to 
be  particularly  benefited  in  this  way  ; and 
in  these  cases  the  fumes  are  most  conveni- 
ently applied  by  placing  a red-hot  heater  at 
the  bottom  of  a night-stool  pan,  and  after 
sprinkling  on  it  a few  grains  of  the  red  sul- 
phuretof  quicksilver,  placing  the  patient  on 
the  stool  On  other  occasions,  a small  ap- 
paratus, sold  at  the  shops,  is  used,  which  en- 
ables the  surgeon  to  direct  the  fumes  through 
a funnel  against  the  ulcer  in  any  situation 


MERCURY. 


Though  mention  has  just  been  made  of  ve-  degree  of  soreness  of  the  gums,  and  (he 
vercat  excrescences,  L am  of  opinion  with  common  specific  effect  of  mercury  in  the 
Mr.  Abernethy,  that  it  is  very  questionable,  animal  system.  But  it  will  often  fail  of  re- 
whether  any  are  ever  really  of  this  nature,  moving  even  a recent  chancre  ; and  where 
[ know,  that  many  excrescences  and  verru-  the  symptom  has  vanished  during  the  ad- 
cae  about  the  anus,  and  parts  of  generation,  ministrations  of  corrosive  sublimate,  I have 
diminish  and  are  cured  by  a course  of  mer-  known  a three  month’s  course  of  that  medi- 
cury.  This  is  the  only  argument  in  favour  cine  fail  of  securing  the  patient  from  a con- 
of  their  being  venereal  ; for.  when  tied,  cut  stitutional  affection.  The  result  of  my  ob- 
oif,  or  made  to  fall  off  by  stimulating  them  servations  is,  that  simple  mercury,  calomel 
with  pulv.  sabina*,  and  the  subacetate  of  or  calcined  mercury,  are  preparations  more 
copper,  they  are  as  effectually  cured,  as  if  to  be  confided  in,  for  the  cure  of  primary 
mercury  had  been  given.  In  the  military  symptoms,  than  corrosive  sublimate.  The 


hospital  at  Cambray,  I remember  a man,  on 
whose  scrotum  there  were  several  warty  ex- 
crescences of  considerable  size.  Mr.  Booty, 
assistant  staff  surgeon,  prescribed  mercury, 
by  which  they  were  certainly  cured  with 
surprising  expedition  In  this  particular 
case,  I think  the  plan  of  treatment  adopted 
was  the  best,  because  on  account  of  the 
number  of  excrescences,  and  the  situation  of 
some  of  them  at  the  lower  and  back  part  of 
the  scrotum,  it  would  have  been  difficult  to 
have  treated  them  altogether  by  local  appli- 
cations. 

PREPARATIONS  FOR  INTERNAL  EXHIBITION. 

The  acetite  of  mercury  is  supposed  to  be  a 
mild  preparation,  and  was  the  active  ingre- 
dient in  the  celebrated  Keyser’s  pills.  In 
solution  it  has  also  been  recommended  to  be 
applied  externally  for  the  removal  of  some 
cutaneous  affections.  It  may  be  made  into 
pills  with  crum  of  bread.  The  dose  is  from 
one  to  five  grains  every  night. 

When  it  is  wished  to  excite  a salivation 
quickly,  when  mercurial  ointment  alone  will 
not  produce  this  effect,  or  cannot  be  em- 
ployed, and  when  fumigations  are  not  con- 
venient nor  agreeable,  the  hydrargyri  oxy- 
dum  rubrum  is  often  prescribed.  The  com- 
mon dose  is  a grain,  which  may  be  increa- 
sed to  two,  a day.  It  is  apt,  however,  to 
disagree  with  the  stomachs  and  bowels  of 
many  patients;  an  inconvenience  sometimes 
obviated  by  conjoining  the  preparation  with 
opium. 

At  present,  the  hydrargyrus  cum  creta  is 
rarely  or  never  prescribed  for  the  cure  of 
the  venereal  disease.  But  it  is  frequently 
prescribed  as  a mild  alterative  for  children 
in  doses  of  from  gr.  v.  to  gr.  x.  twice  a day, 
blended  with  any  viscid  substance. 

The  oxymuriate  of  mercury  (corrosive 
sublimate)  was  a medicine  highly  praised  for 
its  antisyphilitic  virtues  by  the  celebrated 
Van  Swieten,  and,  indeed, there  is  no  doubt, 
that,  like  other  preparations  of  mercury,  it 
possesses  such  qualities.  It  retains  great 
reputation,  even  now,  and,  probably,  will 
always  do  so.  However,  like  the  red  oxide, 
it  sometimes  deranges  the  stomach  and  bow- 
els, and  from  some  surgeons  does  not  receive 
the  same  degree  of  confidence,  in  respect  to 
its  power  over  syphilis,  as  mercurial  frictions. 
Mr.  Pearson  remarks,  that  “ when  the  subli- 
mate is  given  to  cure  the  primary  symptoms 
of  syphilis,  it  will  sometimes  succeed  ; more 
especially  when  it  produces  a considerable 


latter  will  often  check  the  progress  of  secon- 
dary symptoms  very  conveniently  ; and  I 
think  it  is  peculiarly  efficacious  in  relieving 
venereal  pains,  in  healing  ulcers  of  the 
throat,  and  in  promoting  the  desquamation 
of  eruptions.  Yet,  even  in  these  cases,  it 
never  confers  permanent  benefit ; for,  new 
symptoms  will  appear  during  tthe  use  of  it 
and,  on  many  occasions,  it  will  fail  of  afford- 
ing the  least  advantage  to  the  patient,  from 
first  to  last.  I do  sometimes,  indeed,  employ 
this  preparation  in  venereal  cases  ; but  it  is 
either  at  the  beginning  of  a mercurial  course, 
to  bring  the  constitution  under  the  influence 
of  mercury  at  an  early  period,  or  during  a. 
course  of  inunction,  with  the  intention  of 
increasing  the  action  of  simple  mercury.  I 
sometimes,  also,  prescribe  it  after  the  con- 
clusion of  a course  of  frictions,  to  support 
the  mercurial  influence  in  the  habit,  in  or- 
der to  guard  against  the  danger  of  a relapse. 
But.  on  no  occasion  whatever  do  l think  it 
safe  to  confide  in  this  preparation  singly  and 
uncombined,  for  the  cure  of  any  truly  vene 
real  symptom.”  ( Pearson  on  Lues  Venerea.) 

The  dose  of  oxymuriate  is  a quarter  of  a 
grain. 

The  following  is  a common  mode  of  or- 
dering it  : f^.  Hydrargyri  oxmuriatis  gr.  3 
Aquae  Nucis  Moscbatae  ^ij.  Misce.  ^ss.  Omni 
nocte  sumenda. 

The  muriate  of  mercury  (calomel)  is  not 
very  much  used  by  modern  surgeons  for  the 
cure  of  the  venereal  disease.  Sometimes, 
indeed,  it  is  given  in  cases  of  gonorrhoea, 
both  with  the  view  of  preserving  the  consti- 
tution from  infection,  and  keeping  the  bow- 
els regular.  It  is  more  extensively  given  as 
an  alterative,  and  for  the  cure  of  such  surgi- 
cal diseases  as  require  the  system  to  be 
slightly  under  the  influence  of  mercury.  It 
generally  proves  actively  purgative,  when 
more  than  two  or  three  grains  are  given. 

The  most  simple  preparations  of  mercury 
have  generally  been  deemed  the  most  effec- 
tual in  eradicating  the  venereal  disease.  The 
pilulae  hydrargyri  are  the  most  simple  of  the 
internal  formulae,  being  merely  mercury 
triturated  with  mucilaginous  or  saccharine 
substances.  Next  to  mercurial  frictions, 
they  are,  perhaps,  most  frequently  employed 
for  the  cure  of  the  incipient  form  of  the  ve- 
nereal disease,  that  is,  while  a chancre  is 
the  only  complaint.  They  are  also  very 
commonly  given  in  all  stages  of  the  disease, 
to  aid  mercurial  frictions  in  bringing  the  sys- 
tem under  the  influence  of  the  specific 
remedy.  Ten  grains  of  the  mass,  kept  for 


MOLLITIES  OSSIUM. 


235 


these  pills,  is  the  usual  dose.  When  they 
purge,  opium  will  sometimes  prevent  this 
effect.  See  Venereal  Disease. 

Mercury  is  employed  both  constitutional- 
ly and  locally  in  numerous  surgical  cases  ; 
for  the  removal  of  indolent  thickenings  and 
indurations  o:  parts  ; for  the  relief  of  porri- 
go,  herpetic  diseases,  tetanus,  hydrophobia, 
hydrops  articuli,  iritis,  and  a multitude  of 
other  affections,  which  need  not  here  be  spe- 
cified. 

MEROCELE.  (from  yuego?,  the  thigh,  and 
a tumour.)  A femoral  or  crural  hernia. 
See  Hernia. 

MEZEREON  was  recommended  by  Dr. 
A.  Russell  for  a particular  class  of  venereal 
symptoms,  in  the  following  terms  : “ The 
disease,  for  which  I principally  recommend 
the  decoction  of  the  mezereon  root  as  a cure, 
is  the  venereal  node  that  proceeds  from  a 
thickening  of  the  membrane  of  the  bones. 
In  a thickening  of  the  periosteum,  from 
other  causes,  I have  seen  very  good  effects 
from  it : and  it  is  frequently  of  service  in  the 
removal  of  those  nocturnal  pains,  with 
which  venereal  patients  are  afflicted  ; though, 
in  this  last  case,  excepting  with  regard  to  the 
pain  that  is  occasioned  by  the  node,  I own  I 
have  not  found  its  effects  so  certain,  as  1 at 
first  thought  I had  reason  to  believe.  I do 
not  find  it  of  service  in  the  cure  of  any  other 
symptom  of  the  venereal  disease.  {Med. 
Obs.  and  Inq.  Vol.  3,  p.  194,  195.)  Mr.  Pear- 
son, however,  asserts,  unequivocally,  that 
mezereon  has  not  the  power  of  curing  the 
venerea]  disease  in  any  one  stage,  or  under 
any  one  form,  and  if  the  decoction  should 
ever  reduce  the  venereal  node,  yet  there  will 
be  a necessity  for  taking  mercury  in  as  large 
quantity,  and  for  as  long  a time,  as  if  no 
^mezereon  had  been  exhibited.  Cullen  found 
this  medicine  of  use  in  some  cutaneous  af- 
fections, but,  excepting  an  instance  or  two 
of  lepra,  Mr.  Pearson  has  very  seldom  found 
it  possessed  of  medicinal  virtue,  either  in  sy- 
philis, or  the  sequela?  of  that  disease,  scro- 
fula, or  cutaneous  affections.  ( Pearson  on 
Lues  Venerea,  p.  55,  59.) 

As  the  possibility  of  curing  most  forms  of 
the  venereal  disease,  not  only  without  mer- 
cury, but  without  any  internal  medicines 
whatever,  is  now  well  established,  it  is  diffi- 
cult to  know  what  degree  of  importance  to 
attach  to  observations,  declaring  certain  ar- 
ticles of  the  materia  medica  efficient  or  inef- 
ficient in  the  cure  of  that  disease  ; because,  if 
it  admit  of  a spontaneous  cure,  but  will  not 
get  well  when  mezereon,  or  any  other  parti- 
cular medicine  is  exhibited,  we  are  necessa- 
rily-obliged to  suppose,  that  such  medicine 
is  worse  than  useless. 

MODIOLUS.  The  crown  or  saw  of  a 
trepan. 

MOLLITIES  OSSIUM.  A morbid  soft- 
ness of  the  bones,  which  become  preterna- 
turally  flexible,  in  consequence  either  of  the 
inordinate  absorption  of  the  phospate  of 
lime,  from  which  their  natural  solidity  is  de- 
rived, or  else  of  this  matter  not  being  duly 
secreted  into  their  texture.  The  bones  af- 
fected become  specifically  lighter.  ( Sail - 


lant,  Hist,  de  la  Soc.  Royale  de  Med.  T.  8.) 
Dr.  Bostock  made  some  experiments,  with 
the  view  of  ascertaining  the  proportion  of 
earthy  matter  in  bones  affected  with  molli- 
fies : he  examined  a dorsal  vertebra  of  a 
woman  whose  bones  were  found  soft  and 
flexible  after  her  decease.  In  one  part  of 
the  diseased  bone,  he  found,  that  the  quanti- 
ty of  earthy  matter  only  amounted  to  one- 
fifth  of  its  weight,  and  in  another,  only  to 
one-eighth,  while  the  proportion  in  healthy 
bones  amounted  to  more  than  one  half  of 
their  whole  weight.  (See  Med.  Chir.  Trans. 
Vol.  4,  and  Wilson  on  the  Bones  and  Joints, 
p.  253.)  In  rickets,  the  bones  yield  and  be- 
come distorted  only  by  slow  degrees,  and 
retain  their  natural  inflexibility  ; but,  in  the 
present  disease,  they  may  be  at  once  bent  in 
any  direction,  and  frequently  admit  of  being 
readily  divided  with  a knife.  The  mollifies 
ossium  is  an  exceedingly  uncommon  disease, 
and  its  causes  are  buried  in  obscurity.  It  is 
supposed,  however,  to  depend  upon  some 
peculiar  state  of  the  constitution,  and  the  in- 
dividuals, attacked  with  it,  have  been  re- 
marked to  be  mostly  about,  or  rather  be- 
yond, the  middle  period  of  life,  {J.  Wilson , 
Vol.  cit.  p.  252.)  and  generally,  if  not  always, 
women.  (Neumann  in  Abhandl.  der  K.  K. 
Josephs  Acad.  2 B.  p.  173  ; Portal  Cours 
d'Anatomie,  T.  1,  p.  15.)  One  instance,  how- 
ever, is  reported,  in  which  the  patient  was  a 
young  man  seventeen  years  of  age.  ( Thom - 
massin,  in  Journ.  de  Med.  T.  43.  p.  222.) 
Surgical  writers  have  usually  considered 
mollities  and  fragilitas  ossium  as  two  dis- 
tinct and  different  affections.  Boyer  thinks, 
however,  that  this  point  is  by  no  means  well 
established.  He  admits,  that  there  have 
been  a few  rare  instances  of  mollities,  where 
the  bones  were  completely  flexible,  without 
any  degree  of  fragility.  But,  he  contends, 
that  in  almost  all  the  cases  on  record,  the 
fragilitas  and  mollifies  have  been  combined. 
He  regrets  that  bones,  affected  wfith  fragility, 
have  never  been  chymically  nor  anatomi- 
cally examined,  particularly  as  there  have 
been  persons  who,  while  living,  merely  be- 
trayed the  symptoms  of  mollities  ossium, 
yet,  in  whom  unsuspected  fractures,  evi- 
dently of  long  standing,  were  discovered 
after  death  ; while  other  fractures  also  hap- 
pened from  the  slightest  causes  during  the 
examination  of  the  same  bodies.  (See  Boyer , 
Traite  des  Maladies  Chir.  T.  3,  p.  607 — 609.) 
The  truth  of  these  observations  is  well  illus- 
trated in  the  case  lately  reported  by  Mr. 
Wilson.  (On  the  Bones,  fyc.  p.  254.)  In  the 
present  place,  I shall  merely  describe  the 
pure  mollities  ossium,  or  that  disorder  of  the 
bones,  in  which  they  become  completely 
flexible,  and  lose  all  their  natural  firmness. 
And  in  order  to  give  an  idea  of  the  disorder, 
I shall  quote  the  case  of  Madame  Supiot. 
In  the  year  1747  she  had  a fall  which  occa- 
sioned her  to  keep  her  bed  for  some  time, 
and  left  great  pain  and  weakness  in  her 
loins  and  lower  extremities.  In  about  a 
year  and  a half  afterwrard,  she  began  to  per- 
ceive her  left  leg  particularly  affected. 
Along  with  this  weakness,  she  had  violent 


MGLLIT1ES  OSSIUM. 


Hid 


pains  over  her  whole  body,  which  increased 
after  a miscarriage,  and  still  more  alter  a 
natural  delivery,  in  the  year  1751.  She  was 
now  seized  with  startings,  great  inquietude, 
and  such  violent  heats,  that  she  was  almost 
continually  in  a sweat,  and  could  not  In-ar 
the  least  covering  even  in  the  coldest  wea- 
ther, and  while  her  pains  continually  increa- 
sed, she  took  notice  that  her  urine  precipi- 
tated a white  sediment.  Her  pains  abated 
on  the  appearance  of  the  sediment,  but  she 
now  observed  that  her  limbs  began  to  bend, 
and  from  this  time  the  softness  of  them  gra- 
dually increased  till  her  death.  In  the 
month  of  April,  1752,  the  trunk  of  the  body 
did  not  exceed  23  inches  in  length  ; the 
thorax  exceedingly  ill  formed,  and  the  bones 
of  the  upper  part  very  much  distorted  ; those 
of  the  lower  part  were  very  much  bent,  and 
the  thigh  bones  became  so  pliable  that  her 
feet  might  easdy  be  laid  on  each  side  of  her 
head.  The  right  side  did  not,  till  after  some 
time,  become  so  deformed  as  the  left;  but 
it  was  surprising  to  observe  the  alterations 
which  daily  took  place,  and  the  different 
figures  assumed  by  the  limbs,  in  conse- 
quence of  the  increased  softness  .of  the 
bones  ; so  that  when  the  sediment  in  the 
urine  was  considerable,  the  disease  of  l he 
bones  seemed  to  be  at  a stand,  increasing 
considerably  when  it  was  suppressed.  Be- 
sides this,  she  had  violent  pains,  startings, 
difficulty  of  breathing,  spitting  of  blood,  and 
lastly,  a fever,  with  convulsions.  She  d.ed 
in  the  beginning  of  November,  1752  and, 
on  dissecting  her  body,  the  following  ap- 
pearances were  observed  : 1 The  muscles 
in  general  were  of  a very  soft  and  pale  con- 
sistence, the  vastus  externus,  fascialis,  qua 
driceps,  biceps,  and  external  parts  of  the 
gracilis,  were  much  shorter  than  in  their  na- 
tural state,  and  more  firm  and  tense  ; while 
those  on  the  opposite  side  were  much  elon- 
gated, thin,  and  very  tender;  in  short,  the 
whole  muscular  system  had  sulfered  more 
or  less,  according  to  the  action  of  the  mus- 
cles in  her  Jifetime.  2.  The  bones  were 
entirely  dissolved,  the  periosteum  remaining 
unhurt,  so  that  they  exhibited  only  the  form 
of  a cylinder.  3.  The  heart  and  large  blood- 
vessels, both  veins  and  arteries,  contained 
large  black  polypi,  of  a viscid  consistence, 
and  very  unlike  those  usually  found  in  dead 
bodies. 

A case  of  softness  of  the  bones  is  related 
by  Mr.  Gooch,  but  considerably  different 
from  the  above,  as  it  was  attended  with  a 
remarkable  fragility  of  them  before  they 
became  soft.  It  likewise  began  with  pains 
through  the  whole  body,  attended  with  fe- 
verish symptoms ; but  after  some  weeks, 
these  pains  were  confined  chiefly  to  the  legs 
and  thighs,  and  they  were  not  increased  by 
pressure.  This  fragility  of  the  bones  does 
not  appear  to  have  been  the  case  u ith  Ma- 
dame Supiot.  In  the  month  of  June,  17-19, 
]Vlr.  Gooch’s  patient  broke  her  leg  in  walk- 
ing from  her  bed  to  a chair,  and  heard  the 
bone  snap.  No  callus,  however,  formed, 
though  the  fracture  was  instantly  reduced, 
and  treated  by  one  of  the  best  surgeons  iu 


her  part  of  the  country  ; but  instead  of  this, 
the  bones  began  to  grow  flexible,  and  in  a 
few  months,  were  so  from  the  knee  to  the 
ankle.  The  disease  still  continued  to  in 
crease,  so  that,  in  a short  time,  the  other 
leg  and  thigh  were  atfected  in  the  same 
maimer,  after  which  both  legs  became  cede 
matous,  liable  to  excoriations,  and  to  dis- 
charge a thin  yellow  ichor.  Scorbutic 
symptoms  began  to  appear  in  the  winter 
after  the  leg  was  broken,  and  her  gums  be- 
gan to  bleed.  Tonic  medicines  were  exhi- 
bited without  any  success,  except  that  her 
menstruation  became  more  regular,  and  her 
appetite  and  digestion  better  than  before  ; 
but  towards  the  end  of  her  life,  her  breathing 
became  difficult,  the  spine  distorted,  and  a 
pain  in  the  loins  took  place  upon  every 
motion  of  the  vertebra; : and  as  her  limbs 
were  now  quite  useless,  she  was  obliged  to 
sit  upright  in  bed.  At  last,  trie  ends  of  the 
bones  on  which  she  sat,  having  become 
also  very  soft,  spread  much,  and  the  ends  of 
her  lingers  and  thumbs,  by  frequent  endea- 
vours to  raise  herself,  became  also  very 
broad  and  the  phalanges  crooked.  The 
flexibility  of  the  bones  gradually  increased, 
and  became  more  general,  attended  with  a 
wasting  of  the  flesh,  and  excessive  difficulty 
of  breathing.  Hie  menstrual  flux  totally- 
ceased  four  months  before  her  death  ; her 
legs,  which  were  anasarcous,  and  excoriated 
almost  all  over,  became  erysipelatous;  but 
she  retained  her  senses  to  the  last.  She  ex- 
pired suddeidy,  having  talked  in  a composed 
manner  concerning  her  miserable  situation 
and  approaching  end  only  a few  moment* 
before. 

On  examining  the  body,  she  was  found 
to  have  lost  two  feet  two  inches  of  her  na- 
tural stature.  The  heart  and  lungs  appear-* 
ed  sound,  but  had  been  much  confined, 
principally  by  the  liver,  which  was  enlar- 
ged in  an  extraordinary  degree  ; it  was  not, 
however,  scirrhous,  nor  in  any  other  way- 
diseased.  The  spleen  was  very  small,  and 
the  mesentery  had  one  large  scirrhous 
gland.  All  the  bones,  except  the  teeth, 
were  softened,  so  that  scarcely  any  of  them 
could  resist  the  knife  ; but  those  of  the 
lower  extremities  were  the  most  dissolved, 
being  changed  into  a kind  of  parenchymous 
substance,  like  s >ft  dark-coloured  liver, 
without  any  offensive  smell.  So  complete- 
ly, indeed,  were  they  decomposed,  that  the 
knife  met  with  less  resistance  in  efttting 
through  them  than  in  sound  muscular  flesh, 
though  some  bony  lamella;  were  here  and 
there  to  be  met  with,  but  as  thin  as  an  egg- 
shell. The  most  compact  bones,  and  those 
which  contained  the  greatest  quantity  of 
marrow,  were  the  most  dissolved;  and  it 
was  observable,  that  the  dissolution  began 
internally,  for  the  bony  lamina;  remained 
here  and  there  on  the  outside,  and  nowhere 
else.  The  periosteum  was  rather  thicker 
than  ordinary,  and  the  cartilages  thinner  ; 
bul  not  in  a state  of  dissolution.  The  bones 
were  found  to  contain  a great  quantity  of 
oily  matter  and  little  earth.  No  cause  could 
be  assigned  for  the  disease ; and  in  the  ease 


MORTIFICATION 


237 


of  Madame  Supiet,  the  one  assigned,  viz. 
that  of  her  eating  too  much  salt,  seems  to- 
tally inadequate  to  explain  the  origin  of  the 
disorder.  All  the  cases  of  mollities  ossium 
on  record  have  proved  fatal,  and  no  means 
of  cure  are  yet  known. 

For  additional  observations,  connected 
with  this  subject,  reter  to  tragilitas  Ossium 
and  Rickets.  Royer  and  Kicherand  treat  ot 
the  mollities  ossium,  and  rickets,  as  one  and 
the  same  disease.  Rut,  as  Mr.  Wilson  ob- 
serves, the  first  difters  trom  rickets,  in  at- 
tacking people  of  middle  age,  or  rather 
older,  and  not  particularly  children  ; and  it 
differs  also  in  the  change  produced  in  the 
bones  themselves,  which,  when  dried,  do 
not  appear  as  if  they  had  been  long  steeped 
in  weak  acid,  with  their  animal  part  nearly 
unchanged  ; but  both  the  phospnat  ot  Ihne 
and  the  animal  matter  appeal  to  have  been 
absorbed,  so  as  to  leave  mere  shells,  which 
are  also  softer  than  natural  bone  of  the 
same  thickness.  Mr.  Wilson  further  inform's 
us,  that  large  cavities  are  met  with  in  the 
substance  of  tbe  bones,  and  sometimes  com- 
municate with  the  soft  parts  surrounding 
them.  In  some  of  these  c..viiies  is  contain- 
ed oily  matter,  like  boiled  marrow  ; and  in 
others,  masses  of  coagulated  blood,  and  a 
soft  inorganic  substance.  ( J . Wilson  on  the 
Bones , ty-c.  p.  253.  Acrel,  Diss.  Descriplion- 
em  et  Casus  aliquot  Osteomalacia:  sistens;  Up- 
sal,  1788.  Morandin  Joura.des  Savans,  1792, 
et  M6m.  de  VAcad  des  Sciences , i 752.  Morand , 
junr.  in  Mem.  de  l' Acad,  des  Sciences , 1764, 
p.  206.  See  also  T.  Lambert , Relation  de  la 
Matadie  de  Bernard  d'Armagnac,  sur  un 
Ramollissement  des  Os  ; Toulouse,  170o.  Fer- 
nelius , in  lib.  de  abditis  rerum  causis.  Th. 
Bartholinus,  Hist.  Auat.  Cent.  4.  P til , 
Histoire  d6  l' Acad,  des  Sciences,  1722.  Horn, 
ibid.  1764.  Gagliardie,  Anatomes  Ossium, 
Romes , 1789.  C.  G Ludwig,  Pro^ratnma, 
quo  observata  in  sectione  Cudaveris  Fcemina 
cujus  ossa  emollita  erant  proponit ; Lips  1757. 
Fries,  Dissert.de  Emolliti one  Jssium,  Argent- 
tor.  1775.  Thompson  m Med. Ob  e cations  and 
Inquiries.  Vol.  5.  p.  259.  Chirurgiccu  Ob- 
servations and  Cases,  by  Wiilium  Bromjield, 
Vol.  2,  p.  50,  4-’C.  Boyer,  i r ait e des  Maladies 
Chir.  T.  3,  p.  607,  s,c.  Pa  is,  lb  14.  tiiche- 
rand,  JYosogr.  Chir.  T.  •>.  p 14 2.  What  these 

two  writers  say , however,  chiefly  relates  to 
rickets.  We  meet  with  casi  s of  Mollities 
Ossium  in  the  Philosophical  Transactions ; 
Act.  Haffniens  ; Ephem.JVat.  Cur. ; Sudani's 
Obs  Chir.  ; the  writings  of  Foresius ; Gooch's 
Chirurgical  Works,  Vol.  2 ,p.  593 — 399.  Ed. 
1792,  ty-c.  James  W.san  Lectures  on  the 
Structure  and  Bhysiology  of  the  Paris  com- 
posing the  Skeleton  ; and  on  the  Diseuses  of 
the  Bones  and  Joints,  p.  252,  <£-c.  8co.  Load. 
1820.) 

MONOCULUS.  (from  ptova?,  single,  and 
oculus,  the  eye.)  A bandage  formerly  ap- 
plied to  the  fistula  lacbrymalis,  and  diseases 
of  the  eye.  It  consists  of  a single-headed 
roller  three  ells  iong^  In  order  to  apply  it 
to  the  right  eye,  it  is  to  be  held  in  the  hand, 
and  its  end  in  the  left?  et  vice  versa.  This 


end  is  to  be  put  on  the  back  of  the  neck,  and 
one  turn  of  the  roller  is  to  be  carried  round, 
over  the  forehead,  so  as  to  meet  the  ex- 
tremity of  the  bandage.  The  roller  is  then 
to  descend  under  the  ear  of  the  side  affected, 
and  to  pass  obliquely  over  the  cheek  under- 
neath the  eye,  and  next  over  the  root  of  the 
nose,  and  opposite  the  parietal  bone,  to  the 
nape  of  the  neck.  The  third  turn  of  the 
roller  is  to  overlap  the  second  a little  : the 
third  the  fourth  ; making  what  the  French 
call  doloires ; and  the  application  of  the  ban- 
dage is  completed  by  making  turns  round 
the  head,  l he  use  of  the  monoculus  was 
only  to  retain  dressings.  ( Encyclopedic 
Mcthodique  ; Partie  Chir.) 

MORTIFICATION  is  of  two  kinds;  the 
one,  without  inflammation;  the  other,  pre- 
ceded by  it.  To  this  last  species  of  mortifi- 
cation, the  terms  inflammatory,  humid,  or 
acute  gangrene,  are  often  applied,  while 
the  second,  or  that  which  is  not  preceded 
by  any  or  much  inflammation,  has  been 
distinguished  by  the  epithets,  dry  or  chronic, 
and  sometimes  idiopathic,  when  no  cause 
for  the  origin  of  the  disease  can  be  assigued. 
According  to  Mr.  Hunter,  inflammation  is 
an  increased  action  of  that  power,  which  a 
part  naturally  possesses  ; and  in  healthy  in- 
flammations, at  least,  ii  is  probably  attended 
with  an  increase  of  power.  In  cases,  how- 
ever, which  are  to  terminate  in  mortifica- 
tion, there  is  no  increase  of  power  ; but,  on 
the  contrary,  a diminution  of  it.  This,  when 
joined  to  an  increased  action,  becomes  a 
cause  of  mortification,  by  destroying  the 
balance,  which  ought  to  subsist  between  the 
power  and  action  of  evt-ry  part,  i here  are, 
besides,  cases  of  mortification,  preceded  by 
inflammation,  which  do  not  arise  holly 
from  that,  as  a cause  : of  this  kind,  are  the 
carbuncle  and  the  slough  formed  in  the 
small-pox  pustule.  (Hunter.) 

The  first  general  division  of  mortification, 
therefore,  is  into  two  kinds;  first,  into  the 
inflammatory,  humid , or  acute;  and  secondly, 
into  the  dry,  or  chronic.  Rut  the  disorder  is 
also  subdivided  into  many  species,  which 
are  determined  by  the  nature  of  tneir 
particular  exciting  causes,  as  will  be  present- 
ly detailed. 

However,  it  is  remarked,  that  acute,  or 
rapid  mortifications,  are  not  necessarily  hu- 
mid, as  the  slougu  from  the  application  kali 
purum  proves,  and  the  c onverse  also  is  true 
in  some  cases  of  sphacelus  senilis  ( James 

on  Inflammation,  p.  96.)  Another  modern 
writer  also  asserts,  tnat  mortification  from 
wounds  and  external  injuries  may  be  either 
humid,  or  dry*  or  of  both  kinds  together, 
where  tlie  circumstances  are  particular. 
(Guthrie  on  Gunshot  Wounds , fyc.p.  122,  Ed. 
2.)  The  doctrine  also  that  any  case  of 
mortification  is  entirely  without  inflamma- 
tion, has  sometimes  been  deemed  question- 
able ; and  Mr.  James  expresses  bis  belief 
that  the  disorder  is  generally  preceded  by 
inflammation,  and  invariably  accompanied 
with  some  degree  of  it.  And,  says  he., 
“ w hether  mortification  be  a consequence  of 


MORTIFICATION. 


238 


inflammation,  or  not,  it  may,  perhaps,  with 
reason  be  considered,  as  standing  in  the 
same  relation  to  inflammation,  as  adhesion, 
suppuration,  or  ulceration  : they  may  all  be 
preceded  by  a high  degree,  or  it  may  be 
scarcely  sensible.”  (P.  84,  85,) 

When  any  part  of  the  body  loses  all  mo 
tion,  sensibility,  and  natural  heat,  and  be- 
comes of  a brown,  livid,  or  black  colour,  it 
is  said  to  be  atfected  with  sphacelus , that  is, 
complete  mortification.  As  long  as  any 
sensibility,  motion,  and  warmth,  continue, 
the  state  of  the  disorder  is  termed  gangrene 
This  word  is  here  made  use  of  to  signify 
only  a degree  of  sphacelus,  or  rather  the 
process,  by  which  any  local  disorder  falls 
into  the  state  of  complete  mortification. 
Many  authors  use  both  terms  synonymously ; 
but  it  is  to  be  observed,  that  gangrene  does 
not  invariably  end  in  sphacelus  ; nor  is  the 
latter  always  preceded  by  the  former. 
( Richler , Anfangsgr.  der  IVundarzn.  B.  1, 
Kap.  3.)  There  are  some  surgical  writers, 
who  make  the  distinguishing  circumstance 
of  sphacelus  to  be  the  extension  of  the  disor- 
der to  the  bones  as  well  as  the  soft  parts. 
( Lassus . Pathologie  Chir.  T.  1 , p.  30,  Ed. 
1809.) 

At  present,  however,  this  last  application 
of  the  term  sphacelus  is  never  made  ; for,  as 
Mr.  Pearson  has  rightly  observed,  the  dis- 
tinctions, “ which  are  founded  merely  upon 
the  parts,  that  suffer,  or  upon  the  profundity, 
to  which  the  disease  has  penetrated,  seem 
inadequate  and  useless.”  ( Principles  of 
Surgery , p.  115,  Ed.  2)  The  manner,  in 
which  Dr.  J.  Thomson  views  the  subject, 
may  be  considered  as  coinciding  with  the 
general  sentiments  of  the  best  modern  sur- 
geons. “ I shall  employ  the  term  gangrene, 
(says  he)  to  express  that  state  of  mortifica- 
tion, in  inflamed  parts,  which  precedes  the 
death  of  the  part ; a stage,  in  which  there  is 
a diminution,  but  not  a total  destruction  of 
the  powers  of  life  ; in  which  the  blood  ap- 
pears to  circulate  through  the  larger  vessels  ; 
in  which  the  nerves  retain  a portion  of  their 
sensibility  ; and  in  which,  perhaps,  the  part 
affected  may  still  be  supposed  to  be  capable 
of  recovery.  The  word  sphacelus,  I shall 
use  to  denote  the  complete  death,  or  mor- 
tification of  a part ; that  state,  in  which  the 
powers  of  life  have  become  extinct  ; in  which 
the  blood  ceases  to  circulate  ; and  in  which 
the  sensibility  of  the  nerves  is  lost,  whether 
the  dead,  or  mortified  part  has,  or  has  not, 
become  actually  putrid,  or  shown  any  ten- 
dency to  separate  and  fall  away  from  the 
living  and  sound  parts.  Putrefaction  or  the 
spontaneous  process,  by  which  animal  ho  lies 
are  decomposed,  is  an  accidental,  and  not  a 
necessary  effect  of  the  state  of  mortification. 
It  takes  place  at  very  different  periods,  after 
the  death  of  particular  parts ; and  these 
periods,  it  may  be  remarked,  are  always 
regulated,  not  only  by  external  circumstan- 
ces, such  as  the  humidity  and  temperature 
of  the  atmosphere,  but,  also,  by  the  peculiar 
structure  and  morbid  conditions  of  the  ani- 
mal texture,  or  organ,  in  which  the  putre- 
faction occurs.  The  term  sphacelus,  has,  1 


know,  been  employed  to  express,  that  a part 
is  not  only  completely  dead,  or  mortified, 
but,  also,  that  that  part  has  become  putrid, 
and  is  in  a state  of  separation  from  the  sur- 
rounding and  living  parts.  But,  as  putrefac- 
tion is  not  a necessary,  or  immediate  conse- 
quence of  mortification,  or  partial  death  in 
animal  bodies,  this  use  of  the  term  sphacelus 
is  obviously  improper.”  (See  Thomson’s 
Lectures  on  Inflammation,  p.  504  ) 

The  causes  of  mortification  are  either 
internal,  or  external.  It  is  commonly  taught 
in  the  medical  schools  on  the  continent,  that 
the  internal  ca  ises  probably  operate  after 
the  rna oner  of  a deleterious  substance, 
vhich  being  introduced  into  the  circulation, 
occasions  a putrefaction  of  the  fluids.  ( Lassus , 
op.  et  loc.  cit.) — Boyer  also  professes  a simi- 
lar notion,  (See  Trnite  des  Maladies  Chir.  T. 
1,  p.  140.)  as  well  as  Larrey  in  his  account 
of  traumatic  gangrene  ; a statement,  which 
has  drawn  forth  the  criticisms  of  Mr.  Gu- 
thrie. The  doctrine  is  supported  by  no  sort 
of  proof,  and  may  be  considered  as  entirely 
hypothetical,  if  not  decidedly  erroneous. 
There  .are,  indeed,  as  Boyer  has  noticed, 
some  spontaneous  mortifications,  the  primi- 
tive cause  of  which  is  not  always  well  un- 
derstood : an  inflammation,  apparently  slight, 
may  become  gangrenous  immediately  it  has 
made  its  appearance.  In  scorbutic,  venere- 
al, and  small-pox  cases,  we  have  daily  in- 
stances of  this  fact  Other  internal  causes, 
without  any  very  evident  pre-existing  dis- 
ease, sometimes  destroy  persons,  bv  gan- 
grenous mischief,  who  are  but  little  advanced 
in  years.  ( Saviard . Obs.  16.  Haller , Disput. 
Chir.  T.4,/7.551.)  Certain  poisonous,  acrid, 
caustic  substances  taken  inwardly,  or  intro- 
duced under  the  skin,  may  have  the  same 
effect,  by  annihilating  the  vital  action,  or 
destroying  the  texture  of  the  paris.  ( Lassus , 
Pathologie  Chir  T.  1 , p.  31.)  But,  though 
these  observations  may  all  be  entirely  cor- 
rect, they  by  no  means  justify  the  conclusion, 
that  the  internal  causes  of  mortification  ever 
act  like  a deleterions  matter  producing  a 
putrefaction  of  the  fluids.  The  mortification 
of  the  toes  and  feet  so  well  described  by 
Mr.  Fott,  is  supposed  to  proceed  chiefly  from 
unknown  internal  causes,  though  sometimes 
attended  with  an  ossified  state  of  the  arte- 
ries. 

Another  remarkable  specimen  of  mortifi- 
cation from  an  internal  cause,  is  that  origin- 
ating from  eating  bread  made  of  bad  black 
wheat,  or  rye.  Besides  occurring  as  an 
original  idiopathic  disease,  and  from  obstruc- 
tion of  arteries,  chronic,  or  dry  gangrene 
(observes  Dr.  Thomson)  may  be  induced 
by  the  action  of  substances  taken  into  the 
stomach,  which  seem  to  produce  it  as  a spe- 
cific effect  in  parts  remote  from  the  source 
of  the  circulation.  The  most  singular  ex- 
ample, which  we  have  of  this,  is  in  the  gan- 
grene produced  by  the  eating  of  a particular 
kind  of  unsound  or  diseased  rye.  This 
species  of  mortification  has  been  rarely- 
observed  in  England  ; but  it  lias  been  fre- 
quently seen  on  the  continent,  where  it  has 
been  repeatedly  known  to  prevail  in  som 


MORTIFICATION. 


239 


districts,  where  rye  forms  a principal  article  alone.  In  others,  Noel  was  obliged  to  have 


of  food,  as  an  endernial  disease.  It  occurs, 
however,  in  such  districts  only  after  wet 
seasons,  in  which  that  grain  is  affected  with 
a particular  disease,  well  known  in  France 
by  the  name  of  the  Ergot , or  cockspur  rye. 
In  this  disease,  the  grains  of  rye  grow  to  a 
large  size,  acquire  a black  colour,  and  have 
a compact  horny  consistence.  The  species 
of  mortification,  produced  hy  eating  this 
substance,  was  first  particularly  described 
by  Dodard.  (See  Journ.  des  Savans,  an. 
1676.)  The  part  affected  became  at  first 
insensible  and  cold,  and,  in  the  progress  of 
the  disorder,  dry,  hard,  and  withered.  In 
very  malignant  cases,  there  was  delirium. 
Dodard’s  description  of  the  complaint  was 
very  imperfect ; but  he  has  mentioned  a 
circumstance,  tending  strongly  to  prove, 
that  the  disease  actually  arose  from  the 
alleged  cause  ; viz.  that  fowls,  fed  with  cock- 
spur rye,  are  killed  by  it.  Saviard  informs 
us,  that  he  saw  this  disease  in  the  year  1694, 
at  the  Hotel  Dieu  of  Orleans  It  attacked 
the  upper  and  lower  extremities,  which 
were  rendered,  in  the  course  of  the  disorder, 
as  dry  as  touch-wood,  and  as  emaciated  as 
Egyptian  mummies.  In  1710,  Noel,  sur- 
geon to  the  Hotel  Dieu  at  Orleans,  transmit- 
ted to  the  Royal  Academy  of  Sciences  at 
Paris  an  account  of  this  peculiar  mortifica- 
tion. About  fifty  people,  men  and  children, 
had  come  that  season  into  his  hospital,  with 
the  affliction.  According  to  Noel,  the  disor- 
der always  began  in  the  toes,  and  extended 
itself  gradually  along  the  foot  and  leg,  till  it 
sometimes  rose  to  the  upper  part  of  the 
thigh.  He  had  never  seen  any  of  the  female 
sex  affected  with  it,  and  had  observed  only 
one  instance  of  it  in  the  upper  extremities. 
The  Academy  received  the  history  of  one 
case,  in  which  the  lower  extremities  were 
separated  from  the  body  in  the  articulations 
of  the  thigh-bones  with  the  acetabula  ; the 
first  example,  (Dr.  Thomson  believes)  of  this 
separation  upon  record  ; and  it  was  the  oc- 
currence of  this,  and  of  similar  cases,  that 
probably  first  suggested  the  operation  of  am- 
putation at  the  hip-joint.  (See  Thomsons 
Lectures  on  Inflammation,  p.  54E)  As  Noel’s 
patients  did  not  come  under  his  care,  till 
after  the  disease  had  existed  some  time,  he 
could  not  describe  from  his  own  observation 
the  early  symptoms  ; but  the  patients  had 
often  told  him,  that  the  disease  generally 
began  in  one,  or  both  feet,  with  pain,  red- 
ness, and  a sensation  of  heat,  as  burning  as 
the  fire  ; and  that,  at  the  end  of  some  days, 
these  symptoms  ceased,  as  quickly  as  they 
had  come  on,  when  the  extreme  sensation 
of  heat,  which  they  had  formerly  felt,  was 
changed  into  cold.  The  part  affected  (adds 
Noel)  was  black,  like  a piece  of  charcoal, 
and  as  dry  as  if  it  had  passed  through  the 
fire.  After  some  time,  a line  of  separation 
was  formed  between  the  dead  and  living 
parts,  like  that  which  appears  in  the  separa- 
tion of  a slough  produced  by  the  cautery  ; 
and  the  complete  separation  of  the  limb 
was,  in  many  cases,  affected  by  nature 


recourse  to  amputation. 

This  disease  appeared  in  Switzerland  in 
1709  and  1716,  and  its  symptoms  and  pro- 
gress in  that  country  have  been  accurately 
described  by  Langius  in  a dissertation,  enti- 
tled, “ Descriplio  Morborum  ex  esu  Clavo- 
rum  Secalinorum." 

Gassaud,  physician  in  Dauphiny,  where 
this  disease  appeared  also  in  1709,  states, 
that  many  of  the  patients  were  affected  with 
swellings  of  the  feet  and  legs,  and  of  the 
hands  and  arms,  which  degenerated  into  a 
gangrene,  that  penetrated  to  the  bone,  and 
produced  a separation  of  the  affected  limb. 
The  disorder  wras  attended  with  different 
symptoms  in  different  individuals.  Some 
suffered  very  violent  pain,  accompanied  by 
an  insufferable  sensation  of  heat,  although 
the  part  affected  often  felt  cold  to  the  touch. 
In  other  patients  redness,  with  much  swell- 
ing, supervened,  attended  with  fever  and 
delirium.  Other  patients  were  without  any 
fever,  or  delirium,  though  they  seemed  to 
suffer  equal  pain  In  some  patients,  the 
parts  affected  became  withered,  dry,  and 
black,  like  charcoal.  The  separation  of 
the  dead  parts  from  the  living  took  place 
with  the  most  excruciating  pain,  and  a sen- 
sation resembling  that  produced  by  the  di- 
rect application  of  fire.  This  sensation  was 
sometimes  intermittent ; and,  in  other  in- 
stances, it  was  succeeded  by  an  equally 
harassing  sensation  of  cold. 

According  to  Bossau,  surgeon  to  the  hos- 
pital of  St.  Antoine,  in  Dauphiny,  the  cases, 
which  he  saw,  were  not  all  of  the  dry  kind, 
the  limb  sometimes  becoming  putrid,  and 
maggots  being  generated.  He  says  that  the 
disease  was  not  infectious,  and  it  attacked 
indiscriminately  men,  women,  and  chil- 
dren. 

The  degree  of  fatality  caused  by  this  spe- 
cies of  mortification  seems  to  have  been 
extremely  various.  In  the  Memoirs  of  the 
Royal  Academy  of  Sciences  for  1748,  M, 
Duhamel  mentions,  that  of  120  persons 
afflicted,  scarcely  four  or  five  recovered  with 
their  lives.  According  to  Langius,  it  was 
equally  fatal  in  Switzerland. 

Dr.  Thomson  believes,  that  the  preceding 
sort  of  gangrene  has  never  occurred  in  this 
country,  excepting,  perhaps,  the  cases  re- 
corded by  Dr.  Charlton  Woolaston,  in  the 
Phil.  Trans,  for  1762;  and  which  proceeded 
from  eating  unsound  wheat,  not  rye.  (See 
Lectures  on  Inflammation,  p.  548.)  For  fur- 
ther particulars  relating  to  this  curious  kind 
of  mortification,  I must  refer  the  reader  to 
this  valuable  work. 

The  external  causes  of  mortification, 
which  are  manifest,  and  act  mechanically  or 
chymically,  are  burns;  excessive , cold ; the 
application  of  caustics ; the  presence  of  any' 
ichorous,  urinary,  or  fecal  matter  effused  in 
the  cellular  substance  ; violent  contusions, 
such  as  are  produced  by  gunshot  wounds, 
or  bad  fractures  ; the  strangulation  of  a part, 
as  in  cases  of  hernia,  or  when  polypi,  or 
other  tumours  are  tied  ; a high  degree  of  in- 


MORTIFICATION. 


240 


fl  animation;  and,  lastly,  everything,  that 
has  the  power  of  stopping  the  circulation 
and  nervous  energy  in  parts.  ( Lassus , Pa- 
thologic Chir.  T.  1,  p.  34,  35.) 

Inflammation  is  one  of  ihe  most  frequent 
occasional  causes  of  mortification.  But,  as 
we  have  already  remarked,  the  death  of  a 
part  may  take  place  without  any  well-mark 
ed  appearance  of  previous  inflammatory 
disorder  ; and  the  latter  even  when  present 
has  frequently  less  share  in  the  mischief, 
than  other  incidental  circumstances,  and  is 
in  reality,  only  an  effect  of  the  very  same 
cause,  which  produces  the  sphacelus  itself, 
ft  is  oftentimes  a matter  of  doubt,  whether 
actual  inflammation  precedes  the  occur- 
rence or  not ; for  a part,  before  it  mortifies, 
Is  in  certain  instances  only  affected  with 
pain,  and  with  no  degree  of  preternatural 
redness.  Lastly,  when  mortification  is,  un- 
questionably, preceded  by  inflammation, 
there  are  so  many  varieties  of  the  disorder 
depending  on  incidental  causes,  that  these 
latter  demand  more  attention  than  the  inflam- 
mation. (Richter,  .inf angsgr  B 1 Kap.  3.) 

Mr.  James  enumerates  the  following  cir- 
cumstances, as  capable  of  influencing,  in  a 
very  great  degree,  the  disposition  of  inflam- 
mation to  terminate  in  mortification.  1. 
The  powers  of  the  part,  in  which  the  in- 
flammation occurs,  being  naturally  weak,  as 
in  fibrous  membranes,  the  scrotum,  &.c.  2. 

The  remote  supply  of  blood,  or  nervous 
energy,  as  in  the  lower  extremities.  3.  Ob- 
struction to  the  return  of  blood.  4.  To  the 
supply  of  blood.  5.  Disease  in  the  heart  or 
vessels.  6.  Debility  from  age,  habits  of  life, 
disorder  of  the  digestive  organs,  or  fever. 
7.  Poor  living,  foul  air,  improper  food,  scur- 
vy, &c.  8.  Impairment  of  organization 

from  external  injury,  0.  Of  the  nervous 
power  by  poisons.  10  Undue  excitement 
of  weakened  parts.  11.  Depressing  reme- 
dies. 12.  Pressure  and  tension.  13.  Ex- 
cessive violence  of  inflammatory  action. 
34.  Peculiar  disposition  in  the  constitution. 
(James  on  Inflammation,  p.  lo2.) 

Healthy  phlegmonous  inflammation  sel- 
dom ends  in  mortification,  except  when  it  is 
unusually  violent  and  extensive. 

Of  all  the  inflammatory  complaints,  to 
which  the  system  is  liable,  erysipelas  is  ob- 
served most  frequently  to  terminate  in  gan- 
grene ; and  whenever  phlegmon  is,  in  any 
degree,  conjoined  with  an  erysipelatous  af- 
fection, which  it  not  unfrequently  is,  it  seems 
thereby  to  acquire  the  same  tendency,  being 
more  difficult  to  bring  to  resolution  or  sup- 
puration than  the  true  phlegmon,  and  more 
apt  to  run  into  a mortified  state. 

The  symptoms  of  mortification  from  in- 
flammation take  place  variously,  yet  gene- 
rally as  follows: — The  pain  and  sympathetic 
fever  suddenly  diminish,  the  part  affected 
becomes  soft,  and  of  a livid  colour,  losing, 
at  the  same  time,  more  or  less  of  its  natural 
warmth  and  sensibility  In  some  places,  the 
cuticle  is  detached  ; while,  in  other  situa- 
tions, vesicles  arise,  filled  with  a clear,  or 
turbid  fluid.  Such  is  the  state,  to  which  we 
apply  the  term  gangrene,  and  which  stage  of 


the  disorder  too  often  rapidly  advances  to 
sphacelus,  when  the  part  becomes  a cold, 
black,  fibrous,  senseless  substance,  called  in 
technical  language,  a slough. 

It  merits  notice,  however,  that,  “ in  cases, 
in  which  gangrene  immediately  succeeds  to 
inflammation,  these  two  morbid  states  may, 
in  some  measure,  be  regarded  as  stages,  or 
periods,  of  the  same  disease.  They  pass  in- 
sensibly info  one  another;  nor  is  it  possible 
to  say  precisely  where  the  one  state  ends, 
and  the  other  commences.  The  symptoms 
of  inflammation,  in  these  cases,  do  not  dis- 
appear before  those  of  gangrene  come  on  ; 
but  seem  rather  to  undergo  a gradual  and 
almost  imperceptible  change,  or  conversion, 
into  one  another.  The  redness  acquires  a 
deeper  tin^e,  and  spreads  further,  than  for- 
merly ; the  swelling  increases  and  becomes 
more  doughy;  and,  in  this  incipient  stage, 
the  gangrene,  particularly  when  it  attacks 
the  cuta  eous  texture,  often  bears  a consi- 
derable resemblance  to  erysipelas.”  (Sfee 
Thomson's  Lectures  on  Inflammation,  p.  506.) 

It  is  to  be  observed,  also,  that  u the  part 
of  the  body  which  becomes  affected  with 
gangrene,  does  not  immediately  lose  its  sensi- 
bility ; for  the  pain,  on  the  contrary,  is  often 
very  much  aggravated  by  the  approach  of 
this  state.  I'he  blood  also  still  continues  to 
circulate,  at  least  in  the  larger  vessels  of  the 
part,  but,  perhaps,  with  less  force  : and  from 
the  resistance  which  it  meets  with  in  passing 
through  the  capillaries,  in  less  quantity,  than 
formerly.  The  serous  effusion  into  the  cel- 
lular membrane  continuing  to  increase,  and 
the  action  of  the  absorbent  and  sanguiferous 
vessels  to  diminish,  the  part  becomes  at 
length  incapable  of  being  restored  to  its 
former  office  in  the  animal  economy.  It  is, 
therefore,  in  its  earlier  stages  only,  that 
gangrene  is  to  be  considered  as  an  affection 
admitting  of  cure  ; for  there  are  limits,  be- 
yond which,  if  it  pass,  recovery  becomes 
impossible.  These  limits  it  may  not,  in 
every  instance,  be  easy  to  define . but 
they  form  the  boundaries  between  incipient 
gangrene  and  the  ultimate  termination  of 
that  state  in  sphacelus.”  (Thomson,  op.  cit. 
p.  507.)  • 

The  causes  which  produce  mortification 
by  impeding  the  return  of  blood  from  the 
part  affected,  for  the  most  part  operate  by 
making  pressure  on  the  trunk  or  principal 
branches  of  a vein.  In  these  instances, 
there  is  always  an  accumubition  of  blood  in 
the  part  which  first  swells,  becomes  of  a 
livid  colour,  tense,  and  very  painful.  Soon 
afterward,  blisters  arise  and  the  part  be- 
comes soft,  oedematous,  cold,  insensible, 
emphysematous,  black,  and  fetid.  Such  are 
the  circumstances  which  happen  in  strangu- 
lated hernia,  in  tied  polypi,  and  in  a limb 
in  which  the  veins  have  been  so  compressed 
by  any  hard  swelling,  such  as  the*liead  of  a 
dislocated  bone,  as  to  excite  mortification. 

Other  causes  operate  by  preventing  the 
entrance  of  arterial  blood.  The  application 
of  a ligature  to  an  artery,  as  practised  in 
several  surgical  cases,  and  all  external 
pressure,  that,  closes  the  artery,  or  arteries- 


MORTIFICATION 


241 


on  which  a pari  entirely  depends  for  its 
siipply  of  blood,  have  this  effect.  Mortifica- 
tion does  not,  however,  always  take  place 
when  the  trunk  of  an  artery  is  rendered  im- 
pervious, because  nature  furnishes  the  ne- 
cessary supply  of  blood  through  collateral 
ramifications.  But  when  the  disorder  does 
happen,  the  part  commonly  first  becomes 
pale,  ffaccid,  and  cold,  and  soon  afterward 
shrinks,  loses  its  sensibility,  grows  black,  and 
perishes. 

It  is  usually  represented  by  writers,  that 
mortification  may  proceed  from  a mere  less- 
ening of  the  communication  of  blood  and 
nervous  energy  to  a part.  However,  it  is 
to  be  observed,  that  parts,  deprived  of  all 
connexion  with  the  sensorium,  by  the  divi- 
sion or  paralytic  state  of  their  nerves,  do  not 
frequently  perish  on  this  account.  But  as 
their  functions  are  carried  on  with  less  vi- 
gour, and  their  vitality  is  weakened,  the 
same  causes  which  sometimes  produce  mor- 
tification iu  parts  differently  circumstanced, 
must  much  more  readily  occasion  it  in 
them.  Among  the  causes  of  the  present 
species  of  mortification,  maybe  mentioned 
great  universal  debility  ; extreme  old  age  ; 
a thickening  and  ossification  of  the  coats  of 
the  arteries,  and  a consequent  diminution 
of  their  capacity,  and  of  their  muscular  and 
elastic  power. 

Cowper,  the  anatomist,  was  one  of  the 
earliest  writers  who  took  notice  of  this  ossi- 
fication of  the  arteries  of  the  leg,  in  persons 
who  had  died  of  mortification  of  the  feet 
and  toes.  (See  Phil.  Trans.  Vol  23,  p.  1195, 
and  Vol.  24,  p.  1970.)  A similar  case  was 
remarked  by  Mr.  Becket,  of  which  he  has 
given  an  account  in  his  Chirurgical  Obser- 
vations. The  occurrence  was  also  men- 
tioned by  Naish.  (See  Philosoph.  Trans. 
Vol.  31,  p.  226.)  Dr.  J.  Thomson  has  seen 
one  example  of  a very  complete  ossification 
of  the  arteries  of  the  leg,  accompanying 
a mortification  of  the  feet  and  toes.  (0?i 
Inflammation,  p.  537.)  SpeaKing  of  the 
same  subject,  Mr.  Hodgson  remarks : 11  Ex- 
perience has  proved  this  condition  of  the 
arteries  to  be  at/least  a constant  attendant 
upon  one  species  of  gangrene,  to  which  the 
extremities  of  old  subjects  are  liable  ; and  I 
have  found  the  three  principal  arteries  of 
the  leg  nearly  obliterated  by  calcareous 
matter  in  two  fatal  cases  of  this  disease. 
But  our  knowledge  of  the  power  of  collate- 
ral circulation,  in  every  part  of  the  body, 
will  not  allow  us  to  admit  the  obliteration 
of  the  trunks  as  a sufficient  cause  of  mortifi- 
cation, from  a deficient  supply  of  blood.  It 
is  therefore  necessary  for  us  to  remember, 
that  the  same  disease  may  probably  exist  in 
the  collateral  branches,  upon  which  it  has 
produced  similar  effects.  But  if  an  extent 
of  vessel  be  converted  into  a calcareous  cy- 
linder, it  loses  its  elasticity  and  organic  pow- 
ers, so  as  to  be  unable  to  afford  any  assist- 
ance to  the  propulsion  of  the  blood  ; and 
the  existence  of  parts,  supplied  by  vessels  in 
this  state,  constitutes  a strong  argument 
against  the  agency  of  the  arteries  in  the  cir- 
culation of  the  blood-  The  above  observa- 
Vol,  II  31 


tions,  on  the  cause  of  this  species  of  gan- 
grene, at  once  expose  its  incurable  nature  ; 
and  this  stale  of  the  blood-vessels  renders 
the  danger  of  amputation  very  considerable, 
unless  fortunately  the  disease  in  the  arteries 
does  not  extend  to  the  part  at  which  the 
ligature  is  applied.”  (See  Hodgson’s  Trea- 
tise on  the  Diseases  of  the  Arteries  and  Veins , 
p.  41.)  However,  although  the  ossified 
state  of  an  artery  must  certainly  be  unfa- 
vourable to  its  healing,  it  does  not  con- 
stantly prevent  this  desirable  event.  (See 
Case  in  Medico- Chir.  Trans.  Vol.  6,  p.  193.) 

The  preceding  facts  are  particularly  enti- 
tled to  attention,  because,  as  we  shall  pre- 
sently find,  the  opinion  that  the  mortification 
of  the  toes  and  feet  arose  from  an  ossifica- 
tion of  the  arteries,  was  considered  by  Mr. 
Pott  as  destitute  of  foundation. 

It  is  probable,  however,  that  sometimes 
other  causes  are  concerned.  Fabrieius  Hil- 
danus  mentions  a fatal  case  of  mortification 
of  the  feet  and  legs,  where  the  patient  was 
in  the  vigour  of  life,  and  apparently  of  good 
constitution.  After  death,  a scirrhous  tu- 
mour was  found  surrounding  and  compress- 
ing the  inferior  vena  cava,  and  aorta,  near 
their  bifurcation,  so  as  to  prevent  the  free 
circulation  of  the  blood  in  the  lower  extre- 
mities. Mortification  of  the  extremities  also 
sometimes  occurs  from  deficient  circulation, 
in  the  progress  of  diseases  of  the  heart. 

The  mortification,  arising  from  long  con 
tinuance  in  the  same  posture,  is  chiefly  attri- 
butable to  the  unremitted  pressure  which 
parts  sustain,  and  which  obstructs  the  cir- 
culation Surgeons  have  frequent  occasion 
to  see  melancholy  examples  of  this  kind  of 
mortification,  particularly  in  cases  of  frac- 
tures, paralysis  from  disease  of  the  vertebrae, 
&x.  The  mischief  most  readily  occurs 
where  the  bones  have  the  least  flesh  upon 
them,  and,  consequently,  where  all  external 
pressure  has  the  greatest  effect ; as,  for 
instance,  about  the  os  sacrum,  os  ilium, 
•spines  of  the  scapula,  &c.  The  disordered 
part  always  first  becomes  soft,  livid,  red  at 
the  circumference,  and  cedematous,  after- 
ward losing  its  sensibility,  and  acquiring  a, 
black  appearance  : at  length  it  is  converted 
into  a foul  sloughing  ulcer. 

Though  long  continuance  in  the  same 
posture  is  the  grand  cause  of  this  kind  of 
mortification,  yet  incidental  circumstances 
are  frequently  combined  with  it,  and  have 
great  influence  ever  the  disorder.  These  are, 
great  debility,  the  same  state  of  the  system 
as  exists  in  typhus  fever,  impure  air,  unclean 
bedding,  &c. 

There  are  some  causes  which  produce 
death  in  a part  at  once,  by  the  violence  of 
their  operation.  A very  powerful  blow  on 
any  portion  of  the  body  may  destroy  the 
vitality  of  the  fibres  and  vessels  in  this  sud- 
den manner.  Lightning,  strong  concentra- 
ted acids,  and  gunshot  violence,  sometimes 
act  in  a similar  way.  When  a bail  enters 
the  substance  of  parts  with  great  force  and 
rapidity,  many  of  the  fibres,  which  are  in 
its  track,  are  frequently  "killed  at  once,  and 
must  be  thrown  off’ in  the  form  of  sloughs, 


MORTIFICATION, 


242 


before  the  wound  can  granulate  and  heal. 
(See  Hunter  on  Gunshot  Wounds.) 

Cold  is  often  another 'cause  of  mortifica- 
tion, and  when  parts  which  have  been  fro- 
zen, or  frostbitten,  are  suddenly  warmed, 
they  are  particularly  apt  to  slough. 

I find  in  Baron  Larrey’s  valuable  publica- 
tion, some  interesting  observations  on  the 
gangrene  from  cold.  He  acquaints  us,  that 
after  the  battle  of  Eylau,  one  of  the  most 
grievous  events  to  which  the  French  sol- 
diers were  exposed,  was  the  freezing  of  their 
feet,  toes,  noses,  and  ears:  few  of  the  van- 
guard escaped  the  affliction.  In  some,  the 
mortification  was  confined  to  the  surface  of 
the  integuments  of  the  toes  or  heels  ; in 
some,  the  skin  mortified  more  deeply,  and 
to  a greater  or  lesser  extent;  'while,  in 
otters,  the  whole  of  the  toes,  or  foot,  was 
destroyed  (See  Programma  quo  frigoris 
acrioris  in  corpore  humano  effectus  expendit. 
Haller , Disp.  ad  Morh . Lips.  1755.) 

“ All  the  writers,  on  this  species  of  morti- 
fication (says  Larrey)  have  considered  cold 
as  the  determining  cause;  but,  if  we  attend 
to  the  period  when  the  complaint  begins  its 
progress,  and  the  phenomena  which  accom- 
pany it,  we  shall  be  convinced,  that  cold  is 
merely  the  predisposing  cause.  In  fact, 
during  the  three  or.  four  exceedingly  cold 
days  which  preceded  the  battle  of  Eylau, 
(the  mercury  having  then  fallen  to  10,  11, 
12,  13,  14,  and  15  degrees  below  zero  of 
Reaumur’s  thermometer)  and  until  the  se- 
cond day  after  the  battle,  not  a soldier  com- 
plained of  any  symptom  depending  upon  the 
freezing  of  parts.  Nevertheless,  they  had 
passed  these  days,  and  a great  portion  of  the 
nights  of  the  5th,  6th,  7th,  8th,  and  9th  of 
Feb.  in  the  snow,  and  the  most  severe  frost. 
The  imperial  guard  especially  had  remained 
upon  watch  in  the  snow,  hardly  moving  at 
all  for  more  than  four  and  twenty  hours, 
yet  no  soldier  presented  himself  at  the  am- 
bulance,* nor  did  any  one  complain  of  his 
feet  being  frozen.  In  the  night  of  the  9th, 
and  10th  of  February,  the  temperature  sud- 
denly rose,  the  mercury  ascending  to  3,  4, 
and  5 degrees  above  zero.  A great  quantity 
of  sleet,  that  fell  on  the  morning  ofThe  10th, 
was  the  forerunner  of  the  thaw  whhj^took 
place  in  the  course  of  that  day,  and  continu- 
ed in  the  same  degree  for  several  days. 
From  this  moment,  many  soldiers  of  the 
guards  and  the  line  applied  for  succour, 
complaining  of  acute  pain  in  the  feet,  and 
of  numbness,  heaviness,  and  prickings  in-  the 
extremities.  The  parts  were  scarcely  swol- 
len, and  of  an  obscure  red  colour.  In  some 
cases,  a slight  redness  was  perceptible  about 
the  base  of  the  toes,  and  on  the  back  of  the 
foot.  In  others,  the  toes  were  destitute  of 
motion,  sensibility, and  warmth,  being  alrea- 
dy black,  and,  as  it  were,  dried.  All  the 

* The  ambulances  of  the  French  army  are  caravans, 
furnished  with  an  adequate  number  of  surgeons,  and 
every  requsite  for  the  dressing  of  w ounds,  and  the  im- 
mediate performance  of  operations,  upon  which  last 
circumstance,  in  particular,  the  life  of  the  wounded 
soldier  often  depends.  These  caravans  follow  the  most 
rapid  movements  of  the  army,  and  are  always  capable 
of  beeping-  up  with  the  vanguard. 


patients  assured  me,  that  they  had  not  expe- 
rienced any  painful  sensation  during  the 
severe  cold  to  which  they  had  been  exposed 
on  the  night-watches  of  the  5th,  6th,  7th, 
8th,  and  9th  of  February,  and  that  it  was 
not  till  the  night  of  the  10th,  when  the  tem- 
perature had  risen  from  IS  to  20  degrees, 
that  they  felt  the  first  effects  of  the  cold.” 
It  is  further  noticed  by  Larrey,  that  such  pa- 
tients as  had  opportunities  of  warming  them- 
selves in  the  town,  or  at  the  fires  of  the 
night-watches,  suffered  in  the  greatest  de- 
gree. (See  Larrey' s Memoires  de  Chirurgis 
Militaire,  T.  3,  p.  60 — 62.) 

Sometimes  mortification  seems  to  depend 
either  upon  the  operation  of  some  infectious 
principle,  or,  at  all  events,  upon  causes 
which  simultaneously  affect  numerous  indi- 
viduals; for  instances  have  been  known,  inx 
which  almost  all  the  ulcers  and  wounds  in 
large  hospitals  became  nearly  at  the  same 
time  affected  with  gangrenous  mischief. 
(See  Hospital  Gangrene.) 

Mortification  is  very  frequently  occasion- 
ed by  the  injury  which  parts  sustain  from 
the  application  of  fire  and  heated  substances 
to  them.  When  the  heat  is  very  great,  the 
substance  of  the  body  is  even  decomposed, 
and  of  course  killed  at  once.  On  other  oc- 
casions, when  the  heat  has  not  been  so  vio- 
lent, nor  sufficiently  long  applied,  inflamma- 
tory symptoms  precede  the  sloughing. 

Cutaneous  texture  is  that  in  which,  we 
have  the  best  opportunity  of  observing  the 
phenomena  and  progress  of  gangrene.  When 
it  occurs  as  a consequence  of  inflamma- 
tion, the  colour  of  the  skin  changes  from 
the  florid  red  to  a darker  shade  ; and  in 
the  progress  of  the  disease  it  acquires  a livid 
hue.  The  cuticle  often  separates  at  certain 
points  from  the  skin,  and  the  vesications, 
termed  phlyctenee,  are  formed,  which  usu- 
ally contain  a bloody-coloured  serum.  As 
sphacelus  comes  on,  the  livid  hue  disap- 
pears, and  a slough  is  formed,  which  is 
sometimes  ash-coloured  ; sometimes  black. 

It  is  not  always  easy  to  judge  of  the  extent 
of  mortification  from  the  appearance  of 
the  skin  ; for,  when  the  subjacent  cellular 
membrane  is  affected,  the  disorder  may 
occupy  a greater  extent  internally,  than 
upon  the  surface. 

In  a spreading  gangrene,  the  red  colour  of 
the  affected  skin  is  insensibly  lost  in  the  sur- 
rounding integuments  ; but,  when  gangrene, 
followed  by  sphacelus  stops,  a red  line,  of  a 
colour  more  lively  than  that  of  gangrene, 
is  generally  perceptible  between  the  dead 
and  living  parts.  It  is  at  the  inner  edge  of 
this  inflamed  line,  where  we  usually  see  the 
ulcerating  process  begin,  by  which  the  se 
paration  of  the  dead  from  the  living  parts  is 
affected.  (See  Thomson's  Lectures  on  Inflam- 
mation, p.  511,  512.) 

Mortification  occurs  frequently  in  cellular 
texture.  The  skin  which  covers  dead  cellu- 
lar substance,  generally  has  a gangrenous  ap  - 
pearance,  and  afterward  either  ulcerates,  or 
sloughs.  In  some  coses,  the  portion  of  spha- 
celated cellular  texture  is  small,  as  in  the  ma 
Jignant  boil ; in  others,  extensive,  as  in  case* 


MORTIFICATION 


ot  carbuncle.  In  erysipelas  phlegmonoides, 
the  cellular  membrane,  connecting  together 
the  muscles,  tendons,  nerves,  blood-vessels, 
&e.  often  perishes  to  a great  extent.  Here 
large  portions  of  skin  are  frequently  also 
destroyed  by  sloughing,  or  ulceration,  so 
that  Smuscle,  blood-vessel,  tendon,  nerve, 
&c.  are  exposed  to  view,  quite  denuded  of 
their  proper  coverings,  and  in  different  states 
of  disease. 

Artery  is  the  texture,  endowed  with  the 
greatest  power  of  resisting  its  own  destruc- 
tion by  mortification.  “ 1 have  (says  Dr. 
Thomson)  in  various  instances  of  erysipe- 
las phlegmonoides,  seen  several  inches  of 
the  femoral  artery  laid  completely  bare  by 
the  gangrene,  ulceration,  and  sphacelus  of 
the  parts  covering  it,  without  its  giving  way 
before  death.  The  arteries  in  these,  and 
other  similar  instances,  in  which  1 have  seen 
them  laid  bare  in  the  neck  and  arm,  by  ab- 
scess terminating  in  fortification , had  the 
appearance  of  raw  flesh,  and  were  obviously 
thicker  and  more  vascular  than  natural.  The 
blood  circulated  through  them,  and  assisted 
in  supplying  with  nourishment  the  parts  upon 
which  they  were  distributed.”  (P.  513.)  I 
have  often  seen  tbe  truth  of  the  foregoing 
statement  sadly  illustrated  in  cases  of  slough- 
ing buboes,  by  which  several  inches  of  the 
femoral  artery  were  exposed.  I have  seen 
the  throbbing  brachial  artery  denuded  for 
more  than  a month,  nearly  its  whole  extent 
along  the  inside  of  the  arm,  by  the  ravages 
of  malignant  and  pseudo-syphilic  ulceration, 
attended  with  repeated  sloughing  ; and  yet 
hemorrhage  had  no  share  in  carrying  off  the 
unfortunate  patient. 

ft  is  a curious  fact,  that  the  blood  coagulates 
in  the  large  arteries,  which  lead  to  a morti- 
fied part.  This  occurrence  takes  place  for 
some  distance  from  the  slough,  and  is  the 
reason  why  the  separation  of  a mortified 
limb  is  seldom  followed  by  hemorrhage. 

The  same  occurrence  also  affords  an  ex- 
planation, why,  in  the  amputation  of  a mor- 
tified limb, there  is  sometimes  no  hemorrhage 
from  the  vessels,  although  the  incisions  are 
made  in  the  living  part.  This  fact  was  first 
particularly  pointed  out  by  Petit,  the  sur- 
geon. (See  Mim.  de  VAcad.  des  Sciences, 
1732.)  “ When  a gangrened  limb  (says  (his 

celebrated  surgeon)  is  cut  off  in  (be  dead 
'part,  no  hemorrhage  occurs,  because  the 
blood  is  coagulated  a great  way  in  the  ves- 
sels.” He  adds,  l£  We  have  several  exam- 
ples of  limbs  amputated,  on  account  of  gan- 
grene, in  which  no  hemorrhage  occurred, 
although  the  amputation  was  made  a consi- 
derable way  in  the  living  parts ; because  the 
clot  was  not  confined  in  these  cases  to  the 
dead  part,  but  was  continued  forwards  into 
the  living  as  far  as  the  inflammatory  dispo- 
sition extended.” 

According  to  Dr.  Thomson,  cases,  in  con- 
firmation of  the  foregoing  statement,  are 
recorded  by  other  practical  writers,  espe- 
cially Quesnay,  and  Mr.  O’Halloran.  Tri 
one  of  the  cases,  mentioned  by  tbe  latter 
gentleman,  and  in  which  no  hemorrhage 
followed  the  removal  of  the  limb,  the  irici- 


2 43 

sions  were  made  four  inches  above  the  divi- 
sion of  the  dead  from  the  living  parts.  Dr. 
Thomson  has  seen  a still  longer  portion  of 
femoral  artery  dosed  up  with  coagulated 
blood,  after  a mortification  of  the  foot  and 
leg.;  and,  in  one  example,  where  the  morti- 
fication began  in  the  thigh,  he  saw  the  coa- 
gulation of  the  blood  in  tbe  external  iliac, 
extending  up  to  the  origin  of  this  vessel 
from  the  aorta.  “ So  common,  indeed,  is 
this  coagulation  of  the  blood  in  the  limbs 
affected  with  mortification  (observes  Dr. 
Thomson,)  that  it  has  been  supposed  to  be  a 
necessary  and  constant  effect  of  Ibis  disease. 
This  opinion,  however,  does  not  appear  to 
be  well  founded  ; for  I have  now  seen  seve- 
ral instances  in  which  a limb  has  mortified 
and  dropped  off,  without  hemorrhage  having 
occurred  from  tjie  vessels  divided  by  na-7 
ture  : and  yet,  in  examining  the  vessels  of 
the  stumps  of  these  patients  after  death,  1 
have  not  been  able  to  find  any  clots,  either 
of  coagulated  blood,  or  ot  coa  .able 
lymph.  In  the  cases  to  which  I allude,  the 
adhesive  inflammation,  occurring  in  the  line 
of  separation  between  the  dead  and  living 
parts,  had  extended  to  the  blood-vessels,  and 
their  inner  surfaces  being  inflamed  arid  press- 
ed together  by  the  swelling  which  occurs, 
had  adhered  so  as  to  close  up  their  extremi- 
ties. It  is  in  Ibis  way  we  shall  find,  that  the 
common  ligature  acts,  which  is  applied  to 
the  divided  extremities  of  arteries  and  veins; 
and  it  is  this  obliteration,  by  the  process  of 
adhesion  of  the  extremities  of  the  arteries 
and  veins  in  the  neighbourhood  of  the  spha- 
celated parts,  that  in  reality  prevents  the 
occurrence  of  hemorrhage,  when  the  morti- 
fied limbs  fall  off',  or  are  removed  by  the 
knife.  The  coagulation  of  the  blood  in  the 
canal  of  the  vessel  is  not  alone  sufficient.  If; 
may  tend,  in  the  cases  in  which  it  occurs, 
for  a time  to  restrain  hemorrhage ; but  it 
is  by  tbe  obliteration  by  adhesion,  offthe 
canal  in  the  extremities  of  the  arteries 
and  veins,  that  the  occurrence  of  hemor 
rliage  can  be  securely  and  permanently  pro- 
vided against.  Indeed,  to  me  it  seems 
doubtful,  whether  that  coagulation  of  blood, 
which  takes  place  in  mortified  limbs,  ever 
takes  place  in  the  canal  of  the  vessel,  till 
its  extremity  and  lateral  communications 
have  been  plugged  up  by  the  coagulating 
lymph,  which  is  extending  during  the  state 
of  the  adhesive  inflammation.”  (See  Thom- 
son's Lectures  on  Inflammation,  p.  554.) 

When  gangrene  and  sphacelus  happen  to 
any  extent,  the  patient  is  usually  troubled 
with  an  oppressive  hiccough;  a symptom 
well  known  to  the  surgeon  of  experience , 
and  often  an  indication  of  the  mischief, 
when  external  signs  are  less  instructive 
The  truth  of  this  remark  is  frequently  seen 
in  strangulated  hernise. 

The’  constitution  also  suffers  immediately 
a considerable  dejection.  The  patient’s 
countenance  suddenly  assumes  a wild,  ca- 
daverous look  ; the  pulse  becomes  small, 
rapid,  and  sometimes  irregular;  cold  per- 
spirations come  on,  and  the  patient  is  often 
affected  with  diarrhoea  and  delirium 


MORTIFICATION 


244 


As  Dr.  Thomson  observes,  the  constitu- 
tional symptoms  “ form  fevers,  which  par- 
take in  individual  cases,  more  or  less,  of  an 
inflammatory,  typhoid,  or  bilious  character, 
lint,  the  degree  of  these  fevers  varies,  in 
every  particular  case,  from  their  almost  total 
absence  to  the  highest  degree  of  intensity. 
The  skin  is  usually  hot,  and  dry  at  the  com- 
mencement of  the  attack  ; the  tongue  is 
without  moisture,  brown  and  hard;  the  pulse 
is  quicker,  and  less  full  and  strong,  than  in 
inflammation  ; and  this  state  of  the  pulse  is 
often  attended  by  flattering  intermissions, 
and  a considerable  degree  of  subsultus  ten- 
dinum.  The  fever  has,  in  general,  more  of 
the  asthenic,  than  of  the  sthenic  character  ; 
or  it  is  more  of  the  typhoid,  than  of  the  in- 
flammatory type  ; a circumstance  of  great 
importance  in  the  constitutional  treatment 
of  mortification.  The  fever  in  gangrenous  af- 
fections is  often  accompanied  with  great  un  - 
easiness and  restlessness,  dejection  of  spirits, 
wildness  of  the  looks  ; and,  in  severe  cases, 
with  almost  always  more  or  less  delirium. 
In  the  progress  of  the  disease,  cold  sweats, 
palpitations,  and  convulsions,  sometimes  oc- 
cur ; a hiccough,  accompanied  with  nausea, 
often  comes  on,  and  proves  a most  distress- 
ing symptom  to  the  patient.  Frequently, 
this  hiccough  is  the  forerunner  of  death. 
Some  patients  die  comatose  ; others,  after 
suffering  severe  pain,  spasms,  and  delirium. 
But,  in  some,  a slow,  in  others,  a sudden 
abatement  of  the  constitutional  symptoms 
takes  place,  accompanied  also  with  the  ame- 
lioration of  the  local  affection.  The  gangre- 
nous inflammation  stops,  and  a red  line  is 
formed  by  the  adhesive  inflammation  in  the 
extreme  verge  of  the  living  parts  ; the  dead 
part  separates,  and  granulations  form  , and 
when  the  constitution  has  strength  to  sus- 
tain the  injury  it  has  received,  recovery 
takes  place.”  (See  Lectures  on  Inflamma- 
tion, p.  509.) 

In  cases  of  sphacelus,  the  prognosis  chiefly 
depends  on  the  nature  of  the  cause  of  the 
disorder.  The  more  easy  the  cause  is  of  re- 
moval, the  less  room  is  there  for  alarm.  It 
is  an  erroneoussupposition,that  mortification 
arising  from  an  external  local  cause  is  more 
easy  to  be  stopped  and  cured,  than  that 
originating  from  an  internal  cause.  The  lo- 
cal cause  is  sometimes  exceedingly  difficult, 
or  even  incapable,  of  removal  ; and  a spha- 
celus, which  is  at  first  entirely  local,  may 
afterward  become  a general  disorder,  by  the 
universal  debility  and  derangement  of  the 
system,  resulting  from  the  complaint.  Hence, 
it  is  obvious,  that  a sphacelus  may  easily  ex- 
tend beyond  the  bounds  of  its  outward  local 
cause.  On  the  other  hand,  a mortification 
may  be  reduced  to  one  of  a nature  entirely 
local  ; though  it  arose  at  first  from  constitu- 
tional causes.  Sphacelus  from  extreme  de- 
bility, or  from  such  a state  of  the  system,  as 
attends  the  scurvy,  typhoid  fevers,  he.  is 
constantly  perilous,  because  these  causes 
are  very  difficult  to  remove.  It  is  also  a fact, 
that,  when  numerous  causes  are  combined, 
it  is  an  unfavourable  occurrence,  not  merely 
because  the  surgeon  is  apt  overtook  some 


of  them,  but  because  there  are  in  reality 
more  obstacles  to  the  cure. 

Humid  gangrenes,  which  are  frequently 
accompanied  with  emphysema  of  the  cellu- 
lar membrane,  usually  spread  with  great  ra- 
pidity. “ Some  authors,  (says  a modern 
writer,)  have  attributed  this  to  the  influence 
of  the  air  extricated,  and  Dr.  Kirkland  has 
described  emphysematous  gangrene,  as  dis- 
tinct from  the  others,  and  some  have  impu- 
ted this  disposition,  in  a considerable  degree, 
to  the  putrefaction  of  the  juices,  which  are 
effused. ” With  regard  to  the  former,  the 
author  has  mistaken  an  effect  for  a cause  ; 
yet,  “ it  is  important  to  recognize  the  fact, 
that  gangrene,  when  accompanied  with  em- 
physema, has  a remarkable  disposition  to 
spread.”  {James  on  Inflammation,  p.  96.) 

Sometimes  a mortification  spreads  so 
slowly,  that  it  does  not  occupy  much  extent 
at  the  end  of  several  months,  or  even  a 
whole  year.  The  case,  however,  is  often 
not  the  less  fatal  on  this  account.  The  dan 
ger  is  never  altogether  Over,  until  the  dead 
part  has  completely  separated.  The  en- 
trance of  putrid  matter  into  the  circulation 
(says  Richter)  is  so  injurious,  that  patients 
sometimes  perish  from  this  cause,  long  after 
the  mortification  has  ceased  to  spread.  {An- 
fangsg.  der  Wundarzn.  B 1,  Kap.  3,  p.  78. 
79.)  _ 

This  last  circumstance  is  very  much  insist- 
ed upon,  by  all  the  modern  continental  sur- 
geons ; but  the  doctrine  has  never  gained 
ground  among  Fmglish  surgeons,  who  enter- 
tain little  apprehension  of  the  bad  effects  of 
the  absorption  of  putrid  matter  in  cases  of 
mortification  ; and  the  opinion  of  Mr.  Gu- 
thrie may  be  more  correct,  that  nature  re- 
ceives the  shock  through  the  nervous  system, 
and  not  through  the  absorbents.  (On  Gun- 
shot Wounds,  p.  123,  Ed.  2.) 

The  idea  of  a deleterious  principle  being 
absorbed  was  long  ago  well  refuted  by  Mr. 
J.  Burns,  who  pointed  out,  that  the  impression 
upon  the  constitution  was  in  no  degree  com- 
mensurate with  the  size  of  the  slough,  and 
consequently  with  the  quantity  of  putrid 
matter,  as  the  effects  produced  by  a small 
slough  of  intestine,  or  cornea,  will  exempli- 
fy. But  when  the  sloughs  are  of  equal  size, 
and  in  the  same  parts,  the  differences  of  con  - 
stitutional  sympathy,  as  Mr.  James  observes, 
may  depend  upon  the  nature  of  the  surround- 
ing inflammation,  which,  however,  he  con- 
ceives, may  itself  be  affected  by  the  quantity 
of  putrid  irritating  fluids.  {On  Inflammation , 
p.  98.) 

The  danger  of  sphacelus  is  also  propor 
tioned  to  the  size  and  importance  of  the  part 
affected.  The  event  of  the  distemper  like- 
wise depends  very  much  on  the  patient’s  age 
and  constitution. 

Parts,  affected  with  gangrene,  do  not  ini 
mediately  lose  the  whole  of  their  sensibility; 
the  circulation  is  still  continued  in  a certain 
degree  ; and  when  the  progress  of  the  dis 
temper  does  not  surpass  certain  bounds,  the 
functions  of  such  parts  may  be  completely 
re-established.  Gangrene,  strictly  speaking, 
is  not  a decided  mortification  : but  only  the 


MORTIFICATION. 


245 


forerunner  of  this  latter  mischief,  and  may 
he  regarded  as  the  intermediate  link,  be- 
tween the  most  violent  stage  of  inflamma- 
tion and  sphacelus.  The  presence  of  this 
last  implies  the  total  loss  of  life  in  the  part 
affected,  the  destruction  of  its  organization, 
the  abolition  of  all  its  functions,  and  an  ab- 
solute inability  to  resume  them  again.  How- 
ever, even  when  we  see  the  surface  of  a 
part  manifestly  sphacelated,  we  must  not 
always  conclude,  that  the  entire  destruction 
of  its  whole  substance  pr  thickness  is  cer- 
tain ; for,  in  many  cases,  the  disorder  only 
atfects  the  skin  and  cellular  substance.  In 
this  state,  the  integuments  frequently  slough 
away,  leaving  the  tendons,  muscles,  and 
other  organs,  perfectly  sound. 

It  is  only  in  external  affections  of  the  body 
that  the  progress  of  inflammation  to  gan- 
grene and  sphacelus  can  bp  marked  with  any 
degree  of  precision.  The  approaches  of  the 
latter  are  also  not  invariably  announced  by 
the  distinct  and  manifest  symptoms  of  gan- 
grene, even  when  the  disorder  is  quite  su- 
perficial. There  are  cases,  which  justify  the 
conclusion,  that  a small  part  of  the  body 
may  be  affected  with  sudden  death,  just  in 
the  same  manner  as  the  whole  machine. 
Sphacelus  is  often  seen  making  its  appear- 
ance in  a part,  which  is  apparently  quite 
healthy,  without  being  preceded  by  any 
other  symptoms,  than  a sudden  acute  pain  in 
the  seat  of  the  mischief.  Sometimes,  in  the 
earliest  period  of  the  complaint,  a black  spot, 
which  rapidly  spreads  on  every  side,  is  the 
only  change  that  can  be  observed 

Jn  order  to  form  a just  prognosis,  all  the 
above  circumstances  must  be  taken  into 
consideration,  and,  in  particular,  we  must 
never  deliver  an  opinion,  without  having 
closely  examined  the  progress  of  the  disor- 
der; for,  should  we  make  a favourable  prog- 
nosis from  such  appearances. as  might  justify 
us  as  much  as  possible  in  so  doing,  there 
would  be  great  risk  of  finding  ourselves 
most  miserably  mistaken  by  the  event  of  the 
case.  In  all  cases  of  considerable  mortifica- 
tion, even  when  arising  from  an  external 
cause,  the  patient  cannot  be  deemed  exempt 
from  danger,  not  only  while  no  separation  of 
the  mortified  parts  has  begun,  but  also,  not 
before  such  parts  have  been  completely 
detached. 

TREATMENT  OF  MORTIFICATION. 

I shall  arrange  under  two  heads  what  is  to 
be  said  of  the  treatment  of  mortification. 
Under  the  first  will  be  comprehended  every 
thing,  which  relates  to  internal  remedies, 
and  such  other  means,  as  are  indicated  by 
the  general  slate  of  the  system ; under  the 
second,  topical  remedies,  and  the  local  treat- 
ment of  the  parts  affected. 

In  the  treatment  the  surgeon  will  always 
have  one  thing  for  immediate  consideration; 
viz.  whether  the  case  before' him  is  one  of 
acute  mortification,  attended  with  inflamma- 
tion and  inflammatory  fever ; or  whether 
it  is  a chronic  mortification,  beginning  with- 
out fever,  or  attended  with  a fever  of  a ty 


phoid  nature  and  great  prostration  of 
strength  ? By  making  up  his  mind  upon 
this  point,  the  practitioner  will  establish  an 
useful  general  principle  for  his  guidance, 
especially  in  the  commencement  of  the 
treatment. 

1.  When  mortification  is  acute,  and  seems 
to  depend  on  the  violence  of  inflammation  , 
the  first  indication  is  to  moderate  the  inor- 
dinate action  of  the  sanguiferous  system, 
by  the  prudent  employment  of  such  means 
as  are  proper  for  counteracting  inflamma- 
tion. In  short,  relief  is  to  be  sought  in  the 
antiphlogistic  regimen,  which  consists  in 
the  employment  of  blood-letting,  purgatives, 
diaphoretics,  and  diluents,  and  in  abstinence 
from  all  vegetable  or  animal  substances, 
which  have  a tendency  to  excite,  or  to  aug- 
ment the  febrile  action  It  is  a regimen 
which  must  be  pursued,  so  long  as  inflamma- 
tory fever  continues.  It  is  only  in  cases  in 
which  the  fever  from  the  first  assumes  a ty- 
phoid character,  or  where  the  mortification 
takes  place  without  the  previous  occurrence 
of  fever,  that  any  deviation  from  the  anti 
phlogistic  regimen  can  be  allowed. 

Dr.  Thomson,  from  whom  l have  borrow- 
ed the  foregoing  passage,  also  notices  tho 
present  common  aversion  to  bleeding  in 
compound  fractures,  erysipelas,  carbuncle, 
hospital  gangrene,  burns,  and  frostbite  , 
cases  in  which  the  patient,  it  is  said,  can 
seldom  bear  with  impunity  any  considerable 
loss  of  blood.  “ In  many  instances  of  these 
injuries  and  affections  (says  he)  blood-let- 
ting, 1 know,  is  not  required  ; but  I am 
doubtful,  even  if  it  were  generally  employed, 
whether  it  would  produce  all  the  mischiefs, 
which  have  of  late  years  been  ascribed  to 
it.  I believe  it  to  be  the  most  efficacious*ot‘ 
any  of  the  remedies  that  can  be  employed, 
in  all  cases  of  inflammatory  fever  threaten- 
ing to  terminate  in  gangrene,  and  that  its 
use  in  such  cases  ought  never  to  be  omitted 
in  the  young,  strong,  and  plethoric.”  (See 
Lectures  on  Inflammation,  p.  559.)  When 
bleeding  has  not  been  sufficiently  practised, 
during  the  state  of  the  inflammation  anteoe 
dent  to  the  mortification  ; when  the  general 
symptoms,  which  point  out  the  existence  of 
this  state,  continue  violent ; and,  especially, 
when  the  pulse  is  still  quick,  hard,  or  fulf  ; 
it  is  absolutely  necessary  to  empty  the  ves  - 
sels a little  more,  even  though  mortification 
may  have  begun,  particularly  if  the  patient 
be  young  and  plethoric.  Bleeding,  by  dimi- 
nishing the  fever,  and  abating  the  general 
heat,  is  frequently  the  best  means.of  all.  It 
may  then  be  considered  better,  than  all  anti- 
septics, for  stopping  the  progress  of  the  dis- 
order. But  this  evacuation  is  to  be  employed 
with  a great  deal  of  circumspection  : for, 
should  it  he  injudiciously  resorted  to,  from 
the  true  state  of  the  system  not  being  under 
stood,  the  error  may  be  followed  by  the 
most  fatal  consequences.  It  should  also  hs 
well  remembered,  that  however  strongly 
bleeding  may  be  indicated,  the  moment  is 
not  far  off,  when  this  evacuation  is  totally 
inadmissible,  especially  if  the  mortification 
make  much  progress. 


246 


MORTIFICATION. 


In  cases  of  acute  mortification,  after  as 
much  has  been  taken  away  as  may  be  deem- 
ed safe  or  proper,  the  other  parts  of  the 
antiphlogistic  regimen  must  be  continued,  as 
long  as  any  increased  action  of  the  heart  and 
arteries  continues.  “ The  use  of  purgatives 
seems  to  be  particularly  required  in  those 
cases,  in  which  the  local  inflammatory  affec- 
tion is  accompanied  with  derangement  of 
the  digestive  and  biliary  organs.  Antimonial 
diaphoretics  are  those  from  which  1 should 
be  inclined  to  expect  most  advantage  in  the 
commencement  of  the  attack;  but,  after 
the  inflammatory  action  has  been  subdued, 
opiates,  either  alone,  or  combined  with  anti- 
mony, or  what  is  still  better,  with  ipecacuan- 
ha, as  in  Dover’s  powder,  are  frequently  of 
singular  service,  not  only  by  diminishing 
pain,  bu*  also,  by  inducing  a soft  and  moist 
state  of  the  skin.”  {Thomson,  p.  560.)  A 
strict  regimen,  which  may  have*been  useful, 
and  even  necessary,  during  the  inflammatory 
stage,  may  have  a very  bad  effect,  if  conti- 
nued too  long,  by  diminishing  the  patient’s 
strength,  which,  on  the  contrary,  should  be 
supported  by  the  most  nourishing  food. 

A vegetable  diet,  as  Dr.  Thomson  ob- 
serves, is  to  be  preferred  in  the  commence- 
ment both  of  acute  gangrene  w ith  inflamma- 
tory fever,  and  of  chronic  gangrene  w'ith  a 
fever  from  thp  first  of  a typhoid  nature. 
Wine  and  animal  food  given  too  early  in  dis- 
eases, which  have  a tendency  to  gangrene, 
increase  the  febrile  heat  and  frequency  of 
the  pulse,  oppress  the  stombeh,  render  the 
tongue  foul,  the  patient  restless  and  deli- 
rious, and  his  situation  dangerous,  if  not 
hopeless.  In  the  transition  from  gangrene 
to  sphacelus,  an  abatement  of  the  sympto- 
matic fever  usually  takes  piace  in  almost  all 
cases,  which  have  ultimately  a favourable 
termination  Dr.  Thomson  beieves,  that 
this  is  the  first  period,  at  which  it  is  safe  to 
allow  vinous  liquors,  or  diet,  ckiejly  animal. 

(. P . 561.) 

I next  come  to  a second  very  essential 
and  important  indication,  to  he  fulfilled,  as 
soon  as  the  symptoms,  announcing  the  ex- 
istence of  the  inflammatory  state,  appear  to 
abate,  and  the  patient  begins  to  be  debili- 
tated. This  indication  i-  to  prevent  excessive' 
weakness  by  the  suitable  employment  of  cor- 
dials, and,  particularly,  of  tonics.  These 
same  means  also  contribute  to  place  the 
system  in  a proper  state  for  treeing  itself 
from  the  mortified  parts,  or,  in  other  words, 
for  detaching  them.  For,  inflammation  is 
the  preparatory  step,  whicli  nature  takes  to 
accomplish  the  separation  of  mortified  parts 
from  the  living  ones,  arid  such  salutary  in- 
flammation cannot  take  place,  if  the  ener- 
gies of  life  be  too  much  depressed. 

In  order  to  fulfil  the  above  indication,  it  is 
necessary  to  prescribe  a nourishing  diet,  with 
a r.-rtain  quantity  of  good  wine,  propor- 
tio  d to  the  patient’s  strength,  and  the 
symptom-  of  the  complaint.  This  diet  is 
generally  productive  of  more  real  benefit 
than  tiie  whole  class  of  cordial  and  stimu- 
lating medicines.  However,  when  the.  pa- 
tient is  much  weakened,  when  the  mortifi- 


cation of  the  pari  affected  is  complete,  ami 
the  disorder  is  spreading  to  others,  some  of 
the  following  remedies  may  be  ordered 
ammonia,  aromatic  confection,  aether,  &c 
In  general,  however,  wine  is  best,  because 
more  agreeable  than  cordials ; and  for  this 
purpose,  one  ought  to  prefer  the  most  per- 
fect wines,  such  as  those  of  Spain  and  Ma- 
deira. 

Of  all  the  medicines,  hitherto  recom- 
mended for  the  cure  of  mortification,  there 
is  certainly  not  one,  that  has  acquired  such 
a character  for  efficacy,  as  the  Peruvian 
bark.  It  is  said,  that  this  remedy  often  stops, 
in  a very  evident  and  expeditious  manner, 
the  course  of  the  disorder.  Being  a very 
powerful  tonic,  it  is  thought  to  operate  by 
strengthening  the  system,  and  thus  main- 
taining in  every  part  the  necessary  tone  for 
resisting  the  progress  of  mortification.  But, 
w'hatxever  may  be  its  mode  of  acting,  the  ad- 
vocates for  this  medicine  contend,  that  it  is 
now'  a v/ell-knovvn  fact,  that  it  ought  to  be 
employed  in  almost  all  cases  of  mortification, 
as  soon  as  the  violence  of  the  inflammatory 
symptoms  has  been  appeased. 

It  was  Mr.  Rush  worth,  a surgeon  at  North- 
ampton, who  made  this  discovery  in  the  year 
1715.  Arnyand  and  Douglas,  two  surgeons 
in  London,  soon  afterward  confirmed  the 
virtue  of  this  remedy.  Mr.  Shipton.  another 
English  surgeon,  has  also  spoken,  in  the 
Philosophical  Transactions,  of  the  good  ef- 
fects which  he  has  seen  produced  by  this 
medicine.  In  the  Medical  Essays  of  Edin- 
burgh, Drs.  Monro  and  Paisley  published 
several  cases,  illustrative  of  the  efficacy  of 
bark  in  cases  of  mortification.  We  are 
there  informed,  tfiat  when  its  exhibition  was 
interrupted,  the  separation  of  the  eschars 
was  retarded,  and  that,  on  the  medicine 
being  resorted  to  again,  such  a separation 
went  on  again  more  quickly.  Since  this 
period,  all  practitioners,  both  in  England 
and  elsewhere,  have  had  recourse  to  this 
remedy,  which  has  every  where  obtained  the 
highest  praises.  Unfortunately,  these  praises 
have  induced  surgeons  to  employ  it  indis- 
criminately, and  with  equal  confidence,  in 
all  cases. 

We  cannot,  indeed  doubt,  that  bark  has 
frequently  had  the  most  salutary  effect,  in 
cases  of  mortification,  though  sometimes  it 
may  probably  have  had  imputed  to  it  effects, 
which  were  entirely  produced  by  nature. 

I he  follow  ing  observation,  made  by  Dr. 
Thomson,  is  highly  worthy  of  recollection  : 
In  attending  to  the  effects,  supposed  to  re- 
sult from  the  operations  of  the  external  and 
internal  remedies,  w hich  are  daily  employed 
for  the  cure  of  mortification,  there  are  two 
facts,  well  ascertained,  which  appear  to  me 
to  be  peculiarly  deserving  of  your  regard. 
The  first  ot  these  is,  that  mortification  often 
stops  spontaneously,  without  any  assistance 
whatever  from  medicine;  the  second,  that 
it  often  begins,  and  continues  to  spread,  or 
even  after  it  has  stopped  fora  while,  recom- 
mences and  proceeds  lo  a fatal  termination, 
in  spite  of  the  best  directed  efforts  of  the 
healing  art”  (See  Lectures  on  In  ft  a mm  a {ion. 


MORTIFICATION. 


p.  55V.)  In  many  cases,  bark  is  evidenlly 
hurtful,  when  exhibited  prematurely.  There 
are  other  instances,  in  which  it  is  impossible 
to  employ  it  in  a sufficient  quantity, the  sto- 
mach not  being  able  to  bear  it  in  any  form- 
In  general,  it  should  never  be  administered, 
when  the  pulse  is  high,  and  other  inflamma- 
tory symptoms  exist ; but,  when  the  tension 
of  the  part  diminishes,  the  pulse  sinks,  and 
symptoms  of  weakness  commence,  and  par- 
ticularly, when  with  these  circumstances, 
we  perceive  a separation  beginning  to  take 
place  between  the  dead  and  the  living  part, 
bark  hardly  ever  fails  to  support  the  strength 
of  the  constitution,  and  powerfully  to  acce- 
lerate the  separation  of  the  mortified  parts. 
( Encyclop . Method.  Art.  Gangrene .) 

However,  as  I have  already  remarked,  it 
is  quite  wrong  to  prescribe  bark,  in  every 
instance,  as  the  sole  remedy  ; for  there  are 
many  cases,  in  which  it  is  unnecessary ; 
some,  in  which  it  does  harm  ; and  others,  in 
which  it  is  totally  inefficacious.  It  is  a medi- 
cine obviously  of  no  service,  when  the 
mortification  arises  from  an  external  cause, 
and  is  the  only  complaint,  in  a healthy, 
strong  constitution.  It  is  equally  unneces- 
sary, when  the  sphacelus  is  of  the  dry  sort, 
and  has  ceased  to  spread,  at  the  same  time, 
that  the  living  margin  appears  to  be  in  a state 
of  inflammation,  without  any  universal  de- 
bility. But  it  deserves  particular  notice,  that 
the  circumstances  of  each  individual  case 
are  liable  to  such  considerable  variation,  that 
though  bark  may  be  at  first  unnecessary,  it 
may  afterwards  be  indicated. 

In  some  cases  of  sphacelus,  bark  is  hurt- 
ful. The  disorder  is  generally  attended  w ith 
fever,  which  may  be  of  three  kinds  ; inflam- 
matory ; typhoid,  or  attended  with  extreme 
debility  ; or  one  connected  with  a disorder- 
ed state  of  the  abdominal  viscera. 

Inthe  lattercase,  which  isfar  more  common 
than  is  supposed,  bark  is  manifestly  perni- 
cious. Here,  the  indication  is  to  empty  the 
stomach  and  bowels  as  quickly  as  possible. 
When  this  has  been  done,  if  bark  should  now 
be  indicated  by  any  of  the  circumstances 
already  pointed  out,  it  may  be  safely  admi- 
nistered. But  there  is  a great  necessity  for 
procuring  evacuations  as  speedily  as  possi- 
ble, before  much  debility  has  occurred. 

Sometimes,  mortification  is  accompanied 
with  a low  typhoid  kijs-d  of  fever,  which, 
whether  the  cause,  or  the  consequence  of 
the  local  mischief,  demands  the  exhibition 
of  bark. 

However,  mortification  may  be  attended 
with  common  inflammatory  fever,  and  then 
the  living  margin  is  generally  inflamed  and 
painful.  This  is  particularly  the  case,  when 
mortification  is  the  consequence  of  genuine 
acute  inflammation,  or  of  an  external  injury 
in  a healthy  subject.  Here,  bark  must  ob- 
viously be  injurious.  Still,  it  is  wrong  to 
regard  this  medicine  as  invariably  hurtful, 
whenever  sphacelus  is  the  effect  of  inflam- 
mation. It  has  already  been  observed,  that 
the  inflammation  frequently  has  less  share 
in  the  origin  of  the  disorder  than  gome  inci- 
dental cause,  which  oftentimes  requires  the 


exhibition  of  bark.  Even  when  mortifica  - 
tion is  the  pure  effect  of  inflammation,  great 
prostration  of  strength  may  subsequently 
arise,  and  indeed  does  mostly  take  place  at. 
a certain  period  of  the  disorder.  In  this  cir- 
cumstance, the  voice  of  experience  loudlj' 
demands  the  employment  of  bark,  though 
its  exhibition  would  have  been  at  first  use- 
less or  hurtful.  While  genuine  inflamma- 
tory fever,  and  local  inflammation,  are  co- 
existent with  mortification,  antiphlogistic 
means  are  undoubtedly  useful  ; but,  great 
caution  is  requisite,  since,  in  cases  of  humid 
gangrene,  as  it  is  termed,  the  inflammatory 
state  very  soon  changes  into  one,  in  which 
the  great  feature  is  prostration  of  strength. 

When  there  is  mere  prostration  of  strength  . 
without  any  symptom  of  gastric  disorder,  or 
of  inflammation,  or  typhoid  fever,  bark  is 
evidently  proper,  though  seldom  effectual 
alone  ; diaphoretic,  and  nervous  medicines 
being  also  proper,  opium,  wine,  camphor, 
ammonia,  brandy,  &lc.  The  constitutional 
disorder  may  be  either  inflammatory,  ty- 
phoid, or  on6  connected  with  gastric  disor- 
der. Consequently,  there  are  three  plans 
of  constitutional  treatment,  and  it  is  easy  to 
determine  the  particular  cases,  in  which 
bark  is  unnecessary,  hurtful,  or  ineffica- 
cious. 

We  meet  with  one  species  of  mortifica- 
tion, in  which  the  patient  experiences  se- 
vere pain  in  the  part,  w ithout  the  smallest 
appearance  of  inflammation.  Here  bark  is 
never  of  any  use,  and  opium  is  regarded  as 
the  only  medicine  of  much  efficacy.  This 
subject  will  be  more  fully  considered  pre- 
sently, when  Mr.  Pott’s  remarks  on  a pecu- 
liar mortification  of  the  toes  and  feet  will 
be  introduced. 

Bark  sometimes  occasions  purging,  and 
then  it  also  proves  inefficacious  and  hurtful. 

This  effect,  however,  may  frequently  be 
prevented  by  adding  a few  drops  of  lauda- 
num to  each  dose. 

Bark  often  disagrees  wdth  the  stomach  ;. 
but  it  less  frequently  does  so,  when  given 
in  an  exceedingly  fine  powder,  which  also 
generally  proves  most  inefficacious.  Also 
the  administration  of  bark  with  w ine,  some 
aromatic  water,  or  in  the  form  of  the  cold 
infusion,  is  less  likely  to  disorder  the  sto 
rnach.  (Richter,  Anfangsgr.  dcr  Wundarzn . 
Kap.  3.) 

Several  years  ago  I published  a critique 
on  the  indiscriminate  employment  of  bark 
in  cases  of  mortification,  and  my  remarks 
were  inserted  in  the  article  Gangrene  in  Dr. 
Rees's  Cyclopaedia.  Many  of  them  were  in- 
troduced into  the  2d  edition  of  this  Surgical 
Dictionary,  printed  in  1813.  (See  Cinchona.) 
Since  this  period,  I am  happy  to  find,  that 
the  blind  enthusiasm  with  which  bark  was 
prescribed  is  beginning  to  subside,  and  that 
on  this  subject  some  eminent  surgeons  have 
of  late  publicly  avowed  sentiments,  which 
entirely  coincide  with  my  former  state- 
ments. I think  (says  Dr.  Thomson)  ! have 
frequently  seen  it  prove  hurtful,  when  ad- 
ministered in  cases  of  mortification,  by  load- 
ing the  Stomach  of  the  patient,  creating  a 


248 


MORTIFICATION 


dislike  to  food,  and  sometimes  by  exciting 
an  obstinate  diarrhoea.  I believe  il  to  be,  in 
mortification , a medicine  completely  inert  and 
inefficacious.”  (See  Lectureson  Inflammation, 
p.  563.)  By  this  expression,  Professor  Thom- 
son does  not  mean  to  say  that  bark  can  ne- 
ver be  useful  in  cases  of  mortification,  but 
only  that  it  has  no  specific  power  in  check- 
ing the  disorder,  as  many  have  erroneously 
inculcated. 

a Bark  (says  Professor  Boyer)  has  been 
considered  by  several  distinguished  English 
practitioners,  as  a true  specific  against  gan- 
grene in  general,  and  especially  against  that 
which  depends  upon  an  internal  cause  ; but, 
subsequent  observations  to  those  published 
in  England  have  proved,  that  it  has  no 
power  over  the  immediate  cause  of  gan- 
grene, and  that  it  only  acts  as  a powerful 
tonic  in  stopping  the  progress  of  the  disor- 
der, and  promoting  tbe  separation  of  the 
mortified  parts.”  (See  Traiti  des  Maladies 
Chir.  T.  1 .p.  151,  Paris , 1814.)  Boyer  alscP 
particularly  objects  to  bark  being  given 
while  inflammatory  fever  prevails  ; but, 
whenever  he  prescribes  bark  in  cases  of 
mortification,  he  seems  to  entertain  the  old 
prejudice  of  expecting  benefit  in  proportion 
to  the  quantity  which  can  be  got  into  the 
stomach.  On  the  contrary,  Mr.  thrie  de 
dares,  that  he  has  not  found  hark  useful, 
“ further  than  as  a tonic,  and  given  in  such 
quantities  as  not  to  overload  the  stomach.” 
(On  Gunshot  Wounds , p.  148,  Ed.  2.)  a 
plan  which  I have  always  recommended. 
For  further  observations  on  bark,  the  reader 
is  referred  to  the  article  Cinchona. 

The  sulphuric  acid  may  frequently  be  ad- 
vantageously given  at  the  same  time  with 
the  bark,  and  the  best  method  of  exhibiting 
it  is  to  acidulate  with  it  every  thing  w^hich 
the  patient  drinks.  Other  acids  are  also 
sometimes  used  for  the  same  purpose. 

Carbonic  acid  gas  is  another  remedy  of 
the  highest  efficacy  in  cases  of  chronic  mor- 
tification. It  has  even  been  knowm  to  have 
the  most  beneficial  effects  when  bark  has 
failed  in  doing  good.  Water  impregnated 
with  this  gas  should  be  recommended,  as  a 
most  beneficial  kind  of  drink. 

The  hospital  gangrene  is  a case  for  which 
bark  has  been  much  recommended.  The 
best  mode  of  treating  this  particular  case, 
how-ever,  has  been  detailed  in  a separate 
article.  (fsee  Hospital  Gangrene.) 

A third  indication,  which  should  be  ob- 
served together  with  the  second,  or  which 
should  even  precede  it  in  many  instances, 
is  to  lessen  the  irritability  and  sufferings  of 
the  patient,  by  the  use  of  opium.  Attention 
1 o this  desideratum  frequently  contributes 
more  than  any  thing  else  to  stop  the  pro- 
gress of  the  disorder,  and  is  often  indispen- 
sable in  order  to  promote  the  operation  of 
other  remedies.  In  all  cases  of  mortifica- 
tion, every  thing  wdiich  heats,  irritates,  or 
adds  to  the  patient’?  sufferings,  appears,  in 
general,  to  augment  the  disorder,  and  in- 
i' crease  the  rapidity  of  its  progress.  On  the 
other  hand,  every  thing  which  tends  to  calm, 
assuage,  and  relax,  frequently  retards  the 


progress  of  mortification,  if  it  produce  no 
greater  good.  The  pain  also,  which  is  a 
constant  mark  of  too  much  irritation,  con 
tributes  of  itself  to  increase  such  irritation 
and,  in  this  double  point  of  view,  wre  can 
not  do  better,  in  the  majority  of  cases,  than 
endeavour  to  appease  it  by  the  judicious  and 
liberal  use  of  opium.  When  the  inflamma- 
tory stage  evidently  prevails,  tlm  medicine 
may  be  conjoined  with  antiphlogistic  reme- 
dies, such  as  the  nitrate  of  potassa,  antimo- 
ny, &tc.  In  other  instances,  attended  w ith 
debility,  it  may  be  given  with  bark  and  cor- 
dials. 

Mr.  Pott  has  described  a species  of  morti- 
fication, for  which  bark  is  most  frequently 
ineffectual,  and  opium  the  remedy  which  is 
to  be  depended  upon.  It  is  that  particular 
kind,  which,  beginning  at  the  extremity  of 
one  or  more  of  the  small  toes,  does,  in  more 
or  less  time,  pass  on  to  the  foot  and  ankle, 
and  sometimes  to  a part  of  the  leg,  and,  in 
spite  of  all  the  aid  of  physic  and  surgery, 
most  commonly  destroys  the  patient. 

It  is  very  uniike  the  mortification  from  in 
flammation,  that  from  external  cold,  from 
ligature,  or  bandage,  or  from  any  known  and 
visible  cause,  and  this  as  well  in  its  attack 
as  in  its  progress.  In  some  few  instances, 
it  makes  its  appearance  with  little  or  no 
pain ; but,  in  by  much  the  majority  of 
these  cases^,  the  patients  feel  great  uneasiness 
through  the  whole  foot  and  joint  of  the  an- 
kle, particularly  in  the  night,  even  before 
these  parts  show  any  mark  of  distemper,  or 
before  there  is  any  oiher,  than  a small  dis- 
coloured spot  On  the  end  of  one  of  the  little 
toes. 

It  generally  makes  its  first  appearance  on 
the  inside,  or  at  the  extremity  of  one  of  the 
smaller  toes,  by  a small  black  or  blueish 
spot : from  this  spot  the  cuticle  is  always 
found  to  be  detached,  and  the  skin  under  it 
to  be  of  a dark  red  colour. 

If  the  patient  has  lately  cut  his  nails,  or 
corn,  it  is  most  trequently,  though  very  un- 
justly, set  to  the  account  of  such  operation. 

In  some  patients,  it  is  slow7  and  long  in 
passing  from  toe  to  toe,  and  from  thence  to 
the  foot  and  ankle  ; in  others,  its  progress 
is  rapid  and  horridly  painful : it  generally 
begins  on  the  inside  of  each  small  toe,  be- 
fore it  is  visible  either  on  its  under  or  upper 
part;  and  when  it  makes  its  attack  on  the 
foot,  the  upper  part  of  it  first  shows  its  dis 
tempered  state,  by  tumefaction,  change  of 
colour,  and  sometimes  by  vesication  ; but 
wherever  it  is,  one  of  the  first  marks  of  it  is 
a separation  or  detachment  of  the  cuticle. 

Each  sex  is  liable  to  it;  but,  (says  Mr 
Pott)  £:  for  one  female  in  whom  I have  met. 
with  it.  I think  I may  say,  that  I have  seen 
it  in  at  least  twent)  males.  I think  also  that 
1 have  much  more  often  found  it  in  the  rich 
and  voluptuous,  than  in  the  labouring  poor 
more  often  in  great  caters,  than  free  drink  - 
ers. It  frequently  happens  to  persons  ad- 
vanced in  life,  but  is  by  no  means  peculiar 
to  old  age.  It  is  not,  in  general,  preceded 
or  accompanied  by  apparent  distemperaturo 
either  oftflPhe  part,  or  of  the  habit.  I do  no 


MORTIFICATION 


241) 


know  any  'particular  kind  01  constitution 
which  is  more  liable  to  it  than  another ; but 
as  far  as  my  observation  goes,  l think  that  I 
have  most  frequently  observed  it  to  attack 
those  who  have  been  subject  to  flying  un- 
certain pains  in  their  feet,  which  they  have 
called  gouty,  and  but  seldom  in  those  who 
have  been  accustomed  to  have  the  gout  re- 
gularly and  fairly.  It  has,  by  some,  been 
supposed  to  arise  from  an  ossification  of 
vessels',  but  for  this  opinion  I never  could 
find  any  foundation  but  mere  conjecture.” 

In  this  article  1 have  already  stated  the 
observations  of  Cowper,  Dr.  Thomson,  and 
Mr.  Hodgson  upon  the  ossified  state  of  the 
arteries  in  this  species  of  mortification.  The 
facts,  recorded  by  the  two  latter  writers,  at 
least  prove,  that  the  opinion  is  founded,  not 
upon  mere  conjecture,  as  Mr.  Pott  alleges, 
but  upon  actual  observation  and  experience. 

With  respect  to  the  insufficiency  of  Peru- 
vian bark,  Mr.  Pott  observes  : “ I believe  I 
may  venture  to  say,  that  I have  tried  it  as 
fairly,  as  fully,  and  as'  variously  as  any  man 
has  or  can  ; * I have  given  it  in  the  largest 
quantity,  at  the  shortest  intervals,  and  for 
the  longest  possible  space  ; that  is,  as  long 
as  the  patient’s  life  would  permit : I have 
given  it  by  itself  iu  decoction,  extract,  and 
substance  ; I have  combined  all  these  toge- 
ther; l have  joined  it  with  nitre,  sal.  ab- 
synth.  with  snakeroot,  with  confect,  car- 
diac. with  volatile  salts,  and  with  musk,  as 
different  circumstances  seemed  to  require, 
or  admit ; 1 have  used  it  as  fomentation,  as 
poultice,  as  dressing  ; I have  assisted  it  with 
every  thing  which  has  been  usually  thought 
capable  of  procuring  or  assisting  digestion  ; 
still  the  distemper  has  continued  its  course, 
perhaps  a little  more  slowly,  but  still  it  has 
ended  in  death.” 

Mr.  Pott  afterward  relates  the  first  cases 
in  which  he  gave  opium.  His  plan  was  ge- 
nerally to  give  one  grain  every  three  or 
four  hours  ; but  never  less  than  three  or  four 
- grains  in  the  course  of  four  and  twenty 
hours.  Mr.  Pott,  however,  did  not  propose 
opium  as  an  universal  infallible  specific  ; 
but  only  as  a medicine  which  would  cure 
many  cases  not  to  be  saved  by  bark. 

The  observations  of  Mr.  Pott  on  the  local 
treatment  of  these  cases  are  of  great  practi- 
cal importance  : no  part  of  his  writings  has 
a stronger  claim  to  attention. 

“ I have  found  (says  he)  more  advantage 
from  frequently  soaking  the  foot  and  ankle 
in  warm  milk,  than  from  any  spirituous  or 
aromatic  fomentations  whatever ; that  is,  I 
have  found  the  one  more  capable  of  allevi- 
ating the  pain  which  such  patients  almost 
always  feeT,  than  the  other;  which  circum- 
stance I regard  as  a very  material  one. 
Pain  is  always  an  evil,  but,  in  this  particular 
case,  1 look  upon  it  as  being  singularly  so. 
Whatever  heats, irritates,  stimulates,  or  gives 
| uneasiness,  appears  to  me  always  to  increase 
‘ the  disorder,  and  to  add  to  the  rapidity  of 
j its  progress ; and,  on  the  contrary,  I have 
| always  found,  that  whatever  tended  merely 
I to  calm,  to  appease,  and  fo  relax,  at  least 
I retarded  the  mischief;  it  it  did  no  more. 

! Vot.  il.  'S2 


“ The  whole  plan  ot  the  chirurgic  treat- 
ment ol  this  disease  is  founded  on  a general 
idea  of  warming,  invigorating,  stimulating, 
and  resisting  putrefaction  ; and  the  means 
generally  made  use  of  are  very  proper  for 
such  purpose : but  1 must  own  that  I think 
the  purpose,  or  intention,  to  be  improper.” 

Mr.  Pott  afterward  observes:  “ Cases  ex- 
actly similar,  in  all  circumstances,  are  not  to 
be  met  with  every  day,  but  I am  from  expe- 
rience convinced,  that  of  two,  as  nearly 
similar  as  may  be,  in  point  of  pain,  if  the 
one  be  treated  in  the  usual  manner,  with  a 
warm,  stimulating  cataplasm,  and  the  other 
only  with  a poultice  made  of  the  fine  farina 
seminis  lini,  in  boiling  milk  or  water,  mixed, 
with  ung.  sambuc.  or  fresh  butter,  that  the 
pain,  and  the  progress  of  the  distemper, 
vwiil  be  much  greater  and  quicker  in  the 
former  than  in  the  latter. 

“ When  the  black  or  mortified  spot  has 
fairly  made  its  appearance  on  one  or  more 
of  the  toes,  it  is  the  general  prfctice  to 
scarify  or  cut  into  such  altered  part  with  the 
point  of  a knife  or  lancet.  If  this  incision 
be  made  merely  to  learn  whether  the  part  be 
mortified  or  not,  it  is  altogether  unnecessary, 
the  detachment  of  the  cuticle,  and  the  colour 
of  the  skin,  render  that  a decided  point : if 
it  be  not  made  quite  through  the  eschar,  it 
can  serve  no  purpose  at  all : if  it  he  made 
quite  through,  as  there  is  no  confined  fluid 
to  give  discharge  to,  it  can  only  serve  to 
convey  such  medicines  as  may  be  applied 
for  the  purpose  of  procuring  digestion  to 
parts  capable  of  feeling  their  influence,  and 
on  this  account  they  are  supposed  to  be 
beneficial,  and  therefore  right. 

“ When  the  upper  part  of  the  foot  begins 
to  part  with  its  cuticle,  and  to  change  colour, 
it  is  a practice  with  many  to  scarify  imme- 
diately ; here,  as  in  the  preceding  instance, 
if  the  scarifications  be  too  superficial,  they 
must  be  useless ; if  they  be  so  deep  as  to 
cause  a slight  hemorrhage,  and  to  reach  the 
parts  which  have  not  yet  lost  their  sensi- 
bility, they  must  do  what  indeed  they  are 
generally  intended  to  do,  thift  is,  give  the 
medicines,  which  shall  be  applied,  an 
opportunity  of  acting  on  such  parts. 

“ The  medicines  most  frequently  made  use 
of  for  this  purpose  are,  like  the  theriaca, 
chosen  for  this  supposed  activity  ; and  con- 
sist of  the  warm,  pungent  oils  and  balsams, 
whose  action  must  necessarily  be  to  stimu- 
late and  irritate  : from  these  qualities  they 
most  frequently  excite  pain,  which,  accord 
ing  to  my  idea  of  the  disease,  is  diametri- 
cally opposite  to  the  proper  curative  inten 
tion  ; and  this  I am  convinced  of  from  re- 
peated experience. 

“ The  dressings  cannot  consist  of  materi 
als  which  are  too  soft  and  lenient ; nor  are 
any  scarifications  necessary  for  their  appli- 
cation. But  I would  go  farther  and  say, 
that  scarifications  are  not  only  useless,  but, 
in  my  opinion,  prejudicial,  by  exciting  pain, 
the  great  and  chiefly  to  be  dreaded  evil  in 
this  complaint.  The  poultice  should  be 
also  soft,  smooth,  and  unimtating  ; its  in- 
tention should  be  merely  to  «oftcu  and  relax  . 


M0JKT1F1CATI03S. 


i(  should  comprehend  the  whole  foot,  ankle, 
and  part  of  the  leg  and  should  always  be 
so  moist  or  greasy  as  not  to  be  likely  to  be- 
come at  all  dry  or  hard,  between  one  dress- 
ing and  another.” 

When  the  toes  arc,  to  all  appearance, 
perfectly  mortified,  and  seem  so  loose  as  to 
be  capable  of  being  easily  taken  away,  it  is, 
in  general,  thought  right  to  remove  them. 
But,  however  loose  they  may  seem,  if  they 
be  violently  twisted  olF,  or  the  parts,  by 
which  they  hang,  be  divided,  a very  con- 
siderable degree  of  pain  vviil  most  common- 
ly attend  such  operation,  which  therefore 
had  much  better  be  avoided  ; tor  Mr.  Fott 
has  seen  this  very  pain,  thus  produced,  bring 
on  fresh  mischief,  and  that  of  the  gangre- 
nous kind. 

If  the  patient  does  well,  these  parts  will 
certainly  drop  off ; if  he  does  not,  no  good 
can  arise  from  removing  them.  (Pott's 
Works.) 

In  case*,  in  which  the  disorder  is  attended 
with  a great  deal  of  irritation,  many  subse- 
quent practitioners  have  attested  the  efficacy 
of  opium  ; though  it  has  not  always  had  the 
same  success  in  their  hands,  when  the 
mortification  depended  chiefly  on  constitu- 
tional debility.  Dr.  Kirkland  observes,  that 
we  must  be  careful  not  to  force  the  doses, 
especially  at  first  ; and  that  the  medicine 
does  more  harm  than  good,  when  its  sopo- 
rific effects  go  so  far  as  to  occasion  delirium, 
take  away  the  appetite?  or  cause  affections 
of  the  heart. 

Some  authors  have  also  recommended  the 
use  of  camphor,  which,  by  reason  of  its 
narcotic  virtue,  has  sometimes  produced 
good  effects.  Pouteau  attributes  consider- 
able efficacy  to  it.  especially  in  the  erysipe- 
latous gangrene  arising  from  wounds.  In 
such  cases,  he  recommends  it  to  be  given 
in  the  dose  of  live  grains,  with  a double 
quantity  of  nitre,  every  four  hours. 

Few  surgeons  of  the  present  day  believe, 
that  opium  possesses  as  much  power  in  the 
preceding  cases,  as  Mr.  Pott  represented. 
While  Dr.  Th Anson  allows,  that  opium  is 
much  more  entitled  to  the  attention  of 
practitioners  than  bark,  as  an  useful  medi- 
cine in  the  treatment  of  mortification,  yet, 
“in  saying  so  much  in  favour  of  opium,  (he 
observes,)  I would  not  Jby  any  means  have 
you  to  place  the  same  reliance  on  its  powers 
for  stopping,  even  the  mortification  of  the 
toes  and  feet  in  old  people,  which  appeal's 
to  have  been  done  by  Mr.  Pott.  From  the 
trials  which  I have  made,  and  which  I have 
seen  made  by  others,  1 cannot  allow  myself 
to  believe,  that  its  powers  in  stopping  this 
particular  sort  of  mortification  are  greater, 
than  in  stopping  any  other  form,  or  variety 
of  the  disease.  It  is  obvious,  however,  from 
Mr.  Pott’s  account,  that  his  mind  was  strong- 
ly impressed  with  a very  different  opinion. 
His  opinion  seems  to  me  to  have  been  form- 
ed from  the  results  of*a  very  small  number 
of  cases,  and  in  complete  forgetfulness  of 
the  invaluable  observations  of  his  preceptor 
Mr.  Sharp,  with  regard  to  the  frequent  spon- 
taneous stoppage  of  mortification  in  cases 


in  which  no  medicines  whatever  are  used.' 
(See  Thomson's  Lectures  on  Inflammation , p. 
568.) 

2.  With  respect  to  the  external,  or  local 
treatment  of  mortification,  the  first  indication 
consists  in  removing,  if  possible,  such  ex 
ternal  causes,  as  may  have  occasioned,  or 
kept  up  the  disorder  ; as  the  compression  of 
bandages,  ligatures,  tumours?  all  irritating 
substances,  &c. 

When  mortification  arises  from  inflamma- 
tion, which  still  prevails  in  a considerable 
degree,  it  is  evident,  that  the  dead  part  itself 
only  claims  secondary  consideration,  and 
that  the  principal  desideratum  is  to  prevent 
the  mortification  from  spreading  to  the  living 
circumference,  by  lesseningthe  inflammation 
present.  Henee,  under  such  circumstances, 
the  application  of  linen,  wet  with  the  satur- 
nine lotion,  and  the  maintenance  of  a con- 
tinued evaporation,  from  the  inflamed  parts 
surrounding  the  mortified  flesh,  must  be  just 
as  proper  as  if  the  mortification  itself  did 
not  exist,  and  were  quite  out  of  all  con- 
sideration. 

It  has  been  justly  remarked  by  an  eminent 
man,  ( Hunter ) that  the  local  treatment  of 
mortification,  (meaning  that  in  consequence 
of  inflammation)  has  been  as  absurd  as  the 
constitutional ; scarifications  have  been  made 
down  to  the  living  parts,  in  order  that  stimu- 
lating and  antiseptic  medicines  might  be 
applied  to  them  such  as  turpentines,  the 
warmer  balsams,  and  sometimes  the  essential 
oils.  Warm  fomentations  have  been  also 
applied,  as  being  congenial  to  life ; but, 
warmth  always  increases  action,  and  should, 
therefore,  be  well  adjusted  to  the  case  ? for, 
on  the  other  hand,  cold  debilitates  or  lessens 
powers,  when  carried  too  far,  though  it  first 
lessens  action.  Stimulants  are  likewise  im- 
proper, as  the  actions  are  already  too  violent. 
It  is  proper  to  keep  the  parts  cool,  and  all 
the  applications  should  be  cold.  In  cases  of 
mortification  from  inflammation,  good  effects 
have  also  been  seen  to  arise  from  the  topical, 
as  well  as  internal  employment  of  opium. 

But  it  must  be  acknowledged,  that  how- 
ever proper  the  employment  of  cold  appli- 
cations may  be  in  principle,  in  cases  of 
mortification,  attended  with  inflammation, 
fomentations  and  emollient  poultices  are 
most  commonly  preferred  in  practice. 

Besides  common  poultices,  there  are 
several  others,  which  have  acquired  great 
celebrity,  as  topical  applications  In  cases  of 
mortification.  Of  this  kind  are  the  cata- 
plasma  carbonis,*  cataplasnia  cerevisiae,f 
and  the  cataplasma  eft'ervescens.t 

These  local  remedies  are,  perhaps,  in  nine 
cases  out  of  ten,  superior  to  all  others. 

With  respect  to  stimulating  and  spirituous 
applications,  such  as  brandy,  spirit  of  wine, 

* Prepured  by  mixing'  about  oz.  ij.  of  finely  powder- 
ed wood-charcoal  with  half  a pound  of  the  common 
linseed  poultice. 

t Prepared  by  stirring  into  the  grounds  of  strong 
beer  ns  much  oatmeal,  as  will  make  tbe  mass  of  a suita- 
ble consistence. 

+ prepared  by  stirring  into  an  infusion  of  malt  ns 
much  oatmeal,  as  will  render  the  substance  of  a proper 
thickness,  and  then  adding  about  a siroonfulof  vest. 


MORTIFICATION 


251 


balsams,  resins,  and  aromatic  substances, 
which  have  been  recommended  by  a vast 
number  of  authors,  they  are  almost  entirely 
laid  aside  by  modern  practitioners.  Though 
such  things  are  indeed  really  very  useful  in 
preserving  dead  animal  substances  from 
becoming  putrid,  a very  little  knowledge  of 
the  animal  economy  is  requisite  to  make  us 
understand,  that  they  cannot  act  in  this 
manner  on  parts  still  endued  with  vitality; 
but,  on  the  contrary,  that  they  must  have 
highly  prejudicial  effects,  in  the  cases  under 
consideration,  by  reason  of  the  violent  irrita- 
tion which  they  always  excite,  when  applied 
to  the  living  fibres.  It  may  now  and  then, 
however,  be  justifiable  to  apply  spirituous 
applications  to  the  dead  parts  themselves 
with  a view  of  diminishing  the  fetid  effluvia, 
which,  by  contaminating  the  air,  have  some 
share  in  injuring  the  patient’s  health  ; but 
the  greatest  care  is  requisite  to  keep  these 
stimulants  from  coming  into  contact  with 
the  living  surfaces  around  and  beneath  the 
sloughs. 

There  are  a few  surgeons,  however,  who 
still  place  confidence  in  certain  stimulating 
applications.  ■“  in  the  less  acute  and  more 
chronic  cases  of  gangrenous  inflammation, 
as  in  malignant  erysipelas  and  carbuncle,  in 
the  gangrene  of  the  toes  and  feet  of  old  peo- 
ple, in  the  sphacelating  state  of  hospital  gan- 
grene, and  in  severely  contused  wounds,  in 
which  gangrene  and  sphacelus  have  super- 
vened, the  emollient  poultice,  which  is  ap- 
plied to  promote  the  separation  of  the  dead 
parts,  may  have  an  addition  made  to  it  of  a 
greater  or  less  quantity  of  the  unguenturn 
resinosum,  or  even  of  oil  of  turpentine  itself. 
In  the  more  severe  of  these  cases,  where  we 
have  reason  to  dread  the  extension  of  the 
sphacelus,  warm  dressings,  as  they  have-been 
termed,  which  are  formed  by  dipping  pled- 
gets of  ebarpie  in  a mixture  of  equal  parts  of 
the  unguenturn  resinosum  and  oil  of  turpen- 
tine, may  be  applied,  of  a temperature  as 
hot  as  the  patient  can  bear  without  pain  ; 
and  over  thgse  we  may  lay  an  emollient 
poultice,  of  a large  size  and  soft  consistence. 

u After  the  sphacelus  stops,  aqd  the  pro- 
cess of  ulceration  begins  in  the  inflamed  line 
-of  contact,  between  the  dead  arid  living 
parts,  it  will  often  be  found,  that  the  turpen- 
tine dressings  are  too  stimulating,  and  occa- 
sion a considerable  degree  of  pain.  When 
this  happens,  we  must  either  diminish  the 
quantity  of  the  turpentine  in  the  dressings, 
or  remove  it  altogether,  according  to  circum- 
stances. Besides  the  pain,  a considerable 
extension  of  the  ulceration  would  be,  in 
general,  the  effect  of  continuing  these  appli- 
cations after  they  begin  to  produce  uneasi- 
ness. The  ulcerating  surface  is,  in  the  pro- 
gress of  separation,  liable  to  pass  under 
every  mode  of  treatment,  into  the  state  of  a 
painful  and  irritable  ulcer;  and  in  this  state, 
it  may  require  to  be  treated  with  decoctions 
of  poppy-heads,  or  with  the  application  of 
the  turnip,  carrot,  fresh  hemlock  leaf,  stale 
beer,  fermenting,  poultices,  fee.”  (See 
Thomsons  Lectures,  p.  577 , 578.) 

The  hospital  gangrene  is  undoubtedly  a 


case,  which  requires  powerful  applications, 
like  Fowler’s  solution  of  arsenic,  or  the  un- 
diluted mineral  acids  ; and,  in  Guy’s  Hospi- 
tal, phagedenic  sloughing  ulcers  are  usually 
treated  by  Sir  A.  Cooper  with  the  nitric  acid 
lotion,  50  drops  to  a quart  of  water,  and  the 
internal  exhibition  of  the  subcarbonato  of 
ammonia.  The  cases  also  teTmed  sloughing 
phagedeenaby  Mr.  Welbank,  find  considered 
by  him  as  analogous  to  hospital  gangrene, 
may  be  cured  by  dressing  them  with  the  un- 
diluted nitric  acid.  (See  Med.  Chir.  Trans. 
Vol.  1 1.)  I conceive,  that  it  has  only  been 
in  hospital  gangrene,  and  other  cases  of 
sloughing  phagedenic  ulcers,  that  various 
acids,  diluted,  or  undiluted,  other  caustic 
substances,  and  the  actual  cautery,  have 
sometimes  proved  really  serviceable  The 
muriatic  acid,  diluted  with  six  times  its 
quantity  of  water,  was  particularly  recom- 
mended by  Van  Swieten,  who  applied  it 
after  making  scarifications.  In  this  manner, 
he  stopped  a slpughlng  disease  extending  all 
over  the  scrotum  and  penis.  This  author 
strongly  recommends  the  same  topical  ap- 
plication to  the  sloughy  state  of  the  gums  in 
cases  of  scurvy.  In  this  kind  of  case,  he 
mixed  the  muriatic  acid  with  honey,  in  vari- 
ous proportions  ; sometimes,  he  even  em- 
ployed the  pure  acid  itself  for  touching  the. 
parts,  which  were  likely  to  slough.  It  is 
also  by  supposing,  that  the  diseases  referred 
to,  were  of  a phagedenic  character,  that  I 
account  for  the  good  effects,  imputed  by  Dr. 
Kirkland  and  others,  in  cases  of  mortifica- 
tion, to  another  still  more  active  caustic, 
namely,  a solution  of  mercury  in  nitrous 
acid,  with  which  the  edges  of  the  living  flesh 
were  touched.  At  all  events,  if  the  diseases 
were  common  cases  of  sloughing,  I infer, 
that  such  remedies  were  not  really  necessa- 
ry, and  that  nature  triumphed  both  over  the 
disease  and  the  supposed  remedy  The  fol- 
lowing is  a case  related  by  Dr.  Kirkland  : 

A man  met  with  a fracture  of  the  fore- 
arm, and  the  ends  of  the  bones  projected 
through  the  integuments.  The  fracture  was 
very  expeditiously  reduced  ; but,  at  the  end 
of  five  or  six  days,  the  whole  arm  seemed 
to  be  completely  mortified  up  to  the  shoul- 
der. Amputation  was  performed  as  near 
the  joint  as  possible,  and  the  stump,  which 
had  mortified  as  far  as  the  acromion,  was 
cauterized.  The  following  day  the  mortifi- 
cation had  reached  the  inferior  extremity  of 
the  scapula.  A little  of  the  solution  of  mer- 
cury in  nitrous  acid  was  now  applied,  by 
means  of  a probe,  along  the  edges  of  lh*e 
parts  affected,  and  from  this  moment  the  dis- 
order made  no  further  progress.  This  cau- 
terizing was  repeated  every  day,  for  seven 
teen  or  eighteen  days.  The  sloughs,  and 
even  the  scapula  itself,  were  detached,  and 
the  patient  got  well. 

On  the  continent,  liquid  caustics  are  some- 
times used  as  topical  applications  to  gangre- 
nous diseases,  more  especially,  however,  in 
cases  of  hospital  gangrene,  and  malignant 
carbuncle.  Of  this  last  disorder,  Larrey  has 
recorded  a very  dangerous  example,  in 
which  lie  effected  a cure  by  f<r.t  cutting 


1VJ0  LITIFf  C AT  IO!S 


away  as  much  of  tiic  sloughs  as  possible,  piial  Gangrene,  and.  Nitric  Acid.)  The  com 
and  then  applying  to  the  disorganized  sur-  rrion  employment  of  these  terrible  applica 
face  underneath  liquid  caustics.  Under  the  tions,  viz.  the  actual  cautery,  the  undiluted 
use  of  emollients,  two  persons  had  already  mineral  acids,  and  boiling  oils,  is  as  uriscien- 
fallen  victims  to  the  disease  in  the,  same  ti tic,  and  unnecessarily  painful,  as  it  is  un- 
family.  (See  Mtmoires  de  Chirurgie  Mill-  productive  of  any  essential  good.  The 
taire,  Tom.  1,  p.  53.)  grand  object  in  almost  every  case  of  mortifi 

With  respect  to  the  actual  cautery,  Celsus  cation,  is  to  diminish  the  irritation  of  the 


recommended  ft  to  be  applied  to  Ihe  line, 
which  separates  the  dead  parts  from  those 
which  are  still  living,  whenever  medicines, 
and,  particularly,  topical  emollient  applica- 
tions, failed  in  stopping  tiiejprogress  of  the 
disorder.  Pouteau  ventured  to  revive  this 
practice,  which  had  been  entirely  exploded 
from  modern  surgery,  and  he  was  of  opi- 
nion, that  the  method  would  have  the  most 
beneficial  effects,  in  cases  of  erysipelatous 
gangrene,  which  is  so  often  seen  in  hospitals, 
in  consequence  . of  w ounds.  For  this  pur- 
pose, he  recommends  cauterizing  chiefly 
the-  edges  of  such  parts,  as  are  of  a dark  red 
colour,  and  are  on  the  point  of  perishing; 
and  he  advises  this  to  be  done  with  a heated 
iron,  or  boiling  oil,  and  to  repeat  the  cauter- 
izing of  the  dead  parts,  at  every  time  of 
dressing  them,  until  the  sensation  of  heat  is 
even  felt  with  a certain  degree  of  force  in 
ihe  sound  parts.  The  whole  of  the  affected 
part  is  afterward  to  be  covered  with  a large 
emollient  poultice. 

Pouteau  relates  a case  of  anthrax,  which 
took  place  on  a woman’s  cheek,  and  which 
he  cured  in  the  above  manner.  The  tumour, 
which,  on  the  third  day,  was  quite  black, 
and  as  large  as  a walnut,  was  accompanied 
by  an  erysipelatous  oedema,  which  extended 
over  the  whole  cheek,  eyelids,  and  front  of 
the  neck.  Pouteau,  after  having  opened 
the  tumour  in  different  directions  with  a 
lancet,  introduced  the  red  hot  cautery,  and 
repeated  the  application  several  times,  until 
the  heat  was  felt  by  the  sound  flesh.  The 
patient  felt  herself  very  much  relieved  imme- 
diately after  this  had  been  done  ; an  oppres- 
sive beadach,  and  a very  afflicting  sense  of 
strangulation,  which  she  had  before  experi- 
enced, were  got  rid  of,  and,  in  ten  days 
more,  the  slough  w as  detached  on  the  oc- 
currence of  suppuration.  ( Encyclopedic  Me- 
thodique , Partie  Chirurgicale,  Art.  Gan- 
grene.) 

But  perhaps,  of  all  the  species  of  mortifica- 
tion, the  hospital  gangrene  is  that,  for  which 
the  use  of  caustics  and  the  actual  cautery 
itself,  has  had  the  most  numerous  and  respect- 
able advocates.  The  heated  iron  is  even 
jioav  •employed  by  the  first  surgeons  of  Paris 
for  this  particular  case.  (See  Sketches  of 
ihe  Medical  Schools  of  Paris,  by  J.  Cross,  p. 
S4,  and  Hospital  Gangrene.)  . 

The  foregoing  observations  are  introduced 
into  this  work,  that  the  reader  may  not  be 
left  entirely  ignorant  of  what  violent  mea- 
sures have  been  adopted  in  cases  of  mortifi- 
cation, and  the  account  is  not  given,  in  or- 
der that  such  practice  may  be  again  imita- 
ted, with  the  exception  perhaps  of  certain 
cases  of  phagedeena  arid  hospital  gangrene, 
cases,  in  which  the  most  powerful  local 
implication's  seem  indispensable.  See  IIos- 


partsin  immediate  contact  withthose  already 
dead.  This  is  indicated,  lest  the  parts  still 
alive,  and  so  situated,  should  experience  the 
same  fate  as  the  contiguous  ones.  In  most 
of  the  other  cases  specified  by  Dr.  Thomson, 
my  experience  leads  me  to  prefer  emollient 
soothing  applications,  none  of  which  are 
stronger  than  the  cataplasma  carbonis,  or 
the  stale  beer,  fermenting,  hemlock,  or  car- 
rot poultices.  When  the  process,  by  which 
a slough  is  detached,  is  somewhat  advanced, 

1 have  seen  a weak  solution  of  the  extract 
of  opium  in  water  put  under  the  emollient 
poultice,  along  the  line  of  separation,  give 
considerable  ease,  at  the  same  time  that  it 
seemed  to  promote  the  changes,  by  which 
the  dead  parts  were  loosened. 

In  the  gangrene  produced  by  pressure  and 
weakness  in  persons,  who  are  compelled  by 
diseases  and  injuries  to  lie  for  weeks  and 
months  in  one  posture,  the  mode  of  treat- 
ment is  a matter  of  extreme  importance, 
and  frequently  makes  the  difference  of  life 
or  death  to  the  poor  sufferer.  This  affection 
usually  has  its  seat  in  parts  which  are  but 
thinly  covered  with  muscular  flesh.  It  oc- 
curs towards  the  latter  stages  of  long-conti- 
nued febrile  diseases,  as  after  typhus,  or 
hectic  fever,  attended  with  tedious  suppu- 
rations ; or  even  without  these  fevers,  as  in 
paralysis,  and  in  very  bad  compound  frae 
tures.  However,  as  Dr.  Thomson  observes, 
there  are  twro  forms  of  disease,  arising  from 
pressure,  which  have  not  always  been  ac- 
curately discriminated.  One  of  these  is  the 
preceding  sort  of  sloughing;  Ihe  other  is  a 
chafed,  excoriated,  and  ulcerated  state  of 
the  parts. 

sometimes  uncleanliness  tends  to  cause 
this  sort  of  mortification,  that  is,  when  the 
urine  wets  the  patient’s  clothes.  When  this 
is  the  case,  such  irritation  must  he  prevented 
by  every  possible  means.  If  the  skin  be  ex- 
coriated and  broken,  the  powder  of  tutty,  or 
lapis  caiaminaris,  should  be  sprinkled  over 
the  part ; or  if  an  ointment  be  required, 
says  Dr.  Thomson,  those  which  contain  zinc 
or  lead  are  the  best.  But,  when  the  ulcera- 
tion threatens  to  extend,  these  remedies  afe 
to  be  laid  aside,  and  an  emollient,  hemlock, 
carrot,  or  fermenting  poultice  used.  (P. 
580.)  1 have  seen  in  the  irritable  state  of 

such  ulceration,  the  solution  of  opium  under 
a common  linseed  poultice  do  more  good 
than  any  other  application. 

But  no  topical  remedies  will  in  any  of 
these  cases  avail,  unless  the  chief  cause  of 
the  disorder  he  removed.  This  is  to  he  ef- 
fected by  change:  of  position,  and  laying 
pillows  and  cushions  of  Ihe  softest  materials 
in  convenient  places  under  the  patient ; not 
directly  under  the  disease  itself,  but  in  situ- 
ations where  they  will  tend  to  raise  the 


MORTIFICATION". 


25B 


parts  affected  from  the  contact  of  the  bed- 
ding. A circular  hollow  pillow  will  often 
accomplish  this  important  object;  but,  when 
possible,  an  entire  change  of  posture  is  to  be 
preferred. 

When  sphacelus  succeeds  to  gangrene 
from  pressure,  I have  often  seen  campho- 
rated spirit  applied  ; but  never  with  decided 
advantage.  A common  emollient  poultice, 
and  in  very  bad  cases,  the  topical  use  of  the 
solution  of  opium  along  the  living  margin, 
are  the  means  upon  which  I place  most  reli 
ance,  care  being  taken  to  improve  the  ge- 
neral health, without  which  grand  indication, 
neither  the  removal  of  the  pressure,  nor  the 
virtues  of  any  dressings,  will  answer.  Dr. 
Thomson  speaks  most  highly  of  the  ferment- 
ing poultice,  which  I believe  to  be  in  these 
cases  an  excellent  application.  He  confesses, 
however,  that  he  has  sometimes  found  it  too 
stimulating,  and  been  obliged  to  substitute 
the  simple  emollient,  carrot,  or  turnip  poul- 
tice. (P.  580.) 

When  mortification  arises  from  cold,  every 
sort  of  warm  emollient  application  must  be 
avoided,  and  cold  water,  or  even  snow,  or 
ice,  employed.  See  Chilblains. 

The  local  treatment  of  the  mortification 
of  the  toes  and  feet,  as  described  by  Mr. 
Pott,  has  been  already  considered,  and  is 
that  to  which  my  observations  incline  me 
to  give  the  preference. 

The  gangrenous  affection  of  the  pudenda, 
to  which  female  children  are  liable,  was 
imccessfnlly  treated  by  Mr.  X.  Wood  by  ap- 
plying the  liquor  plumbi  acet.  dilutus  in  a 
tepid  state,  and  bread  poultices  ffraae  with 
the  same  lotion.  As  soon  as  the  ulcers'  be- 
came clean,  they  were  dressed  with  the  uii- 
guentum  zinci.  (See  Med.  Chir.  Trans.  Vol. 
7.)  Other  cases,  which  also  ended  well, 
have  been  dressed  with  lint,  dipped  in  cam- 
phorated spirit,  and  covered  with  a poul- 
tice ; or,  at  first,  poultices  made  with  the 
opium  lotion,  and  after  the  separation  of  the 
sloughs,  the  ulcer  was  dressed  with  port 
wine  and  decoction  of  bark  in  equal  pro- 
portions. In  some  cases,'  however,  mild 
stimuli  proved  injurious.  ( Jameson  Inflam- 
mation, p.  289.) 

The  old  practitioners  used  to  give  vent  to 
putrid  matter,  by  making  deep  scarifications 
in  the  integuments.  The  majority  of  authors 
who  have  treated  of  mortification  have  very 
much  insisted  upon  this  plan,  which  they 
recommend  in  all  cases.  They  even  advice 
the  incisions  to  be  made  down  to  the  sound 
parts,  in  order  to  facilitate  the  application 
of  topical  stimulants,  and  to  favour  the  ope- 
ration of  the  supposed  antiseptic  qualities  of 
these  dressings.  But,  with  the  exception  of 
cases,  in  which  the  gangrenous  parts  lie  un- 
der an  aponeurosis,  or  others  in  which  the 
integuments,  which  have  escaped  destruc- 
tion, cover  a mixture  of  matter  and  sloughy 
cellular  substance,  either  in  consequence  of 
foregoing  inflammation,  or  any  other  cause, 
such  as  the  extravasation  of  urine  in  the 
scrotum,  all  scarifications  which  penetrate 
as  far  as  the  living  parts,  are  often  produc- 
tive of  the  most  serious  mischief,  instead  of 


advantage.  Such  incisions  cannot  be  prac  - 
tised, without  occasioning  a great  deal  ot 
pain,  and  producing  inflammation,  which 
often  makes  the  mortification  spread  still, 
further.  But,  as  parts,  which  are  in  a com 
plete  state  of  sphacelus,  are  absolutely  ex- 
traneous substances,  in  regard  to  those  which 
still  retain  their  vitality,  all  such  portion  of 
them  as  is  already  loose  should  be  removed. 
By  lessening  the  size  of  the  putrid  mass,  the 
fetor  is  diminished,  an  outlet  may  sometimes 
be  made  for  the  escape  of  a great  deal  of 
putrid  discharge,  which  being  confined, 
might  have  a bad  effect  on  the  neighbouring 
living  parts  ; and  the  latter  are  enabled  to 
free  themselves  more  easily  from  the  rest  of 
the*  sloughs. 

The  too  common  practice  of  accelera- 
ting, with  a cutting  instrument,  the  separa  - 
tion of  the  mortified  parts,  previously  to  the 
completion  of  the  process,  by  which  nature 
breaks  the  connexion  between  them  and  the 
living  flesh,  in  general  ought  to  be  strongly 
reprobated,  as  causing  unnecessary  pain,  and 
irritation,. and  creating  the  risk  of  a renewal 
of  the  sloughing.  As  far  as  my  experience 
goes,  gangrenous  phagedeena  is  the  only  in- 
stance, in  which  it  seems  useful  to  remove 
the  sloughs,  before  they  are  loose,  so  as  to 
let  the  topical  applications  extend  their  ac- 
tion without  delay  to  the  subjacent  living- 
surface.  (Sec  Hospital  Gangrene.)  Pott  s 
sentiments,  with  respect  to  the  danger  and 
inutility  of  cutting  the  tendonsand  ligaments, 
in  the  mortification  of  the  toes  and  feet, 
have  been  already  stated. 

If  the  surgeon  prudently  await  the  event; 
of  things,  the  separation  of  the  mortified 
from  the  living  parts  will  soon  follow  the 
establishment  of  inflammation  and  suppura- 
tion at  the*cdgcs  of  the  slough. 

But  when  the  whole  thickness  of  a limb 
is  affected  with  mortification,  ought  the  sur-, 
geon  to  leave  things,  to  nature  ? or  ought  In- 
to have  recourse  to  amputation. 

In  general,  the  performance  of  amputation 
is  indispensable;  not  that  nature  would  not  in 
raanv  instances  detach  the  sphacelated  part  ; 
but,  because  a great  length  ot  time^  would 
be  required  for  the  completion  of  the  pro- 
cess, and'  a serviceable  stump  would  rarely 
be  left. 

Another  important  question  then  arises, 
Should  the  surgeon  amputate,  while  the  mor- 
tification is  in  a spreading  state  ? Or  ought 
he  to  defer  the  operation,  until  a line  of  se- 
paration begins  to  form  between  the  dead 
and  living  parts  ? 

“ Amputation  (says  a distinguished  profes- 
sor) was  long  regarded  as  one  of  the  most 
effectual  means  which  could  be  employed  to 
prevent  the  extension  of  gangrene.  This 
practice,  however,  has  not  received  the 
sanction  of  experience  ; on  the  contrary,  it 
has  been  generally  found,  wherever  it  has 
been  practised,  in  either  acute  or  chronic 
gangrene,  to  accelerate  much  the  progress  of 
the  disease  ; and,  in  this  way,  to  hasten  the 
death  of  the  patient.  The  parts,  which  were 
divided  in  amputation,  though  at  a distance 
from  a spreading  gangrene  and  from  sphace 


'ICATION. 


254 

Ins,  were  found  speedily  to  assume  the  ap- 
pearance of  the  affection,  for  which  the  ope- 
ration had  been  performed.  Till,  therefore , 
the  adhesive  inflammation  comeson , and  a dis- 
tinctly marked  separation  of  the  dead  from  the 
sound  parts  takes  place , amputation  is,  in  few , 
if  any  cases  of  mortification , admissible.  We 
never  know,  previously  to  this,  where  a gan- 
grene, or  sphacelus,  is  to  stop,  nor  whether 
the  powers  of  the  constitution  be  sufficient 
to  sustain  the  injury  that  the  mortification 
has  inflicted.  Even  when  the  adhesive  in- 
flammation comes  on,  it  is  in  most  cases 
best  to  allow  some  time  to  elapse  before  we 
operate,  partly  with  a view  to  give  time  for 
the  constitutional  symptoms  to  abate,  in 
other  instances,  to  allow  the  patient’s 
strength  to  be  recruited  by  nourishment  and 
cordials ; and  partly  also  with  a view  to 
learn  whether  the  constitution  of  the  patient 
be  indeed  capable  of  so  great  a fresh  shock, 
as  that  which  amputation  must  necessarily 
occasion.”  (See  Thomson's  Lectures,  p.  582.) 

According  to  Richter,  there  is  never  any 
certainty,  that  we  are  amputating  in  living 
parts.  Mortification  rapidly  ascends  along 
tiie  cellular  substance,  surrounding  the  large 
blood-vessels,  and  is  frequently  much  more 
extensive  internally,  than  external  appear- 
ances would  lead  one  to  supp  -se.  The  ad 
jacent  surface,,  still  apparently  alive,  is  often 
so  affected,  that  it  must  inevitably  slough, 
though,  at  present,  it  may  not  actually  have 
sphacelated.  The  surgeon  imagines,  that  am- 
putation is  performed  on  living  parts;  but, 
soon,  afterward  discovers,  that  he  has  been 
dividing  those  which  are  dead.  The  opera- 
tion, he  observes,  can  do  no  good,  while  the 
mortification  is  in  a spreading  sla  e,  and  it 
may  do  considerable  mischief.  I he  disorder 
enlarges  its  limits,  because  its  eause  still 
operates,  and  this  is  not  removable  by  ampu- 
tation If  the  operation  be  now  injudicious- 
ly undertaken,  the  sphacelus  invades  the 
wound,  and  is  the  more  certainly  mortal,  as 
the  patient  has  been  further  weakened  by 
amputation,  and  its  consequences. 

Many  mortifications, especially  those  which 
arise  from  external  causes,  very  often  spon- 
taneously stop  and  separate.  But  the  place 
where  this  will  happen,  can  never- be  fore- 
seen. By  amputating  in  this  circumstance, 
we  run  a risk  of  disturbing  nature  in  her  sa- 
lutary work,  and  rendering  the  disorder  fajal. 

The  following  are  the  only  cases,  in  which 
Richter  allows  that  the  use  of  the  knile  is 
justifiable  and  proper.  There  exists  a spe- 
cies of  sphacelus,  which  rapidly  occasions 
death,  before  it  is  yet  of  great  extent.  Here 
indeed,  amputation  might  be  really  advisa- 
ble; but,  die  nature  of  the  case  is  unfortu- 
nately never  disclosed, before  the  fatal  catas- 
trophe. Some  external  injuries  would  be, 
without  the  operation,  inevitably  followed  by 
mortification.  In  such  cases,  early  amputa- 
tion is  evidently  proper  ; for,  the  simple  in- 
cision is  attended  with  less  danger  than 
sphacelus.  Sometimes,  says  Richter,  a spha- 
celus spontaneously  ceases  to  spread.  This 
happens  most  frequently,  in  cases  which 
originate  from  an  extern;-!  cause,  such  as  a 


violent  contusion,  burn,  Sic.  But,  the  occur- 
rence is  not  restricted  to  this  kind  of  casc^ 
nor  is  it  invariably  attendant  on  it.  When 
there  are  no  other  occasional  causes  present, 
the  mortification  does  not  readily  go  beyond 
the  limits  of  the  contusion,  or  violent  burn  : 
but  the  interference  of  surgery  can  hardly 
ever  put  a stop  to  its  progress,  before  it  has 
spread  as  far  as  the  extent  of  the  local  injury. 
(Anfangsgrunde  der  Wundarzneykunst , Band. 
1,  Kap.  3.) 

How  different  are  the  doctrines  of  Baron 
Larrey  upon  this  subject  from  those  enter- 
tained by  Richter,  and,  indeed, the  generality 
of  eminent  modern  surgeons  “ Writers  on 
gangrene,  or  sphacelus  of  the  extremities, 
(says  Larrey)  indiscriminately  recommend 
the  amputation  of  a sphacelated  limb  never 
to  be  undertaken  before  the  mortification  is 
bounded  or  limited  by  a reddish  circle,  form- 
ing a true  line  of  separation  between  the 
dead  and  living  parts.  This  circumstance 
can  only  occur  in  a case  of  spontaneous 
gangrene  from  an  internal  cause  ; or  if  it 
happens,  as  is  very  unusual,  in  a case  arising 
from  a wound,  its  progress  is  different,  and 
it.  would  be  exceedingly  imprudent  to  wait 
for  it.  The  gangrene  from  external  injuries 
almost  always  continues  to  spread ■;  the  infec- 
tion becomes  general ; and  the  patient  dies.” 
(Mem  de  Chirurgie  Militaire , T.  3,  p.  142.) 
Respecting  the  want  of  foundation  for  this 
hypothesis  of  infection,  I need  here  offer  no 
remarks,  having  already  expressed  my  opi- 
nion upon  it  in  a foregoing  page.  On  the 
other  hand,  Larrey  asserts,  that,  in  the  dry. 
or  spontaneous  ga  igrene,  absorption  takes 
place  with  more  difficulty,  and  it  is  not  un- 
common to  see  the  sphacelated  parts  sepa- 
rate from  the  living  ones  by  the  powers  of 
nature  alone,  without  the  general  functions 
being  impaired.  He  argues  that  there  is  a 
manifest  difference  between  what  he  terms 
the  traumatic  and  the  spontaneous  gangrene, 
or,  in  other  words,  between  the  humid  gan  - 
grene from  an  external  cause,  and  the  dry 
gangrene,  which  ordinarily  proceeds  from 
an  internal  cause.  (P  148.) 

In  cases  of  mortification,  arising  from  ex- 
ternal injuries,  Larrey  maintains,  that,  “ not- 
withstanding any  tiling  that  writers  and  prac- 
titioners may  allege  to  the  contrary,  we 
should  not  hesitate  about  promptly  perform  - 
ing amputation,  as  soon  as  the  necessity  for 
the  operation  is  decidedly  established.  There 
is  no  reason  to  apprehend,  that  the  stump 
will  be  seized  with  gangrene,  as  in  the  spon- 
taneous mortification,  which  has  not  ceased  to 
spread,  because  the  traumatic  gangrene,  after 
having  arisen  from  a local  cause,  is  only  pro- 
pagated by  absorption,  and  a successive  affec- 
tion of  the  texture  of  parts  by  continuity  of 
the  vessels.  Amputation,  performed  in  a 
proper  situation,  stops  (he  progress  and  fatal 
consequences  of  the  disorder. 

a Supposing  then  the  lower  half  of  the  leg 
should  be  affected  with  sphacelus,  in  con- 
sequence of  a gunshot  injury,  attended 
with  a violent  contusion  ot  tiie  part,  and 
a forcible  concussion  of  the  vessels,  nerves, 
and  ligaments,  if  the  skin,  is  elsewhere  unin- 


M0RT1F1CATICJA 


juved,  the  operation  may  he  clone  in  (he 
place  of  election,  without  any  fear  of  the 
stump  becoming  gangrenous,  notwithstand- 
ing the  cellular  membrane  of  the  upper  part 
of  the  member  may  be  already  atFected. 
But,  when  the  skin  of  the  whole  leg  is  struck 
with  mortification,  the  operation  must  be 
done  on  the  thigh,  and  no  time  should  be 
lost.  The  same  practice  is  applicable  to 
the  upper  extremities.  We  must  be  careful 
not  to  mistake  a limb  affected  with  stupor 
for  one  that  is  actually  sphacelated.  In  the 
first  case,  warmth,  motion,  and  sensibility 
are  still  retained,  although  the  skin  may  be 
blackish  and  the  parts  may  be  swollen. 
Besides,  if  there  were  any  doubt,  it  would 
be  proper  to  try  at  first  tonic  repellent 
applications,  and  cordial  medicines,  &.c.” 
(See  Mim  de  Chirurgie  Militaire,  T.  3,  p. 
152,  153.) 

When  amputation  has  been  practised, 
this  author  recommends  the  exhibition  of 
bark,  good  wine,  tonics,  &c.  in  order  to  pro- 
mote the  good  effects  of  the  operation. 
(P.  154.) 

“ The  facts  (says  Larrey)  which  I shall 
relate  in  the  course  of  this  dissertation,  will 
prove,  {I  think,  in  an  incontestable  manner, 
the  truth  of  the  principle  which  I laydown, 
that  when  gangrene  is  the  result  of  a mechani- 
cal cause , and  puts  the  patient's  life  in  danger , 
amputation  ought  to  be  performed , without 
leading  until  the  disorder  has  ceased  to  spread. 

“ 1 have  been  a witness  of  the  death  of 
several  individuals,  from  too  rigorous  an  ad- 
herence to  the  contrary  precept ; and,  at 
length,  grievously  impressed  with  this  loss,  l 
had  long  ago  determined  to  depart  from  an 
axiom,  which  was  always  considered  by  me 
as  false.  Besides,  following  the  maxim  of 
Celsus,  I preferred  employing  an  uncer- 
tain remedy,  rather  than  abandon  the  pa- 
tient to  an  inevitable  death.  Salius  csl  enirti 
anceps  auxilium  experiri  quam  nullum. 

a I made  the  first  attempt  at  Toulon,  in 
the  year  1796,  upon  a soldier,  who,  in  con- 
sequence of  a violent  contusion  of  the  foot, 
was  afflicted  with  a gangrenous  ulcer,  which 
soon  threw  the  whole  part  into  a sphacelated 
state.  While  the  mortification  was  yet  spread- 
ing, I resolved  to  amputate  the  leg.  The 
success  of  the  operation  surpassed  my  ex- 
pectations ; the  stump  healed  ; and,  in  less 
than  forty-five  days,  the  patient  got  quite 
well.  This  case  served  to  encourage  me. 

During  the  siege  of  Alexandria,  in  Egypt, 
in  1801,  a second  case,  very  analogous  to 
the  preceding,  occurred  in  my  practice ; it 
happened  in  a dragoon  of  the  lSlh  regiment, 
w hose  fore-arm  and  afterward  arm  sphace- 
lated, in  consequence  of  a gunshot  wound 
in  the  articulation  of  the  left  arm.  The  mor- 
tification had  extended  nearly  as  high  as  the 
shoulder,  and  the  patient’s  life  wTas  in  great 
danger,  when  I determined  to  amputate  the 
limb  at  the  shoulder-joint.  The  disorder 
was  manifestly  spreading,  and  the  patient’s 
brain  already  affected,  for  he  had  symptoms 
of  ataxia  : the  operation,  however,  arrested 
the  progress  of  the  sloughing,  and  saved  the 


patient’s  life,  who,  at  the  conclusion  of  the 
siege  of  Alexandria,  was  quite  cured. 

“ After  the  taking  of  Uhn,  M.  Ivan,  sur- 
geon to  his  majesty  the  Emperor,  performed 
in  my  presence,  and  at  my  ambulance  es- 
tablished at  Elchiugen,  the  amputation  of  the 
thigh  of  a soldier  belonging  to  the  76th  regi- 
ment of  the  line,  the  leg  having  sphacelated 
in  consequence  of  a gunshot  injury.  The 
gangrene  was  not  limited,  and  evidently  ex- 
tending itself ; yet,  the  effects  of  the  dis- 
order were  destroyed,  and  the  patient  was 
quite  cured  on  our  return  to  Austerlitz. 

“ A fourth  patient,  an  officer  in  the  same 
regiment,  shot  in  the  ankle,  at  the  capture  of 
the  same  town,  was  conveyed  to  my  ambu- 
lance, in  order  to  be  dressed  : it  was  the 
third  day  after  the  accident ; the  foot  was 
gangrenous,  and  the  leg  was  swelled,  and 
threatened  likewise  with  mortification.  Fe- 
brile symptoms  had  also  come  on.  1 has- 
tened to  amputate  the  leg  a little  above  the 
place  of  election.  The  cellular  membrane 
of  the  stump,  of  a yellow*  blackish  colour, 
was  already  infected  with  the  gangrenous 
principle  (as  Larrey  terms  it.)  The  opera- 
tion, however,  stopped  the  progress  of  the 
mischief;  suppuration  took  place  in  the 
stump  ; some  sloughs  were  detached  ; the 
wound  assumed  a cleaner  appearance  ; and 
cicatrization  was  completed  on  the  fifty- 
second  day.  The  patient  could  already 
w alk  w’ith  a wooden  leg,  w hen  he  caught  the 
hospital  fever,  which  wras  epidemic  at  (Jim, 
where  he  awaited  his  regiment,  and,  to  my 
great  regret,  he  was  carried  off  by  this  dis- 
ease, after  having  escaped  the  former 
danger. 

“ After  the  battles  of  Austerlitz  and  Jena, 
(continues  Larrey.)  several  of  my  colleagues, 
surgeons  of  the  first  class,  undertook,  in 
consequence  of  my  advice,  and  the  exam- 
ples of  success  which  I had  recited  to  them, 
the  amputation  of  limbs  equally  sphacelated, 
although  the  mortification  was  not  limited, 
rather  than  abandon  the  patient  to  a death, 
which  appeared  inevitable.  In  general,  these 
practitioners  experienced  the  same  success 
as  I did  myself.”  ( Larrey , in  Mim.  de  Chirur- 
gie Militaire,  T.  3.  p.  154 — 157.) 

In  Larrey’s  memoir  upon  this  subject, 
there  are  some  additional  facts  and  argu- 
ments in  favour  of  what  he  endeavours  to 
prove,  viz.  that,  in  cases  of  mortification 
from  external  injuries,  if  the  patient’s  life  is 
in  danger,  amputation  ought  to  be  performed, 
although  the  sloughing  may  yet  be  in  a 
spreading  state.  I must  be  content,  however, 
with  having  stated  the  particulars  already 
explained  ; and  the  reader,  desirous  of  more, 
must  refer  to  Larrey’s  own  publication.  Cer- 
tainly, the  facts,  which  this  gentleman  has 
adduced,  are  highly  important : they  tend 
to. subvert  a doctrine,  and  to  prove-the  error 
of  a practice,  which  have  been  urged  in 
most  forcible  terms  by  most  of  the  distin- 
guished surgeons  of  modern  times.  The 
sentiments  of  Mr.  Sharp  are  rendered  ques- 
tionable; and  the  truth  ofthe  positive  assertion 
of  Mr.  Pott  is  yet  a matter  to  be  examined. 
The  latter,  it  is  well  known,  tells  us.  that  he 


MORTIFICATION. 


tia  0 


has  often  seen  tiie  experiment  made  of  am- 
putating, while  a mortification  wasspreadirig, 
but  never  knew  it  answer.  Are  we  to  con- 
clude, that  all  these  cases,  which  Pott 
alludes  to,  were  mortifications  from  an  inter- 
nal cause  ? Or,  are  we  to  suppose  that  the 
operation  failed  from  having  been  delayed 
too  long  ? Or,  must  Vve  imagine,  that  the 
nature  of  the  human  constitution  has  been 
changed  between  the  era  of  Pott,  and  that 
of  Larrey  ? 

It  should  be  remarked,  that  the  practice, 
of  amputation,  in  cases  of  spreading  morti- 
fication, has  generally  had  some  partisans 
for  many  years  past  • but  the  weight  of  au- 
thorlies  has  unquestionably  been  against  it, 
and  few  surgeons  in  this  country  have  ven- 
tured to  deviate  from  the  advice  of  Sharp 
and  Pott.  It  is  curiouSj  however,  that  Mehee, 
a writer  who  wrote  for  the  express  purpose 
of  declaring  bis  disapprobation  of  the  early 
performance  of  amputation  in  gunshot 
wounds,  should  have  admitted  of  only  one 
case,  in  which  the  operation  is  proper, 
namely,  gangrene  succeeding  the  wound  made 
by  a cannonskot.  Here  he  thinks,  that  am- 
putation ought  to  be  performed  on  the  first 
appearance  of  the  gangrene,  in  order  to 
prevent  it  from  spreading  up  the  limb.  (See 
Trait 6 des  Plaies  d’Armes  dfeu.  Paris , 1799.) 
It  appears,  that  about  the  year  1809,  Mr.  A. 
C.  Hutchison  performed  with  success  two 
amputations  in  cases  of  spreading  gangrene 
from  gunshot  wounds.  (See  Practical  Ob- 
servations on  Surgery,  p.  72.) 

My  friend  Mr.  Lawrence  has  also  success- 
fully amputated  at  the  shoulder  joint  in  a 
spreading  mortification  of  the  arm,  the  con- 
sequence of  external  violence.  ei  The  skin 
of  the  amputated  limb  was  greenish  and 
livid  ; but  the  cuticle  not  yet  detached.  The 
cellular  substance  distended  with  air,  and 
with  a discoloured  offensive  sanies ; its  ap- 
pearance was  not  quite  natural,  where  the 
incision  took  place  ; it  was  yellowish  and 
anasarcous.  Small  effusions  of  blood  were 
observed  here  and  there  in  the  course  of  the 
nerves  ; even  as  high  as  the  amputated  part. 
No  coagulation  of  blood  in  any  of  the  arte- 
lies,  even  down  to  the  ulnar  and  digital 
branches.  All  the  soft  parts  were  disco- 
loured, dark  red,  and  livid,  and  a frothy 
reddish  fluid  issued  on  incision.”  This  case 
had  the  most  favourable  termination,  and  it 
clearly  proves,  that  the  humid  kind  of  gan- 
grene, which  occurs  in  a healthy  subject 
from  severe  local  injury,  which  so  rapidly 
affects  a whole  limb,  and  reaches  the  trunk 
in  a few  hours,  must  constitute  an  exception 
to  the  general  maxim,  that  ampuiation  should 
never  be  done,  before  a line  of  separation  is 
established  between  the  dead  and  living 
Parts.  Mr.  Lawrence,  however,  would  not 
be  Understood  as  meaning  to  recommend 
the  practice  in  all  instances  of  mortification 
from  local  injury.  He  conceives,  that  a 
gangrene  may  arise,  in  an  unsound  constitu- 
tion, from  a comparatively  slight  accident ; 
so  that  it  may  be  regarded  as  the  result  of 
constitutional  disposition, rather  than  of  the 
local  cause  Amputation  wonld  be  hopeless 


under  such  circumstances,  it  is  particularly 
in  mortification, following  very  severe  injury, 
in  a subject  otherwise  healthy,  that  Mr. 
Lawrence  believes  the  operation  to  be  pro- 
per. (See  Medico- Chir.  Trans.  Vol.  6,  p. 
184.) 

Mr.  Lawrence  also  reports  another  in- 
stance, in  which  he  saw  the  operation  suc- 
ceed, though  the  mortification  was  in  a 
spreading  stale.  About  three  years  ago,  I 
was  asked  my  opinion  about  the  propriety  of 
amputating  at  the  shoulder  in  a spreading 
mortification  of  the  arm  from  external  vio- 
lence. The  operation  was  done,  and  the 
patient  lived  a fortnight  afterward,  which  is 
favourable  to  the  practice,  inasmuch  as  he 
would  certainly  have  perished  in  a few 
hours,  if  the  operation  had  not  been  done. 

Among  the  experienced  approvers  of  Lar- 
rey’s  advice,  I must  not  omit  to  mention 
Dr.  Hennen,  who  has  repeatedly  amputated, 
under  the  circumstances  above  pointed  out, 
without  waiting  for  the  line  of  separation  ; 
“ and  (says  he)  although  I certainly  was  not 
uniformly  successful,  I have  no  reason  to 
imagine,  that  death  was  occasioned  by  a de- 
parture from  the  rule  so  generally  laid  down 
by  authors.”  (On  Military  Surgery, p.  243. 
Ed.  2.) 

With  regard  to  the  early  performance  o^ 
amputation,  where  the  substance  of  a limb 
perishes  after  exposure  to  eold,  I find  some 
difference  of  sentiment  between  two  very 
high  authorities.  jThus  Schmucker  observes 
“The  mortification,  which  comes  on  after 
a part  has  been  frozen,  increases  so  rapidly, 
it  the  limb  be  exposed  to  warmth,  that,  in  the 
space  of  twenty-four  hours,  its  vitality  and 
organization  are  quite  destroyed,  and  no- 
thing will  now  avail  in  restoring  its  sensi- 
bility. Here  the  speedy  performance  of  am- 
putation is  the  only  means  of  preservation 
to  be  depended  upon.  In  mortification 
from  an  internal  cause,  the  case  is  different.” 
(See  Vermischte  Chirurgtsche  Schriften,  B.  1, 
p.  15,  8 vo.  Berlin,  1785.)  According  to 
Larrey,  however,  this  species  of  gangrene 
at  length  stops,  and  a line  of  separation 
forms  between  the  dead  and  healthy  parts. 
If  the  disorder  be  superficial,  the  sloughs  are 
usually  thrown  off'  between  the  ninth  and 
thirteenth  days,  leaving  an  ulcer  of  propor- 
tionate extent,  that  soon  heals  up.  If  the 
whole  of  the  limb  be  sphacelated,  nature 
cannot  of  herself  effect  a cure,  or  but  very 
rarely,  the  patient  mostly  falling  a victim  to 
the  effects  of  absorption,  when  the  sloughs 
are  detached,  and  the  mouths  of  the  lym- 
phatics are  opened  ou  the  occurrence  of 
suppuration.  Larrey  assures  us  that  he  has 
seen  numerous  patients  carried  off  by  this 
'cause,  while  the  examples  of  a spontaneous 
cure  were  exceedingly  few,  and,  in  these, 
the  stump  was  left  irregular,  t#ul  unfit  for 
bearing  the  pressure  of  a wooden  leg.  Ho 
agrees,  therefore,  with  the  generality  of  sur- 
geons, that  it  is  in  these  instances  advanta- 
geous to  amputate  the  mortified  portion  of 
the  limb,  but  not  before  the  extension  of  the 
gangrene,  has  ceased , and  the  mischief  >r 


bounded  by  an  inflammatory  line.  (bee 
Mem.  de  Chir.  Mil.  T.  3,  p.  <55 — 72.) 

In  the  article  amputation , notice  has  been 
taken  of  a sloughing,  which  commences  in  the 
loot,  and  extends  up  the  leg,  and  sometimes 
follows  gunshot  injuries  of  the  thigh,  which 
involve  the  femoral  artery  : this  is  a case 
particularly  instanced  by  Mr.  Guthrie,  as  re- 
quiring the  very  early  performance  of  am- 
putation. Sir  Astley  Cooper  also  refers  to 
cases,  in  which  the  rule  was  successfully  de- 
viated from,  of  noi  amputating,  before  limits 
nre  set  to  the  spreading  of  mortification  ; the 
instances  in  question  arose  from  injury  of 
blood-vessels,  and  other  local  violence,  in 
patients  of  a healthy  constitution.  In  such 
cases,  it  is  admitted  by  this  very  experienced 
surgeon,  that  the  practice  should  be  different 
from  what  is  usually  pursued  in  mortification 
from  constitutional  causes.  ( Surgical  Essays , 
Part  2,  p.  1S6.) 

Fabricii  Hilda  ni  Traci.  Method  tens  de  Gan- 
grcena  et  Sphacelo.  Quesnai,  Traile  de  la 
Gangrene , 12 mo.  Paris , 1749.  Encycloptdie 
Meihodique , Parlie  Chirurgicale , Art.  Gan- 
grene. Kirkland  on  Gangrene,  and  on  the 
Present  State  of  Medical  Surgery.  Richter , 
An fangsgr.  der  Wundarzn.  B.  i , Kap.  3. 
Various  parts  of  Hunter  on  Inflammation,  fyc. 
Sharp's  Critical  Inquiry  into  the  present  Slide 
of  Surgery , Chap.  8.  Richtrand,  Nosographie 
Chir.  T.  1,  p.  215,  fyc.  Edit.  4.  Lassus , Pa- 
thologic Chir.  T.  1 , p.  30,  fyc.  Edit.  1809. 
Levtillt,  JYouvelle  Doctrine  Chir  T.  4,  p. 
321,  dye.  Paris,  1812.  Larrey,  Mtmoires  de 
Chirurgie  Militaire,  T.  3,  particularly  the 
Mdm.sur  la  Gangrene  de  Congelation,  p.  60, 
and  that  sur  la  Gangrene  Traumaiique,p.  141. 
Callisen,  Systema  Chirurgice  Hoditrnce,  Vol. 
2,  p.  374,  Edit.  1800.  Dr.  J.  Thomson's 
Lectures  on  Inflammation,  p.  501,  Edinb. 
1813.  O’ Halloran  on  Gangrene  and  Sphacelus , 
8 vo.  Dublin,  1765.  Pott's  Obs.  on  the  Mor- 
tification of  the  Toes  and  Feet  in  his  Ch  irurg. 
Works,  Vol.  3.  J.  Kirkland , Thoughts  on 
. Imputation , <*yc.  with  a short  Essay  on  (he 
Use  of  Opium  in  Mortification,  8 vo  London, 
1780.  J.  Harrison,  The  remarkable  Effects 
affixed  Air  in  Mortifications  of  the  Extremi- 
ties, Sro.  Loud.  1785.  ./  A.  Murray,  In 

Gangnenam  Scroti  Obs.  {Frank.  Del.  Op.  10.) 
C.  White,  Observations  on  Gangrenes  and 
Mortifications,  accompanied,  fyc.  with  convul- 
sive spasms,  8 vo.  1790.  Pearson's  Principles 
of  Surgery,  p.  114,  Edit.  2.  Lawrence  in 
Medico- Chir.  Trans.  Vol.  6,  p.  184,  fyc.  Del- 
pech , Mdmoire  sur  la  Complication  des  Plaies 
cl  des  Ulceres,  eonnue  sur  le  Norn  de  Pov.rri- 
ture  d'Hopital ; also,  Precis  Element  air  6 des 
Maladies  Reputees  Chirurgicales,  T.  1 , p.  73, 
fyc.  Paris,  1816.  Boyer,  T raites  des  Ma- 
ladies Chir.  T.  1,  p.  105,  fyc,  Paris,  1814. 
John  Bell's  Principles  of  Surgery.  Professor 
Himly's  Abhandlung  uber  der  Brand  der 
Weichen  und  harlen  Thtile,  Git.  1800.  For 
an  Account  of  the  dry  gangrene,  see  particu- 
larly the  Writings  of  Hildanus,  Tulpius, 
Quesnai  Mtmoires  de  la  Sociele  Roy  ale  de 
Medecine,  Tom.  1.  Operc  di  Bertrandi  ; Me- 
dical Museum,  fyc.  For  a description  of  the 
mortification  caused  by  eating cockspur  rye,  see 

Vox  If  33 


Dodard's  letter  in  Journal  des  Savans,  1676, 
Noel,  in  Mem.  de  TAcad.  des  Sciences,  1710. 
Langius.  “ Descriptio  Morborum  ex  esu  Cla- 
vorum  Secalinorum."  Duhamel,  in  M6m.  de 
TAcad.  des  Sciences,  1748.'  Dr.  C.  Woolaston , 
in  Philosophical  Trans.  1762.  Tessier,  in 
Mtm.  de  la  Societt  Royale  de  Medecine,  T.  i, 
and  2,  tfc.  0.  Presscott,  A Dissertation  on 
the  Natural  History  and  Medicinal  effects  of 
the  Secale  cornutum.  or  Ergot.  8 vo.  Land. 
1813.  D.  F.  Heffter , Doctrines  de  Gangrana 
brevis  Expositio,  4 to.  Lips.  1807.  C.  L.  G 
Liessehing,  De  Gangrana,  4lo.  Colt.  1S11. 
Hennen's  Principles  of  Military  Surgery , p. 
241,  &pc.  Ed.  2,  8 vo.  Loud.  1820.  G.  J. 
Guthrie  on  Gunshot  Wounds,  fyc.  p.  Ill,  8fc. 
Ed.  2,  St’o.  Loud.  1820.  J.  H.  James,  Obs. 
on  the  Principles  of  Inflammation,  p.  84.287, 
dye.  8vo.  Land.  1821.  Sir  Astley  Cooper, 
Surgical  Essays,  Part  2,  p.  186,  Sro.  Loud. 
1820. 

MOXA.  A soft  lanuginofrs  substance  pre- 
pared from  the  young  leaves  of  a species  of 
mugw’ort.  It  is  used  in  the  following  way  : 
A little  cone  of  the  moxa  is  laid  upon  the 
part,  previously  moistened,  and  set  on  fire  at 
the  top.  It  burns  down  w ith  a temperate 
glowing  heat,  and  produces  a dark-coloured 
spot,  the  separation  of  which  is  promoted 
by  applying  a little  garlic.  The  ulcer  is  left 
to  discharge,  or  is  healed  up  according  to  the 
object  in  view.  The  moxa  is  famous  in  the 
East  for  curing  several  diseases ; and  the 
French  are  much  in  the  habit  of  using  it  ; 
but,  when  English  surgeons  wish  to  produce 
a slough,  they  generally  have  recourse  to 
caustics,  in  preference  to  actual  fire. 

M.  Roux,  when  he  visited  the  London  hos- 
pitals, had  two  opportunities  afforded  him 
of  applying  the  moxa,  in  order  to  convince 
the  rising  generation  of  surgeons  in  this 
country  of  its  superior  efficacy.  The  first 
was  in  a ca-e  of  spontaneous  paralysis  of  the 
deltoid  muscle  at  St.  Bartholomew’s.  The 
moxa  was  applied  a lit ? le  below  the  acro- 
mion, and  a fewT  days  afterward  the  motion 
of  the  arm  began  to  be  restored.  This, 
however,  was  a case,  which,  according  to 
(he  account  of  Roux  himself,  had  relapsed, 
after  having  been  cured  by  other  means.  I 
think  one  of  the  surgeons  of  St.  Bartholo- 
mew's informed  me,  that  notwithstanding 
the  moxa,  the  relief  proved  again  only  tern-, 
porary.  If,  however,  the  moxa  had  suc- 
ceeded, a caustic  issue,  a blister,  or  volatile 
liniments,  would  probably  have  answered 
equally  well.  The  second  instance,  in  which 
M Roux  applied  the  rnoxa,  was  a case  of 
white  swelling  at  Guy’s  Hospital  ; but  the 
disease  had  advanced  too  far  to  allow  any 
hope  of  •*  favourable  issue.  (See  Voyage 
fait  a Londres  en  1814,  ou  Par  allele  de  la 
Chirurgie  Angloise  avec  la  Chirurgie  Fran - 
caise,  p.  19,  20  ) M.  Roux  flatters  himself 
that,  “ Its  chirurgiens  Anglois  repugneront 
sans  doute  moins  a I'avenir  a faire  usage  du 
moxa."  The  truth  is,  English  surgeons,  as 
well  as  English  farriers,  knew  very  well  be- 
fore the  arrival  of  M.  Roux  what  might  be 
done  with  moxa  and  the  actual  cautery. 
But,  though  the  application  of  fire  still  pre 


MURIATIC  ACii*. 


vails  in  Hie  veterinary  art,  as  a mode  of  disease,  in  which  a cure  tons'  effected  without 


curing  diseases,  it  has  long  been  abandoned 
as  a means  of  relief  in  the  English  practice 
of  surgery  : not  on  the  ground  of  its  being 
always  ineffectual ; but,  because  equal  good 
has  been  found  to  result  from  measures, 
which  are  milder,  always  less  terrific,  and 
frequently  less  painful.  In  order  to  con- 
vince an  English  surgeon  that  moxa  and  the 
actual  cautery  ought  to  be  introduced  into 
practice,  M Roux  should  prove,  that  there  is 
at  least  some  particular  disease,  which  may 
in  this  manner  be  cured,  but  which  cannot 
be  cured  by  other  means,  ordinarily  em 
ployed  in  our  practice.  He  should  also 
make  us  forget,  that  the  application  of  actual 
fire  was  once  as  common  in  English  surgery 
as  in  French  ; but  that  it  had  not  attractions 
enough  to  maintain  if-  ground. 

MURIATIC  ACID.  Acidum  Muriaticum. 
Gargles,  containing  this  acid,  are  often  made 
use  of  with  advantage  in  various  cases  of 
sore  throat,  and  the  disease  known  by  the 
name  of  eancrum  oris.  The  following  for- 
mula is  employed  at  St.  Bartholomew’s  Hos- 
pital. JJ.  Rosas  rubrae  exsiecatae  3<j-  Aquae 
ferventis  fbj.  lnfunde  per  horam  dimidiam, 
dein  colaet  adde  Accidi  muriatici  3j-  Mellis 
Rosae  ^ij.  Sacchari  purificati  3vj-  Misce. 

Muriatic  acid  appears  to  have  been  tried 
in  syphilis  earlier  than  the  nitric,  Dr.  Zeller, 
of  Vienna,  having  employed  it  as  a success- 
ful remedy  for  this  disease  ever  since  the 
year  1789.  ( Vid . Sim.  Zeller's  Prakt.  Bem'erk 
aber  den  vorzugl.  JVutzen  d.  allerem.  bekannt. 
Badeschwamens , fyc.  JVebst.  einetn  Anhange  v. 
d.  SalzaUre,  fyc.  Wien.  1797.) 

As  a medicine  capable  of  improving  the 
appearance  of  venereal  ulcers,  and  of  re- 
straining for  a time  the  progress  of  the  dis- 
ease, it  has  been  known  to  Mr.  Pearson 
many  years.  He  says,  that  he  was  first  in- 
duced to  give  this  acid  in  venereal  ulcers  of 
the  tongue,  and  of  the  throat,  in  consequence 
of  the  great  benefit  which  he  had  seen  re- 
sult from  its  use  in  examples  of  cancrum 
oris  : and  without  viewing  it  as  an  antidote 
for  lues  venerea,  he  has  frequently  availed 
himself  of  its  useful  qualities,  when  it  was 
desirable  to  gain  a little  time  previously  to 
the  commencement  of  a mercurial  course. 
( Obs . on  the  Effects  of  Various  Articles  in  the 
Cure  of  Lues  Venerea,  p.  193,  Ed.  2.)  From 
what  he  saw,  however,  he  never  inferred 
that  the  sulphuric  and  muriatic  acids  could 
radically  cure  the  venereal  disease  ; and  he 
ascribed  the  benefit  derived  from  them 
partly  to  their  salutary  effects  on  the  sto- 
mach and  constitution,  and  partly  to  their 
agency  on  ulcers  of  the  throat  and  tongue, 
as  local  applications.  (P.117.)  When  Mr. 
Pearson  made  these  observations,  the  fact, 
which  has  now  been  so  unequivocally  de- 
monstrated in  the  army  hospitals,  that  nearly, 
if  not  all,  the  forms  of  disease,  going  under 
the  name  of  syphilis,  maybe  cured  without 
mercury,  had  not  undergone  the  strict  and 
impartial  investigations  which  have  of  late 
years  been  devoted  to  the  subject.  (See 
particularly  Obs.  on  the  Treatment  of  Syphi- 
lis, with  an  account  of  several  cases  of  that 


the  use  of  Mercury , by  T.  Rose,  in  Medico- 
Chir.  Trans.  Vol.  8,  p.  349 ) If  this  point 
be  admitted  as  fully  established,  the  ques- 
tion about  the  antisyphilitic  virtues  of  vari- 
ous articles  of  the  materia  medica  requires 
to  be  taken  up  in  a very  different  light,  not 
clouded  with  a notion  that  the  disease  will 
certainly  get  worse  and  worse,  if  no  remedy 
whatever  be  exhibited,  or  that  it  cannot 
finally  get  well  of  itself.  While  these  doc- 
trines prevailed,  the  amendment  of  any  sy- 
philitic affection  during  the  use  of  muriatic, 
or  any  other  acid,  wras  entirely  referred  t© 
some  specific  effect,  supposed  to  appertain 
to  such  medicine.  But  now  the  question 
involves  several  considerations ; first,  the 
actual  virtue  of  the  medicine  in  expediting 
the  cure  of  the  disease;  secondly,  the 
changes  which  might  happen  if  the  com- 
plaint wqre  left  to  itself;  and  thirdly,  the 
benefit  sometimes  ascribable  to  the  improve- 
ment produced  in  the  constitution,  under 
particular  circumstances,  by  the  discontinu- 
ance of  mercury.  The  latter  mineral  no 
longer  claims  the  name  of  a specific  for  the 
venereal  disease,  either  in  the  sense  of  the 
only,  or  a completely  certain,  antidote ; be- 
cause nature  herself  would  in  time  bring 
most  cases  to  a favourable  conclusion;  be- 
cause the  cure  can  be  completed  by  a variety 
of  other  medicines,  noticed  in  this  publica- 
tion; and,  lastly,  because  mercury,  though 
it  may  be  generally  the  quickest  means  of 
cure,  is,  in  particular  cases,  complicated 
with  much  debility  and  constitutional  irrita- 
bility, the  surest  medicine  for  aggravating 
the  complaint,  and  preventing  any  progress 
towards  a favourable  termination.  Here  it 
is  enough  to  know,  (and  Mr.  Pearson  him- 
self acknowledges  the  fact)  that  in  the  cir- 
cumstances above  specified,  muriatic  acid 
is  a safer  medicine  than  mercury.  The  do$e 
is  from  ten  to  twenty  drops,  which  are  to  be 
mixed  with  a proper  quantity  of  water. 

Muriatic  acid  has  sometimes  been  ein 
ployed  as  the  active  ingredient  in  injections 
for  the  cure  of  gonorrhoea,  in  the  proportion 
of  eight  or  ten  drops  to  four  ounces  of  dis- 
tilled water. 

In  cases  of  poison  from  muriatic  acid,  the 
experiments  made  by  Orfila  lead  him  to  con 
sider  calcined  magnesia  and  prepared  soap 
the  most  fit  substances  for  neutralizing  suclu 
portion  of  the  acid  as  may  not  yet  be  com 
bined  writh  the  texture  of  the  (esophagus, 
stomach,  &.c.  They  should  be  given  as  soon 
as  possible  after  the  corrosive  poison  has 
been  swallow’ed,  care  being  taken  to  let  the 
patient  drink  copiously  of  warm  water, 
milk,  broth,  or  some  mucilaginous  diluting 
liquid.  When,  from  the  symptoms,  there  is 
reason  to  believe  that  inflammation  exists  in 
the  viscera,  or  w hen  spasms  and  convulsions 
come  on,  antiphlogistic  remedies,  and  anti- 
spasmodics,  are  indicated.  (Trait d des  Poi- 
sons,  p.  476,  Vol.  1,  Ed.  2,  Paris,  1818.)  In 
order  to  detect  the  presence  of  muriatic 
acid,  when  mixed  with  wine  or  other  fluids, 
we  are  recommended  to  distil  a portion  ot 
it  from  a small  retort,  over  a candle,  into  n 


US. 


phial  containing  a solution  of  nitrate  of  sil- 
ver. The  precipitation  of  muriate  of  silver, 
which  is  soluble  in  ammonia,  hut  not  in 
nitric  acid,  will  take  place  if  the  poison 
contain  muriatic  acid.  ( Thomson's  Dispen- 
satory, p.  434,  Ed.  2.) 

By  Morveau,  who  employed  himself  in 
investigating  the  merits  of  Dr.  Carmichael 
Smith’s  mode  of  destroying  infection,  the 
muriatic  acid,  in  the  new  form  of  gas,  was 
alleged  to  have  the  very  important  quality 
of  neutralizing  putrid  miasmata.  The  gas 


is  extricated  from  common  salt  by  means  of 
sulphuric  acid  In  this  way  it  is  often  em- 
ployed in  hospitals  as  a mode  of  preventing 
and  obviating  infection. 

The  use  of  muriatic  acid,  as  an  application 
to  certain  cases  of  sloughing,  and  phagedee- 
na,  has  been  explained  in  the  articles*  Hos- 
pital Gangrene  and  Mortification. 

MYDRI'ASIS.  (from  y.iS'im,  to  abound  in 
moisture.)  A preternatural  dilatation  of  the 
pupil. 


N. 


TVTiEVlJS.  (Congenitce  No  tee ; Envies; 
JLl  Mvlter-mahl ; Mother-spots,  fyc.)  A 
molp,  or  congenital  mark,  or  excrescence  of 
the  skin.  INeevi  materni  signify  the  little 
spots,  excrescences,  or  swellings,  with  which 
many  children  are  born.  Some  of  them 
(says  Dr.  Bateman)  are  merely  superficial, 
or  stain-like  spots,  and  appear  to  consist  of 
a partial  thickening  of  the  rete  mucosum, 
sometimes  of  a ydlow,  or  yellowish  brown, 
sometimes  of  a bluish,  livid,  or  nearly  black 
colour.  To  these  the  term  spilus  has  been 
more  particularly  appropriated  Others 
again  exhibit  various  degrees  of  thickening, 
elevation,  and  altered  structure  of  the  skin 
itself,  and  consist  of  clusters  of  enlarged  and 
contorted  veins,  freely  anastomosing,  and 
forming  little  sacs  of  blood  These  are  some- 
times spread  more  or  less  extensively  over 
the  surface,  occasionally  covering  even  the 
whole  of  an  extremity,  or  one  half  of  the 
trunk  of  the  body  ; and  sometimes  they  are 
elevated  into  prominences  of  various  form 
and  magnitude.  Occasionally,  these  marks 
are  nearly  of  the  usual  colour  of  the  skin ; 
but  most  commonly  they  are  of  a purplish 
red  colour,  of  varying  degrees  of  intensity  ; 
such  as  the  presence  of  a considerable  col- 
lection of  blood-vessels,  situated  near  the 
surface,  and  covered  with  a thin  cuticle,  na- 
turally occasions.  (See  Batemans  Practical 
Synopsis  of  Cutaneous  Diseases,  p.  324,  Edit. 
4.)  When  a naivus  is  of  a dark  red  colour, 
its  intensity  is  generally  augmented  by  every 
thing  which  tends  to  accelerate  the  circula- 
tion of  the  blood.  Fits  of  anger,  hot  wea- 
ther, fevers,  and  the  period  of  menstruation, 
in  particular,  are  observed  to  be  attended 
with  an  increased  turgescence  and  disco- 
louration of  the  part  affected.  Indeed  the 
excrescence  sometimes  bursts,  and  pours  out 
a dangerous  quantity  of  blood,  and  in  fe- 
males it  has  been  known  to  become  the  seat 
of  a regular  menstrual  discharge.  {Boyer, 
Trail6  des  Maladies  Chir  T.2,p.  277;  and 
John  Bell's  Principles,  Discourse  9.)  Some 
naevi,  especially  those  usually  called  moles , 
frequently  have  long  irregular  hairs  grow- 
ing upon  them  ; while  the  surface  of  others 
is  streaked,  and  even  granulated.  Such  as 
appear  rn  the  form  of  a mere  red,  purplish 
stain,  have  been  absurdly  supposed  to  arise 
from  a desire  for  claret,  or  some  other  wine 


of  that  colour,  entertained  by  the  mother  of 
the  patient  during  her  pregnancy.  The 
granulated  naevi  have  been  compared  with 
raspberries,  strawberries,  mulberries,  &tc.  for 
which  the  mother’s  longing  is  ascribed  by 
the  vulgar  as  a cause.  The  truth  is,  howe- 
ver, that  this  doctrine,  imputing  the  origin  of 
na3vi  to  fancies  of  the  mother,  is  neither 
consistent  w ith  experience  nor  sound  phy- 
siology. The  causes  (as  Callisen  observes) 
“ potius  autem  in  evolutione  prirnorum  fla- 
minum,  a naturaj'solita  via  aberrante,  uti  in 
aliis  rebus  monstrosis  quserenda?  erunt.” 
( Syst . Chir.  Hodiernee . Pol.  2.  p.  201.) 

From  what  has  been  said,  then,  it  appears 
that  certain  ntevi  are  merely  cutaneous  spots, 
of  a red,  violet,  or  purplish  colour,  of 
greater  or  lesser  extent,  and  with  scarcely 
any  perceptible’  elevation.  They  are  aii 
organic  malformation  of  the  skin,  the  natu- 
ral texture  of  which  does  not  exist,  but  has 
substituted  for  it  a plexus  of  vessels,  not  en- 
dued with  the  natural  sensibility  of  the  cutis 
itself.  These  naevi  generally  continue  sta- 
tionary during  life,  and  may  be  regarded 
rather  as  a deformity  than  a disease.  ( Lassus , 
Pathologic  Chir.  Tom.  1,  p.  477.)  Other 
naevi  are  either  of  the  same  nature  as  the 
disease,  well  known  by  the  name  of  the 
aneurism  by  anastomosis,  or  bear  a consi- 
derable resemblance  to  it.  They  are  some- 
times of  great  size,  and  their  shape  is  subject 
to  much  variety.  They  are  soft  and  indo- 
lent, and  of  a violet  or  dark  red  colour.  The 
skin  which  covers  them  is  very  thin,  and, 
when  they  are  opened,  their  structure  is 
like  that  of  a spleen,  whose  blood-vessels  are 
varicose.  Some  are  covered  with  a delicate 
white  skin,  and  do  not  increase  with  age. 
Others  are  more  disposed  to  grow  large. 
These  tumours  frequently  occur  in  the  skin 
of  the  face,  and  in  other  parts  of  the  integu- 
ments, on  the  inside  of  the  labia  pudendi, 
and  cheeks,  and  in  the  substance  of  the  up- 
per and  lower  lip,  where  they  sometimes 
form  a kind  of  elongation,  attended  with 
great disGgurement.  Nrevi  of  this  kind,  so 
situated  in  new-born  infants,  may  produce 
a serious  obstacle  to  the  action  of  sucking. 
M.  A.  Severinus-has  particularly  described 
them  under  the  appellation  of  “ tuberculnm 
atro-cruentum  labii  inferioris.”  (De  Ah&es- 
smtm  natum,  Cop  29.  p . 803.) 


\ECROSl'- 


26,0 

The  mevi,  which  form  in  the  subcutane- 
ous cellular  substance,  and  were  named  by 
Petit  “loupes  variqueuses,”  ((Lucres  Post- 
humes, Tom.  1,  p.  276.)  are  also  of  the  same 
nature  as  the  aneurism  by  anastomosis.  In 
time,  they  attain  a very  large  size.  Mr. 
Latin  says,  he  once  saw  in  a child,  two 
years  old,  a tumour  of  this  kind  weighing 
fourteen  ounces,  which,  at  the  time  of  birth 
was  only  equal  in  size  to  a large  bean  During 
the  first  year,  it  did  not  enlarge  much  ; but 
it  afterward  grew  rapidly  to  the  size  already 
specified.  (System  of  Surgery  Vol.  2,  Chap. 
22.)  Lassus  nas  even  seen  a tumour  of  this 
description  as  large  as  a man’s  head.  (Pa- 
thologie  Chir.  Tom.  I,  p.  479.)  Having 
treated  particularly  of  the  aneurism  by 
anastomosis,”  in  another  place,  (see  Aneu- 
rism,) I shall  merely  repeat  the  necessity 
there  is  for  cutting  every  particle  of  the 
disease  away,  every  portion  of  the  congeries 
of  vessels  and  cells  of  which  it  consists, 
whenever  it  is  meddled  with  at  all.  Punc- 
turing the  swelling,  or  the  partial  removal 
of  it,  has  cost  many  persons  their  li  .es  by 
hemorrhage,  as  the  records  of  surgery  fully 
prove.  (Petit,  Traits  des  Maladies  Chir.  T. 
1 ; Lassus,  Palhologie  Chir.  T.  1,  p.  484, 

Although  the  original  causes  of  naevi  are 
buried  in  obscurity,  experience  proves,  that 
whatever  produces  irritation  in  the  part  af- 
fected, or  an  increased  determination  of 
blood  to  it,  has  generally  the  effect  of  acce- 
lerating the  growth  and  enlargement  of  the 
swelling.  Tims,  a trifling  bruise,  or  a tight 
hat,  will  sometimes  excite  a mere  stain-like 
speck,  or  a minute  livid  tubercle,  into  that 
diseased  action,  which  occasions  its  growth. 
(Bateman's  Pract.  Synopsis , p.  327, 

Edit.  3.) 

With  regard  to  the  treatment  of  naevi,  the 
subject  may  be  explained  in  a few  words. 
When  these  marks,  or  swellings,  are  super- 
ficial, without  any  disposition  to  enlarge,  or 
spread,  and  their  trivial  elevation  does  not 
expose  them  to  accidental  rupture,  there 
appears  to  be  no  good  reason  for  interfering 
with  them.  Indeed,  they  could  only  be 
destroyed  with  caustic,  or  the  knife,  and 
these  severe  means  would  leave  scars,  ac- 
companied with  nearly  the  same  degree  of 
disfigurement. 

But,  as  a valuable  writer  observes,  when 
naevi  evince  a tendency  to  enlarge,  or  are 
very  prominent  excrescences,  and  either 
troublesome  from  their  situation,  or  liable  to 
be  ruptured,  either  their  growth  must  be 
repressed  by  sedative  applications,  or  the 
whole  congeries  ol  vessels  extirpated  with 
the  knife.  Mr.  Abernelhy  has  proposed  the 
application  of  cold  washes,  and  the  pressure 
of  a bandage.  This  practice  was  found  by 
him  in  several  instances  to  have  the  desired 
effect  of  checking  the  growth  of  the  tu- 
mours, which  afterward  shrunk,  and  be- 
came no  longer  objects  of  any  consequence. 
(See  Aberntthy's  Surgical  Works , Vol.  2,  p. 
224.)  Boyer  also  knew  of  a casp,  in  which 
a naevus  of  the  upper  lip  was  cured  by  the 
mother  pressing  the  part  with  her  finger 


unremittingly  for  seven  hours  at  a timev 
and  the  use  of  alum  wash.  (Traitd  des 
Maladies  Chir.  T.  2,  p.  269.)  Boyer,  how- 
ever, is"  not  generally  an  advocate  for  this 
inode  of  treatment  ; and  Dr.  Batemen  ex 
pressly  states,  that,  in  the  majority  of  cases, 
pressure  is  the  source  of  great  irritation  to 
these  maculae,  and  cannot  be  employed. 
(P  329.) 

For  all  those  examples,  which  partake  of 
the  nature  of  aneurism  by  anastomosis,  and 
are  disposed  to  grow,  the  best  general 
mode  of  cure  is  extirpation  with  the  knife. 
The  prudence  of  this  practice,  and  the  ne- 
cessity of  taking  away  every  particle  of  the 
disease,  has  been  already  explained  : this  is 
what  was  advised  by  F.  Hildanus,  (Cent. 
5.  Obs.  46.)  what  was  strongly  urged  bv  the 
celebrated  Petit,  ((Euvres  Posthumes,  T.  1.) 
what  was  recoin  mende  in  still  more  ani- 
mated terms  by  Mr.  John  Beil,  (Principles 
of  Surgery , Discourse  9. ;)  and  it  is  what  is 
particularly  insisted  upon  in  another  part  of 
this  Dictionary.  See  Aneurism. 

In  general,  stimulating  applications  can- 
not he  made  to  naevi,  without  risk  of  exas- 
perating, instead  of  lessening  them.  Mere 
thickenings,  and  discolourations  of  the  rete 
mucosum,  however,  have  sometimes  been 
removed  by  a mixture  of  spirit  and  the  liquor 
potasses.  ( Bateman , p.  330.) 

Formerly  caustic  was  much  in  vogue  for 
the  removal  of  naevi ; but,  unless  its  action 
extend  deeply  enough  to  destroy  every  part 
of  (he  disease,  il  may  cause  a dangerous 
degree  of  irritation,  copious  hemorrhages, 
and  a sudden  and  fatal  enlargement  of 
the  tumour.  Therefore,  as  it  is  a more 
painful  measure  than  the  knife,  and  less  cer- 
tain in  its  effects,  it  should  be  on  every  ac- 
count discarded  from  practice.  It  cannot  be 
denied,  however,  that  the  old  surgeons  had 
success  with  their  caustics,  where  the  nasvi 
were  altogether  superficial.  Thus,  in  speak- 
ing of  caustic  femedies,  Callisen  observes 
“ inter  quae  eximio  cum  successu  adhibetur 
sapo  cum  aequali  parte  calcis  vivas  subtilissi- 
tna?  coinmixtus,  naevo  per  emplastrum  per- 
foratum aduif  vendus,et  alio  ernplastro  impo 
sito  firmandus;  hoc  remedioesebara  inuritur, 
qua  soluta,  cicatrix  alba  remanere  solet.” 
(Syst.  Chirurgice  Hodiernce,  Vol.  2,  p.  202.) 

Consult  Petit's  ( Euvres  Posthumes,  T.  1 . 
Lassus,  Pathologie  Chir.  V.  1 , p.  476,  <^e.  Ed. 
1S09.  Callisen' s Systema  Chirurgice  Hodi- 
ernce, Vol.  2,  p.  201,  Hafnice,  1800.  Aber 
nethy's  Surgical  Works,  Vol.  2,  p.  224,  fyc. 
Lalta's  System  of  Surgery,  Vol.  2.  Chap.  22 
J.  Bell's  Principles  of  Surgery , Vol.  1,  Dis- 
course 9.  Boyer,  Traitt  des  Maladies  Chi- 
rurgicales,  T.  2,  p.  225,  fyc.  Paris , 1814.  A 
Practical  Synopsis  of  Cutaneous  Diseases  by 
T.  Bateman , M.  D.  Edit.  3,  181,4.  Delpeck 
Precis  Elimentaire  des  Maladies  Chir.  T.  3, 
p.  244,  Paris , 1816.  J.  Wardrop,  On  one 
Species  of  JVeevus,  with  the  Case  of  an  Infant , 
where  the  Carotid  Artery  was  tied , in  Med. 
Chir.  Trans.  Vol.  9,  p.  199,  «!pc. 

NECROSIS,  (from  vat^c®.  to  destroy.)  This 
word,  the  strict  meaning  of  which  is  only 
mortification,  is,  by  the  general  consent  of 


NECROSIS  261 


surgeons,  confined  to  this  affection  of  ihe 
bones.  It  was  first  used,  in  this  particular 
sense,  by  the  celebrated  M.  Louis,  who  re- 
stricted its  application,  however,  to  exam- 
ples, in  which  the  whole  thickness  of  a bone 
was  destroyed.  (See  Mem.  de  l' Acad.  Roy- 
alt  de  Chirurgie,  T.  5.  4/o.)  By  the  ancients 
the  death  of  parts  of  bones  was  not  distin- 
guished from  caries.  However,  necrosis 
and  caries  are  essentially  different  ; for,  in 
the  first,  the  affected  part  of  the  bone  is  de- 
prived of  the  vital  principle  . but  this  is  not 
the  case  when  it  is  simply  carious.  Caries 
is  very  analogous  to  ulceration,  while  ne- 
crosis closely  resembles  mortification  of  the 
soft  parts. 

Between  caries  and  necrosis,  says  Weid 
mann,  there  is  all  that  difference,  which  exists 
between  ulcers  and  gangrene,  or  sphacelus 
of  the  soft  parts.  In  caries,  the  nutrition  of 
the  bone  is  only  impaired,  and  an  ir  egnlar 
action  disunites  the  elements  of  the  bony 
structure,  which  consequently  sustains  a loss 
of  substance;  but  every  remaining  part  of 
il  is  yet  alive.  In  necrosis,  on  the  contrary, 
the  vitality  and  nutritive  functions  cease 
altogether  in  a certain  portion  of  the  bone, 
the  separation  of  u'hich  then  becomes  indis- 
pensable. ( DtJYecrosi  Ossium,  p.l .) 

I have  men-soned  that  M.  Louis  confined 
the  term  necrosis  to  cases,  in  which  the 
whole  thickness  of  a bone  perished  ; but 
Weidmann  jud;r  •<  usly  criticises  this  limita- 
tion of  the  word,  and  maintains,  that  the 
nature  of  the  disorder  is  the  same  whether 
it  aff  -ct  a single  scale,  the  whole,  or  a mere 
point,  of  the  bone.  He  also  objects  to  the 
definition  of  necrosis  proposed  by  Chopart, 
(Dissert,  de  Necrosi  Ossium,  Paris , 1765,) 
and  adopied  by  David.  ( Obs.  sur  une  Mala- 
die  connue  sous  le  nom  de  JY6cn.se.  Paris, 
1782.)  These  two  authors  have  defined 
necrosis  io  be  a disorder,  in  which  a portion 
of  bone  perishes,  ancHmrns  dry,  in  order  to 
be  soon  separated  from  the  living  parts,  and 
replaced  by  a new  bony  substance,  which  is 
to  perform  its  functions.  But  as  Weidmann 
observes,  it  may  happen,  that  a piece  of 
bone,  which  dies  and  separates,  may  not  be 
replaced  by  any  new  formation  of  bone, 
though  tht  disease  is  of  the  same  character, 
and  merely  varies  in  some  modifications. 
He  therefore  argues,  and  every  rational  sur- 
geon will  agree  with  him,  that  a true  necro- 
sis must  always  be  said  to  exist,  whenever  a 
dead  portion  of  bone  has  either  separated, 
oris  about  1o  separate.  “ Vera  demum  nec- 
rosis semper  est,  si  aliquod  ossis  rumentum,  in 
quo  vis  vitce  exiinda  est,  absctssii,vel proxime 
abscessurum  est.”  ( P . 7.) 

The  tibia,  femur,  lower  jaw,  clavicle,  hu- 
merus, fibula,  radius,  and  ulna,  are  the 
bones  most  frequently  affected  with  necro- 
sis. Excepting  the  lower  jaw  and  scapula, 
the  process  of  regeneration  has  only  been 
noticed,  in  the  cylindrical  bones.  From  12 
to  18  years  of  age,  is  the  time  of  life,  most 
subject  to  necrosis.  The  necrosis  of  the 
lower  jaw,  however,  seldom  occurs  before 
the  age  of  30.  In  some  persons,  the  bones 


are  affected  at  once,  owing  to  constitutional 
causes. 

No  climate,  age,  sex,  mode  of  life,  nor 
condition,  (says  Weidmann)  is  exempt  fr«>m 
t his  disorder.  Childhood  and  puberty,  how- 
ever, are  the  periods  most  liable  to  it.  The 
same  thing  may  l^said  ot  persons,  who  la- 
bour hard,  and  aremiuch  exposed  to  external 
injuries.  Every  bone  of  the  human  body  is 
subject  Ui  necrosis  ; but  those  which  are 
superficial,  and  enter  into  the  formation  of 
the  extremities,  are  more  frequently  affected 
than  others  whose  situation  is  deeper.  Ne- 
crosis less  commonly  attacks  the  spongy 
substance  of  the  bones,  because  this  being 
endued  with  a. higher  degree  of  vascularity 
and  life,  suppuration  is  most  apt  to  occur. 
Necrosis,  on  the  contrary,  is  oftener  seen  in 
the  compact  substance,  where  the  vital  prin- 
ciple is  less  energetic,  and  more  readily  ex  - 
tinguished. Lastly,  tbe  disorder  may  affect 
the  long  bones,  or  the  broad  ; the  large  oe 
small  ; and  even  ttiose  of  the  very  least 
size  ; ince  it  is  well  known,  that  the  ossi- 
cula  of  the  ear  m v be  destroyed  by  necrosis, 
and  separate.  I have  seen  this  happen  in 
two  instances,  and  the  fact  is  recorded  by 
several  writers.  (See  As true  de  Morbis  Ve - 
nereis,  lib.  4.  cap.  1.  Henri , Journal  d<i 
Medicine,  T.  15.  p.  363.) 

Though  necrosis  rnos’ly  attacks  the  cylin- 
drical bones,  the  fl  w ones  are  not  exempt 
from  (he  disease.  Pott  makes  mention  of 
a parietal  bone,  the  whole  of  which  was 
detached,  and  of  an  os  fi  ontfe,  the  greatest 
part  of  which  came  awa\ . In  a thesis  on 
necrosis,  in  1776,  aux  ecoles  de  chirurgie 3 
may  be  found  the  case  of  a young  man,  a 
very  large  part  of  whose  scapula  perisned 
and  separated.  Chopart^  who  relates  the* 
case,  mentions,  that  he  saw  the  patient  quite 
recov<  : ed,  and  felt  a new  triangular  movea- 
ble bon?,  firmly^upporting  the  clavicle,  but 
smaller  and  Hatter  thau  natural,  and  without 
any  spinous  process.  The  same  has  happen- 
ed to  the  lower  jaw.  as  m.r,  be  seen  by 
referring  to  the  EphemeridesjYat.  Cur.  nd 
M6m.  de  I' Acad,  de  Chirurgie.  In  the  fifth 
volume  of  the  latter  work,  is  an  account  of 
a woman,  who  applied  to  be  relieved  of  some 
venereal  complaints.  From  the  beginning 
of  the  treatment,  the  bone  was  discovered 
to  be  loose  just  under  the  gums,  and  seemed 
shortly  afterward,  to  move  backwards  and 
forwards  with  a tooth.  M.  Guernery  took 
hold  of  the  tooth  with  a key-instrument, 
and  found  it  firmly  inserted  in  the  moveable 
jaw  ; he  made  with  caution  the  necessary 
manoeuvres  for  extracting  the  portion  of 
bone;  but  was  greatly  surprised  on  -finding 
what  an  extensive  part  yielded  to  his  very 
moderate  efforts.  It  was  the  whole  of  the 
lower  jaw,  above  its  right  angle  from  its  di- 
vision into  the  coronoid  and  condyloid  pro- 
cesses to  the  -p  Te  betw-sen  the  first  and  se- 
cond of  the  front  grinders  of  the  left  side.  On 
the  right,  there  only  remained  the  condyle  in 
the  articular  cavity  of  the  temporal  bone. 
This  destruction  left  a considerable  empty 
space,  from  which  great  deformity  was  appre  - 
hended, in  consequence  of  the  unsupported 


NECROSIS. 


162 


soft  part s falling  do  w n . The  woman , h o w - 
ever,  got  well  in  two  months,  and  had  the 
most  perfect  use  of  a new  jaw.  A similar 
fact  is  recorded  in  the  Journal  de  M6d6cine, 
1791. 

When  the  body  of  a cylindrical  bone,  or 
the  middle  portion  of  a bone,  is  destroy- 
ed by  necrosis,  their  exs Amities,  which  are 
of  a cellular  texture,  continue  unaffected,  so 
that,  for  example,  in  the  cylindrical  bones,  the 
articularends  are  always  formed  of  portions 
of  the  original  bone,  which  are  engrafted, 
as  it  were,  on  t he  new  production.  There 
are,  however,  a few  had  cases,  in  which  the 
necrosis  does  not  altogether  spare  the  heads 
of  the  bones,  and  the  disease  communicates 
with  the  joint.  These  examples  are  very 
uncommon,  and  are  attended  with  consider 
able  danger  to  the  limb  ; indeed,  they  tre- 
nerally  require  amputation.  (See  Boyer , 
Traitt  des  Mai.  Chir.  T.  3,  p.  442.)  Ivj  • . 
Brodie  has  known  an  instance,  in  which, 
without  any  obvious  cause,  a large  portion 
of  the  head  of  the  tibia  died,  and  exfoliated? 
and  the  destruction  of  the  knee-joint  was 
the  consequence.  ( Pathol . and  Surg.  Obs. 
on  tlic  Joints,  p.  269.) 

Besides  the  differences  arising  from  ihe 
particular  bones  affected,  necrosis  also  va- 
ries, according  ns  the  portion  of  bone 
attacked  happens  to  be  thin,  and  of  iittle 
extent,  or  large  and  of  considerable  thick- 
ness. The  disease  is  simple,  when  it  is  con- 
fined toorie  bone,  and  the  patient  is  in  other 
respects  healthy  ; compound , when  several 
different  parts  of  the  sam^  bone,  or  several 
distinct  bones,  are  affected  at  the  same 
time;  when  the  health  is  bad;  and  other 
parts  of  the  body  are  also  diseased.  It  should 
also  be  known,  hecause  the  information  is 
of  practical  importance  in  the  treatment, 
that  necrosis  has  three  different  stages,  or 
periods.  In  the  first,  the  bone  affected  pe- 
rishes ; in  the  second,  the  process  of  exfolia- 
tion or  separation  of  the  dead  hone  from  the 
living,  is  going  on  : and,  in  the  third,  the  se- 
paration is  completed.  (See  Weidmann, 
V-  8-) 

The  causes  of  necrosis  are  not  essentially 
different  from  those  which  produce  ulcers 
and  gangrene  of  the  soft  parts.  As,  how- 
ever, the  vitality  of  the  bones  are  weaker, 
we  may  infer,  that  necrosis  may  be  occa- 
sioned in  them  by  causes  which  are  less  nu- 
merous and  intense,  and  such  as  would  only 
give  rise  to  suppuration  in  the  soft  parts. 
Everything,  whether  in  the  periosteum  or 
the  substance  of  the  bone  itself,  1 hat  tends 
to  interrupt  the  nutrition  of  the  bone,  must 
be  regarded  as  conducive  to  the  origin  of 
necrosis.  It  is  observed,  however,  that 
•when  the  mischief  in  the  periosteum,  me- 
dulla, or  substance  of  the  bone,  is  of  trivial 
exterit,the  consequence  is  merely  an  abscess. 
Some  of  the  causes  of  necrosis  are  external, 
while  others  are  internal,  or  constitutional. 
Sometimes  the  life  of  the  bone  is  instanta- 
neously destroyed  by  them  ; but  in  other  in- 
stances, the  bone  is  first  stimulated  and  en- 
larged. so  that  its  death  is  preceded  by  true 
inflammation- 


The  external  causes,  which  injure  the  pe- 
riosteum and  medullary  structure,  and  thus 
produce  necrosis,  are  wounds,  contusions, 
pressure,  fractures,  comminutions,  acrid  sub- 
stances, caustics,  and  extreme  degrees  of 
heat  or  cold. 

When  the  periosteum,  in  consequence  of 
an  external  cause,  inflames  and  sloughs,  or 
is  at  once  deprived  of  its  vitality,  as  it  may- 
be by  the  action  of  caustic,  fire,  or  intense 
cold,  the  vessels  which  conveyed  nourish- 
ment to  the  bone  are  destroyed,  and  the 
death  and  exfoliation  of  the  denuded  por- 
tion of  the  bone  are  inevitable.  But,  if  the 
detachment  of  the  periosteum  is  of  little  ex- 
tent, the  patient  young  and  healthy,  and  the 
treatment  calculated  to  prevent  inflamma- 
tion, and  preserve  uninjured  the  vessels 
distributed  to  the  bone,  hopes  may  be  en- 
tertained that  no  part  of  the  hone  will  die, 
but  that  granulations  will  very  soon  arise 
from  its  surface,  being  adherent  to  it  as  the 
periosteum  was,  and  that  they  will  grow  to 
and  cicatrize  with  the  surrounding  parts. 
Weidmann  has  explained,  that  this  fact  of 
bones  not  always  exfoliating  when  deprived 
of  the  periosteum,  which  is  of  great  practi- 
cal importance  in  the  treatment  of  wounds, 
was  inculcated  by  Felix  Wurtz,  Cesar  Ma- 
gatus,  and  Belloste,  at  a time  when  the  con- 
trary opinion  prevailed.  Weidmann  also 
adverts  to  his  own  experience  and  to  the 
experiments  of  Tenon,  in  further  proof  of 
ihe  preceding  fact.  (Mem  de  I'jQcad.  dcs 
Sciences,  1758,  p.  372.) 

On  the  other  hand,  when  the  detached 
piece  of  die  periosteum  is  extensive  ; when 
the  bone  itself  is  contused ; or  when  it  has 
been  long  exposed  to  the  air,  the  effect  of 
which  is  to  drv  up  the  few  vessels  which 
belong  to  it ; when  the  inflammation  is  vio- 
lent and  extensive  ; when  the  patient  is  old. 
deerepit,  or  of  bad  constitution  ; and  more 
especially  when  improper  applications  are 
used,  as  was  almost  always  the  case  in  for- 
mer times  ; necrosis  cannot  he  avoided. 

An  internal  necrosis,  affecting  the  spongy 
texture  of  bones,  generally  arises  from  con- 
stitutional causes,  though  sometimes  an  ex- 
ternal cause,  which  seems  to  affect  only  the 
surface  of  a bone,  extends  its  action  to  the 
interior,  so  as  to  destroy  the  medullary 
membrane,  and  produce  an  internal  ne- 
crosis. 

In  external  injuries  of  the  head,  where 
the  pericranium  is  lacerated,  contused,  or 
otherwise  hurt,  or  where  the  outer  table,  or 
the  diploe,of  the  skull,  is  injured,  theinflam- 
mation  frequently  extends  to  the  inner  table, 
and  the  dura  mater  becomes  detached. 
Hence,  a collection  of  matter  forms,  which 
may  occasion  many  bad  symptoms,  and 
even  death  itself ; or  if  the  patient  survive, 
exfoliation  of  part  of  both  tables  of  the  skull 
is  the  consequence.  (See  Pott's  Chir.  Works , 
Londo",  1779,  Vol.  I,  p.  32.) 

The  same  thing  may  occur  • i other  bones, 
as  well  as  those  of  the  cranium.  Broitifiold 
had  an  opportunity  of  seeing  a necrosis  of 
the  spongy  substance  of  the  upper  nnd  in- 
ternal part  of  t.he  tibia,  brought  ou  bv  five 


NECROSIS 


improper  uaode  iu  which  au  issue  was  dress- 
ed. in  order  to  keep  the  peas  from  slipping 
out  of  their  places,  a compress  with  a shil- 
ling in  it,  and  a tight  bandage  were  applied  ; 
but  the  part  was  attacked  with  excruciating 
pain,  and  the  spongy  texture  of  the  tibia  in 
the  vicinity  became  affected  with  necrosis. 
( Chir . Observations  and  Cases,  Vol.  2 ,p.  9.) 

This  circumstance,  as  Weidmann  observes, 
ought  not  to  surprise  us  : as  numerous  ves- 
sels quit  the  periosteum  to  descend  into  the 
substance  of  the  bone,  to  ramify  on  the  me- 
dullary cells  themselves,  and  freely  anasto- 
mose there,  it  cannot  be  difficult  to  con- 
ceive, how  inflammation,  which  is  at  first 
confined  to  the  outside  of  the  bone,  may 
(through  the  medium  of  the  vessels  which 
serve  as  conductors  to  it)  penetrate  more 
deeply,  and  extend  its  ravages  in  every  di- 
rection. 

But  necrosis  may  proceed  from  another 
description  of  causes,  which  are  of  a con- 
stitutional nature.  In  fevers  of  bad  type, 
in  the  small-pox  and  in  the  measles,  expe- 
rience has  fully  proved,  that  the  bones  are 
sometimes  attacked  with  necrosis.  Scrofula, 
lues  venerea,  and  the  scurvy,  are  also  dis- 
eases, which,  according  to  the  testimony  of 
all  surgical  writers,  frequently  produce  such 
mischief  in  the  bones  as  terminates  in  ne- 
crosis. It  is  likewise  well  ascertained,  that 
mercury,  the  judicious  ernploymentof  which 
in  venereal  cases  will  prevent  necrosis,  or 
cure  them  when  formed,  may  itself  give 
rise  to  the  disorder,  especially  in  the  lower 
jaw-bone.  (See  M6m.  de  VAcad.  de  Chir.  T. 
5,  p.  356,  4 to.) 

This  happens  either  in  consequence  of 
mercury  having  been  introduced  too  quick- 
ly into  the  system,  or  because  the  patient 
exposes  himself  to  cold,  or  deviates  in  some 
other  respect  from  a proper  regimen.  Cer- 
tain necroses  of  the  lower  jaw,  however, 
appear  also  to  have  been  caused  by  blows, 
and  the  application  of  acrid  substances  to 
carious  teeth.  But,  says  Weidmann,  “ I feel 
it  incumbent  upon  me  particularly  to  de- 
clare, that  the  irrational  treatment  pursued 
by  the  ancient  practitioners,  who  neither 
understood  the  nature  of  the  bones,  nor  the 
differences  of  their  diseases,  and  which 
treatment  is  too  confidently  adopted  in  our 
own  days,  had  frequently  the  effect  of  kill- 
ing these  parts,  by  attacking  with  spirituous, 
acrid,  oVcaustic  remedies,  or  even  with  the 
knife,  diseases  which  required  the  mildest 
applications,  and  to  be  left  in  a great  mea- 
sure to  nature.  The  old  surgeons  were 
afraid  of  laying  on  the  exposed  injured  sur- 
face of  a bone  unctuous  emollient  dressings, 
and  yet,  for  what  reason  I know  not,  they 
subjected  the  part  to  the  action  of  spiritu- 
ous, acrid,,  drying  applications.  As  for  my- 
self, I deem  it  proved  by  infallible  and  fre- 
quently repeated  trials,  not  only  that  an  ex- 
posed injured  bane  may  be  dressed  with  a 
mild  ointment  without  any  ill  consequences, 
but  even  with  the  greatest  advantage.  Why 
should  that  which  is  beneficial  to  the  soft 
parts,  be  so  prejudicial  to  the  bones  ? In 
ulcers  of  the  soft  parts,  indeed,  tlie  employ- 


ment of  the  remedy  which  i recommend,  is 
less  important,  because  these  parts  are  na- 
turally humid,  and  there  is  no  risk  of  their 
becoming  dry.  But  with  regard  to  the 
bones,  whose  dry  texture  is  only  penetrated 
by  few  vessels,  which  may  easily  be  destroy- 
ed if  they  be  suffered  to  become  quite  dry, 
it  h absolutely  necessary  to  use  an  emol- 
lient ointment,  as  a dressing,  well  calculated 
to  defend  these  vessels,  which  are.  the  sup- 
port of  life,  and  preserve  them  from  the  bad 
effects  of  exposure  to  the  air.  Therefore, 
observes  Weidmann,  if  a surgeon  would 
avoid  producing  a necrosis  himself,  and  not 
neglect  any  means  that  tend  to  prevent  such 
disorder,  he  should  make  it  a rule  never  to 
apply  any  thing  acrid  to  exposed  bones,  but, 
on  the  contrary,  to  defend  them  with  a dress- 
ing of  some  unirritating  ointment .”  {De  jYe- 
crosi  Ossium,  p.  11.) 

It  was  formerly  supposed,  that  purulent 
matter,  collected  near  a bone,  might  in  time 
become  acrimonious,  corrode  the  bone,  and 
produce  necrosis.  Hence,  it  was  a rule  to 
open  such  an  abscess  as  soon  as  its  exist- 
ence was  known.  But  Weidmann  questions 
whether  there  was  any  real  necessity  for 
this  practice.  No  doubt,  says  he,  the  pre- 
ceding erroneous  opinion  arose  from  the 
circumstance  of  the  bones  being  often  found 
bare,  carious,  or  even  affected  with  neero 
sis,  when  abscesses  were  near  them  ; but 
things  happened  thus,  because  the  inflam- 
mation which  caused  the  suppuration,  had 
also  extended  its  effects  to  the  periosteum 
and  bone.  He  affirms,  that  he  has  witness- 
ed ulcers,  in  which  the  surface  of  bones, 
bare  and  uncovered  by  the  periosteum,  lay 
bathed  in  pus  fora  very  considerable  time  j, 
yet,  being  dressed  with  a mild  ointment, 
they  continued  entire,  granulations  grew 
from  them,  and  cicatrization  followed.  He 
had  also  in  his  possession  portions  of  bones 
affected  with  necrosis,  which  had  lain  for 
years  in  pus  ; still  their  surface  was  smooth, 
and  presented  no  marks  of  erosion.  If  then 
these  pieces  of  bone  underwent  no  altera 
tion,  how  much  less  likely  to  do  so  are 
bones,  which  are  endued  with  life  ! 

But  though  Weidmann  wisely  rejects  the 
doctrine  of  pus  being  capable  of  destroying 
the  periosteum  and  bones  by  any  corrosive 
qualities,  he  acknowledges  his  belief,  that 
the  matter  of  an  abscess  may  by  its  quantity 
compress  and  inflame  the  adjacent  parts, 
and  occasion  their  removal  by  the  absorb- 
ents. While  the  periosteum  intervenes  be- 
tween an  abscess  and  the  bone,  he  does  not 
see  how  the  latter  Can  be  hurt  by  the  pus 
but  when  the  abscess  is  copious  and  lodged 
between  that  membrane  and  the  bone,  the 
vessels  passing  from  the  former  will  be  de- 
stroyed, and  either  caries  or  necrosis  ensue. 

The  inflammation  arising  from  the  causes 
which,  excite  necrosis,  may  be  either  acuta 
or  chronic.  It  is  chronic,  when  it  begins 
and  passes  through  its  different  stages  slow- 
ly, and  when  the  mildness  of  the  symptoms 
may  lead  us  to  mistake  the  nature  of  fbe 
case.  This  sort  of  inflammation  chiefly  hap- 
pens in  debilitated  constitutions-  in  which 


INECKOalb 


“64 


the  necrosis  only  afreets  the  external  part  of 
a bone,  and  originates  from  some  chronic 
cause,  such  as  scrofula,  lues  venerea,  and 
the  scurvy.  But  when  necrosis  attacks  the 
interior,  and  the  disease  occurs  in  a strong, 
irritable,  plethoric  subject,  inflammation  is 
immediately  kindled,  attended  with  the 
most  acute  symptoms,  severe  pain,  consider- 
able fever,  restlessness,  delirium,  &c.  Chro- 
nic inflammation  is  more  supportable  ; but 
its  duration  is  longer  : acute  inflammation  is 
more  afflicting,  but  sooner  comes  to  a crisis. 

The  part  in  which  a necrosis  is  situated, 
is  aft'ected  with  swelling.  What  has  been 
observed,  respecting  the  inflammation,  is 
also  applicable  to  this  tumour,  which  most 
frequently  forms  gradually,  but  sometimes 
with  great  rapidity.  In  the  first- case,  the 
accompanying  pain  is  dull  and  inconsidera- 
ble ; in  the  second,  it  is  violent.  The  swell- 
ing has  not,  like  that  of  abscesses,  an  eleva- 
ted apex.  On  the  contrary,  it  is  so  widely 
diffused,  that  the  limits  which  circumscribe 
it,  can  hardly  be  distinguished. 

This  diffusion  of  the  swelling  is  the 
greater,  in  proportion  as  the  diseased  bone 
is  more  deeply  buried  in  soft  parts  : it  may 
extend  over  the  whole  morbid  bone,  or  even 
over  the  whole  limb. 

The  swelling  comes  on  at  the  very  begin- 
ning of  the  disorder,  and  continues  to  in- 
crease, until  the  matter  which  it  contains 
finds  its  way  out,  when  the  evacuation  is 
followed  by  a partial  subsidence  of  the  tu- 
mour. The  swelling  is  sometimes  also  com- 
bined with  oedema,  especially  in  persons 
whose  constitutions  have  been  impaired  by 
the  severity  of  the  disease,  the  violence  of 
the  sufferings,  and  the  long  and  profuse  dis- 
charge. 

When  the  inflammation  is  acute, purulent 
matter  of  good  quality  soon  collects  in  the 
vicinity  of  the  necrosis.  In  the  contrary 
case,  the  pus  forms  slowly,  and  is  thinner 
and  less  healthy. 

The  abscess  which  accompanies  a necro- 
sis, naturally  soon  bursts  when  it  arises 
from  intense  inflammation,  and  is  situated 
near  the  skin,  which  is  itself  inflamed.  But 
when  the  bone  is  surrounded  by  a great 
thickness  of  soft  parts,  and  the  inflammation 
is  chronic,  the  quantity  of  matter  daily  in- 
creases, the  cavity  which  it  occupies  be- 
comes larger  and  larger,  and  considerable 
pressure  is  made  in  the  abscess  on  every 
side.  The  bones  and  tendons  resist  for  a 
long  while  the  progress  of  the  matter  ; but 
the  cellular  substance  yields,  and  different 
sinuses  form,  which  sometimes  run  to  a vast 
distance  from  the  main  collection  of  matter, 
especially  when  the  abscess  lies  under  an 
aponeurosis. 

It  was  supposed  a few  years  ago,  that  in 
cases  of  necrosis,  the  matter  was  invariably 
sanious,  acrid,  and  fetid.  But  the  celebrated 
Weidmann  exposed  the  error  of  this  opi- 
nion. He  had  often  seen  abscesses  and  ul- 
cers, arising  from  necrosis,  discharge  a whi- 
tish, inodorous,  thick  pus,  absolutely  devoid 
of  any  bad  quality  whatsoever.  He  had 
particularly  seen  this  happen  in  patients 


whose  necroses  proceeded  trom  an  external 
cause,  or  an  internal  one  of  a slight  nature, 
and  whose  health  was  generally  good.  ( Dc 
JVecrosi  Ossium,p.  16.)  If,  says  the  same  ex- 
cellent writer,  we  sometimes  find  in  prac- 
tice the  suppuration  dark  and  fetid,  we 
must  not  ascribe  it  to  the  affection  of  the 
bone,  but  to  the  weakness  and  bad  state  of 
the  patient’s  health.  Under  the  same  cir- 
cumstances, common  sores  of  the  soft  parts 
would  also  emit  a discharge  of  bad  quality. 

After  the  ulcerated  openings  have  emit- 
ted for  some  time  a profuse  discharge,  the 
sinuses,  if  considerable,  receive  the  appella- 
tion of  fistula;,  on  account  of  their  edges 
putting  on  a callous  appearance,  throwing 
out  fungous  granulations,  and  there  being 
impediments  to  cicatrization.  These  im- 
pediments are  caused  by  the  dead  portions 
of  bone,  which,  whether  loose  or  adherent, 
act  as  extraneous  bodies  in  hindering  the 
sores  from  healing.  In  some  instances  also, 
the  ulcers  will  not  heal  though  the  dead 
bone  has  come  away,  because  they  run  to  a 
great  depth,  and!  such  a quantity  of  pus  is 
secreted  from  every  point  of  their  surface, 
as  prevents  all  contact,  and  the  adhesions 
which  would  result  from  it. 

The  fistulas  vary  in  number  ; but  they  are 
fewer  in  proportion  as  the  disease  is  slighter 
In  an  extensive  necrosis,  several  of  these 
openings  are  seen,  either  near  together,  or 
separated  by  considerable  spaces ; and, 
when  the  necrosis  affects  every  side  of  the 
bone,  the  fistula;  in  the  integuments  occur 
on  every  side  of  the  limb. 

Besides  the  inflammatory  fever,  which  at- 
tends the  beginning  of  every  severe  case  of 
necrosis,  which  is  sometimes  accompanied 
with  exceedingly  violent  symptoms,  and 
which  usually  abates  when  matter  is  form- 
ed, the  patient  is  subject  to  another  fever  of 
a slow  hectic  type.  This  takes  place  in  the 
decline  of  the  disease,  is  the  effect  of  the 
long-continued  profuse  suppuration,  gradu- 
ally reduces  the  patient,  and  at  length  brings 
him  to  the  grave,  unless  the  timely  removal 
of  the  sequestrum  be  effected  either  by  na- 
ture or  art. 

Let  us  next  endeavour  to  trace  the  signs, 
by  which  we  may  not  only  ascertain  the 
presence  of  the  disease,  but  its  modifications. 

In  the  first  place,  we  should  make  our- 
selves acquainted  with  every  thing,  which 
may  have  predisposed  to  the  disorder;  as, 
for  instance,  what  accidental  circumstances 
have  occurred,  and  what  symptoms  followed 
them.  We  should  also  inquire  into  any  pre- 
vious treatment  which  may  have  been 
adopted  ; for,  as  Weidmann  truly  remarks, 
injudicious  remedies  have  caused  many  a 
necrosis  that  would  not  have  occurred  at 
all,  if  the  case  had  been  properly  treated,  or 
confided  to  nature. 

The  kind  of  inflammation  with  which  the 
disease  commences,  may  afford  grounds  for 
suspecting  that  rfecrosis  will  happen  : it  is 
generally  slow  and  deeply  seated,  passing 
through  its  stages  tardily,  and  the  attendant 
symptoms  are  severer.  The  skin  retains  its 
natural  colour  a long  while  : but,  at  length. 


.NECROSIS. 


265 


exhibits  a reddish,  or  livid  discolouration. 
The  matter  does  not  reach  the  skin  till  a 
considerable  time  has  elapsed,  and  when 
the  abscess  bursts,  the  inflammatory  symp- 
toms are  still  slow  in  subsiding.  When  the 
inflammation  is  acute,  the  patient  suffers  in- 
tolerable pain  a long  time. 

There  are  also  other  symptoms  of  a ne- 
crosis; viz.  the  swelling  which  accompa- 
nies the  inflammation,  is  situated  upon  a 
bone,  or  rather  the  bone  is  included  in  the 
tumour ; the  swelling  is  at  the  same  time 
very  diffused  ; and  the  suppuration  lies  deep- 
ly, and  can  only  be  felt  in  an  obscure 
way. 

The  ulcers,  beneath  which  a necrosis  is 
situated,  discharge  a large  quantity  of  mat- 
ter, and  their  edges  are  bent  inward.  The 
granulations  are  either  yellowish  and  pale, 
or  else  of  an  intense  red  colour;  they  are 
also  irregular,  and  generally  not  very  ten- 
der, though  sometimes  extremely  painful, 
and  on  being  slightly  touched,  they  bleed. 

It  has  been  already  noticed,  that,  some 
years  ago,  the  discharge  from  the  sores, 
which  atteud  necrosis,  was  described  as  be- 
ing always  thin,  fetid,  and  sanious ; and 
such  qualities  of  the  matter  were  regarded 
as  a symptom  of  the  disease  of  the  bone. 
But  that  excellent  practical  writer,  Weid- 
mann,  has  well  explained,  that  it  is  a symp- 
tom undeserving  of  confidence.  In  cases  of 
necrosis  the  pus  is  often  thick,  white,  and 
inodorous  ; while  other  ulcers,  unattended 
with  diseased  bone,  sometimes  discharge 
thin  fetid  matter.  Weidmann,  at  the  same 
time,  does  not  mean  to  assert,  that  in  cases 
of  necrosis  the  sores  never  emit  unhealthy 
pus ; but  he  firmly  believes,  that  such  dis- 
charge is  not  always  the  result  of  a disease 
of  the  bone.  As  far  as  he  could  judge,  the 
suppuration  from  ulcers,  situated  over  dis- 
eased bones,  continues  white  and  laudable 
as  long  as  the  patient’s  general  health  is 
good  ; but,  that  it  deviates  from  these  pro- 
perties, in  proportion  as  the  health  becomes 
impaired. 

Neither  is  the  black  colour,  imparted  to 
the  dressings  of  ulcers,  a circumstance  which 
necessarily  indicates  the  existence  of  ne- 
crosis; for  it  may  occur  when  the  bone  is 
sound,  and  may  not  happen  when  the  bone 
is  affected. 

None  of  the  preceding  symptoms  convey 
such  information,  as  leaves  no  doubt  of  the 
positive  existence  of  necrosis,  the  touch 
is  the  only  thing  which  can  give  us  this 
knowledge,  when  the  bone  is  not  too  deeply 
situated,  and  the  sinuses  not  tortuous,  nor 
obstructed  with  fungous  growths. 

When  the  openings  of  the  ulcers  are  con- 
siderable, the  finger  may  be  introduced.  If 
in  this  way  the  bone  can  be  felt  to  be  ex- 
tensively uncovered  by  the  periosteum,  the 
surgeon  may  conclude  that  all  such  portion 
of  the  bone  has  perished.  He  may  be  still 
more  certain  of  the  fact,  when  he  finds  the  ed- 
ges of  the  denuded  bone  unequal  and  rough. 

The  examinations,  made  directly  with  the 
finger,  give  the  most  correct  and  exact  in- 
formation of  the  state  of  the  bone  ; but  the 
Vox.  If  34 


orifices  of  the  sores  are  sometimes  so  small, 
that  the  finger  cannot  be  introduced  without 
causing  great  pain.  A probe  must  then  be 
used  for  the  purpose  of  ascertaining  the  ex- 
tent of  the  denudation  of  the  bone  ; whe- 
ther its  edges  are  rough  ; whether  the  dead 
portion  is  loose,  and  likely  to  separate 
soon. 

Sometimes  the  dead  fragment  of  bone 
protrudes  from  the  ulcer,  or  is  visible  on  se- 
parating its  edges.  When  it  is  black,  there 
cannot  be  a doubt  of  its  being  actually  dead ; 
but,  on  the  other  hand,  when  its  whiteness 
is  increased,  the  diagnosis  is  difficult,  be- 
cause bones  being  naturally  white,  much 
experience  is  necessary  to  be  able  to  judge 
whether  they  are  so  in  excess. 

It  merits  attention,  also,  that  the  black 
colour  of  the  bone  is  not  owing  to  the  ne- 
crosis itself,  but  seems  rather  to  depend  upon 
the  fragment  having  been  exposed  to  the 
air.  In  fact,  dead  pieces  of  bone  with  which 
the  air  comes  into  contact,  turn  black, 
while  those  which  are  covered  with  matter, 
retain  their  whiteness.  The  cylindrical  por- 
tion of  a humerus,  which  was  almost  totally 
affected  with  necrosis,  was  universally  black 
at  the  part,  which  protruded  through  the 
flesh  ; but  the  rest,  which  lay  under  the  in- 
teguments, remained  white.  ( Weidmann  dt 
JYecrosi  Ossium,p.  19,  et  Tab.  9,  fig.  1.) 

When  the  early  symptoms  of  the  disease 
are  mild,  the  surgeon  may  infer  that  it  is 
only  a superficial  portion  of  the  bone  which 
is  about  to  be  separated.  But  this  judgment 
will  be  more  certain  if  confirmed  by  exami- 
nation with  the  finger  or  probe  ; or,  if  the 
swelling  which  occurred  in  the  beginning, 
has  nor  spread  beyond  the  affected  point, 
and  if  the  pain  affects  only  the  outer  part 
of  the  bone.  In  this  sort  of  case,  there  is 
also  great  probability  that  the  dead  bone 
will  be  separated  within  a moderate  time. 

It  is  also  of  importance  to  ascertain  the 
existence  of  an  internal  necrosis,  and  to 
learn  whether  it  is  situated  in  the  spongy 
substance,  or  in  the  internal  parietes  of  the 
canal  of  the  bone  ; whether  it  affects  on- 
ly a part,  or  extends  to  the  whole  body 
of  the  bone.  When  there  is  an  internal 
necrosis,  says  Weidmann,  the  disease  is 
generally  more  aggravated,  and  of  longer 
duration  ; and  in  the  first  stage,  the  patient 
is  affected  Avith  severe  symptoms,  intolera- 
ble pain,  loss  of  rest,  ardent  fever,  profuse 
perspirations,  and  such  disorder  of  the  sys- 
tem, as  may  prove  fatal,  unless  the  patient 
be  young  and  strong.  The  hard  swelling 
which  Avas  observable  at  the  commence- 
ment of  the  disease,  increases  but  slowly, 
and  extends  very  gradually  over  the  cir- 
cumference of  the  limb,  while  the  skin  yet 
remains  free  from  redness  and  tension.  If 
the  part  be  somewhat  roughly  handled , the. 
pain,  which  is  fixed  in  the  bone,  is  not  ren- 
dered more  acute,  as  would  happen,  were 
the  case  an  external  inflammation.  In  this 
suffering  condition  the  patient  continues  a 
good  Avhile,  before  the  formation  of  matter 
brings  a degree  of  relief.  When  the  matter 
is  formed,  it  spreads  through  the  adjacent 


266 


NECROSIS. 


cellular  substance,  among  the  muscles  and 
other  parts,  and  the  abscess  generally  bursts 
after  a considerable  time,  by  several  open- 
ings, very  distant  from  the  main  collection 
of  matter,  as  also  remote  from  each  other, 
sometimes  in  diametrically  opposite  situa- 
tions. 1 he  evacuation  of  the  matter,  how- 
ever, does  not  produce  any  material  subsi- 
dence of  the  swelling.  The  pus  is  of  good 
quality,  and  issues  in  large  quantities  from 
the  ulcerated  apertures,  the  quantity,  how- 
ever, not  being  increased  when  pressure  is 
made . If  some  of  the  openings  heal,  others 
are  formed  ; but,  in  general,  the  edges  be- 
come callous,  and  they  lose  all  disposition 
to  cicatrize.  When  the  case  presents  the 
foregoing  circumstances,  and  the  weakened 
limb  can  neither  bear  the  action  of  the 
muscles,  nor  the  weight  of  the  body,  and  by 
either  of  these  causes,  its  shape  becomes  al- 
tered, the  surgeon  may  conclude  that  the 
disease  is  an  internal  necrosis.  But,  in  or- 
der to  avoid  mistake,  he  should  introduce 
into  the  sinuses  a probe,  which,  passing 
through  the  openings  in  the  subjacent  bone, 
will  touch  the  dead  piece,  which  it  con- 
tains, and  which  will  sometimes  be  even 
distinguished  to  be  loose  and  moveable. 
The  extent  of  the  sequestrum  must  be  jucged 
of  by  the  extent  of  the  swelling , and  the  dis- 
tances between  the  apertures  in  the  bony  shell, 
which  includes  the  sequestrum. 

The  surgeon  should  also  endeavour  to 
ascertain  with  the  probe,  whether  there  is 
only  a single  sequestrum,  or  several.  When 
there  are  several,  they  may  be  felt  with  the 
probe  in  different  places,  down  to  which  this 
instrument  is  passed,  and  the  removal  of  one 
or  two  of  the  fragments  is  not  followed  by 
a cure.  It  ought  to  be  remembered,  how- 
ever, that  the  same  fragment  may  be  touched 
by  the  probe  in  several  different  places, 
when  it  is  very  extensive.  If  there  are 
several  dead  pieces  of  bone,  situated  at  a 
distance  from  each  other,  each  of  them  is 
generally  accompanied  with  a distinct  swell- 
ing, and  sinuses.  Frequently,  these  frag- 
ments are  so  concealed,  that  they  cannot  be 
felt  with  a probe  ; but,  their  existence  may 
then  be  suspected  from  the  ulcers  not  heal- 
ing, which  can  be  ascribed  to  nothing  else. 

It  is  also  necessary  to  distinguish  with  the 
greatest  attention  the  different  stages  of  the 
disease.  Theirs!  stage  may  be  considered 
as  existing,  when  the  attack  is  yet  recent, 
and  the  inflammation  and  its  concomitant 
symptoms,  the  pain,  swelling,  and  symptom- 
atic fever,  prevail  in  a high  degree,  and 
when  no  suppuration  has  taken  place,  or  at 
least  no  discharge  of  matter.  The  second 
period,  in  which  the  dead  bone  is  undergoing 
the  process  of  separation,  is  indicated  by  a 
diminution  of  the  inflammation,  a partial 
subsidence  of  the  swelling,  and  the  discharge 
of  purulent  matter.  When  a probe  is  passed 
into  the  ulcers,  the  bone  is  felt  bare,  and  dry, 
and,  towards  the  limits  of  the  swelling,  it  is 
rough,  where,  as  will  be  afterward  noticed, 
an  excavation  is  formed.  Every  part  of  the 
bone,  however,  which  is  to  be  detached, 
*till  continues  adherent  to  the  rest  of  the 


living  bone.  At  length,  the  surgeon  knows, 
that  the  disease  has  reached  its  last  stage,  or 
that  in  which  the  dead  portion  of  bone  is 
entirely  separated,  when  sufficient  time  for 
the  completion  of  this  separation  has  expired, 
and  when  the  dead  bone  can  be  distinguished 
with  the  finger,  probe,  or  even  the  eye,  to  be 
loose  and  free  from  all  connexions 

Although  a necrosis  must  generally  be 
classed  with  diseases  w hich  are  serious  and 
of  long  duration  ; yet,  the  character  of  the 
disorder 'is  not  essentially  bad,  since  it  is 
often  cured  by  nature,  or  with  the  assistance 
of  surgery.  Confident  hopes  of  a cure  may 
be  entertained  when  the  necrosis  is  confined 
to  the  external  part  of  a bone ; when  it 
is  simple  and  of  moderate  extent ; when  it  is 
not  situated  in  a bone,  destined  for  impor- 
tant uses,  or  near  any  viscus,  or  organ,  that 
may  be  injured  by  it ; and  w hen  it  proceeds 
from  an  external  cause,  and  the  general 
health  is  good.  On  the  contrary,  the  cure  is 
difficult,  and  the  prognosis  doubtful,  when 
the  disease  is  extensive,  and  complicated 
with  other  affections,  either  of  the  same,  or 
different  bones : when  it  attacks  bones,  which 
are  of  high  importance  on  account  of  their 
functions,  or  situation;  wrhen  it  is  situated 
in  the  interior  of  the  bone,  and  affects  seve- 
ral parts  of  it ; w hen  it  arises  from  an  internal 
cause,  for  which  there  is  no  certain  and 
quick-acting  specific  ; when  the  patient  is 
weakened  by  age,  or  disease  ; and  especially, 
when  the  sinuses  extend  into  the  neighbour- 
ing articulations.  ( Weidmann  de  Neci'osi 
Ossium,  p.  22  ) 

The  process  of  cure  is  said  to  take  place 
with  more  celerity  in  the  lower  jaw,  than 
any  other  bone,  and  may  be  completed  in 
three  months.  Mr.  Russell  has  never  known 
a necrosis  of  the  tibia  get  well  in  less  than  a 
year;  but,  in  general,  nearly  two  years 
elapse  first ; sometimes,  the  cure  is  protract- 
ed to  a much  greater  length  of  time. 

Necrosis  of  the  lower  jaw  and  clavicle 
never  proves  fatal : that  of  the  lower  ex- 
tremities, which  is  the  worst  case,  does  so 
very  seldom,  and  only  from  the  violence  of 
the  first  inflammatory  symptoms,  which  ra- 
pidly bring  on  a hectic  fever,  which  proves 
incurable,  unless  its  local  cause  be  removed 
by  a timely  amputation.  When  the  violence 
of  the  first  stage,  however,  has  abated,  the 
irritation  ceases,  and  the  hectic  symptoms, 
if  there  are  any,  are  generally  moderate. 
Nor  is  this  state  of  tranquillity  disturbed,  till 
the  sequestrum,  in  making  its  way  outward, 
again  produces  irritation.  At  this  second 
period  of  urgency,  extensive  inflammation 
may  originate,  ulcerations  spread  all  over 
the  surface  of  the  limb,  assume  an  unhealthy 
appearance,  violent  fever  succeed,  and  the 
patient  either  perish,  or  sink  into  a state,  in 
which  he  must  consent  to  amputation,  as  the 
only  means  of  saving  his  life.  This  is  the 
last  crisis  of  imminent  danger;  but,  in  gene- 
ral, it  is  less  perilous,  than  when  the  inflam- 
mation comes  on  in  the  incipient  stage  of 
necrosis.  (Russell.) 

In  the  treatment  of  necrosis,  the  first  grand 
object  of  the  surgeon  should  be  to  aid  nature 


NECROSIS. 


267 


in  her  endeavours  to  effect  a cure,  and  not 
to  disturb  her  operations  by  any  superfluous, 
or  unseasonable  interference.  The  second 
should  be  to  assist  her  sometimes  by  the 
boldest  proceedings,  when  she  loses  her 
way,  and  cannot  by  herself  accomplish  the 
end. 

But,  in  order  not  to  attempt  any  thing 
wrong,  the  surgeon  must  understand  cor- 
rectly what  nature  does  in  this  disease,  what 
it  is  in  her  power  to  perform  ; what  she  either 
cannot  accomplish  at  all,  or  not  with  any 
degree  of  certainty  ; and  lastly,  the  circum- 
stances in  which  she  may  err,  and  endanger 
the  patient’s  life. 

When  a portion  of  bone  dies,  nature  uses 
all  her  endeavours  to  bring  about  its  separa- 
tion from  the  part  of  the  bone  which  still 
remains  alive.  Surgeons  have  denominated 
this  process, exfoliation,  (see  this  word)  which 
resembles  the  separation,  that  occurs  be- 
tween parts  affected  with  gangrene  and 
sphacelus,  and  the  living  flesh.  An  exfolia- 
tion of  bone,  however,  happens  much  more 
slowly,  than  the  separation  of  a slough  of 
the  soft  parts.  Neither  are  all  exfoliations 
completed  at  a regular  period  ; for  they 
proceed  most  quickly  during  youth,  when 
the  constitution  is  usually  more  full  of  ener- 
gy, the  bones  more  vascular,  and  less  replete 
with  solid  inorganic  earthy  matter.  On  the 
other  hand,  the  process  is  slower,  in  old,  de- 
bilitated subjects,  whose  vitality  is  less  ac- 
tive. A thin  small  scale  of  bone  separates 
sooner,  than  a large  thick  portion  ; and  the 
most  tedious  exfoliation  is  that  of  a thick 
bone,  from  which  a portion,  including  its  en- 
tire diameter,  is  coming  away.  The  separa- 
tion of  a necrosis  takes  place  more  expedi- 
tiously in  bones  of  a light  texture,  than  in 
those  of  a solid  structure  ; and  sooner,  in  the 
less  compact  parts  of  bones,  such  as  the  epi- 
physes and  spongy  substance,  than  in  those 
of  greater  density. 

When  a necrosis  has  originated  from  the 
scurvy,  syphilis,  &.c.  and  appropriate  reme- 
dies are  not  administered,  nature  cannot  ef- 
fectually accomplish  the  process,  by  which 
the  dead  bone  is  separated ; the  case  becomes 
worse  ; and  life  endangered. 

The  separation  happens  precisely  at  the 
different  points  where  the  living  and  dead 
parts  of  the  bone  come  into  contact ; and  it 
is  obvious,  that  the  particles  of  the  dead 
bone,  which  are  at  a distance  from  the  part 
that  retains  its  vitality,  cannot  be  acted  upon 
by  it. 

A variety  of  opinions  have  been  entertain- 
ed, concerning  the  means  employed  by  na- 
ture in  effecting  this  separation.  Hippo- 
crates believed,  that  the  dead  part  was  push- 
ed away  by  a fleshy  substance,  which  grew 
underneath  it.  (De  Cap.  vuln.  Cap.  xxiv.) 
Ludwig,  Aitken,  Bonn,  and  many  others, 
adopted  the  same  idea.  (See  Adversaria 
Med.  Pract.  Vol.  3,  p.  63  ; Systematic  Ele- 
ments of  the  Theory  and  Practice  in  Surgery , 
p.  287.  Thesaur.  Oss.  Morb.  p.  1.) 

Van  Swieten  conceived,  that  the  dead  part 
was  forced  away  by  the  incessant  beating  of 
the  arteries.  ( Comment . inAphor.  Boerrhavii , 


§ 252.)  M.  Fabrc  ascribed  the  separation  to 
the  extension  and  expansion  of  the  vessels. 
( Mem . de  VAcad.  de  Chir.  Tom.  4,  p.  91.) 
Others  supposed  that  the  exfoliating  piece 
of  bone  became  loosened  partly  by  the  sup- 
puration, and  partly  by  the  rising  of  the  new 
granulations.  (See  B.  Bell  on  Ulcers.) 

As  Weidmann  observes,  there  is  unques- 
tionably a reddish  fleshy  substance  formed 
between  the  dead  and  livingbone,  and  which 
Celsus  has  noticed  under  the  appellation  of 
caruncula.  ( De  Medecina , lib.  8,  cap.  3.) 

But,  it  would  be  erroneous  to  refer  the  ex- 
pulsion of  the  dead  portion  of  bone  to  it, 
since  it  can  never  be  produced,  before  a 
change  has  taken  place  in  the  structure  of 
bone,  there  being  in  fact  no  space  for  it  to 
grow  in  ; and  hence,  it  is  never  seen  before 
the  disunion  of  the  parts  has  considerably 
advanced.  There  must  consequently  be 
some  other  power,  which  destroys  the  cohe- 
sion between  the  dead  and  living  bone,  and 
produces  the  groove,  or  interspace,  in  which 
the  soft  granulations  arise.  Besides,  among 
other  facts  proving  the  falsity  of  the  idea, 
that  the  granulations  push  off  the  dead  bone, 
Weidmann  particularly  adverts  to  the  occa- 
sional exfoliations  of  the  whole  circumfer- 
ence of  a cylindrical  bone.  Here,  if  the 
granulations  had  the  power  of  causing  a 
disunion  on  one  side,  they  could  not  have 
the  same  effect  on  the  opposite  one  ; but 
would  tend  to  make  the  contact  more  inti- 
mate. 

The  separation  also  cannot  be  made  by 
the  pulsation  of  the  small  arteries,  nor  by 
the  weak  expansive  motion  of  the  vessels  of 
(he  bone.  Weidmann  knows  not  what  mo- 
tives have  induced  certain  writers  to  impute 
the  effect  to  suppuration,  and  observes,  that 
as  the  doctrine  is  not  founded  upon  reason- 
ing, it  is  superfluous  to  offer  any  arguments 
against  it.  If  the  least  attention  be  paid  to 
what  nature  really  tries  and  accomplishes  in 
this  operation,  nothing  will  be  more  mani- 
fest, than  that  it  is  completed  in  a very  differ- 
ent manner.  Swelling  first  affects  the  peri- 
osteum and  bone,  which  by  degrees  softens. 

( Vid . Troja  passim.  Bonn.  Thesaur.  Oss.Mor- 
bos,  p.  122,  and  Weidmann  de  JYecrosi  Ossiutn , 
Tab.  4,  Fig.  1,  and  3.)  At  the  margins  of 
the  necrosis,  the  bony  surfaces,  which  were 
smooth,  become  rough,  and  irregular.  A 
fissure  is  there  produced,  which  extends  in 
every  direction  under  the  piece  of  bone,  that 
is  about  to  be  detached.  The  bony  texture 
is  also  daily  rendered  less  solid,  so  that  the 
number  of  adhesions  between  the  dead  and 
living  parts  diminish,  and  in  the  end  are  to- 
tally destroyed.  Weidmann  then  explains, 
that  the  true  mode  by  which  the  separation 
is  effected  consists  in  the  absorption  of  the 
particles,  situated  betwixt  the  livingand  dead 
parts  of  the  bone,  in  such  a way,  however, 
that  the  first  loses  a great  deal  of  its  sub- 
stance ; the  last,  scarcely  any  thing.  (P. 
25.)  After  the  dead  bone  has  come  away, 
the  swelling  of  the  periosteum  subsides,  and 
the  living  bone  recovers  its  original  hardness 
and  solidity.  (Troja,  p.  67.) 

For  a further  account  of  the  process,  by 


268 


NECROSIS. 


which  dead  portions  ot'  bone  are  separated 
from  the  living,  see  Exfoliation. 

When  dead  portions  of  bone  are  separated 
and  loose,  they  still  lodge  in  the  cavities  of 
the  ulcers,  and,  like  all  other  extraneous  bo- 
dies, occasion  irritation  of  the  soft  parts,  and 
keep  up  a discharge  of  matter.  Sometimes, 
however,  nature  of  herself  succeeds  in  ex- 
pelling them.  This  happens  in  cases,  where 
the  size  and  shape  of  the  ulcer  are  calculated 
to  facilitate  the  issue  of  the  dead  bone, 
which  does  not  lie  too  deeply,  and  is  pro- 
pelled outward  by  its  own  weight.  In  ne- 
croses of  trivial  size,  indeed,  it  is  asserted, 
that  the  small  fragments  of  bone  may  be 
dissolved  in  the  pus,  and  come  away  with  it ; 
{David  ; Bousstlin , Hist,  de  la  Society  Royale 
de  Medecine,  Tom.  4,  p.  308  ; Weidmann  de. 
JYecrosi  Ossium,  p.  26;)  but,  such  an  event 
can  never  be  expected  when  the  dead  por- 
tion of  bone  is  at  all  extensive. 

The  last  thing  which  nature  does,  is  to  re- 
store the  loss  of  substance  w’hich  the  bone 
has  suffered.  Although  this  operation  is  so 
extraordinary  and  wonderful,  that  one  might 
be  disposed  to  doubt  its  reality,  numerous 
examples,  recorded  in  the  annals  of  surgery, 
prove  not  only  its  possibility,  but,  also,  its 
frequency. 

In  works  referred  to  at  the  conclusion  of 
this  article,  the  following  authors  speak  of 
the  regeneration  of  a part,  or  the  w hole  of 
the  lower  jaw-bone  : viz.  Bonetus,  Bayer, 
Guernery,  Belmain,  Acrel,  Van  Wy,  Trioen, 
Bonn,  Reiplein,  Desault,  Henkel,  and  Dus- 
saussoir.  A student  showred  Weidmann  a 
lower  jaw-bone,  which  had  been  thus  rege- 
nerated, and  taken  from  the  body  of  a man, 
whom  the  latter  distinguished  writer  had 
been  w7ell  acquainted  wdth.  The  bone  could 
not  be  freely  depressed  ; but,  yet  it  per- 
formed its  functions  tolerably  well. 

Moreau  saw  a case,  in  which  the  clavicle 
was  regenerated,  and  the  new  bone  was  pre- 
sented by  Dangerville,  after  the  patient’s 
decease,  to  the  Academy  of  Surgery  at  Paris. 
{De  JYecrosi  Ossium  Theses , Prccs.  F.  Chopart, 
resp.  P.  G.  Robert , Parish's,  1776.) 

Chopart  had  an  opportunity  of  witnessing 
the  death  and  reproduction  of  a scapula. 

Weidmann  saw  an  instance,  in  wdiich 
nearly  the  whole  cylindrical  shaft  of  the  hu- 
merus perished,  and  was  afterw  ard  regene- 
rated ; a phenomenon,  that  had  been  obser- 
ved at  earlier  periods  by  Job  of  Mekren, 
Cajetano  Taconi,  E.  Blancard,  Buhamel, 
David,  Acrel,  Bcehmer,  Cheselden,  and  Vi. 
garoux,  whose  respective  works  are  cited  at 
the  end  of  this  article. 

Morand,  Cheselden,  and  Bromfield  pub- 
lished engravings,  respecting  a reproduction 
of  the  upper  part  of  the  humerus,  where  the 
old  dead  bone  was  included  in  a sort  of  bony 
tube. 

Regenerations  of  the  ulna  have  been  ob- 
served by  Ruysch,  Duverney,  and  Fowles. 
(See  Thesaur,  X.  JYo.  176.  Trait6  des  Mai, 
des  Os.  Paris,  1751 ; and  Phil.  Trans.  JYo. 
312.) 

A similar  reproduction  of  the  lower  ends 
of  the  radius  and  ulna  was  witnessed  by  Acrel. 


{Chirurgische  Vorfdllt  von  Murray,  Vel.  1 ,p. 
194.) 

Similar  reproductions  of  the  thigh-bone 
are  recorded  by  Wedel,  Battus,  Koschius, 
Hofmann,  Scultetus,  Diemerbroeck,  Wright, 
Fabricius  Hildanus,  Raw1,  Dobyns,  M‘Ken- 
zie,  Ludwig,  David,  Rousselin,  Larrey, 
Hutchison,  &c.  in  publications  specified  at 
the  conclusion  of  this  subject. 

The  followingcase  of  necrosis  of  the  thigh- 
bone is  related  by  Dr.  M‘Kenzie.  William 
Baxter,  a boy  thirteen  years  old,  received  a 
blow  on  his  thigh  at  school,  of  which  he  at 
first  hardly  complained  ; but,  in  a few 
months,  he  began  to  have  pain  in  the  thigh, 
which  inflamed,  swelled,  and  appeared  to 
have  matter  in  it.  The  parents  being  poorA 
no  surgeon  was  called,  and  the  boy  was  al- 
lowed to  linger  for  a great  while.  At  length 
the  matter  made  its  way  through  the  skin, 
by  a small  opening,  on  the  interior  part  of 
the  thigh,  about  three  inches  above  the  knee, 
and  a thin  sanies  continued  to  be  discharged 
for  eighteen  or  tw  enty  months.  At  length, 
the  hole  in  the  skin  enlarged,  and  the  point 
of  a bone  began  to  protrude,  and  give  a good 
deal  of  pain,  when  the  clothes  rubbed  against 
it.  After  suffering  in  this  manner  for  two 
years  and  a half,  the  boy,  as  he  lay  irj  bed 
one  morning,  felt  the  bone  looser,  and  pro- 
jecting more  than  ordinary.  He  gave  it  a 
strong  pull,  and  brought  the  piece  a.vay  en- 
tirely, w hich  proved  to  be  seven  inches  and 
a half  of  the  thigh-bone.  A good  deal  of 
bleeding  followed  ; but,  the  wround  soon 
healed,  and  he  has  never  since  found  the 
least  inconvenince.  Dr.  M‘Kenzie,  hearing 
of  this  singular  case,  sent  for  the  boy,  care- 
fully examined  his  thigh,  and  found  it  as  firm 
as  the  other.  The  only  difference  was,  that 
it  was  somewhat  thicker,  and  a little  more 
curved.  The  muscles  retained  their  natural 
softness,  and  looseness  on  the  bone.  The 
detached  piece  of  bone  wras  a portion  of  its 
whole  circumference.  (See  Med.  Obs.  and 
Inquiries,  Vol.  2.) 

We  may  infer,  that  the  occurrence  is  more 
frequent  in  the  tibia  than  any  other  bone, 
from  the  accumulated  facts,  mentioned  by 
Albucasis,  La  Marche,  Muralto,  De  La 
Motte,  Ellinchuys,  Ruysch,  Tacconi,  Laing, 
Johnson,  Hunter,  David,  Boehmer,  Sigwart, 
Th.  Bartholine,  Hofmann,  Saviard,  Le  I >ran, 
Duverney,  Trioen,  Gunther,  Ludwig,  Mi- 
chael, Bousselin,  Weidmann,  Russell, 
Whately,  Desault,  &,c.  See  the  works  refer- 
red to  at  the  end. 

Dr.  Hunter  mentions  a tibia  which  was 
sent  to  him  by  a Mr.  Inett,  after  amputation. 
On  examination,  the  case  at  first  sight  seem- 
ed to  be  a swelling  of  the  whole  bone,  with 
a loose  internal  exfoliation.  However,  it 
proved  to  be  a remarkable  instance  of  the 
separation  of  the  greatest  part  of  the  origi- 
nal bone,  whose  place  was  supplied  by  a 
callus.  The  external  surface  of  the  enclo- 
sed loose  piece  of  bone  was  smooth.  A 
small  part  of  the  surrounding  bony  substance 
being  removed,  the  contained  piece  was 
taken  out,  and  found  to  be  the  whole  body 
of  the  tibia.  It  had  separated  from  the  epi- 


Necrosis. 


269' 


pbysis  at  each  extremity.  The  middle  part 
of  the  bone  had  perished,  consequently,  had 
lost  its  connexion  witli  the  periosteum,  and 
was  gradually  thrown  off  from  the  living 
parts  of  the  bone  at  each  end.  A callus  ex- 
tended from  end  to  end,  united  the  two  ex- 
tremities of  the  original  tibia,  preserved  the 
length,  and  gave  firmness  and  inflexibility 
to  the  part.  The  exfoliation  was  so  encom- 
passed by  the  new  bony  case,  that  though 
quite  loose,  it  could  not  be  thrown  out. 
(Med.  Obs.  and  Inq.  Vol.  2.) 

Weidmann  saw  a shoemaker,  who,  after 
much  suffering,  extracted  himself  the  great- 
est part  of  the  diaphysis  of  the  tibia  ; yet, 
the  loss  wa3  so  well  repaired,  that  the  man 
could  walk  afterward  nearly  as  ably  as  ever- 
(De  Necrosi  Ossium,p.  29.) 

“ We  are  not  to  imagine,  (says  Weid- 
mann) that  these  regenerations  happen  by 
chance  : experiments  made  upon  living  ani- 
mals by  Troja,  Blumenbach,  Koehler,  De- 
sault, and  myself,  prove  that  they  invariably 
follow  certain  laws.” 

In  fact,  whenever  the  medullary  structure 
of  the  long  bones  of  pigeons,  or  dogs,  is 
destroyed,  these  bones  become  affected  w ith 
necrosis,  and  are  afterward  reproduced  to 
the  full  extent  of  their  destruction. 

The  observations  and  experiments,  cited 
by  Weidmann,  also  prove,  that  it  is  the  long 
bones  which  are  usually  reproduced  ; though 
the  flat  ones  are  not  entirely  destitute  of  the 
power  of  regeneration,  since  experience 
fully  evinces,  that,  when  a portion  of  the 
skull  is  removed,  either  by  a wound,  by 
disease,  or  by  the  trepan,  nature  always 
endeavours  to  cover  the  deficiency,  the 
edges  of  the  aperture  extending  themselves 
by  means  of  a bony  substance,  furnished  by 
the  periosteum,  the  dura  mater,  and  cranium 
itself.  (Tenon  Mem.  de  l' Acad.  des  Sciences, 
1758,  p.  412,  413,  415,  416,  418.)  But  still 
the  reproduction  is  imperfect,  as  a space 
unfilled  up  is  always  left,  even  when  the 
bone  has  lost  only  a small  piece,  like  what 
is  taken  out  by  the  trephine  ; and  when  the 
destruction  of  the  cranium  is  very  extensive, 
no  reproduction  at  all  happens.  This  fact 
is  proved  by  examples  mentioned  by  5avi- 
ard,Pott,  Sabatier,  &tc 

When  in  a case  of  necrosis,  says  Weid- 
mann, a scale  or  table,  of  either  a long  or 
flat  bone,  is  separated,  no  regeneration  fol- 
lows, because  the  granulations,  which  rise 
up  under  the  sequestrum,  then  serve  as  a 
periosteum,  and  as  soon  as  the  dead  bone 
19  removed,  they  become  united  to  the  ad- 
jacent parts. 

It  is  likewise  ascertained,  that  the  power 
of  reproduction  in  the  bones  is  particularly 
active  in  the  early  periods  of  life,  and  in 
healthy  subjects ; and  that  it  is  languid  and 
even  annihilated  in  old  persons,  pregnant 
women,  (Bonm  Thesaur.  p.  174,)  and  in  ve- 
nereal. cancerous,  and  rickety  patients. 

( Callisen , Syst.  Chir.  Hodiernce , Pars  1,  p. 
636.) 

In  order  that  a new  bone  may  form,  the 
periosteum  and  other  membranes,  concern- 
ed in  the  ^nutrition  of  the  original  bone,  must 


have  been  spared  from  destruction.  In  fact, 
continues  Weidmann,  we  observe  that  in 
cases  where  the  tube  of  a long  bone  has 
suffered  necrosis,  the  bone  is  never  repro- 
duced, when  the  periosteum  has  been  de- 
stroyed by  inflammation  or  other  causes. 
Surgeons  ought  also  to  understand  that  it  is 
not  always  a reproduction  which  has  hap- 
pened, when  a part  of  a bone  perishes  ; not 
even  when  a tubular  portion  of  a long  bone 
dies,  and  is  contained  in  the  medullary 
canal.  For,  says  \\  eidmann  if  the  inner- 
most layers  of  a long  bone  perish,  while 
those  which  compose,  as  it  w ere,  the  bark, 
are  preserved,  the  latter  swell  and  soften, 
as  if  they  were  actually  a new  bone.  Se- 
veral round  apertures  are  observable  upon 
their  surface,  w'hieh  serve  for  the  transmis- 
sion of  vessels,  and  are  larger  than  those 
which  perform  this  office  in  the  natural 
state.  There  are  likewise  formed  large 
openings,  or  fistulae,  which,  as  in  a new 
bone,  lead  to  the  medullary  canal.  Here 
it  would  be  erroneous  to  conclude  that  a 
new  bone  has  been  produced,  and  a very 
little  attention  will  discover  that  all  is  limit- 
ed to  some  changes  in  the  external  part  of 
the  bone,  which  the  necrosis  has  not 
affected. 

When,  therefore,  the  interior  of  the  canal 
of  a long  bone  is  destroyed  by  a necrosis, 
which  does  not  extend  to  the  external  lay- 
ers, the  case  is  not  a reproduction  of  the 
bone. 

When,  however,  w7e  find  the  tube  of  any 
long  bone  included  in  a sort  of  osseous  shell, 
and  the  surface  of  this  tube  smooth,  like  that 
of  a bone  in  the  natural  state,  we  may  be 
certain  that  it  has  been  detached  directly 
from  the  periosteum,  and  that  the  bony 
shell  w hich  contains  it,  is  a new  production. 
On  the  contrary,  if  the  surface  of  the  dead 
tube  is  rough,  we  may  infer  that  the  separa- 
tion has  taken  place  between  the  innermost 
layers  of  the  bone  and  those  which  are 
superficial,  the  latter  composing  now  the 
osseous  shell,  in  which  the  sequestrum  is 
included.  (Weidmann  De  Arecrosi  Ossium, 
p.  31*) 

This  fhst  theory,  concerning  the  produc- 
tion of  the  osseus  shell  in  necroses  of  the 
long  cylindrical  bones,  is  adopted  by  Riche- 
rand  as  the  true  one,  not  only  in  the  in- 
stances specified  by  Weidmann,  but  in  every 
other  example  w here  the  old  bone  seems  to 
be  included  in  another  which  has  the  ap- 
pearance of  being  a new’  production,  and 
which  w as  supposed  by  Troja,  David,  &c, 
to  be  formed  by  the  vessels  of  the  perioste- 
um. (See  JYusographie  Chir.  T.  3,  p.  158, 
161,  Edit.  4.)  Boyer  does  not  espouse  this 
theory  exclusively  ; but  represents  the  thing 
as  sometimes  happening.  (See  Traiti  des 
Mai.  Chir.  T.  3 ,p.  426.) 

As  far  as  the  observations  of  Weidmann 
informed  him,  the  short  or  cuboid  bones  do 
not  appear  to  be  capable  of  reproduction. 
(P.  31.)  Duverney  mentions  an  astragalus, 
w7hich  was  destroyed  by  necrosis  , but  does 
not  state  that  any  substitute  for  it  was  after- 


270 


NECROSIS. 


ward  formed.  ( Trait6  des  Maladies  des  Chir. 
Os.  p.  458.) 

Weidmann  also  never  witnessed  a repro- 
duction of  the  spongy  substance,  such  as  it 
was  before  its  destruction,  round  the  me- 
dulla. He  always  found  the  substituted 
matter  dense  and  compact,  at  least  for  some 
time  after  its  formation. 

It  is  now  admitted,  however,  that  in  pro 
cess  of  time,  the  inner  surface  of  the  new 
bone  becomes  cellular,  and  is  lined  with  a 
membrane  containing  medulla.  The  rege- 
neration of  the  medulla  was  first  observed 
by  Koehler,  and  afterward  in  an  extensive 
series  of  experiments,  which  Professor 
Thomson  made  with  Dr.  Alexander  McDo- 
nald, and  which  were  published  in  the  lat 
ter  gentleman’s  inaugural  dissertation,  in 
1799.  (See  Thomson's  Lectures  on  Inflam- 
mation. p.  393.;  Mr.  Russel  does  not  ap- 
pear to  adopt  this  opinion  concerning  the 
regeneration  of  the  medulla;  for,  he  states 
that,  after  the  absorption  or  removal  of  the 
sequestrum,  the  cavity  of  the  new  bone  be- 
comes filled  up  with  granulations,  which  are 
at  length  converted  into  bony  matter  Thus, 
be  says,  the  new  bone  differs  from  the  ori- 
ginal one,  in  being  solid  instead  of  hollow. 
Authorities,  however,  are  decidedly  against 
Mr.  Russell  on  this  point : in  the  5th  vol.  of 
the  M6m  de  VAcad.  de  Chir.  is  the  history 
of  a man,  the  whole  of  whose  clavicle  came 
away  without  his  being  deprived  of  any  of 
the  motions  of  the  arm.  The  death  of  this 
patient,  which  happened  shortly  afterward, 
afforded  an  opportunity  of  examining  how 
nature  had  repaired  the  loss.  Another  cla- 
vicle was  found  regenerated,  which  neither 
differed  from  the  original  one  in  length  nor 
solidity  ; but  only  in  shape,  being  flatter,  and 
not  so  round.  It  was  connected  with  the 
acromion  and  sternum,  just  like  the  primi- 
tive bone. 

The  power,  which  thus  reproduces  bones, 
is  only  a modification  of  that  which  unites 
fractures.  Indeed,  w hat  consolidates  bro- 
ken bones,  and  is  known  by  the  name  of 
callus,  presents  all  the  characters  of  new 
bone,  begins  and  grows  in  the  sarnejvay, 
and  may  be  impeded  and  retarded  m its 
formation  by  the  same  causes.  (See  Callus 
and  Fractures.)  It  is  further  highly  probable, 
as  Weidmann  remarks,  that  the  power  which 
effects  the  reproduction  of  bones,  is  the 
same  as  that,  which.  in  the  sound  state,  nou- 
rishes and  supports  these*parts.  But  to  what 
organ  appertains  the  function  of  reprodu- 
cing bones  ? 

Many  able  men  have  ascribed  the  whole 
work  to  the  periosteum.  (C.  Havers;  Du- 
hamel,  Mem.  de  l' Acad,  des  Sciences,  1739, 
1741,  1742,  1747.  Fougeroux,  Mem.  sur  les 
Os;  Paris,  1760.  Swencke , Hnrlemer  Ab- 
handlungen  1,  th.  p.  39.  Berlin,  Osteologie. 
Marigues,  Abhandlung  von  der  Fatur  und 
Erzeugung  des  Callus,  p.  199.) 

Haller,  ( Elem . Physiol.  T.  8,  p.  352.) 
Callisen,  ( Collect . Hafn.  T.  2,  p.  187.)  Te- 
non, ( Mem  de  VAcad.  des  Sciences,  1758 ,p. 
415.)  Bordenave,  (Mem.  sur  les  Os,p.  227) 
and  many  others,  have  seen  a part  of  the 


new  production  spring  up  from  the  substance 
of  the  old  bone  ; a thing,  says  Weidmann, 
which  one  is  also  led  to  believe  by  the  fact, 
that,  when  the  whole  tube  of  a long  bone 
is  affected  with  necrosis,  the  epiphyses 
which  remain  sound  and  untouched,  unite 
and  grow'  to  the  new  tube,  though  no  peri- 
osteum exists  in  the  situation  of  the  union. 

Nor  does  Weidmann  think  that  the  speci- 
men of  a fractured  thigh,  of  which  Blumen- 
bach  has  published  an  engraving,  proves  the 
contrary.  (Geschichte  und  Berschreibung  der 
Knocker;  Gottingen,  1786,  Tab.  I,  Jig.  1.) 
This  preparation  exhibits  an  union  which 
had  taken  place  by  means  of  a very  broa 
osseous  ring,  encompassing  the  ends  of  th 
fracture  w hich  lie  far  asunder.  The  even 
appears  to  Weidmann  to  have  been  thi 
result  of  rachitis,  or  lues  venerea,  with  wdiic! 
the  young  patient,  according  to  Blumenbac' 
himself,  had  been  affected,  and  by  whicl 
the  nutrition  of  this  bone  had  been  disorder 
ed  For,  says  Weidmann,  in  other  exam 
pies  of  united  fractures,  the  ends  of  the  bom 
are  so  connected  together  by  the  callus, 
that  there  does  not  exist  a single  point  be- 
tween them,  where  this  substance  is  not 
effused,  and  the  medullary  canal  itself  is 
obstructed  and  filled  with  it.  In  the  Journ. 
Comptem.  du  Did.  des  Sciences  Med.  T.  8, 
may  be  found  some  considerations,  offered 
by  Larrey,  against  the  doctrime  that  the 
periosteum  is  the  organ  of  ossification. 

That,  however,  the  periosteum  is  fre- 
quently the  organ  of  the  reproduction  of 
the  bones,  seems  proved  by  the  experiments 
of  Troja,  Blumenbach,  Desault,  and  Koeh- 
ler, since  in  these  the  bones  were  invariably 
regenerated,  though  there  was  nothing  left 
of  the  old  bone  that  could  furnish  the  new 
reproduction,  except  the  periosteum. 

If  we  examine  the  new  bone,  at  different 
periods  of  its  developeinent,  it  appears  in 
the  earliest  state  in  the  form  of  a redidsh 
fluid,  as  has  been  observed  by  Duhamel. 
Fougeroux,  Bordenave,  Haller,  Callisen, 
and  others.  If  we  also  attend  to  the  pro- 
gressive changes  which  this  fluid  undergoes, 
we  cannot  but  believe  that,  as  in  the  em- 
bryo, an  organic  and  fixed  arrangement  of 
parts  takes  place.  Indeed,  it  would  be  er- 
roneous to  consider  such  fluid  as  destitute 
of  organization  and  extravasated  at  random. 
Thin  and  little  in  quantity  on  its  first  appear- 
ance, its  consistence  and  quantity  afterward 
gradually  increase  (Troja,  p.  42,  44,)  so 
that  what  at  first  appeared  like  a liquid, 
soon  becomes  a gelatinous  substance,  in 
which  are  developed,  especially  at  its  inner 
surface  and  towards  its  lower  part,  bony 
fibres,  which  incessantly  become  more  and 
more  numerous.  These  fibres  in  a short 
time  form  little  layers  and  cells,  and  extend 
themselves  every  where,  so  that  at  length 
all  which  was  fluid  disappears,  and  the  new 
bone  is  produced.  While  young,  however, 
it  is  still  spongy  and  reddish,  (Troja,  p.  44;) 
but  soon  becomes  denser,  harder,  and  more 
solid,  than  that  was  for  which  it  is  a substi- 
tute, and  it  acquires  the  ordinary  colour  o 
the  rest  of  the  bones. 


NECROSIS. 


271 


The  external  surface  of  the  new  bone, 
which,  during  the  period  of  its  formation, 
was  irregular,  and  studded  with  several  ex- 
crescences of  various  sizes,  and  pierced  with 
apertures  of  different  dimensions,  becomes 
in  the  course  of  time  smooth  and  regular, 
especially  after  the  expulsion  of  the  seques- 
trum. 

The  sides,  or  walls  of  the  new  bone  which 
at  first  were  of  considerable  thickness,  in 
time  also  grow  thinner.  ( Truja , p.  21.) 
When  the  entire  dead  bony  cylinder  con- 
tinues in  its  cavity,  the  new  bone  is  neither 
shorter,  nor  longer,  than  the  original.  But, 
should  one  of  the  ends  of  the  dead  tube 
protrude  from  the  cavity,  while  by  the  side 
of  the  affected  bone,  there  is  not  another 
one  capable  of  resisting  the  action  of  the 
muscles,  the  new  bone  will  be  shortened, 
and  undergo  some  change  in  its  shape  and 
direction.  Indeed,  says  Weidmann,  the  new 
bone  in  its  early  state,  from  want  of  con- 
sistence, must  yield  to  the  efforts  of  the 
muscles. 

Its  shape  is  not  exactly  like  that  of  the 
original  bone:  the  sides  are  flatter;  the 
usual  angles,  depressions,  and  eminences 
are  not  observable,  and  sometimes  others 
are  formed. 

How  admirable  is  the  process,  by  which 
the  muscles,  detached  from  a bone  affected 
with  necrosis,  have  other  insertions  given  to 
them,  and  are  thus  rendered  capable  of  per- 
forming their  functions  ! (Troja,  p.  27.) 

The  periosteum,  which  swells  as  soon  as 
the  exfoliation  of  the  old  bone  commences, 
shrinks,  and  is  not  at  all  thickened,  when 
the  exfoliation  is  finished.  Troja,  having 
destroyed  the  medullary  structure  of  a long 
bone,  found  the  periosteum  swelled  at  the 
end  of  36  hours;  but  he  observed,  that  the 
whole,  of  such  swelling  disappeared  before 
the  25th  day.  (P.  43,  67.) 

The  periosteum,  which  thus  survives,  ad- 
heres to  the  new  bone,  as  it  did  to  the  old 
one  : its  vessels,  which  are  now  increased 
in  diameter,  and  convey  a larger  quantity  of 
blood,  dive  into  large  apertures  in  the  re- 
generated bone,  ramify  every  where  in  its 
substance,  and  nourish  it. 

Dr.  Macartney’s  observations  nearly  agree 
with  those  of  Troja  and  Weidmann,  respect- 
ing the  formation  of  the  new  bone  by  ihe 
periosteum,  with  this  difference,  however, 
that  he  does  not  describe  the  original  perios- 
teum as  becoming  afterward  attached  to  the 
new  bone,  but  as  disappearing.  Dr.  Macart- 
ney remarks,  “ that  the  first  and  most  im- 
portant circumstance  is  the  change,  which 
takes  place  in  the  organization  of  the  perios- 
teum ; this  membrane  acquires  the  highest 
degree  of  vascularity,  becomes  considerably 
thickened,  soft,  spongy,  and  loosely  ad 
herent  to  the  bone.  The  cellular  substance, 
also,  which  is  immediately  connected  with 
the  periosteum,  suffers  a similar  alteration  : 
it  puts  on  the  appearance  of  being  inflamed, 
its  vessels  enlarge,  lymph  is  shed  into  its 
interstices,  and  it  becomes  consolidated  with 
the  periosteum.  These  changes  are  prepara- 
+orv  to  the  absomtion  of  the  old  bone,  and 


the  secretion  of  the  new  osseous  matter,  and 
even  previous  to  the  death  of  the  bone, 
which  is  to  be  removed.  In  one  instance,  I 
found  the  periosteum  vascular  and  pulpy, 
when  the  only  affection  was  a small  abscess 
of  the  medulla,  the  bone  still  retaining  its 
connexion  with  the  neighbouring  parts,  as  it 
readily  received  injection.  The  newly  or- 
ganized periosteum,  &c.  separates  entirely 
from  the  bone,  after  which  it  begins  to  re- 
move the  latter  by  absorption  and,  while 
this  is  going  on,  its  inner  surface  becomes 
covered  with  little  eminences,  resembling 
granulations.  “ In  proportion  as  the  old 
bone,  is  removed,  new  osseous  matter  is  dis- 
persed in  the  substance  of  the  granulations, 
whilst  they  continue  to  grow  upon  the  old 
bone,  until  the  whole,  or  a part  of  it,  is  com- 
pletely absorbed,  according  to  the  circum- 
stances of  the  case.  What  remains  of  the 
investment,  after  the  absorption  of  the  old 
bone,  and  the  formation  of  the  osseous  tube, 
wThich  is  to  replace  it,  degenerates,  loses  its 
vascularity,  and  appears  like  a lacerated 
membrane.  I have  never  had  an  opportuni- 
ty of  examining  a limb,  a sufficient  time  after 
the  termination  of  the  disease,  to  ascertain, 
whether  the  investment  be  at  last  totally  ab- 
sorbed, but  in  some  instances,  1 have  seen 
very  little  remaining.  During  the  progress 
of  the  disease,  the  thickened  cellular  sub- 
stance, which  surrounded  the  original  perios- 
teum, becomes  gradually  thinner  ; its  vessels 
diminish,  and  it  adheres  strictly  to  the  new- 
formed  bone,  to  which  it  ultimately  serves 
as  a periosteum.”  Dr.  Macartney  states, 
that  the  anatomical  preparations,  which  au- 
thenticate the  above  observations,  are  pre- 
served at  St.  Bartholomew’s  Hospital.  (See 
Crowther  on  Whitt  Swelling,  p.  183.  Ed.  2.) 

Mr.  Stanley,  however,  lately  showed  me 
in  the  same  museum,  a preparation,  which 
tends  to  confirm  the  accuracy  of  Troja's 
account  of  the  old  periosteum  becoming 
adherent  to  the  new  bone.  In  this  example, 
the  periosteum  is  perfectly  continuous  with 
that  covering  the  epiphyses.  If  this  were 
not  the  fact,  wre  should  have  to  explain  iu 
what  way  the  periosteum  of  the  new  bone  is 
formed.  We  know  that  the  vessels  of  the 
original  periosteum  enter  the  new  bone,  in 
order  to  complete  its  formation,  and  it  seems 
more  consonant  with  the  uniform  simplicity 
of  nature’s  operations,  to  suppose  that  this 
connexion  is  kept  up,  than  that  the  old 
periosteum  should  be  totally  removed,  after 
the  production  of  the  new  bone,  and  another 
membrane  of  the  same  kind  be  then  gene- 
rated. 

An  interesting  example  of  necrosis  of  the 
thigh-bone,  published  some  time  ago  by  Mr. 
C.  Hutchison,  tends  also  to  prove,  that  the 
new  osseous  shell  is  commonly  formed  by 
the  periosteum,  as,  in  this  case,  the  medulla- 
ry bags,  or  cells,  were  found  completely 
ossified,  ( Practical  Obs.  in  Surgery , p.  135) 
and  could  not  therefore  be  supposed  to  be 
capable  of  the  work.  Among  the  moderns, 
also;  Dr.  McDonald  deserves  to  be  mention- 
ed as  one  of  the  most  distinguished  advo- 
cates for  the  truth  of  Troia’s  explanation  of 


.272 


NECROSIS. 


this  subject.  (See  MDonald’s  Thesis  de 
JYecrosi  ac  Callo ; Edinb.  1799.)  Another 
late  writer  has  adduced  many  arguments  to 
prove  that  the  pulpy  mass,  which  extends 
from  one  epiphysis  to  the  other,  and  is  itself 
at  last  converted  into  bone,  is  formed  quite 
independently  *>f  the  original  bone,  or  the 
periosteum.  (See  R ussell's  Practical  Essay 
on  Necrosis,  p.  27,  Edinb.  1795.)  This  ac- 
count, however,  is  contrary  to  the  observa- 
tions of  Troja,  David,  Weidmann,  ATDouald, 
Macartney,  and  numerous  other  observers. 
Indeed,  a modern  author  seems  to  think  the 
periosteum  so  essential  to  ossification,  or  the 
production  of  a new  bone,  that  he  attempts 
to  explain  the  cause  of  fractures  of  the 
patella  not  becoming  united  by  a bony  sub- 
stance, by  adverting  to  the  deficiency  of 
periosteum  upon  it ; a circumstance  which 
lie  deems  also  a strong  argument  against 
Mr.  Russells  doctrine.  (See  Hutchison's 
Practical  Observ.  in  Surgery,  p.  141,  142.) 

These  very  same  cases,  however,  fractures 
of  the  patella,  do  sometimes  unite  by  bone, 
and,  therefore,  while  Mr.  Hutchison  is  urging 
them  as  facts  against  Mr.  Russell’s  opinion, 
Baron  Larrey  is  actually  adducing  them  in 
its  support.  (See  Journ.  Compttm.  du  Did. 
des  Sciences.  Med.  T.  8.)  The  experiments 
of  Breschet  and  Villerme  are  decidedly 
against  the  periosteum  being  exclusively 
the  organ  of  ossification. 

Professor  Boyer  does  not  refer  all  the 
work  of  reproducing  bones  exclusively  to 
the  periosteum  in  every  instance  ; but  joins 
Weidmann  in  believing,  that  what  seems  a 
new  bone  is  sometimes  only  a separation 
and  thickening  of  the  external  layers  of  the 
original  bone,  which  have  escaped  destruc- 
tion. He  notices  the  modifications,  to 
which  the  phenomena  of  necrosis  are  sub- 
ject when  the  disorder  affects  the  whole 
thickness,  and  the  whole,  or  the  greater  pari, 
of  the  circumference  of  a long  cylindrical 
bone.  When  the  periosteum  is  destroyed 
together  with  the  bone,  and  the  medullary 
membrane,  which  does  the  office  of  an  in- 
ternal periosteum,  is  preserved,  Boyer 
represents  the  latter  membrane  as  under- 
going similar  changes  to  those  which  we 
have  mentioned  as  taking  place,  under 
other  circumstances,  in  the  external  perios- 
teum, and  he  describes  it  as  becoming  the 
organ  by  which  the  new  bone  is  formed. 
(See  Traiii  des  Maladies  Chir.  T.  3,  p.  432.) 
But  when  the  whole  thickness  and  circum- 
ference of  along  bone  are  destroyed,  together 
with  the  medullary  membrane,  while  the 
periosteum  survives,  Boyer  agrees  with 
Troja,  kc.  in  believing  the  latter  membrane 
to  be  the  means  by  which  the  new  bone  is 
generated. 

The  internal  surface  of  the  new  bone  is 
lined  by  a new  membrane,  which  serves  as 
a periosteum,  and  is  at  first  hardly  distin- 
guishable. ( Troja , p.  56.)  In  the  early 
state,  it  is  soft  and  pulpy  ; (ibid,  p 22  .)  but, 
by  degrees,  it  grows  thicker  and  firmer,  and 
is  at  length  converted  into  a true  membrane, 
which  sends  a great  number  of  vessels  into 
jhe  substance  of  the  bone.  When  this  mem- 


brane is  torn  off,  the  surface,  which  it  cover- 
ed, is  found  somewhat  smooth,  the  edges  of 
the  bony  layers,  and  projections  of  the  fibres 
being  blunt  and  rounded 

The  cavity  of  the  new  bone  includes,  and 
almost  entirely  onceals  the  dead  fragments. 
Sometimes,  however,  the  new  bone  forms  a 
sort  of  bridge  over  the  sequestrum,  in  such  a 
manner  that  the  cavity  is  open  above  and 
below,  in  both  which  situations  the  seques- 
trum can  be  felt.  ( Hunter , in  Med.  Obs.  and 
Inquiries  Vol.  2,  p 418.) 

Sometimes, it  is  only  a narrow  cross-piece, 
which  forms  the  bridge  retaining  the  seques- 
trum. ( Weidmann . vid  Tab.  5,  Fig.  1,  a.) 

The  new  bone  may  also  have  an  opening 
in  it,  out  of  which  the  dead  portion  protrudes. 
(lb.  p 35.) 

Sometimes  the  cavity  of  the  new  bone  is 
single  ; while  in  other  instances,  there  are 
several  successive  cavities  in  the  direction  of 
the  length  of  the  bone,  with  transverse 
interspaces  between  them  ; or  else  the  cavi- 
ties are  situated  laterally  with  respect  to 
each  other,  and  divided  by  partitions. 

( Weidmann , 77*6.7,  Fig  2.) 

These  cavities  are  proportioned  in  size 
and  shape  to  the  fragments  of  dead  bone, 
w'hich  lodge  in  them.  It  occasionally  hap- 
pens. that  they  open  into  some  neighbouring 
joint,  and  bring  on  suppuration  there  : a 
very  unfavourable  complication.  (Ibid.p. 
34,  and  Tali.  6,  Fig.  3;  also , Boyer , Trail6 
des  Mai.  Chi-.  Tom  3 ,p.  435.) 

Let  us  next  follow  Weidmann,  and  take 
notice  of  the  holes,  by  which  the  cavities, 
including  the  dead  pieces  of  bone,  open 
externally,  which  Troja  denominated  the 
large  foramina,  and  which  the  preceding  ex- 
cellent writer  preferred  calling  the  cloacae , 
because  they  serve  to  convey  outward  the 
matter  and  any  separated  pieces  of  bone. 
In  the  beginning  of  the  disorder,  they  are  not 
observable,  a certain  space  of  time  appear- 
ing to  be  requisite  for  their  formation.  They 
are  noticed  in  long  cylindrical  bones,  whe- 
ther original,  or  of  new  production,  whose 
cavities  contain  dead  fragments. 

These  openings  vary  in  number:  when 
the  sequestrum  is  small,  only  one  is  found  ; 
but,  when  the  piece  of  dead  bone  is  exten- 
sive, there  may  be  two,  three,  or  four. 
Weidmann  never  saw'  more  than  five.  But 
Troja  met  with  eight.  ( P . 58.)  Weidmann 
possessed  a small  portion  of  the  diploe  of 
the  os  innominatum,  which  was  affected 
with  necrosis,  and  contained  in  a bony 
cavity,  that  had  no  external  opening  what- 
ever. 

When  there  are  several  distinct  cavities 
iu  the  same  bone,  containing  dead  frag- 
ments, each  cavity  has  at  least  one  external 
opening. 

These  cloacae,  or  apertures,  are  commonly 
situated  at  the  lower  and  lateral  parts  of  the 
cavities  ; pass  obliquely  outwards;  and  com- 
municate with  fistulous  ulcers,  which  open 
on  the  surface  of  the  skin.  (David,  p.  186.) 
Some  of  the  cloacas,  however,  form  uttlie 
middle,  or  (what  is  exceedingly  rare)  at  the 
upper  part  of  the  cavities,  and  proceeding 


NECROSIS'. 


*2.73 


outward,  without  any  oblique  track,  go  to 
the  front,  back,  or  lateral  parts  of  the  limb. 

They  are  of  a round,  or  oval  shape,  or 
nearly  so.  Their  usual  size  is  such,  that  it 
will  just  admit  a quill,  and  they  vary  very 
little  from  this  dimension. 

They  terminate  internally  by  converging 
approaching  edges,  in  the  manner  of  a fun- 
nel ; while,  on  the  contrary,  the  margins  of 
their  outer  extremity  expand.  The  canal 
between  these  two  orifices  is  sometimes 
long,  sometimes  short,  and  in  certain  cases, 
of  no  extent  at  all. 

Different  opinions  have  been  broached, 
respecting  the  causes  which  produce  the 
apertures  in  the  new  bone,  termed  by  YVeid- 
mann  the  cloaca. 

M.  David  says,  that  the  pus  collecting  in 
an  eariy  stage  of  the  disease  between  the 
bone  and  periosteum,  distends  and  corrodes 
this  membrane,  and  that  the  openings  which 
form  in  it  become  afterward  a cause  of  fis- 
tulas in  the  new  bone.  (P.  186.)  But  it  is 
observed  by  Weidmann,  that  this  explana- 
tion is  inadmissible,  since  the  existence  of 
the  collection  of  pus,  mentioned  by  M.  Da- 
vid, is  not  proved  by  observation  : in  fact, 
it  was  never  met  with  by  Troja,  Blumen- 
bach,  Desault,  Koehler,  and  many  others,  in 
repeated  experiments  made  on  the  subject. 
(Troja,  p.  56  and  66  ; Weidmann , p.  36.) 

Koehler  thought  he  had  seen  the  new  bone 
itself  destroyed  by  the  pus,  and  cloaca  thus 
produced.  (P.  68 — 72.) 

YVeidman,  however,  deems  this  opinion 
quile  as  improbable  as  the  preceding,  for 
the  fact  of  the  surface  of  these  bony  aper- 
tures being  always  smooth,  always  formed 
in  one  manner,  and  constantly  lined  by  the 
periosteum,  decidedly  proves  that  they  can- 
not arise  from  erosion. 

Troja,  in  his  third  experiment  upon  the 
regeneration  of  bones,  remarked,  that  forty- 
two  hours  after  the  destruction  of  the  me- 
dulla, there  took  place,  between  the  bone 
and  the  periosteum,  an  effusion  of  lymph, 
which  was  at  first  thin  and  little  in  quantity, 
but  afterward  became  thicker.  He  noticed, 
in  the  midst  of  this  gelatinous  substance,  some 
small  spaces , where  il  teas  deficient,  and  which 
had.  instead  of  it,  a subtile,  whitish,  dry  in- 
crustation, which,  though  tolerably  adherent , 
could  be  rubbed  ojf.  These  small  spaces,  ac- 
cording to  Troja,  produce,  the  apertures  called 
the  cloaca.  ( Troja,  p.  45.) 

In  another  experiment,  he  had  an  opportu- 
nity of  examining  the  above  little  spaces 
at  the  end  of  forly-eight  hours  ; he  affirms, 
that  they  were  replaced  by  the  large  aper- 
tures, or  cloacae,  of  the  new  bone  (P.  47  ;) 
and  that  such  openings  were  invariably 
formed  in  the  place  of  the  small  incrusted 
spaces  already  described.  (P.  58.)  As 
Troja  took  notice  that  no  lymph  was  effused 
at  these  particular  points,  he  was  inclined  to 
impute  the  circumstance  to  adefect  in  the  os- 
sification, and,  perhaps,  to  the  death  of  some 
]iartsif  the  periosteum.  Weidmann  acknow- 
ledges, thai  the  mode,  in  which  the  lorma- 
tion  of  the  cloacee  happens,  is  exceedingly 
obscure ; and  expresses  his  belief,  that 

Vot  II  35 


Troja’s  account  of  it  approaches  the  nearest 
to  the  truth.  But,  says  he,  one  thing  is  cer- 
tain, namely,  that  these  openings  have  no 
other  use,  but  that  of  conveying  outward 
the  pus  which  collects  in  the  cavity,  and 
the  small  bony  fragments,  since,  as  soon  as 
every  atom  of  dead  bone  has  passed  out, 
they  diminish,  and,  at  length,  are  lotally 
obliterated.  ( W eidmann  Dt  JYecrosi  Ossi um , 
p.  36.) 

It  is  a remarkable  circumstance,  in  the 
history  of  necrosis,  that,  in  favourable  in- 
stances of  the  disease,  the  inflexibility  and 
firmness  of  the  limb  are  preserved  during 
the  whole  of  the  process,  by  which  the  new 
bone  is  formed.  Consequently,  the  new 
bone  must  have  begun  to  grow,  and  have 
acquired  firmness  before  the  old  bone  sepa- 
rates, «r  is  absorbed.  Were  this  not  the 
case  the  limb  must  become  flexible  and  use- 
less, the  moment  the  dead  bone  is  removed. 
Another  consequence  of  the  new  bone  being 
formed,  before  the  removal  of  the  old  one, 
is  that  the  former  must  surround  and  include 
the  latter.  For,  since  the  lifeless  portion  of 
bone  completely  occupies  the  space  between 
the  two  living  ends,  these  cannot  be  imme- 
diately connected  by  the  new  bony  matter. 
The  connexion  can  alone  be  completed  by 
the  new  bone  being  deposited  on  the  outside 
of  the  old  one,  from  one  end  to  the  other,  and 
attaching  itself  to  the  portions  which  still 
remain  alive.  The  new  bone  must  also  be 
necessarily  larger  than  the  old  one,  because 
externally  situated,  and  hence  the  affected 
limb,  after  the  cure  is  complete,  will  always 
continue  larger,  clumsier,  and  less  shapely 
than  the  other.  The  length  of  it,  however, 
remains  unaltered,  because  the  old  bone  re- 
tains its  attachment,  while  the  rudiments  of 
the  new  bone  are  lying  on  its  outside,  and 
connect  the  living  ends  of  the  old  one,  by 
an  inflexible  mass,  equal  in  length  to  the 
portion  which  is  destroyed. 

Thus  we  see,  that,  in  the  process  which 
nature  follows  in  the  formation  of  the  new 
osseous  shell,  the  old  bone  serves  as  a mould 
for  Ihe  new  one,  and  the  first  stef)  of  the 
process  is  to  surround  the  old  bone  with  an 
effusion  of  coagulating  lymph.  (See  Russell 
on  Necrosis,  p.  2 — 7.) 

When  the  sequestrum  isthrow'n  off  slowly, 
the  inflammation  is  moderate  ; but  when  it 
separates  quickly,  while  the  new  bone  is  in  a 
soft  stale,  the  detachment  is  always  preceded 
by  severe  inflammatory  symptoms,  and  fol- 
lowed by  a temporary  loss  of  the  natural 
firmness  of  the  limb.  This  premature  sepa- 
ration of  the  sequestrum  often  occurs  in  ne- 
crosis of  the  lower  jaw,  and  the  chin  conse- 
quently falls  down  on  the  neck.  In  certain 
cases,  the  sequestrum  separates  at  each  end 
from  the  living  portions  of  the  old  bone, 
before  the  new  osseous  shell  has  acquired 
firmness,  so  that  the  limb  feels  as  if  it  were 
broken  in  two  places.  (Russell.) 

Let  us  next  consider  the  states  and  circum- 
stances of  necrosis,  in  which  the  art  of  sur- 
gery may  be  advantageously  exerted  in  the 
assistance  of  nature,  and  the  means  which 
may  be  employed  for  this  purpose. 


NECKUS1S. 


A common  error  of  medical  and  surgical 
practitioners  is  always  to  impute  the  cure  of 
every  disease  to  whatever  remedies  happen 
to  be  employed,  and  successes  are  loo  oiten 
boasted  of,  the  merit  of  which  belongs  en- 
tirely to  nature.  It  is,  indeed,  not  very  u»- 
frequent  to  hear  remedies  panegyrically 
spoken  of,  which  counteract  the  salutary 
efforts  of  nature,  who,  in  this  case,  is  obliged 
to  overcome  both  the  disease,  and  the  i> ra- 
tional treatment,  which  is  applied  to  it.  As 
Weidmann  observes,  this  erroneous  mode  of 
considering  things  has  happened  particularly 
often  among  surgeons  who  have  bad  cases 
of  necrosis  under  their  care,  all  of  whom 
boast  of  the  cures  which  they  have  accom- 
plished, although  some  employed  absorbent 
earths,  others,  aromatics ; some,  spirituous 
applications  ; others,  balmy  remedies  ; some, 
acids;  others,  caustics;  and  some,  armed 
with  a wimble,  made  numerous  perforations 
in  the  dead  bone  ; while  many  others  rasped 
the  part,  or  attacked  it  with  the  trepan,  cut- 
ting forceps,  the  gouge  and  mallet,  or  even 
the  actual  cautery  ; and  a certain  number 
did  nothing  more,  than  apply  dry  lint.  Na- 
ture, who  was  favourable  to  all,  did  her  ow  n 
work  in  silence,  whatever  were  the  remedies 
employed  for  her  assistance,  whether  mild 
and  inert ; acrid  and  corrosive  ; or  hurtful 
and  improper. 

We  have  already  noticed,  that  a dead 
portion  of  bone  separates  from  the  living 
exactly  in  the  same  way,  as  gangrenous  soil 
parts  spontaneously  drop  off,  without  the 
interference  of  art.  The  separation  happens 
precisely  at  the  points  to  which  death  has 
extended  ; limits,  w hich  are  w ell  understood 
only  by  nature,  and  of  course  can  be  mea- 
sured only  by  her.  Art  w ould  incur  great 
risk  of  either  going  beyond  them,  or  else  of 
not  reaching  them  at  all.  Perhaps,  it  may 
be  deemed  unsafe  to  confide  the  process  of 
separation,  or  exfoliation,  to  nature.  Bui, 
in  what  other  manner  could  it  be  more  safely 
accomplished,  without  hemorrhage,  or  pain 
to  the  patient — w'itbout  any  risk  of  a recur- 
rence of  inflammation,  or  of  a fresh  necrosis? 

Is  there  reason  to  fear,  that  when  every 
thing  is  left  to  nature,  the  separation  cannot 
be  finished  till  after  a very  long  period  of 
time  ? It  is  true,  say  Weidmann,  that  the 
process  frequently  requires  a considerable 
time ; but,  as  the  vitality  of  the  bones  is  not 
possessed  of  much  energy,  and  their  compo- 
nent parts  strongly  cohere,  slow  ness  is  in- 
evitable in  an  operation,  which  depends 
entirely  upon  the  vital  power.  What  is  it 
then  which  surgery  can  do  to  accelerate  the 
process  ? 

Will  any  of  the  above-mentioned  topical 
applications  have  this  effect  ? They  are  put 
upon  the  inert  surface  of  a dead  piece  of 
bone,  in  which  no  vital  power,  or  action, 
can  be  again  excited.  When  acrid,  they 
prove  irritating,  inflaming,  and  destructive  of 
the  neighbouring  flesh,  without  any  utility — 
and  cause  pain  to  the  patient,  which  is  com- 
pensated by  no  good.  Would  the  perfora- 
tions, recommended  by  Celsus,Belloste,  and 
many  others,,  have  the  desired  effect  ? If, 


says  Weidmann,  they  are  confined  to  the 
dead  hone,  they  cannot  have  more  effect, 
than  the  scarifications,  which  were  formerly 
practised  by  ignorant  surgeons  in  cases  of 
gangrene  ; and,  if  they  extend  to  the  living 
bone,  this  will  be  injured  or  at  least  run  the 
risk  of  being  so.  Lastly;  Weidmann  demands, 
if  the  separation  can  be  accelerated  by  the 
actual  cautery,  which  cannot  act  upon  every 
point  of  the  necrosis,  and  which,  unless 
applied  with  the  greatest  precautions,  will 
burn  the  subjacent  parts,  and  bring  on  a 
new  attack  of  inflammation,  without  for 
warding  the  exfoliation  in  the  smallest  de- 
gree ? 

Of  what  use  can  rasping  and  scraping  in 
struments  be,  which  act  merely  upon  the  ' 
dead  part  ? Or  will  the  gouge,  and  other 
cutting  instruments,  do  more  good?  They 
cannot  take  away  the  whole  of  the  dead 
portion,  w ithout  injuring  the  adjacent  living 
bone,  and  causing  a risk  of  another  necrosis . 
And,  if  they  leave  any  pieces  of  the  old 
dead  bone  behind,  nature  will  be  as  long  in 
effecting  the  separation  of  these,  as  she 
would  have  been  in  detaching  the  entire  ne- 
crosis. 

Weidmann  mentions  a case,  w hich  occur- 
red in  the  hospital  of  St.  Roch  at  Mentz.  A 
man’s  legs  were  seized  with  mortification,  in 
consequence  of  exposure  to  cold  ; the  whole 
of  the  dead  parts  separated  ; and  the  bones 
were  sawn  through  on  a level  with  the 
living  flesh.  A portion  of  the  end  of  each 
bone,  however,  was  afterward  thrown  oft 
altogether  by  nature,  and  Weidmann  thence 
concludes,  that  the  previous  use  of  the  saw- 
had  been  fruitless.  Weidmann  then  cites 
another  case  of  mortification  of  the  leg  and 
half  of  the  thigh,  which  was  the  conse- 
quence of  a putrid  fever.  The  leg  sloughed 
awray,  leaving  the  lower  portion  of  the  thigh 
bone  uncovered  and  projecting.  Under  a 
tonic  plan  of  treatment,  this  part  of  the 
bone  spontaneously  separated.  As,  however, 
a considerable  quantity  of  integuments  had 
been  destroyed,  the  ulcer  was  slow-  in  heal- 
ing ; but,  it  cicatrized  at  last,  and  the  young 
woman  continued  well  long  afterward. 

Weidmann  has  quoted  the  memorable  case, 
in  which  Mr.  Charles  White  first  sawed  oft' 
the  upper  part  of  a diseased  humerus.  (See 
Amputation.)  As,  in  this  instance,  nature 
accomplished  of  herself  the  separation  of 
another  dead  portion  of  the  same  bone,  two 
months  after  the  operation,  Weidmann  seems 
disposed  to  think  the  cure  would  have  hap- 
pened equally  wrell  without  it. 

In  cases  of  slight  superficial  necrosis,  sur- 
geons have  frequent  opportunities  of  trying- 
every  kind  of  topical  application  ; and  when 
the  cure  takes  place,  during  the  use  of  any 
of  them,  the  benefit  is  ascribed  to  whatever 
happens  to  be  in  use.  But,  says  Weidmann. 
in  numerous  more  serious  examples  of  ne- 
crosis, itis  impossible  to  make  these  applica- 
tions reach  the  whole  surface  of  the  dead 
bone;  but,  notwithstanding  this  circum- 
stance, the  separation  is  not  impeded.  Some 
exfoliations  happen,  without  our  knowing  of 
their  occurrence,  nnrl  without  a thought 


.NECROSIS 


2 75 


navingbeen  entertained  of  promoting  them 
by  any  vaunted  applications.  We  even  see 
necrosis  separate,  whose  situation  rendered 
them  inaccessible  to  our  remedies  ; such  are 
the  necrosis,  which  occur  within  the  long 
bones,  and  comprehend  the  whole  of  their 
cylindrical  shaft  or  body.  What  surgeon 
shall  presume  to  boast  of  his  having  etfected 
by  topical  applications,  the  separation  of  the 
whole  lower ja  w-b one  . atiiing,  w-iich  nature 
has  very  frequently  accomplished  ? And, 
when,  as  often  happens,  the  entire  diaphysis 
of  the  thigh-bone,  tibia,  or  other  long  bone, 
comes  a.  tv;  or,  split  longitudinally,  such 
bone  loses  \ half  of  its  cylinder  ; h -w  is  it 
possible  for  any  topical  applications  to  reach 
every  point,  at  which  the  separation  occurs  ? 

The  internal  remedies,  such  as  assafcetida, 
madder,  sarsaparilla,  hemlock,  belladonna, 
oaopordum,  lime-vvater,  &c.  recommended 
by  numerous  practitioners,  have  in  reality 
no  direct  efficacy  in  promoting  the  separa- 
tion of  necrosis  : if,  says  Weidmann,  they 
do  any  good,  it  can  only  be  by  their  tonic 
and  alterative  qualities,  or  rather  by  keep- 
ing the  patient  amused,  so  as  to  gain  the  re- 
quisite time  for  the  completion  of  the  pro- 
cess of  exfoliation.  The  employment  of  all 
these  ineffectual  means,  Weidmann  con- 
ceives, must  have  originated  from  ignorance 
of  the  process,  followed  by  nature  in  separa- 
ting dead  portions  of  bone,  and  from  ascri- 
bring  to  the  arterial  puisations  or  the  power 
of  the  granulations,  what  certainly  depends 
upon  the  action  of  the  absorbent  vessels. 

A < aestion  here  naturally  presents  itself. — 
Wou  J there  be  any  utility  in  exciting  by 
stimulants  the  action  of  the  lymphatic  ves- 
sels, in  order  to  accelerate  the  separation,  of 
which  it  is  the  efficient  cause  ? 

Weidmann  thinks,  that  very  beneficial 
effects  might  result  from  the  plan.  But,  he 
asks,  what  means  should  be  used  for  this  ob- 
ject ? Cold  ? Purgative  medicines  ? Repeat- 
ed vomits  ? Squills  ? Camphor  r Neutral 
Salts  ? Issues  ? (Fi’d.  Wrisberg,  Comment , Soc. 
Reg.  Gotl.  Vol.9,  p.  136,  1789.)  He  adds, 
that, perhaps,  many  valuable  discoveries  will 
hereafter  be  ma  le  on  this  subject. 

The  reasons  already  detailed,  and  a varie- 
ty of  experiments  successfully  made  by  Weid- 
mann,  lead  him  to  set  it  down  as  an  esta- 
blished principle,  that  the  separation  of  a 
necrosis  is  almost  entirely  the  work  of  nature, 
and  that  surgery  tan  do  very  little  in  the 
business. 

Ignorance  of  this  important  fact  paved 
the  way  to  the  wrong  practice  of  making 
incisions,  for  the  purpose  of  exposing  the 
whole  surface  of  a necrosis,  immediately 
the  existeuce  of  the  disorder  was  known. 
As  such  incisions  very  soon  closed  up  again, 
so  as  to  leave  only  a small  outlet  for  the 
matter,  they  were  in  many  cases  repeated- 
ly practised  before  the  dead  bone  became 
loose. 

The  avowed  design  of  the  incisions  was 
to  make  room  for  the  topical  remedies,  which 
w ere  to  render  the  exfoliation  quicker  ; but, 
as  these  remedies  possess  no  real  efficacy, 
it  follows,  that  making  incisions,  before  the 


dead  bone  is  loose,  only  torments  the  patient, 
without  producing  the  least  benefit. 

The  orifices  of  the  ulcers,  then,  which 
allow  the  discharge  to  escape  freely,  are, 
says  Weidmann,  sufficient  as  long  as  the  frag- 
ments of  bone  are  not  entirely  detached, 
and. the  surgeon  should  all  this  period  ab- 
stain from  the  use  of  the  knife. 

Although  Weidmann  condemnsevery  mode 
of  treatment,  which  is  inefficacious,  painful, 
and  sometimes  even  hurtful,  he  would  not 
hwe  it  supposed  that  he  altogether  rejects 
all  assistance  from  medicine.  On  the  con- 
trary, he  approves  of  all  those  means,  which 
are  consistent,  with- the  views  of  nature, 
which  ireally  assist  her.  and  do  not  tease  the 
patient  to  no  purpose.  In  short,  says  he,  the 
indications  are  limited  to  removing  the  origi- 
nal cause  of  the  disease  ; to  alleviating  the 
symptoms ; to  supporting  the  patient's  strength, 
and  improving  the  state  of  the  constitution , in 
whatever  respect  it  may  be  bad;  and , lastly, 
removing  the  dead  portions  of  bone,  when  they 
become  loose. 

Above  all  things  (continues  this  sensible 
practitioner)  the  surgeon  must  not  regard 
every  piece  of  exposed  bone,  as  necessarily 
affected  with  necrosis,  and,  in  consequence 
of  such  idea,  have  recourse  to  acrid,  dry- 
ing caustic  applications.  Such  means  are 
not  only  useless,  but  absolutely  pernicious; 
because  they  may  actually  cause  a necrosis, 
which  did  not  exist,  before  they  were  used, 
and  which  would  not  have  taken  place  at 
all,  if  only  mild  simple  dressings  had  been 
employed. 

VYT  . the  disease  presents  itself  with  vio- 
lent symptoms,  the  inflammation  and  fever 
being  intense,  the  severity  of  the  case  is  to 
be  assuaged  by  low  diet,  antiphlogistic  reme- 
dies, emollient  applications,  and  venesection 
in  moderation,  the  disease  being  one  which 
is  of  long  duration,  and  apt  to  wear  out  the 
patient’s  strength.  Here,  perhaps,  topical 
bleeding  ought  always  to  be  preferred  to 
venesection.  When  the  necrosis  has  arisen, 
from  syphilis,  scrophula,  or  scurvy,  &c.  the 
medicines,  calculated  for  the  cure  of  these 
affections,  must  be  exhibited,  ere  any  fa- 
vourable changes  can  be  expected  in  the 
state  of  the  diseased  bone. 

Lastly,  it  is  the  duty  of  the  practitioner  to 
extract  the  fragments  of  dead  bone,  in  order 
Ihat  the  deficiencies  produced  by  them  may 
be  filled  up,  and  the  ulcers  of  the  soft  parts 
heal. 

Nature,  who  succeeds  by  herself  in  detach- 
ing the  dead  pieces  of  bone,  can  do  very 
little  in  promoting  their  passage  outward. 
Frequently,  indeed,  she  has  no  power  at  all 
in  this  process,  and  it  is  only  from  surgery 
that  assistance  can  be  derived.  When  a 
dead  piece  of  bone  is  still  adherent  at  some 
points,  its  extraction  should  be  postponed, 
until  it  has  become  completely  loose.  If  it 
were  forcibly  pulled  away,  there  would  he 
danger  of  leaving  a part  of  it  behind,  which 
must  have  time  to  separate,  ere  the  cure  can 
be  accomplished. 

But,  when  a fragment  is  entirely  detached, 
and  the  orifices  of  the  sores  are  sufficiently 


NECROSIS 


276 


large,  it  is  to  be  taken  hold  of  with  a pair  of  adherent  to  the  adjacent  parts ; and,  if  they 
forceps,  and  extracted. 

When  the  ulcer  has  only  a very  narrow 
opening,  suitable  incisions  must  be  practised, 

• fv.  fsw.ilitatft  th«  removal  of  the  Toosf 


in  order  to  facilitate  the  removal  of  the  foose 
dead  bone. 

Sometimes,  the  dead  fragment  protrudes 
from  the  ulcer,  and  projects  externally,  so 
that,  if  loose,  it  admits  of  being  taken  hold 
of  with  the  fingers,  and  removed.  In  this 
way,  Weidmann  took  away  a large  dead 
piece  of  the  humerus,  which  protruded  near- 
ly two  inches  out  of  an  ulcer  in  the  middle 
of  the  arm.  The  patient  was  a young  lad, 
14  years  of  age  ; and  the  limb  concave 
within,  convex  externally,  thicker,  and  one 
inch  shorter  than  its  fellow.  He  got  quite 
well  three  weeks  after  the  removal  of  the 
dead  bone. 


delay  too  long,  the  patient  may  be  irreco- 
verably reduced,  while  the  new  bone,  on 
account  of  the  hardness  which  it  has 
now  acquired,  cannot  be  so  easily  perfora- 
tecf 

Patients  are  met  with,  who  have  been 
afflicted  with  necrosis  several  years.  In 
such  cases,  great  circumspection  is  necessa- 
ry, and  the  practitioner  should  carefully 
endeavour  to  ascertain,  that  the  dead  pieces 
of  bone  have  not  been  absorbed,  or  come 
away  piecemeal  in  the  discharge,  lest  an 
useless  operation  should  be  done,  as  once 
happened  in  the  practice  of  M.  Bousselin. 
(M6m.  de  la  Sucirte  Royale  de  Mddecine,  T.  4, 
/>.304.)  Therefore,  when  the  disease  is  of 
long  continuance  ; when  the  discharge  is 
much  less  than  it  v\  as  at  the  commencement ; 


We  have  already  adverted  to  the  example,  when  small  pieces  of  bone  have  at  times 
recorded  by  Weidmann,  in  which  a shoe-  been  voided  ; and  the  sequestrum  cannot 
maker  removed  by  himself  nearly  the  whole  be  felt  with  a probe;  it  is  doubtless,  says 
body  of  the  tibia. " Doubtless,  the  projection  Weidmann,  most  prudent  to  abandon  all  idea 
of  the  bone,  and  its  looseness,  enabled  the  of  operating,  and  allow  nature  to  finish  what 


man  to  do  this  easily  with  his  fingers.  But, 
there  are  cases,  which  present  more  difficulty ; 
such  arc  those,  in  which  the  sequestrum  is 
included  in  a cavity,  either  of  the  original, 
or  new  bone. 


she  has  so  well  begun.  In  short,  when  the 
sequestra  are  undergoing  a gradual  absorp- 
tion, without  ever  making  their  appearance 
externally,  or  giving  any  considerable  dis- 
turbance to  the  constitution,  or,  w hen  the 


The  old  surgeons  were  in  the  habit  of  am-  dead  bone  is  making  its  way  outward,  with 
putating  limbs  which  were  in  this  state;  out  occasioning  urgent  inconveniences  ; the 
although  instances  were  not  wanting  in  their  surgeon  should  interfere  very  little  with  the 
days  to  prove  the  possibility  of  relieving  the  natural  progress  of  the  case.  When  the 
disease,  w ithout  amputation.  Thisbiamable  dead  bone  does  not  tend  to  make  its  way 
custom  of  removing  every  limb,  thus  affect-  through  the  skin,  but  lies  quietly  concealed 
ed,  is  justly  exploded  from  modern  surgery,  in  the  new  osseous  shell,  the  occurrence  of 
Aibucasis  was  the  first  who  attempted  to  extensive  suppurations  may  be  prevented, 


cure  such  a case  of  necrosis,  by  the  judicious 
employment  of  the  knife  and  saw.  (Lib.  2, 
cap.  88.)  The  same  kind  of  practice  wms 
successfully  adopted  in  iwo  instances  by  the 
celebrated  Scultetus.  vSee  Armament  Chi- 
rurg.  Tab.  46,  and  Obs.  81.)  This  commen- 
dable method,  however,  afterward  fell  into 
disuse,  until  M.  David,  by  twenty  examples  of 
success,  refuted  all  the  objections  which  had 
been  urged  against  it.  (P.  197.)  Since  the 


by  occasionally  applying  leeches,  and  keep 
iug  open  a blister  w iih  the  savine  cerate,  as 
recommended  by  Mr.  Abernethy  in  his  lec- 
tures, and  Mr.  Crowther,  in  his  work  on  the 
White-Swelling.  The  blister  will,  at  the 
same  time,  have  great  effect  in  promoting 
the  absorption  of  the  sequestrum,  and, 
of  course,  in  accelerating  the  process  of 
cure. 

If  the  surgeon  operate  as  soon  as  the  se- 
period  of  this  distinguished  author,  the  prac-  questrum  becomes  loose,  he  will  find  the 
tiee  has  been  imitated  by  all  enlightened  new  bone  so  soft,  that  it  can  be  divided  with 
surgeons,  so  that  the  case  is  no  longer  re-  a knife  ; a circumstance,  which  materially 
warded  as  a disease  necessarily  requiring  facilitates  and  shortens  the  operation, 
amputation.  M.  Bousselin  has  cut  out  the  Keeping  in  mind  the  foregoing  precepts, 
sequestrum  eight  times  from  the  tibia,  and  the  surgeon  is  to  begin  with  exposing  the 
four  times  from  the  thigh-bone,  with  per-  bone  in  which  the  sequestrum  is  contained, 
feet  success.  ( Rid  J\I6m.  de  la  Society  Royale 
de  M6decine,  Tom,.  4.) 

The  method  consists  in  exposing  the  bone, 
and  making  in  it  an  opening  of  sufficient 
size  for  the  removal  of  the  loose  dead  frag- 
ments. 

Experience  has  proved,  not  only  that, 


When  the  bone  lies  immediately  under  the 
skin,  Weidmann  recommends  making  such 
incisions  as  will  lay  bare  the  whole  of  its 
surface,  and  when  its  situation  is  deeper 
beneath  the  muscles,  he  even  sanctions  cut- 
ting away  as  much  of  the  flesh  as  may  be 
necessary  to  allow  the  instruments  to  be 


patients  affected  with  necroses,  easily  bear  freely  worked  upon  the  bone.  I cannot, 


this  operation,  but  also  that  after  its  perform- 
ance, the  ulcers  commonly  heal  very 
favourably,  the  health  becomes  re  establish- 
ed, and  the  functions  of  the  part  affected  are 
hardly  at  all  impaired. 

Surgeons,  however,  are  not  indiscriminately 
to  choose  any  period  for  doing  the  operation. 
If  they  are  too  hasty,  they  will  run  a risk 
of  finding  the  dead  portion  of  bone  still 


however,  see  the  propriety  of  this  advice  ; 
exposing  the  wdiole  surface  of  the  bone  in 
the  first  instance,  before  it  is  known  whether 
the  saw  need  be  so  extensively  used  as  to 
require  such  a denudation,  certainly  appears 
irrational.  And,  as  for  cutting  away  any 
portions  of  muscle,  this  can  be  no  more  ne- 
cessary here,  than  it  is  in  the  operation  of 
trephining.  But  it  is  unquestionably  proper 


Necrosis. 


to  make  with  the  bistoury  sufficient  space 
for  the  use  of  whatever  instrument  is  em- 
ployed for  the  division  of  the  bone.  Yet  it 
is  only  necessary  to  make  this  exposure  in 
the  first  instance  in  one  place.  The  surgeon 
can  afterward  enlarge  the  incision  or  prac- 
tise others,  as  circumstances  may  indicate. 
The  surface  of  the  bone  being  brought  into 
view,  if  the  cavities,  in  which  the  dead  frag- 
ments lodge,  present  apertures  which  are  too 
nariow,  these  apertures  must  be  rendered 
larger  by  means  of  small  trephines,  or  saws 
constructed  on  the  principles  of  those  des- 
cribed by  Mr.  Hey  of  Leeds.  The  perpen- 
dicularly acting  wheel-like  saw,  turned  by 
machinery,  and  invented  by  Mr.  Machell, 
here  promises  also  to  be  of  important  assist- 
ance. It  has  been  used  by  Sir  Astley  Coo- 
per, who  has  given  an  engraving  of  it  in  bis 
Surgical  Essays.  Part  I.  PI.  8.  Fig.  7.  And 
another  saw,  constructed  on  somewhat  si- 
milar principles,  has  been  employed  by 
Graefe  of  Berlin  with  great  advantage  for 
several  years.  A tract,  giving  an  account 
of  it,  was  sent  to  me  by  the  late  Dr.  Albers, 
a little  before  his  death  ; but  as  I have  now 
lent  the  publication  to  Mr.  Stanley  for  the 
purpose  of  assisting  Mr.  Evans  in  the  con- 
struction of  the  instrument,  I shall  merely 
add,  that  Graefe’s  saw  is  turned  by  a handle 
which  projects  horizontally  from  the  cutting 
part  of  the  instrument  and  that  it  has  a 
frame  or  fulcrum,  on  which  it  works  With 
such  instruments  the  pieces  of  bone  extend- 
ing across  the  above  openings,  and  imped- 
ing the  extraction  of  the  sequestra,  may  also 
be  removed. 

But  when  the  preceding  cavities  are  closed 
on  every  side,  and  it  is  impossible  to  reach 
into  them  in  any  other  way,  than  through 
the  cloacae,  a trephine  is  to  be  applied, 
which  must  comprise  within  its  circle  a half 
of  the  fistulous  opening.  The  crown  of  the 
trephine,  however,  must  not  be  broader  than 
the  cavity  of  the  bone,  nor  yet  narrower 
than  the  sequestrum. 

If,  after  making  a perforation  in  this  man- 
ner, the  sequestrum  should  be  found  too 
large  to  pass  through  the  opening,  a small 
saw  must  be  employed  for  enlarging  the 
aperture,  * * 

When  the  bone  is  so  hard  and  thick  that 
it  cannot  be  well  cut  with  a saw,  the  sur- 
geon has  the  sanction  of  authority  and  ex-./ 
perience,  for  using  a gouge  and  mallet. 

When  the  sequestrum  is  found  to  be  very 
large,  it  will  be  necessary  to  expose  more 
of  the  surface  of  the  bone  by  incisions.  In 
this  sort  of  case,  Weidraann  recommends 
applyingthe  trephine  to  the  upper  and  lower 
parts  of  the  cavity,  and  then  cutting  away 
the  intervening  portion  of  bone  with  the 
saw  or  gouge.  But  there  can  be  no  doubt 
that  a more  prudent  way  would  be  to  goon 
with  the  enlargement  of  the  aperture  in  the 
bone,  at  the  place  where  the  first  perforation 
took  place,  if  the  sequestrum  presented  it- 
self equally  well  there,  because,  by  pro- 
ceeding in  this  manner,  the  surgeon  might 
discover  that  the  dead  fragment  could  be 
taken  out  without  so  great  a destruction  of 


bone  as  is  caused  in  the  other  mode  ; and, 
if  this  were  not  to  be  the  case,  no  harm  is 
done,  as  the  necessary  removal  of  bone  can 
be  continued. 

When  the  bone,  which  includes  the  se- 
questrum, is  a new  production,  and  the  ope- 
ration is  not  too  long  deferred,  the  soft  state 
of  the  bone  will  enable  the  operator  to 
perform  the  needful  excisions  with  the 
bistoury  alone. 

When  the  sides  of  the  cavity,  in  the  ori- 
ginal bone,  are  thin,  fragile,  and  pierced 
with  numerous  holes,  the  surgeon  can  break 
away  a sufficient  portion  with  a pair  of  for- 
ceps. 

When  several  sinuses  exist  in  the  bone, 
each  may  be  dilated,  in  the  manner  which 
seems  most  advantageous. 

Sufficient  openings  having  been  made  into 
the  cavities  including  the  sequestra,  the 
next  object  is  to  extract  these  dead  portions 
of  bone.  In  accomplishing  this  part  of 
the  operation,  Weidmann  particularly  ad- 
vises two  things;  first,  that  no  piece  of  the 
sequestrum  be  left  behind;  secondly,  that 
no  injury  be  done  to  the  membrane,  which 
lines  the  cavity  in  which  the  dead  bone  is 
lodged. 

This  author  observes,  that  there  are  ex- 
amples, in  which  the  vicinity  of  certain 
parts  impedes  the  surgeon  from  making  an 
opening  in  the  bone,  large  enough  for  the 
extraction  of  a voluminous  sequestrum  in 
an  entire  state.  In  this  circumstance,  he 
recommends  the  sequestrum  to  be  broken 
into  pieces  by  any  convenient  means,  and 
the  fragments  to  be  separately  removed. 

Weidmann  has  recorded  an  extremely  in- 
teresting case  to  prove  how  much  may 
sometimes  be  effected  by  taking  away  the 
sequestrum.  A man,  34  years  of  age,  who 
had  an  internal  necrosis  of  the  tibia,  with 
abscesses  and  cedema  of  the  whole  limb, 
and  who  Was  reduced  to  the  lowest  ebb  of 
weakness,  was  put  under  this  excellent  sur- 
geon’s care.  A perforation  was  made  with 
a trephine  in  the  upper  head  of  the  tibia  ; 
but,  this  opening  not  proving  ample  enough, 
it  was  enlarged  with  a small  saw',  and  a 
gouge  and  mallet.  The  sequestrum  was 
then  extracted.  The  patient’s  state  after- 
ward gradually'  improved,  and  in  nine 
months  he  was  completely  well. 

It  is  not  to  be  dissembled,  however,  that 
cases  do  exist,  in  which  amputation  affords 
the  only  chanco  of  saving  the  patient’s  life. 
In  fact,  it  sometimes  happens,  that  the  cavi- 
ties, in  which  the  sequestra  are  contained, 
communicate  with  those  of  the  neighbour- 
ing joints,  which  then  become  filled  with 
matter,  and  caries  attacks  part  of  the  bones, 
to  which  the  necrosis  does  not  extend.  On 
some  occasions,  the  dead  pieces  of  bone 
are  very  numerous,  and  each  has  a sepa- 
rate cavity  ; while,  in  other  instances,  me 
sequestra  lie  so  deeply,  that  a passage  for 
their  extraction  cannot  be  prudently  at- 
tempted. Sometimes,  also,  a necrosis  is 
complicated  w ith  another  disease  in  its  vi- 
cinity. Lastly,  such  may  be  the  reduced 
state  of  the  patient’s  health,  and  the  parti* 


NKCKGSIS. 


::s 


cular  condition  of  the  necrosis  itself,  that 
the  constitution  cannot  hold  out  during  the 
whole  time  which  would  be  requisite  for 
the  detachment  of  the  sequestrum.  Under 
circumstances  like  these,  amputation  is  ne- 
cessary, and  ought  not  to  be  delayed. 

For  the  authorities  of  many  of  the  obser- 
vationsand  cases  in  the foregoingarticle,  and 
for  additional  information  on  the  subject,  see 
Albu  casts,  lib.  2,  cap.  88.  Scultelus , .firma- 
ment. Chir.  Tab.  46,  and  Obs.  81.  Belloste , 
Le  Chirurgien  d' Hdpital,  part  1,  chap  12.  J. 
Louis  Petit , Traite  des  Mi  ladies  des  Os, 
Tom.  2,  chap.  16.  Monro's  Works  by  his 
Son.  Tenon  in  M6m.  de  l' Acad,  des  Sciences, 
1758.  Aitken,  Systematic  Elements  of  the 
Theory  and  Practice  of  Surgery,  Edinb. 
1779,  p.  288.  Some  interesting  cases  and  re- 
marks, chiefly  about  the  question  of  amputa- 
tion, are  contained  in  Schmucker's  Vermischte 
Chir.  Schriften.  B.  1,  p.  17,  \c.  Ed.  2.  Cal- 
lisen,  Sy  sterna  Chirurgice  Hodiernce,  Vol.  2, 
p.  893,  Gott.  1800.  C.  White,  Cases  in  Sur- 
gery,  London,  1770,  p 57,  fyc.  Wrisberg, 
Comment.  Soc  Reg.  Gott.  Vol.  9,  p.  136,  fyc. 
Boussclin,  in  Mem  de  la  Society  Royale  de 
Medecine,  Tom.  4.  Louis,  in  Mem.  de  l' Acad, 
de  Chirurgie,  Tom.  5.  Chopart,  Dissert,  de 
Necrosi  Ossium,  Paris,  1776.  David,  Obs 
sur  une  Maladie  connue  sous  le  nom  de  JYd- 
crose,  Paris,  1782.  Poll's  Chirurgical  Works, 
Land.  1779,  Vol.  1 ,p.  32.  Bloomfield's  Chir. 
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Kortum,  Comment,  de  Viiio  Scrofuloso.  Lem- 
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S.G.Rcederer  Progr.  de  Ossium  Vitiis  Observa- 
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Morbos  Bond,  Med.  Septentr.  L.  2,  Sect.  4. 
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des  Maladies  des  Os,  p.  457,  Pans,  1751. 
Phil.  Trans.  No.  312.  Wedel,  in  Ephem. 
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310.  Dumcrbroeck,  vid.  Wolfli  Obs.  Chir. 
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Trans,  abridged,  Vol.  9,  p.  252.  Fabricius 
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Med.  Obs.  and  Inquiries,  Vol.  2,  p\  299. 
Ludwig  Advers  Med.  Prncl.  Vol.  3 p 60. 
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Slalpart  Van  der  Wielin  Cent.  1,  Obs  96. 
Muralto,  in  Schriften  von  der  Wundarzn. 
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maximis,  ob  morbos.  deperdilionibus,  Regent- 
ratione , Experimenta.  Lutetice  Parisiorum, 
1775.  Troja' s Work,  though  drawn  up  in 

an  incorrect  style,  as  Weidmann  remarks,  con- 
tains many  highly  interesting  experiments. 
Blumenb  tch,  in  A.  G.  Richter's  Bibiiothek, 
T.  4.  p.  107.  Desault's  Parisian  Chirurg. 
Journal.  Vol  1,  p.  100,  and  Vol.  2,  p.  199. 
Koehler , Experimenta  circa  Regeneralionem 
Ossium , Gott.  1786.  This  is  a valuable  work , 
and  contains  the  original  discovery  of  the  re- 
production of  medullary  structure.  I.  V. 
Weidmann  De  Necrosi  Ossium  Fol.  Franco- 
furti  ad  Moenum  1793  ; el  de  Necrosi  Os- 
sium adnotatio  ; Frank.  Del.  4.  This  publican 
tiori  is,  perhaps,  the  best  general  account  of  the 
whole  subject  of  necrosis.  It  is  not  only  en- 
riched with  the  observations  of  numerous  other 
writers  on  the  disease,  but  contains  the  most 
approved  theories  and  opinions  respecting  many 
other  affections  of  the  bones,  Caries,  Exfolia- 
tions tyc.  It  was  a great  assistance  to  me  in 
the  composition  of  the  foregoing  article.  Con- 
sult also  Richerand  Nosogr.  Chir.  T.  3.  p. 
153,  tyc.  Ed.  4,  Paris,  1815.  Dr.  Alex. 
tM‘ Donald’s  Thesis  de  Necrosi  ac  Callo, 
• Edinb.  1799.  Hutchison's  Pract.  Obs.  in 
Surgery,  p.  180,  §-c.  London,  1816  James 
; Russell's  Practical  Essay  on  a certain  Disease 
of  the  Bones , termed  Necrosis,  1794.  Whale - 

ly's  Pract.  Obs.  oti  Necrosis  of  the  Tibia, 
1815.  Macartney,  in  Crowther's  Obs.  on 
While-Swelling,  \~c.  Edit,  2.  Encyclopedic 
Mithodique,  Parlie  Chir.  art.  Necrose.  Le - 
viilii  Nouvelle  Doctrine  Chir.  T.  4,  p.  321, 
fyc.  Paris,  1812.  Larrey’s  Mam.  de  Chirur- 
gie Miiitaire,  T.  3,  p.  367,  fyc.  Thomson's 
Lectures  on  Inflammation,  p.  39  <Vc.  Edinb. 
1813.  Boyer  s Traite  des  Maladies  Chirur- 
gicales, T.3  p 418,  Paris,  1814.  Del- 
pcch , Precis  Elemenlaire  des  Mai.  Chir.  T I, 
Chap.  3 ; Paris,  1816.  Some  account  of  an 
operation  in  wnioij  !Yf.  Oupuytren,.  of  Paris. 


NITRIC  AND  NITROUS  ACID; 


'9 


removed  the  mental  portion  of  the  lower 
jaw,  may  be  found  in  the  London  Medical 
Repository , Vol.  3,  p.  432.  The  wound  heal- 
ed by  the  first  intention,  and  the  patient 
recovered. 

^NEEDLE.  See  Appendix. 

NEPHROTOMY,  (from  ve^os,  a kidney; 
and  T«,uy®,  to  cut.)  The  operation  ot  cut- 
ting a stone  out  of  the  kidney  ; a proceeding 
which,  perhaps,  has  never  been  actually  put 
in  practice.  In  the  Mr6gi  Chronologique 
de  V Historic  de  France,  par  M6zerai,  and  in 
the  Phil.  Trans,  for  1696,  two  cases  of  what 
is  called  nephrotomy  are  mentioned  ; but 
several  circumstances  in  the  accounts  led 
Haller  and  others  to  conclude,  that  the 
operation  alluded  to  in  the  first  work  was 
nothing  more  than  the  high  operation  for 
the  stone.  With  respect  to  the  example  in 
the  latter  work,  the  particulars  are  not  de- 
tailed enough  to  prove  that  an  incision  w7as 
really  made  into  the  kidney.  There  is  no 
doubt  that  stones  have  often  been  extracted 
from  abscesses  about  the  region  of  the  kid- 
ney, after  being  touched  with  a probe.  But, 
with  regard  to  cutting  into  the  kidney,  the 
deep  situation  of  this  viscous,  and  the  want 
of  symptoms  by  which  the  lodgment  of  a 
stone  in  it  can  be  certainly  discovered,  will 
always  be  strong  objections  to  the  practice. 
When  a stone,  from  its  size,  cannot  pass 
from  the  kidney,  and  excites  inflammation 
and  suppuration,  no  doubt  the  surgeon  may 
make  an  incisiou  into  the  tumour,  and  ex- 
tract the  calculus.  In  this  sense,  nephroto- 
my is  certainly  a practicable  operation. 
Warner  contends  that  it  can  only  be  prac- 
tised in  such  circumstances,  notwithstanding 
whatever  may  have  been  said  by  Marchetti 
or  others,  upon  the  subject.  In  such  a case, 
the  operation  would  not  be  attended  with 
any  greater  difficulty  than  the  opening  an 
abscess  in  any  other  part  of  the  body.  (See 
Warner's  Cases  in  Surgery,  p.  241,  Edit.  4.) 

NITRIC  and  NITROUS  ACIDS.  As 
these  are  medicines  of  considerable  import- 
ance in  surgery,  they  claim  particular  no- 
tice. Nitrous  acid  is  a yellow,  or  orange- 
coloured  fluid,  emitting  when  exposed  to  the 
air,  deep  orange-coloured  extremely  suffo- 
cating fumes.  It  consists  of  nitrous  gas, 
loosely  combined  with  nitric  acid  and  wa- 
ter ; and  the  colour  varies  according  to  the 
proportion  of  nitrous  gas  which  is  present. 

Nitric  acid  is  a colourless,  or  very  pale 
yellow,  limpid  fluid,  emitting  when  exposed 
to  the  air,  white  suffocating  vapours.  It  is 
highly  corrosive,  and  tinges  the  skin  yellow, 
the  tint  remaining  till  the  epidermis  peels 
off.  The  constituents  of  nitric  acid,  inde- 
pendent of  the  w7ater,  which  gives  it  the  fluid 
form,  are  25.97  azote,  and  74.03  oxygen,  in 
100  parts.  (See  Thomson's  Dispensatory,  p. 
433,  439,  Ed.  2.) 

Both  these  acids,  in  a diluted  state,  have 
been  extensively  tried,  as  a substitute  for 
quicksilver  in  the  cure  of  lues  venerea  ; and 
really  upon  looking  over  the  mass  of  evi- 
dence brought  forward  in  proof  of  the  pow- 
er which  they  seem  to  possess  over  this  dis- 
ease, it  is  at  first  difficult  to  entertain  the 


slightest  doubt  of  their  efiicacy.  The  cases 
adduced  are  numerous,  some  of  them  mi- 
nutely detailed,  the  gentlemen  who  have 
published  them,  men  of  reputation  and  abi- 
lities, and  (w  hat  especially  claims  attention) 
these  examples  of  successful  treatment  are 
generally  allowed  to  have  been  syphilitic, 
or,  at  all  events,  complaints,  the  differences 
of  which  from  the  venereal  disease  have 
not  been,  and  could  not  be, specified.  Who- 
ever impartially  considers  the  immense  body 
of  facts  published  by  Dr.  Kollo,  Mr.  Cruick- 
shank,  Dr.  Beddoes.  Dr.  P.  G.  Prioleau,  of 
Charleston,  South  Carolina,  and  others,  ex- 
emplifying the  success  witn  which  the  ve- 
nereal disease  may  be  treated  by  the  nitrous 
or  nitric  acid,  must  be  surprised  to  find,  that 
the  accounts  delivered  by  these  gentlemen 
by  no  means  correspond  to  those  of  some 
other  eminent  practitioners.  How7  to  re- 
concile these  seemingly  discordant  state- 
ments, whether  by  supposing  some  undefined 
differences  in  the  nature  of  the  cases  addu- 
ced, or  some  variation  in  the  goodness  of 
the  medicine  itself,  is  indeed  perplexing. 
Nor  is  a solution  of  the  question  at  all  faci- 
litated, by  the  results  of  later  investigations 
tending  to  prove  the  general  curability  c 
syphilis  without  mercury,  or  any  medicine 
whatever;  because,  if  we  admit  this  as  a 
fact,  the  circumstance  of  a considerable 
proportion  of  cases  not  yielding,  or  bein<r 
radically  cured,  when  the  nitric  and  nitrous 
acids  are  exhibited,  as  asserted  by  Mr 
Pearson  and  others,  wrould  argue,  that  giv- 
ing such  acids  is  worse  than  leaving  the 
disease  entirely  to  itself.  The  more  I reflect 
upon  all  that  we  know  about  the  venereal 
disease,  however,  the  more  I am  inclined  to 
adopt  the  sentiment,  that  it  is  not  one  dis- 
order, but  probably  many,  w7hich  go  under 
this  name,  their  exact  shades  of  difference 
not  having  yet  been  detected  nor  described. 
If  this  supposition  be  admissible,  the  con- 
tradictory statements,  given  by  various  au 
tbors  about  what  their  experience  has  taught 
them  of  this  or  that  mode  of  treating  the 
, disease,  may  all  be  immediately  reconciled 
The  practice  of  exhibiting  nitric  acid,  in 
lieu  of  quicksilver,  began  with  Mr.  Wm 
Scott,  a surgeon  at  Bombay,  who  is  said  to 
have  been  led  to  the  experiment  by  a sug- 
gestion thrown  out  by  Girtanner,  that  the 
efficacy  of  the  various  preparations  of  quick- 
silver probably  depended  upon  the  quantity 
of  oxygen  combined  with  them.  (Grens 
Journ.  d.  Physick.  B.  S,p.  31, 1790.)  In  Au- 
gust, 1793,  Mr.  Scott  being  himself  afflicted 
with  chronic  hepatitis,  resolved  to  take  a. 
quantity  of  oxygen,  united  to  some  sub- 
stance, for  which  it  has  no  great  attraction 
and  after  some  reflection,  nothing  appeared 
to  him  belter  than  nitric  acid.  September 
11th,  he  took  at  different  times  about  a dram 
of  the  strong  nitric  acid  diluted  wrnter.  Soon 
after  drinking  it,  he  felt  a sense  of  w armth 
in  his  stomach  and  chest ; but  no  disagree- 
able sensation,  nor  any  other  material  effect. 
The  two  following  days  the  medicine  was 
continued,  the  gums  beginning  to  be  some- 
w'hat  red,  and  enlarged  He  slept  ill ; but 


NITRIC  AND  NITROUS  ACIDS 


280 


could  lie  for  a length  of  time  on  his  left 
side,  which  the  disease  of  the  liver  had  pre- 
vented him  from  doing  during  many  months 
previous  to  this  period.  He  also  felt  a pain 
in  the  back  of  his  head,  resembling  what  he 
had  commonly  experienced,  when  taking 
mercury  On  the  fourth  day,  his  gums  were 
a little  tender ; the  headach  and  pain  about 
his  jaws  still  troubled  him:  but  the  symp- 
toms of  his  liver  complaint  had  already  left 
him.  The  acid  wras  continued  on  the  4th, 
5th,  and  6th  days ; the  soreness  of  the 
mouth  increasing,  and  a salivation  taking 
place.  On  the  7th  day,  he  felt  his  mouth 
so  troublesome,  that  he  took  no  more  acid. 
His  mouth  got  gradually  well,  and  he  found 
his  health  considerably  improved. 

Mr.'  Scott  likewise  administered  the  nitric 
acid  in  several  cases  of  tedious  intermit- 
tents,  in  two  cases  of  diabetes,  and  in  many 
syphilitic  cases,  with  the  happiest  effect. 

This  gentleman's  account  of  the  nitrous 
acid  was  first  published  in  the  Bombay  Cou- 
rier of  April  30th,  1796,  and  soon  afterward 
republished  in  this  country.  (See  “ An  Ac- 
count of  the  Effects  of  the  Nitrous  Acid,  on  the 
Homan  Body,"  by  JV.  Scott,  in  Duncan's  An- 
nals of  Medicine  for  1796,  Vol.  1,  p.  375 — 
383.)  The  hypothesis  suggested  by  Girtan- 
ner,  in  1790,  that  the  efficacy  of  mercury  in 
the  treatment  of  the  venereal  disease  de- 
pended upon  the  oxygen  combined  with 
this  mineral,  required  but  little  extension  to 
lead  to  the  discovery  of  the  antisyphilitic 
virtues  of  the  acids.  Yet  Girtanner  had  all 
his  attention  so  fixed  on  mercury,  that  it 
never  struck  him,  that  the  principle  on 
which  he  explained  the  efficacy  of  this  me- 
dicine, might  apply  to  other  substances, 
which  abound  with  oxygen,  and  are  readily 
separable  from  it.  This  was  the  idea,  which 
made  Mr.  Wm.  Scott  begin  to  suspect,  that 
the  nitric  acid  might  be  as  efficacious  as 
mercury  in  venereal  cases  ; and  as  he  had 
already  observed  a great  analogy  between 
the  effects  of  this  acid  and  mercury  in  the 
experiments  which  he  made  with  the  first 
of  these  medicines  in  his  own  case  of  chro- 
nic hepatitis,  and  other  diseases,  he  ventured 
to  recommend  the  trial  of  it  in  syphilis. 
The  result  was,  that  the  acid  was  found  not 
only  to  equal  the  preparations  of  mercury, 
but  sometimes  to  surpass  them  ; for  it  had 
the  best  effect  in  some  cases  where  mercu- 
ry had  been  tried  in  vain,  and  it  was  observ- 
ed to  remove  the  disease  in  less  time  than 
the  common  remedy.  Nor  were  any  of  the 
inconveniences,  usually  known  under  the 
names  of  mercurial  symptoms,  mercurial  fe- 
ver, found  to  be  the  consequence  of  its  em- 
ployment, however  long  continued.  With 
it  alone  many  syphilitic  cases  are  stated  to 
have  been  cured,  the  disease  not  having  re- 
turned at  the  end  of  two  years.  (See  Dun- 
can's Annals  of  Medicine,  fyc.  Vol.  1,  1796,  p. 
383,  fyc.) 

The  letter  from  Mr.  Scott  to  Sir  Joseph 
Banks,  describing  these  effects  of  the  nitric 
acid  in  India,  soon  excited  the  attention  of 
medical  practitioners  both  in  Europe  and 
America*  the  inquiry  being  taken  up  with 


all  the  zeal  which  the  preceding  accounts 
were  calculated  to  inspire.  In  1797,  Mr 
G.  Kellie,  a surgeon  of  the  navy,  gave  the 
nitric  acid  to  five  sailors  affected  with  go- 
norrhoea, venereal  sores,  and  buboes.  Three 
of  them  were  perfectly  cured.  A fourth, 
who  had  sores  on  the  glans,  and  who  had 
been  much  debilitated  by  the  long  use  of 
mercury,  recovered  nearly  his  original 
strength,  while  taking  the  acid  ; but  the 
sores  were  not  healed,  before  mercury  had 
been  repeatedly  exhibited.  In  the  fifth  pa- 
tient, who  was  aho  scrofulous,  ibe  nitric 
acid  contributed  very  essentially  to  heal  the 
sores.  On  the  whole,  Mr.  Kellie  seems  to 
regard  this  medicine  as  possessing  very 
efficient  power  of  stopping  and  eradicating 
the  venereal  disease.  (See  Letters  from  G. 
Kellie,  respecting  the  Effects  of  Nitrous  Acid 
in  the  Cure  of  Syphilis. ' Duncan's  Annals  of 
Medicine  for  1797 ,p.  254,  277.) 

In  the  same  year  appeared  a letter,  in  a 
German  periodical  w ork  ( Hufeland's  Jonrn. 
der  Prakt.  Heilk.  4 Bd.  p.  356—359.,)  writ- 
ten by  Albers,  giving  the  history  ot  a vene- 
real ulcer  on  the  breast,  successfully  treat- 
ed by  the  nitric  acid. 

The  reports  of  Dr.  Prioleau,  who  tried 
the  nitric  acid  in  the  autumn  of  1797,  are 
particularly  favourable  to  the  practice. 
“We  have  seen  (says  he)  every  stage  and 
form  of  syphilis  cured  by  this  medicine,  and 
even  in  habits  broken  down  by  the  antece- 
dent use  of  mercury,  under  which  the  dis- 
order had  gained  ground.  The  patients  re- 
covered their  health  and  strength  in  a short 
time,  without  the  use  of  diet-drinks,  bark, 
or  any  other  tonic  medicine  whatever.” 
See  Caldwell's  Medical  Theses,  p.  103,  8 vo 
Philadelphia,  1805.) 

The  praise  of  the  nitric  acid  from  nume- 
rous quarters  induced  Dr.  Rollo  to  try  it  in 
the  military  hospital  at  Woolwich,  and  in 
conjunction  with  Mr.  Cruikshank  to  examine 
further  into  the  antisyphilitic  virtues  of  oxy- 
genated substances.  The  results  of  Mr. 
Cruikshank’s  investigations  constitute  the 
second  part  of  Rollo’s  work  on  diabetes, 
published  in  1797  The  medicines  which 
were  selected  for  the  experiments,  were  the 
nitric,  citric,  and  muriatic  acids,  and  oxyge- 
nated muriate  of  potash.  Of  these,  the  nitric 
acid  and  the  oxygenated  muriate  of  potash 
were  found  to  possess  the  greatest  efficacy; 
the  first  acting  in  many  cases  with  remark- 
able mildness;  the  second,  with  greater  ex- 
pedition and  certainty.  The  new  plan  was 
tried  upon  young  persons,  affected  with  pri- 
mary venereal  complaints,  who  had  never 
used  mercury,  and  no  other  internal  medi- 
cine was  given,  except  opium,  when  requi- 
red for  diarrhoea,  or  colic.  The  liquor  plumbi 
acetatis  dilutus  was  used  as  a wash  for  chan- 
cres. In  debilitated  subjects,  sure  and  spee 
dy  good  effects  were  observed  uniformly  to 
follow,  and  hence,  previously  to  giving  the 
acid  to  strong,  plethoric  patients,  the  me 
thod  of  preparing  them  for  this  treatment 
by  purging  and  bleeding  was  adopted,  as  is 
alleged,  with  great  success.  In  some  cases, 
after  the  nitric  acid  had  been  continued,  a 


NITRIC  AND  NITROUS  ACIDS. 


281 


good  while  without  producing  a salivation, 
the  exhibition  of  mercury  for  a short  time 
completed  the  cure.  Mr.  Cruikshank’s  opi- 
nion in  favour  of  the  new  remedies  was  on 
the  whole  extremely  sanguine,  as  he  ven- 
tures to  express  his  conviction,  that  they 
would  render  the  employment  of  mefcury 
in  the  cure  of  the  venereal  disease  un- 
necessary. (See  An  Account  of  two  Cases 
of  Diabetes  Mellilus , with  Remarks  fyc.,  by 
John  Hollo , M.  D.  Vol.  2,  Svo.  Lond.  1797.) 

In  the  same  year,  Dr  Beddoes  published 
a valuable  work,  comprising  all  the  informa- 
tion, which  had  then  transpired  respecting 
the  antisyphilitic  virtues  of  the  nitric  acid, 
with  additional  communications  from  his 
medical  friends.  (See  Reports  principally 
concerning  the  Effects  of  JVitrous  Acid  in  the 
Venereal  Disease , by  Thom.  Beddoes , Bristol , 
1797.)  And  two  years  afterward,  the  same 
author  finished  a still  more  comprehensive 
volume  on  the  subject.  (A  Collection  of 
Testimonies , respecting  the  Treatment  of  the 
Venereal  Disease  by  JYitrious  Acid.  Lond.  1799.) 

From  the  preceding  work  we  learn,  that, 
in  the  Plymouth  hospital,  Mr.  Haimnick, 
gave  the  nitric  acid  to  between  sixty7  and 
seventy  venereal  patients;  and  that  the  cures 
were  generally  more  speedily  accomplished, 
than  with  mercury,  no  ill  effects  being  pro- 
duced on  the  system,  similar  to  those  usually 
remaining  after  the  use  of  the  latter  mi- 
neral. He  assures  us,  that,  after  the  remo- 
val of  the  symptoms,  the  disease  never  re- 
turned, and  that  for  debilitated,  scorbutic, 
or  scrofulous  patients,  affected  with  vene- 
real compiniais,  the  acid  was  found  a most 
valuable  means  of  relief. 

Dr.  Geach  of  the  same  hospital  is  also 
staled  to  have  employed  the  nitric  acid  with 
such  effect,  that  he  rarely  had  occasion  for 
mercury,  the  livid  colour  of  the  counte- 
nance, sordid  fetid  excoriations  of  the  scro- 
tum, and  other  symptoms,  which  had  long 
resisted  the  latter  mineral,  all  quickly 
giving  way  to  the  new  medicine.  Another 
practitioner  of  the  name  of  Giedlestone, 
however,  had  not  equal  success  in  his  expe- 
riments, for,  in  several  cases,  the  acid  did 
not  bring  about  a cure,  and,  after  being  con- 
tinued eight  or  ten  days,  and  inducing  a sa- 
livation, it  even  rendered  the  condition  of 
some  patients  worse.  On  the  other  hand, 
Mr.  Sandford,  a surgeon  at  Worcester,  found 
the  acid  a very  useful  and  effectual  medicine 
in  venereal  cases,  where  rpercurials  had 
been  long  exhibited  in  vain.  The  trials  of 
the  nitric  acid,  made  by  Professor  Ruther- 
ford at  Edinburgh,  had  various  results  ; the 
medicine  sometimes  proving  completely  in- 
effectual ; and,  in  other  instances,  appearing 
to  be  a perfect  antidote  for  the  worst  syphi- 
litic complaints. 

Dr.  Beddoes  concludes  with  some  obser- 
vations in  answer  to  Mr.  Blair,  who  had 
become  averse  to  the  new  practice. 

In  1798,  Dr.  Ferriar  published  some  re- 
marks on  the  nitrous  acid.  (See  Medical 
Histories  and  Reflections , Vol.  3,  p.  290 — 3 JO.) 
He  tried  this  medicine,  in  various  ways, 
either  alone,  or  after,  or  in  conjunction  with, 

Vol.  U 36 


the  exhibition  of  mercury.  His  inferences 
are,  that,  in  the  treatment  of  the  venereal 
disease,  the  nitrous  acid  is  useful  only  in 
protracted  cases.  He  corroborates,  how- 
ever, the  generally  received  opinion,  that 
where  the  patient  lias  been  considerably  re- 
duced by  the  long,  or  injudicious  employ- 
ment of  mercury,  the  nitrous  acid  is  a 
most  beneficial  medicine. 

In  the  same  year,  Mr.  Blair  wrote  some 
observations  on  the  venereal  disease,  and  tiic 
new  method  of  treating  it.  (Essays  on  the 
Venereal  Disease , and  its  concomitant  Affec- 
tions, Lond.  179S.)  In  this  work,  the  new 
remedies  are  generally  condemned,  as  inef- 
fectual, and  hence  originated  a paper-war 
between  this  writer  and  Dr  Beddoes,  ‘ lile- 
rarium  certameri,  non  sine  b le  gestum,”  as 
Dr.  Holst  has  expressed  it.  (De  Acidi  Kitrici 
Usu  Medico,  p.  73,  Svo.  Christian te , 1816.) 
In  this  controversy,  numerous  other  practi- 
tioners readily  joined,  as  for  instance,  Ma- 
cartney, Rowley,  Philips,  Hooper,  Lidder- 
dale,  &,c.,  all  of  whom  adduced  cases,  in 
proof  of  the  frequent  inefficacy  of  nitrous 
acid,  ami  these  were  collected  and  published 
by  Mr.  Blair,  who  suspecting  the  cases  of 
failure  with  this  medicine  to  be  more  nu- 
merous, than  those  of  success,  considers 
himself  unjustified  in  regarding  it  as  an 
antisyphilitic  to  be  depended  upon.  At  the 
same  time,  he  bears  testimony  to  the  virtues 
of  the  acids, exhibited  in  venereal  cases  either 
singly,  or  alternately  with  mercury,  w7here 
the  patient’s  strength  had  been  much  redu- 
ced ; and  he  confesses,  that  venereal  buboes, 
indurated  glands,  noctu rnal  pains  in  the  bones, 
and  gonorrhoea,  yielded  to  these  remedies. 

Seven  years  after  the  appearance  of  Mr. 
Blair’s  work,  Mr.  Pearson  delivered  his  sen- 
timents in  a book  of  considerable  merit. 
(Observations  on  the  Effects  of  various  Articles 
of  the  Materia  Medico  in  the  Cure,  of  Lues 
Venerea,  2 d Ed.  Lond.  1807,  p.  198,  fyc.) 
He  relates  a very  few  examples,  in  which 
the  nitrous  acid  appeared  effectual  in  curing 
chancres,  and  one  of  its  virtues  in  gonor- 
rhoea ; the  only  one,  which  this  gentleman 
had  ever  seen.  The  rest  of  his  observations 
are  unfavourable  to  the  character  of  the 
medicine,  as  an  antisipbylitic  meriting  con- 
fidence. The  first  trials,  which  Mr.  Pearson 
made,  were  of  the  nitric  acid  ; but,  as  he 
did  not  remark  any  of  its  effects  to  be  dif- 
ferent from  those  produced  by  the  nitrous 
acid,  he  commonly  employed  the  latter  in 
the  following  form.  Nitrous  acid,  two 
drachms,  pure  water  a pint  and  a half,  syrup 
four  ounces.  This  mixture  was  usually  ta- 
ken in  the  space  of  twenty-four  hours.  As 
local  applications,  he  employed  a saturnine 
lotion  to  the  sores  ; and  emollient  poultices 
to  tumours  and  inflamed  parts.  All  mercu- 
rial applications  were  absolutely  prohibited. 
(P.  200.)  In  making  his  inferences,  in  a sub- 
sequent page,  he  says,  “ The  nitric  and  ni- 
trous acids  have  removed  both  primary  and 
secondary  symptoms  of  syphilis;  and,  in 
some  instances,  it  seems  that  the  former  have 
not  recurred,  nor  have  secondary  symptoms 
appeared  at  the  period  they  commonly  show 


NITRIC  AND  NITROUS  ACIDS. 


themselves,  when  tlie  cure  has  been  imper- 
fect. But,  as  far  as  my  own  experience  ex- 
tends, and  that  of  many  respectable  friends, 
who  are  connected  with  large  hospitals,  a 
permanent  cure  has  never  been  accomplish- 
ed by  these  acids,  where  secondary  symp- 
toms have  been  present.  The  same  acids, 
when  exhibited  with  the  utmost  care  and  at- 
tention to  many  patients,  labouring  under 
the  primary  symptoms  of  the  venereal  dis- 
ease, and  where  they  have  agreed  perfectly 
well  with  the  stomach,  have  been  never- 
theless found  inadequate  to  the  cure  of  those 
symptoms.  Indeed,  the  failures  which  have 
occurred,  both  in  my  own  practice,  and  that 
of  many  of  my  surgical  friends,  have  been 
so  numerous,  that  I do  not  think  it  eligible 
to  rely  on  the  nitrous  acid,  in  the  treatment 
ef  any  one  form  of  the  lues  venerea.”  How- 
ever, Mr.  Pearson  joins  several  other  writers 
in  bearing  witness  to  the  good  effects  of  this 
medicine,  where  impairment  of  the  constitu- 
tion renders  the  employment  of  mercury  in- 
convenient, or  improper.  Here,  he  says,  it 
will  restrain  the  progress  of  the  disease,  and 
improve  the  health  and  strength.  On  some 
occasions,  he  thinks,  that  it  may  be  given,  in 
conjunction  with  a course  of/mercurial  in- 
unction, and  he  agrees  with  other  practition- 
ers about  its  supporting  the  tone  of  the  sto- 
mach, acting  as  a diuretic,  and  counteracting 
the  effects  of  mercury  on  the  mouth  and 
fauces.  (P.  236—238.) 

While  these  inquiries,  were  going  on  in 
England,  numerous  experiments  on  the  same 
subject  were  undertaken  in  France.  In  a 
work,  published  in  1797,  Alyon  positively 
declares,  that  mercury  ought  to  be  entirely 
relinquished  in  the  cure  of  the  venereal  dis- 
ease. (Essai  sur  les  Proprieties  Medecinales  de 
VOxyghie,  et  sur  V application  de  ce  principt 
dans  les  maladies  vinkriennes,  psoriques,  et 
dartreuses ; Paris,  an.  5,  8 vo.)  Here  we  find 
a relation  of  many  cases,  successfully  treat- 
ed in  t^e  hospitals  of  Val-de-Graee  and  St. 
Dennis,  by  the  oxygenated  muriate  of  pot- 
ash, the  nitric,  oxymuriatic,  and  citric  acids, 
an  ointment  of  the  author’s  own  invention, 
called  the  unguentum  oxygenatum,  being  ap- 
plied to  the  sores.  (See  Unguentum.)  In  a 
second  edition  of  the  above  book,  which 
came  out  in  1799,  the  same  doctrine  and 
practice  are  corroborated  by  further  obser- 
vations. 

In  1798,  Dr.  Swediaur  brought  out  the  third 
edition  of  his  treatise  on  the  venereal  dis- 
ease, (TraitJ  Comp  let  sur  les  Symptdmes , les 
EffSts , la  Nature,  et  le  Traitement  des  Mala- 
dies Syphilitiques,)  in  which  he  highly  com- 
mended the  virtues  of  the  nitrous  acid,  and 
oxygenated  acid,  as  expediting  the  cure,  with 
very  few  exceptions.  But,  in  the  fourth 
edition,  he  retracts,  and  details  the  results  of 
the  new  practice,  as  tried  upon  twenty-six 
venereal  patients  in  the  Hospice  d'Humanite  : 
of  these  only  seven  cases  remained  perma- 
nently cured  ; the  issue  of  seven  others  was 
doubtful ; and,  in  twelve,  no  amendment  was 
observed. 

Nor  were  the  statements  of  Lagneau  much 
more  favourable  to  the  reputation  of  the  ni- 


trous acid  as  an  antisyphilitic  ; for,  from  the- 
trials  which  he  had  seen  made  of  it,  he  con  - 
cluded, that  it  was  not  unfrequently  ineffec- 
tual, while  it  was  apt  to  excite  an  obstinate 
cough  and  hcemoptysis.  ( ExposS  des  >iymp- 
tomesde  la  Maladie  VSndrienne,  des  diverses 
MSthodes  de  traitement,  fy-c.  3m  e Ed.  Paris, 
1812.) 

The  reports  of  Dr.  Odier,  of  Geneva,  how- 
ever, were  rather  more  propitious,  as  he 
says,  the  nitrous  acid  increases  the  efficacy 
of  mercury,  and  lessens  or  removes  the  in- 
conveniences arising  from  its  unskilful  ad- 
ministration. Ruthe  candidly  acknowledged, 
that  his  experience  had  not  been  great 
enough  to  enable  him  to  pronounce,  what 
degree  of  confidence  ought  to  be  put  in  the 
acid  as  a remedy  for  syphilis.  (Man.  de 
M6d.  Pratique ; Geneve,  p.  249.) 

The  practice  of  exhibiting  the  nitric  acid 
for  the  cure  of  syphilitic  affections  was  not 
tried  in  Germany  so  soon  as  in  England  and 
France.  Albers,  however,  in  1797,  gave  an 
account  of  Scott’s  successful  experiments, 
and  of  the  efficacy  which  they  evinced  in 
some  cases  seen  by  that  gentleman  in  the 
Infirmary  at  Edinburgh.  (Hufeland  Journ. 
d.  Prukt.  Heilk.  Vol.20,p.  68;)  while  Behn, 
who  had  visited  Paris  in  the  winters  of  1797 
and  1798,  briefly  noticed  the  various  results 
of  the  trials,  which  he  had  seen  made  of 
this  acid,  in  the  “ Clinique  de  Perfectionne- 
ment,”  for  the  cure  of  obstinate  syphilitic 
cases.  ( Erirmerun gen  an  Paris,  zuntichst  fllr 
Jierzte  gescrieben  von  G.  H.  Pehn  Erst.  Heft. 
Berl.  1799,  p.  110.)  At  length,  in  1799, 
Struve,  who  translated  Mr.  Blair’s  first  pub- 
lication into  German,  communicated  to  the 
profession  the  particulars  of  some  experi- 
ments made  by  himself  with  the  acid;  he 
declares,  that  he  bad  very  often  found  it  an 
excellent  remedy  for  inveterate  pains  in  the 
bones,  and  derangement  of  the  constitution;, 
produced  either  by  the  syphilitic  virus  or  the 
injudicious  employment  of  mercury.  How- 
ever, in  common  cases,  mercury  is  repre- 
sented as  the  best  antisypliilitic  medicine. 

Afterward  Professor  Wiirzer  was  induced 
to  try  the  nitrous  acid  in  a case,  that  had  re- 
sisted mercury  for  six  months,  the  patient 
having  got  rid  of  some  chancres  and  a sore 
throat,  but  being  left  with  violent  noctur- 
nal pains,  blotches,  and  sores  all  over  his 
body,  and  in  a very  reduced  condition,  with 
out  the  least  appetite.  Here,  in  27  days  the 
acid,  together  with  sarsaparilla  and  the  warm 
bath,  not  only  removed  all  the  complaints, 
but  actually  restored  the  patient’s  original 
strength,  and  healthy  appearance.  In  a 
short  note  annexed  to  this  case,  Hufeland 
gives  it  as  his  opinion,  derived  from  experi- 
ence, that  the  nitrous  acid  is  effectual  in  ob- 
viating the  sequela?  and  anomalous  diseases 
induced  by  lues  venerea,  but  that  it  does  not 
permanently  cure  the  latter  affection  itself. 
(Etwas  aber  die  Keilkraft  der  Salpetersatire  yn 
venerischen  Kranklieiteu,  Hufel.  Journ.  d. 
Prakt.  Heilk.  8 Bd.  4 St.  p.  139—143.) 

These  vague  and  endless  contradictions 
induced  Schmidt,  an  eminent  professor  at 
Vienna,  to  make  a series  of  experiments  with 


NITRIC  AND  NITROUS  ACIDS 


m 


liie  nitric  acid,  for  the  purpose  of  ascertain- 
ing its  power  in  cases  of  syphilis.  (See  Beo- 
bacht,  der  Kaiserl.  Kvnigl.  Med.  Chir.  Josephs 
Akademit  zu  Wien.  1,  Bd.  Wien  1807,  p.  147 — 
189.)  Under  his  directions,  the  acid  was 
given  in  the  winter  of  1799  to  five  soldiers, 
affected  with  the  venereal  disease  in  various 
degrees  and  forms.  In  every  one  of  these 
cases,  the  medicine  was  found  efficacious  ; 
but  the  degree  of  efficacy  was  remarked  to 
vary  considerably  according  to  the  nature 
of  the  constitution,  and  the  kind  of  local 
complaints.  Thus,  in  robust  patients,  mode- 
rate doses  of  the  acid  soon  produced  bene- 
fit . while,  in  weak  persons,  disposed  to  scurvy 
or  scrofula,  a larger  quantity  of  the  medicine, 
and  more  time  were  requisite.  This  asser- 
tion we  see  is  exactly  the  reverse  of  what 
appeared  to  happen  in  the  cases  treated 
by  Mr.  Cruikshank.  However,  Professor 
Schmidt  entertains  strong  doubts,  whether 
the  nitric  acid  is  adequate  to  the  cure  of  all 
the  forms  of  syphilis,  and  he  thinks,  that 
neither  this  nor  any  similar  medicines  will 
ever  supersede  the  necessity  for  mercury. 

Ontyd,  a Dutch  practitioner,  approves  of 
the  use  of  the  nitric  acid,  with  some  limita- 
tion : while  he  admits  its  efficacy  in  remo- 
ving local  symptoms,  he  is  strongly  against 
its  employment  in  cases  of  confirmed  lues, 
as  they  used  formerly  to  be  termed.  The 
latter  assertion,  I conceive,  is  exactly  con- 
trary to  the  results  of  modern  experience, 
most  of  these  protracted  bad  cases  being 
those,  which  are  particularly  benefited  by 
this  acid.  (JViewve  scheidekundige  Bibl.  te 
Amsterdam  ; by  Doll.  6de  St.  1799,  p.  166.) 
The  tracts  of  Boetticher,  (Betnerk.  fiber  Medi- 
cinal-verfass.  Hospit,  u.  Cnrarten.  ‘lies  Hefr. 
Kdnigsb  1800,  8,)  of  Ritter  ( Erfahr  fiber 
die  innerl  u.  afisserl.  Anwendung  d.  Salpeters. 
Hufel.  Journ.  10  B 3 St.  p.  191 — 197.)  and 
of  Frankenfeld  ( Hufelund's  Journ. der  Prakt. 
Heilk.  22  Bd.  4 St.  p.  96 — 98)  need  only  be 
specified  here,  as  decidedly  unfavourable  to 
the  character  of  the  nitrous  acid,  as  areme- 
_dy  for  syphilis. 

The  following  German  practitioners  are  to 
be  classed  with  the  moderate  approvers  of 
the  medicine,  though  as  Holst  observes,  {De 
Acidi  JYitric  (Jsu  Medico , p.  88  ; Christiana, 
1816,)  they  do  not  appear  to  have  made 
any  new  experiments  of  their  own  with  it, 
viz.  Munchmeyer  {Comm,  de  Viribus  Oryge- 
wii  in  procreandis  et  sanandis  Morbis ; Goetl. 
1801, p.  54:)  Burdach  {Hdb.  d.  neuest  Eut- 
deck,  in  d.  Heilmittellehre  ; Leipz.  1806pp. 
11,  12  ;)  Aronsson  ( Vollst.  Abhdl.  aller  vene- 
rischtn  Krankh.  Berl.  1808,  p.  211  ;)  Horn 
\Hdb.  der  Prakt.  Arzneymittellehre,  2/e.  Aujl. 
Berl.  1805,  p.  95  ;)  Consbruch  ( Taschb . d. 
Arzneymittellehre,  2 te.  Aujl.  Leipz.  1810,  p. 
283 ;)  Toepelmann  (JVeuere  Erfahr.  fiber 
zweekem.  Behdl.  venerisch.  Schleim  ausfUisse , 
^c.  Leipz.  1809,  p.  151  ;)  and  Wolikopfs 
{Pharmac.  extemp.  Leipz.  1811,  p.  92.) 

Another  German  author,  who  has  entered 
into  the  present  inquiry,  is  F.  A.  Waich, 
whose  statements  are  very  unfavourable  to 
the  use  of  the  nitrous  acid,  as  he  absolutely 
denies,  that  it  ever  accomplishes  a lasting 


cure.  ( Aitsfnhrl . Darslell.  d.  Urs)rr.  fye.  d. 
Venerisch.  Krankh.  Jena,  1811,  p.  197,  198.) 

In  a periodical  work,  mention  is  made  of 
one  case,  which,  after  resisting  a long  course 
of  mercury,  and  also  the  nitric  acid,  was  ul- 
timately cured  by  restricting  the  patient  for 
a few  weeks  to  a very  reduced  diet.  {Hujel. 
Journ.  d.  Prakt.  Heilk.  34,  Bd.  2 St.  p.  66.) 

For  much  of  the  foregoing  historical  ac- 
count, I am  indebted'to  Holst  s Diss.  de  Acidi 
Nitrici  Usu  Medico,  8vo.  Christ.  1816;  in 
which  an  explanation  of  the  results  of  fur- 
ther trials  of  the  medicine  in  Denmark  and 
Sweden  may  be  perused.  From  these  coun- 
tries, the  reports  are  mostly  less  favourable 
to  the  reputation  of  the  medicine,  than  the 
accounts  already  delivered. 

According  to  Holst  the  following  are  the 
chief  circumstances,  under  which  the  em- 
ployment of  nitrous,  or  nitric  acid  is  gene- 
rally sanctioned. 

1 . Where  the  disease  is  complicated  with 
scurvy. 

2.  Where  it  is  attended  with  scrofulous  en- 
largement of  the  glands,  and  other  strumous 
symptoms.  I may  remark,  however,  that 
these  complaints  are  often  as  undefinable,  as 
some  of  the  forms  of  syphilis,  and  therefore 
tiie  rule  is  frequently  difficult  of  application. 

3.  Where  the  disease  is  accompanied  with 
considerable  debility,  either  brought  on  by 
mercury,  or  febrile  indisposition. 

4.  Where  from  idiosyncrasy,  mercury  can- 
not be  safely  exhibited.  Experience  fully 
proves,  that  there  are  some  patients,  more 
especially  females,  in  whom  a few  grains  of 
mercury  taken  inwardly,  or  mercurial  fric- 
tions on  the  most  limited  scale,  bring  on 
vomiting,  rheumatic  pains,  nervous  febrile 
symptoms,  colic,  spasms,  severe  headachy 
and  a rapid  immoderate  salivation. 

5.  Where  pregnant  women  are  the  subjects 
of  the  disease,  several  practitioners  forbid 
the  use  of  mercury,  during  the  latter  months 
of  pregnancy.  ( Bangri , Prax.  Med.  Haj'n. 
1789,  p.  570  ; Swediaur  ; Aronsonn  Vollst. 
Abhdl.  aller  Ven.  ICrkht.  Berlin,  1811,  p.  211.) 
Holst  observes,  that  the  reason  of  this  ad- 
vice is  not  stated,  though  no  doubt  it  must 
proceed  from  an  apprehension  of  mercury 
exciting  a miscarriage. 

Mi  .Pearson’s  mode  of  exhibiting  the  nitrous 
acid  has  been  already  mentioned.  Some 
practitioners  give  it  as  follows:  1^.  Gum. 
Arab.  3>v.  aqua*  menth.  |viij.  acid,  nitrosi, 
vel  nitrici  3‘j-  3«ij-  F.  M.  Of  this  mixture,  a 
table  spoonful  is  to  be  taken  every  hour 
mixed  w ith  some  sweetened  water.  Should 
the  acid  occasion  colic,  or  diarrhoea,  its 
quantity  must  be  lessened,  and  opium  added 
to  the  mixture. 

As  the  nitrous  and  nitric  acids  decompose 
and  destroy  the  teeth,  some  care  must  be 
taken  to  prevent  so  serious  an  effect.  Their 
being  properly  diluted,  and  blended  with 
sugar,  syrup,  or  mucilage,  will  materially 
tend  to  hinder  the  evil.  But  the  safest  way 
is  always  to  drink  the  mixture  through  a 
glass  tube,  and  wash  the  mouth  well  imme- 
diately after  every  dose. 

Strong  nitrous  acid,  extricated  in  Ore? 


NIT 


NOL 


2.84 

form  of  vapour, is  often  employed  as  a means 
of  purifying  the  air  of  large  crowded  hospi- 
tals and  sick-rooms  ; a subject  on  which  the 
observations  of  Dr.  J.  C.  Smyth  and  G.  de 
Morveau  are  particularly  interesting.  The 
nitrous  acid  is  sometimes  taken  by  accident, 
or  design,  as  a poison.  Here,  according  to 
the  observations  of  Tartra  Orlila,  he.  the 
best  antidote  is  calcined  magnesia,  or  soap. 
If  the  first  of  these  articles  be  at  hand,  a 
dram  of  it,  suspended  in  a glass  of  water, 
is  to  be  instantly  given,  followed  by  copious 
draughts  of  some  mucilaginous  drink,  the 
design  of  which  is  to  fill  the  stomach,  and 
excite  it  to  reject  the  diluted  poison.  While 
the  vomiting  is  going  on,  the  doses  of  mag- 
nesia are  to  he  repeated,  and  followed  as  in 
the  first  instance  by  draughts  of  linseed  tea, 
solution  of  gum  arable,  milk,  or  broth. 

The  nitrous  acid  has  also  been  extensively 
tried  as  a means  of  curing  syphilitic  com- 
plaints, in  the  form  of  what  is  termed  the 
nilro  muriatic  bath , of  which  a description 
will  be  given  in  speaking  of  the  Venereal 
Disease. 

When  reiterated  courses  of  mercury  in- 
duce dropsy,  as  not  unfrequently  happens 
in  very  impaired  constitutions,  Mr.  Carmi- 
chael prescribes  the  nitrous  acid,  in  as  large 
doses  as  the  stomach  will  bear,  conjoined 
with  digitalis.  ( Essays  on  Venereal  Diseases, 
fyc.)  Taken  in  doses  of  eight,  ten,  or  fifteen 
drops,  two  or  three  times  a day,  it  is  alleged 
to  be  efficacious  in  the  cure  of  some  erup- 
tive complaints,  especially  of  the  lower  ex- 
tremities, connected  with  disorder  of  the 
liver.  (fVihon's  Pharm.  Chir.  p.  6.)  Another 
well-informed  writer  also  bears  testimony 
to  its  good  effects  when  used  together  with 
mercury,  for  old  obstinate  ulcerations  of  the 
legs,  though  no  venereal  taint  can  be  sus- 
pected ; and,  he  says,  it  may  be  applied 
with  benefit  as  a local  stimulant  to  fetid 
ulcers,  attended  with  a thin  ichorous  dis- 
charge, and  in  some  examples  of  caries.  In 
such  cases  3>j-  of  the  diluted  acid  is  to  be 
mixed  with  Jj  of  water.  (See  A.  T.  Thom- 
son's Dispensatory,  p.  441,  Ed.  2.)  With 
respect  to  caries,  in  the  sense  of  necrosis, 
however,  the  reader  will  understand  from 
what  is  stated  in  the  article  on  that  subject, 
that  it  can  rarely  be  adviseable  to  apply  this 
or  any  other  acid  either  to  the  exfoliating 
portion  of  bone  or  to  that  which  is  yet  alive. 
The  nitrous  acid  has  sometimes  been  used 
for  destroying  warts,  condylomata,  and 
other  excrescences.  By  Sir  E.  Home  it  is 
praised  as  a local  application  for  certain 
ulcers  when  properly  diluted.  (See  Ulcers.) 
It  is  likewise  commended  by  some  writers 
as  a very  useful  local  application  in  cases  of 
hospital  gangrene.  And  an  interesting  paper 
has  been  just  published  by  Mr.  R.  Welban k, 
detailing  the  excellent  effects  of  the  undilu- 
ted nitric  acid  as  an  application  to  diseases 
which  he  has  described  under  the  name  of 
sloughing  phagedeena,  and  which  he  consi- 
ders as  identical  with  hospital  gangrene.  “ If 
the  disease  be  not  far  advanced,  (says  this 
gentleman)  I at  once  apply  the  undiluted 
acid,  after  cleansing  the  surface  with  tepid 


water,  and  absorbing  the  moisture  with  lint. 
Where,  however,  there  is  a thick  and  pulpy 
slough,  it  is  better  to  remove  as  much  of  it 
as  possible,  with  forceps  and  scissors,  before 
the  application  is  made.  The  surrounding 
parts  being  then  protected  by  a thick  coat- 
ing of  lard,  or  cerate,  I proceed  to  press 
steadily,  and,  for  some  minutes,  a thick 
pledget  of  lint,  previously  immersed  in  the 
undiluted  acid  on  every  point  of  the  disea- 
sed surface,  till  it  appears  converted  into  a 
firm  and  dry  mass.  The  parts  may  be  then 
covered  with  simple  dressings,  and  evapora- 
tion kept  up  externally  by  cooling  lotions. 
An  opiate  is  afterward  given,  and  the  eschar 
removed  at  the  end  of  16  or  20  hours.  When 
there  is  no  pain,  and  the  subjacent  parts 
present  a florid  healthy  appearance,  the  sore 
may  now  be  treated  as  a common  wound, 
though  stimulant  dressings  are  generally 
best.  Mr.  Welbank  uses  the  ceratum  lapidis 
calaminaris,  or  a solution  of  the  argentum 
nitratum,  in  the  proportion  of  two  or  three 
gr.  to  an  ounce  of  distilled  water.  But,  if 
there  is  any  recurrence  of  pain,  whether  the 
affection  be  slight  or  severe,  and  the  remain- 
ing slough  deep  or  superficial,  Mr.  Welbank 
advises  the  reapplication  of  the  undiluted 
acid.  (See  Med.  Chir.  Trans.  Vol.  11,  p. 
369.)  The  cases  reported  by  this  gentle- 
man are  highly  favourable  to  the  practice 
which,  as  may  be  seen  by  reference  to  the 
article  Hospital  Gangrene,  is  not  entirely 
new  with  respect  to  this  disease,  and  in 
speaking  of  Mortification,  I have  mentioned, 
that  it  was  Dr.  Kirkland’s  practice  some- 
times even  to  dress  certain  sloughing  disea- 
ses with  a solution  of  mercury  in  nitrous 
acid.  But,  notwithstanding  these  facts,  and 
the  well-known  custom  of  Sir  Astley  Cooper 
to  apply  to  sloughing  phagedenic  ulcers  the 
nitric  acid  lotion,  composed  of  50  drops 
of  the  acid,  and  a quart  of  distilled  water,  I 
feel  that  Mr.  Welbank  has  rendered  a ser- 
vice to  the  profession  by  drawing  their 
attention  still  more  particularly  to  the  use 
of  undiluted  nitric  acid  in  the  forms  of 
phagedeena,  which  he  has  so  well  descri- 
bed. 

NODE.  A swelling  of  a bone;  a thick- 
ening of  the  periosteum,  .or  a fascia  ; or  a 
tumour  on  a tendon,  from  a venereal  cause. 
See  Exostosis  and  Venereal  Disease. 

NOLI  ME  TANGERE.  A species  of 
lupus,  under  which  term  Dr.  Willan  intend- 
ed to"  comprise,  together  with  the  noli  me 
tangere  affecting  the  nose  and  lips,  other 
slow  tubercular  affections,  especially  about 
the  face,  commonly  ending  in  ragged  ulcer- 
ations of  the  cheeks,  forehead,  eyelids,  and 
lips,  and  sometimes  occurring  in  other  parts 
of  the  body,  where  they  gradually  destroy 
the  skin  and  muscular  parts  to  a considera- 
ble depth.  ( Bateman's  Synopsis  of  Cutane- 
ous Diseases,  p.  296,  Ed.  3.) 

Sir  K.  Home  says,  that  the  ulcers,  for 
which  he  has  been  led  to  employ  arsenic, 
are  named,  from  (he  virulence  of  their  dis- 
position, noli  me  tangere,  and  are  very  nearly 
allied  to  cancer  ; differing  from  it  in  not. 
contaminating  the  neighbouring  parts  by 


NOLI  ME  TANGERE. 


285 


absorption,  but  only  spreading  by  immedi- 
ate contact.  Ulcers  of  this  kind  differ  ex- 
ceedingly from  one  another  in  their  degree 
of  virulence  ; but  they  are  all  so  far  of  the 
same  nature  that  arsenic  in  general  agrees 
with  them,  and  puts  a stop  to  their  progress, 
while  they  are  aggravated  by  milder  dress- 
ings. ( Home  on  Ulcers , Edit.  2,  p.  267.) 

The  disease  generally  commences  with 
small  tubercles,  which  change  after  a time 
into  superficial,  spreading  ulcerations  on  the 
alas  of  the  nose,  more  or  less  concealed  be- 
neath furfuraceous  scabs.  The  whole  nose 
is  frequently  destroyed  by  the  progressive 
ravages  of  this  peculiar  disorder,  which 
sometimes  cannot  be  stopped  or  retarded 
by  any  treatment,  external  or  internal. 

The  specific  ulcerations  do  not  generally 
extend  to  the  parts  far  within  the  nostrils  ; 
but,  at  the  time  that  I am  writing  this  article, 
there  is,  under  Sir  L.  Harvey,  in  St.  Bartho- 
lomew’s Hospital,  a curious  example,  in 
which  the  greatest  part  of  the  nose  is  de- 
stroyed and  the  ulceration  proceeds  even 
through  the  front  part  of  the  palate  into  the 
mouth.  The  morbid  process  sometimes 
stops  for  a considerable  time,  and  then  is 
renewed  with  increased  violence.  The 
following  case  illustrates  the  nature  of  noli 
me  tangere,  and  one  mode  of  treatment,  to 
which  it  yielded.  Jane  Chatillon,  45  years 
of  age,  w’as  attacked,  in  the  course  of  Sep- 
tember, 1788,  with  an  inflammation  on  the 
left  ala  of  the  nose.  Some  time  afterward 
the  part  ulcerated,  which  occasioned  a trou- 
blesome and  sometimes  a painful  itching  ; 
different  means  were  unsuccessfully  employ- 
ed, and  the  case  remained  nearly  in  the 
same  situation  till  the  month  of  September 
in  the  following  year.  At  this  period  the 
ulcer  spread  very  fast ; the_septum  nasi, 
the  muscles  and  cartilages  of  both  sides 
were,  in  a short  space  of  time,  destroyed. 
The  ulceration  extended  on  the  left  -ide, 
along  the  loose  edge  of  the  upper  lip.  This 
w as  the  state  of  her  case  on  her  admission 
into  the  Hospital  of  St.  Louis,  in  the  month 
of  October,  1789. 

A poultice  moistened  with  aq.  veg.  was 
applied  twice  a day  to  the  ulcer ; a sudorific 
ptisan  prescribed,  and  a pill,  composed  of 
one  grain  of  calomel  and  one  grain  of  sulpb. 
aurat.  anlimonii,  ordered  to  be  taken  every 
day.  From  the  fifth  day,  the  inflammation 
lessened.  No  other  sensible  alteration  took 
place  till  the  21st.  The  suppuration,  which 
till  this  time  had  been  black  and  putrid, 
now  became  wrhite  and  inodorous. 

On  the  37th  the  discharge  was  trifling, 
and  the  part  was  dressed  with  pledgets  dip- 
ped in  a solution  of  verdigris  and  corrosive 
sublimate,  in  the  proportion  of  six  grains  of 
each  to  a pint  of  water.  On  the  40th  day, 
cicatrization  began  to  take  place,  and  was 
finished  by  the  60th. 

Some  time  before  the  disease  was  com- 
pletely cicatrized,  an  issue  was  made  in  the 
arm,  which  was  healed  up  without  any  in- 
convenience to  the  patient,  six  months  after 
the  cure.  (Parisian  Chirurgical  Journal, 
Vol.  1.) 


One  of  the  best  external  applications  to 
noli  me  tangere  is  the  following  lotion  : fj;. 
Kali  arsenicati,  gr.  iv.  Aq.  menthae  sativa?, 
^iv.  Spiritus  vini  tenuioris,  ^j.  Misce  et 
cola.  1 have  seen  several  cases  in  St.  Bar- 
tholomew’s Hospital,  which  were  either 
cured  or  seemed  disposed  to  get  well 
with  this  useful  application.  The  solu- 
tion of  arsenic,  which  Sir  E.  Home  has 
always  used,  is  made  by  boiling  white 
arsenic  in  water  for  several  hours,  in  a sand 
heat.  When  given  internally,  the  dose  is 
from  three  to  ten  drops  ; when  for  external 
application,  a dram  is  to  be  diluted  with  fLij. 
of  w ater  ; and  this  solution  is  gradually  made 
stronger,  as  the  parts  become  accustomed 
to  it,  till  it  is  of  double  strength.  However, 
this  mode  of  using  arsenic  is  by  no  means  a 
well-regulated  one  ; and  Plunket’s  caustic 
(see  Arsenic)  for  outward  employment,  i ; 
not  nearly  so  neat  an  application  as  the 
above-mentioned  lotion.  At  St.  Bartholo- 
mew’s Hospital,  arsenic  is  administered  in- 
ternally in  the  following  formula  : Kali 

arsenicati,  gr.  ij.  Aquae  menthae  sativae,  |iv. 
Spiritus  vin.  ten.  ^j.  Misce  et  cola.  Dosis 
3ij.  ter  quotidie.  ~In  this  way,  the  quantity 
of  arsenic  is  nicely  determined.  We  shall 
only  just  add,  with  regard  to  this  medicine, 
that,  both  as  an  external  application  and  an 
inward  remedy,  in  cases  of  noli  me  tangtre , 
it  perhaps  deserves  the  highest  rank.  One 
scruple  of  the  argentum  nitratum,  dissolved 
in  half  an  ounce  of  distilled  water,  makes  a 
very  good  application  which,  although  ge- 
nerally inferior,  in  point  of  efficacy,  to  ar- 
senical ones,  in  the  present  disease,  occa- 
sionally does  good,  when  nothing  else  seems 
to  produce  any  benefit.  The  above  case 
makes  us  acquainted  with  another  lotion, 
which  deserves  further  trial  All  fluid  reme- 
dies must  be  applied  to  the  part,  by  dipping 
little  bits  of  lint  in  them,  placing  these  on 
the  ulcerations,  and  covering  the  whole 
with  a pledget. 

The  ointments  which  seem  most  likely  to 
prove  useful  applications  to  noli  me  ta?igere , 
are  the  unguentum  hydrargyri  nitrati,  the 
unguentum  picis,  and  unguentum  sulphuris. 
As  far  as  my  experience  extends,  they  are 
generally  less  efficacious  than  lotions  in  the 
present  cases  ; but,  in  particular  instances, 
they  prove  superiorly  useful,  and  it  deserves 
especial  notice, that  surgeons  can  often  make 
no  progress  against  this  inveterate  disease, 
unless  they  apply  a different  sort  of  dressing 
every  day  ; sometimes  a lotion  ; at  other 
times  an  ointment.  The  little  ulcers  may 
occasionally  be  touched  with  the  argentum 
nitratum.  The  small  furfuraceous  scabs, 
which  are  continually  forming  on  the  part 
affected,  should  be  softened  with  a little  of 
the  unguentum  spermatis  ceti,and  removed 
with  as  much  tenderness  as  possible. 

We  have  already  remarked,  that  arsenic 
is  a good  medicine  to  be  given  internally, 
and  the  best  mode  of  exhibiting  it  has  been 
already  explained.  Another  medicine,  w'bieh 
is  often  useful  in  these  cases,  is  what  is 
known  by  the  name  of  Plummer’s  pill,  or 
the  compound  calomel  pill.  Hydrargyri 


NYCTALOPIA. 


1286 

submuriatis,  sulphuris  antimonii  pra?cipitati, 
singulorum  gr  xii.  Guaiaci  gum  mi  resinae, 
gr.  xxiv.  Saponis  quod  satis  sit  Misce  ; fiant 
pilulae  duodecim.  Dosis  una  bis  quotidie. — 
In  other  instances,  we  may  try  the  decoctum 
ulmi,  or  sarsaparilla?,  with  one  of  the  fol- 
lowing pills  thrice  a day:  Hydrargyri 

submuriatis  gr.  vj.  Succi  spissati  cicuta?  3j 
Misce ; fiant  pilula?  duodecim.  The  hy- 
drargyrus  sulphuratns  has  occasionally  been 
given  as  an  alterative  medicine,  for  the 
relief  of  noli  me  tangere  ; with  what  good 
effect  I cannot  pretend  to  say. 

In  three  or  four  less  severe  cases  of  lupus 
tubercles  on  the  face,  which  had  made  no 
progress  towards  ulceration,  Dr.  Bateman 
saw  the  solution  of  muriate  of  barytes,  taken 
internally,  materially  amend  the  complaint. 
Sqmetimes,  also,  a separation  of  the  diseased 
parts  from  the  sound  has  been  effected  with 
the  knife,  or  caustic,  and  the  progress  of  the 
complaint  been  stopped.  (Synopsis  of  Cu- 
taneous Diseases,  p.  296,  Edit  3.) 

NYCTALOPIA,  (from  vu|,  night;  and 
the  eye  ; or  07rra>,  to  see.)  An  affection 
of  the  sight,  in  which  the  patient  is  blind  in 
the  daylight,  but  sees  very  well  at  night 

Nyctalopia,  visus  nodurnus,  or  day-blind- 
ness, vulgarly  called  owl-sight,  (says  M. 
Lassus)  is  an  affection  in  which  the  patient 
either  cannot  see  at  all,  or  sees  l ut  very 
feebly,  objects,  which  are  in  the  open  day- 
light, or  situations  where  there  is  a strong 
light ; bu\  discerns  them  very  well,  w hen 
they  are  in  a darkish  place,  or  at  sunset,  or 
in  the  nighttime,  if  not  immoderately  dark. 
(See  Pathologic  Chirurgicale , T.  2,  p.  539, 
540.) 

The  Greek  physicians  are  divided  in  their 
opinions  concerning  the  now  uncommon 
disease  nyctalopia.  Hippocrates  expressly 
says,  “ we  call  those  nyctalopes  who  see  by 
night.”  The  author  of  Dejin.  Medic.  “that 
they  see  nothing  in  the  daytime,  but  have 
their  sight  by  night.”  On  the  contrary, 
Paulus  iEgineta  and  \ctuarius  are  as  explicit 
in  asserting,  that  they  have  their  sight  perfect 
in  the  daytime,  but  are  blind  by  night. 
iEtius  is  of  the  same  mind,  though  he  is 
thought  to  favour  the  contrary  opinion,  when 
lie  says,  “ they  see  better  by  night  than  in 
the  day,  and  if  the  moon  shines  they  are 
blind.”  The  author  of  Isagoge  embraces 
both  opinions,  when  he  says,  “ they  call 
those  nyctalopes  who,  in  the  daytime,  see 
more  obscurely,  at  the  setting  of  the  sun 
more  clearly,  but,  when  it  is  night,  much 
better  ; or,  on  the  contrary,  by  day  they  see 
a little,  but,  in  the  evening,  or  at  night,  they., 
are  blind.”  Galen  explains  the  word  by  a 
night  blindness.  Pliny,  Varro,  Nonius,  Fes- 
t.us,  Celsus,  and  other  writers,  give  equally 
opposite  definitions  of  the  disorder.  Dr. 
'JPye  questions,  whether  these  two  descrip- 
tions of  nyctalopia,  so  diametrically  opposite 
to  each  other,  may  not  be  reconciled  by 
considering  the  disorder  as  an  intermittent 
one.  The  difference  then  will  only  consist 
in  the  different  times  of  the  approach  of  the 
disease  ; that  of  Hippocrates  came  on  in  the 
morning ; that  of  j^figineta,  in  the  evening  ; 


both  were  expressly  periodical,  and  the  dis* 
tance  of  time  between  the  paroxysms,  in 
both,  was  respectively  the  same  ; a whole 
day,  or  a whole  night.  The  various  shapes, 
in  which  intermittents  appear,  very  much 
favour,  says  Dr.  Pye,  such  an  opinion  ; and 
the  apparent  success  of  bark  in  the  case, 
which  he  has  related,  notwithstanding  the 
unfavourable  circumstances  of  the  evacua- 
tions his  patient  laboured  under,  and  the 
consequent  necessity  of  its  disuse,  seem  to 
confirm  it  in  this  gentleman’s  mind.  (Med. 
Obs.  and  Inq.  Vol.  1.) 

In  this  work  I shall  follow  Callisen,  Rich- 
ter, and  the  best  modern  surgical  writers,  in 
calling  day-blindness,  nydalopia,  and  night- 
blindness,  hemeralopia.  (See  Callisen , Syst. 
Chir.  Hodiernal,  Vol.  2,  p.  392  and  Richter , 
Anfangsgr.  der  JVundarzn.  B.  3,  p.  479.) 

Nyctalopia,  in  the  sense  of  day-blindness, 
is  a very  rare  disease,  in  comparison  with 
hemeralopia,  which  is  a very  common  disor- 
der in  warm  climates.  According  to  Dr. 
Hillary,  there  are  a people  in  Siam,  in  the 
East  Indies,  and  also  in  Africa,  w ho  are  all 
of  this  cat-eyed  species,  or  subject  to  *he 
disease  of  being  blind  in  the  daytime,  and 
seeing  well  by  night.  (Mod.  Univ.  Hist.  Vol. 
7.)  The  same  author  notices  the  general 
rarity  of  the  disorder,  and  mentions  his 
having  met  with  but  two  examples  of  it. 

With  respect  to  the  causes  of  the  com- 
plaint, Dr.  Hillary  observes,  that  it  proceeds 
from  too  great  a tenderness  and  sensibility 
of  the  iris  and  retina.  M.  Lassus  thinks  the 
causes  may  be  of  different  kinds.  “ If.  for 
instance,  (says  he)  there  were  a very  small 
opacity,  like  a point,  exactly  opposite  the 
pupil,  or  centre  of  the  crystalline  lens,  the 
pupil,  contracting  in  the  open  daylight, 
would  stop  the  entrance  of  the  rays  of  light 
into  the  eye,  and  a day-blindness  arise,  which 
would  be  diminished  by  the  expansion  of  the 
pupil  in  the  shade.  Here,  the  cure  would 
depend  upon  the  removal  of  the  opacity. 

“ Persons,  wdiose  pupils  do  not  move 
freely,  but  remain  much  dilated,  and  do  not 
sufficiently  contract  in  light  situations,  are 
also  affected  with  nyctalopia  ; for.  so  large 
a quantity  of  the  rays  of  light  pass  into  their 
eyes,  that  it  serves  rather  to  destroy,  than 
assist  vision.  Such  persons  see  tolerably 
wrell,  and  better  than  the  preceding  class  of 
patients,  in  a darkish  place,  and  they  ought 
to  wear  green  spectacles  in  the  daytime,  in 
order  to  weaken  the  impression  of  the  rays 
of  light.  When  a person  is  shut  up  a long 
while  in  a dark  place,  the  pupils  become 
habitually  dilated,  and  ii  he  exposes  himself 
suddenly  and  incautiously  to  a strong  light, 
the  eyesight  may  be  destroyed.  There  are 
other  individuals,  who,  from  excessive  sensi- 
bility of  the  iris,  cannot  bear  much  light ; 
their  pupils  instantly  contract,  and  close, 
This  case  (continues  M.  Lassus)  may  be 
brought  on  by  too  great  indulgence  in  vene- 
real pleasures,  and  in  persons,  who  have 
debilitated  their  constitutions  during  their 
youth.”  The  same  author  mentions  other 
cases,  which  seem  to  depend  upon  a species 
of  irritability  of  the  iris.  In  one  instance,  an 


<EDE 


(Es>0 


issue  in  the  arm  effected  a cure,  and  he 
mentions  the  utility  of  blisters.  He  admits 
likewise  witli  Dr.  Pye  cases  of  intermittent 
or  periodical  nyctalopia,  which  begin  regu- 
larly in  the  morning,  and  go  off  in  the  even- 
ing, the  patient  continuing  blind,  whether 
he  keep  himself  in  a dark  or  a light  place. 
The  cause  of  these  instances,  which,  he  ob- 
serves, are  very  uncommon,  is  generally 
seated  in  the  primal  via?,  and  requires  eme- 
tics, resolvents,  purgatives,  and  bark.  (See 
Palhologie  Chir.  T 2,  p.  540 — 542.  Also 
Richter,  Anfangsgr.  der  fVundarzn.  B.  2,  p. 
481.)  In  1787,  Baron  Larrey  met  with  a 
case  of  day-blindness  in  an  old  man,  one  of 
the  galley-slaves  at  Brest,  who  had  been  shut 
up  incessantly  for  thirty-three  years  in  a 
subterraneous  dungeon.  His  long  residence 
in  darkness  had  had  such  an  effect  on  the 
organs  of  vision,  that  he  could  only  see  in 


the  dark,  and  was  completely  blind  in  the 
daytime.  (See  M6m.  de  Chir.  Militaire , T. 

hp-6-) 

Nyctalopia  may  sometimes  depend  on  a 
peculiarity  in  the  structure  and  organization 
of  the  eye  ; by  reason  of  which,  the  quantity 
of  light,  which  only  suffices  for  vision  in  an 
eye  of  natural  formation,  proves  too  abun- 
dant for  a nyctalops,  and  absolutely  prevents 
him  from  seeing  at  all.  We  know,  that  in 
the  eye  there  is  a black  substance,  named 
the pigmentum  nigrum  ; one  supposed  use  of 
which  is  to  absorb  the  redundant  rays  of 
light,  which  enter  the  pupil.  A deficiency  of 
it  might  perhaps  account  for  a nyctalops 
being  blinded  with  daylight,  and  seeing 
best  at  night. 

For  an  account  of  nyctalopia,  in  the  sense 
of  night-blindness,  refer  to  Hemeralopia, 


DEMA.  (from  oi4ia>,  to  swell.)  The 
ancients  understood,  by  this  term,  all 
kinds  of  tumours  ; but  it  is  now  restricted  to 
a swelling,  arising  from  the  effusion  of  a 
serous  fluid  in  the  cellular  substance  of  a 
part ; the  affection,  when  more  extensive, 
and  accompanied  with  a general  dropsical 
tendency,  becoming  a medical  case,  and 
receiving  the  name  of  anasarca.  An  oedema- 
tous  part  is  usually  cold,  and  of  a pale 
colour;  and,  as  it  is  little,  or  not  at  all 
elastic,  it  pits,  as  surgeons  express  themselves, 
or,  in  other  words  it  retains,  for  some  time, 
the  mark  of  the  finger,  after  being  handled, 
or  pressed.  (Edematous  swellings  are  often 
connected  with  constitutional  causes.  In 
many  cases,  however,  they  seem  to  be  en- 
tirely local  affections,  arising  from  such 
causes  as  only  act  upon  the  parts,  in  which 
the  swelling  is  situated.  Thus  we  observe, 
that  after  violent  sprains  of  the  wrist,  or 
ankle-joint,  the  bands  and  feet  often  become 
(edematous  ; and  limbs  are  frequently  affect- 
ed with  oedema,  in  consequence  of  the  re- 
turn of  blood  through  the  veins  being  ob 
structed  by  the  pressure  of  tumours  on  them, 
or  that  of  splints,  bandages,  &c.  Pregnant 
women  are  known  to  be  particularly  subject 
to  oedema  of  the  legs,  owing  to  the  pressure 
of  the  gravid  uterus  on  the  iliac  veins  Per- 
sons who  have  been  confined  in  bed,  with 
fractured  thighs,  or  legs,  generally  have 
more  or  less  oedema  in  their  feet  and  ankles, 
on  first  getting  up  again  ; and  the  affection 
in  these  cases  is  probably  quite  dependent 
on  loss  of  tone  in  the  vessels  of  the  limb. 

In  the  treatment  of  oedema,  great  attention 
must  always  be  paid  to  the  nature  of  the 
cause,  in  order  to  determine  whether  the 
disease  originates  from  a mere  local,  or  a 
eneral  constitutional  affection.  When  it 
epends  on  the  pressure  of  a tumour  on  the 
veins,  as  we  often  see  happen  in  cases  of 
aneurisms,  the  effect  cannot  be  got  rid  of 


till  the  cause  is  removed  ; and  the  aneuris- 
mal  swelling  must  be  lessened,  before  the 
cedeinatous  one  can  admit  of  the  same  be- 
neficial change.  When  oedema  is  the  effect 
of  vascular  weakness  in  a limb,  in  conse- 
quence of  sprains,  contusions,  &c.  the  best 
means  of  relief  is  to  support  the  parts  affect- 
ed, with  a laced  stocking  or  a flannel  roller, 
while  they  are  also  to  be  rubbed  with  lini- 
ments, and  bathed  with  cold  spring  water, 
till  they  have  perfectly  recovered  their 
tone. 

With  regard  to  the  oedema,  attendant  on 
the  advanced  stage  of  pregnancy,  a com- 
plete cure  cannot  be  expected  till  after  deli- 
very. The  affection  is  generally  more  con- 
siderable in  the  afternoon  than  the  morning, 
owing  to  the  different  effects  of  an  erect 
and  a recumbent  position.  Some  relief 
may  be  obtained  by  the  patient’s  keeping  as 
much  as  possible  in  a horizontal  posture  ; 
and,  when  much  inconvenience  and  pain 
are  felt,  the  parts  may  be  fomented  with  any 
aromatic  or  spirituous  application. 

Frequently,  oedema  is  one  of  the  symp- 
toms of  suppuration,  and,  when  the  collec- 
tion of  matter  is  very  deeply  situated,  some- 
times leads  to  its  discovery,  as  is  exem- 
plified in  cases  of  empyema. 

There  is  a species  of  oedema,  accompanied 
with  a degree  of  heat,  pain,  &c.  in  the  part, 
and  which,  in  short,  seems  combined  with 
phlegmon  In  this  case,  cold  evaporating* 
lotions,  the  application  of  leeches,  and  the 
exhibition  of  saline  purgatives,  are  proper. 
An  erysipelatous  oedema  is  also  met  with,  in 
which  the  treatment  should  very  much  re- 
semble what  is  explained  in  the  article 
Erysipelas. 

(ESO  P H A GOTO  MY.  (from  oesophagus  and 
'n/uvcD,  to  cut  ) The  operation  of  cutting 
into  the  oesophagus,  in  order  to  take  out  of 
this  tube  any  foreign  body  which  lodges  in 
it,  and  can.  neither  be  extracted  through  the 


(ESOPHAGOTOMY. 


■28S 


mouth,  nor  pushed  down  into  the  stomach, 
though  its  removal  is  absolutely  necessary 
for  the  preservation  of  the  patient’s  life.  A 
substance,  above  a certain  size,  lodged  in 
the  upper  part  ot  the  oesophagus,  not  only 
obstructs  deglutition,  but  by  its  pressure 
against  the  trachea,  produces  the  most  urgent 
symptoms  of  suffocation.  In  this  circum- 
stance, if  relief  cannot  be  expeditiously  af- 
forded in  any  other  manner,  and  the  situation 
of  the  foreign  body  is  denoted  by  a prominence 
distinguishable  in  the  neck , oesophagotomy 
should  be  practised  without  delay.  How- 
ever, when  the  symptoms  are  pressing,  yet 
unattended  with  any  possibility  of  feeling 
the  foreign  body,  either  externally  or  with  a 
probang,  desperate  as  the  situation  of  the 
patient  may  be,  modern  surgeons  do  not 
sanction  the  practice.  And  this  difference 
from  the  opinion  of  the  first  proposers  of 
cesophagotomy,  does  notarise  so  much  from 
any  reflections  upon  the  greater  difficulty  of 
the  operation  in  this  circumstance,  as  from 
the  consideration  of  its  being  unlikely  to 
answer  the  only  purpose,  which  makes  its 
performance  at  anytime  proper,  viz.  enabling 
the  practitioner  to  extract  with  reasonable 
certainty  the  substance,  whose  continuance 
and  pressure  in  the  oesophagus  are  the  imme- 
diate cause  of  the  patient’s  danger.  Hence, 
when  the  symptoms  of  suffocation  are  ex- 
tremely urgent,  but  the  foreign  body  produ- 
ces no  external  prominence  in  the  neck,  the 
surgeon  should  in  the  first  instance  perform 
tracheotomy,  so  as  to  obviate  the  imminent 
peril  arising  from  the  impeded  state  of  respi- 
ration, and  afterward  try  such  measures  for 
the  removal  of  the  substance  lodged  in  the 
oesophagus  as  experience  points  out  as  most 
likely  to  prove  successful.  Though  oesopha- 
gotomy was  cursorily  mentioned  by  Verdue 
in  his  “Pathologie  Chirurgicale,”  Guattani, 
formerly  a distinguished  surgeon  at  Rome,  is 
entitled  to  the  honour  of  having  published 
the  first  valuable  observations  on  the  subject. 
(M6m.  de  l’ Acad,  de  Chir.  T.  3,  4to.)  Guatta- 
ni proved  by  experiments,  that  the  operation 
might  be  safely  performed  upon  dogs,  which 
recovered  after  it  very  well,  and  he  demon- 
strated on  the  dead  body,  that  it  was  equally 
practicable  on  the  human  subject  Nay, 
what  is  still  more  to  the  point,  he  brought 
forward  two  instances,  in  which  the  practice 
had  been  successfully  adopted  on  living  pa- 
tients. “ In  May,  1738,  Goursauld,  a sur- 
geon at  Coussat-Bonneval,  in  Limousin,  was 
called  to  a man,  in  whose  oesophagus  a bone 
wras  lodged,  an  inch  long  and  half  an  inch 
broad.  Various  ineffectual  endeavours  were 
made  to  force  it  down  into  the  stomach,  and, 
as  it  was  perceptible  on  the  left  side  of  the  neck , 
Goursauld  ventured  to  make  an  incision  for 
its  extraction.  The  bone  was  thus  easily  ta- 
ken out,  no  bad  symptoms  followed  and  the 
wound  healed  up  favourably  with  the  aid  of 
an  uniting  bandage.  For  six  days  the  pa- 
tient was  not  allowed  to  swrallow  any  kind 
of  food,  but  was  nourished  entirely  with 
clysters.  According  to  Morand,  a similar 
operation  was  performed,  with  equal  suc- 
bv  Roland,  surgeon-major  of  the  regi- 


ment of  Mailly.”  ( Mem.de  VAcad.  de  Clive. 
T.  3.) 

Although  the  deep  situation  of  the  oeso- 
phagus, among  the  most  important  parts  in 
the  neck,  makes  cesophagotomy  an  operation 
of  considerable  delicacy  in  the  hands  even 
of  a skilful  surgeon,  and  one  of  great  danger 
irnthose  of  a man,  deficient  in  anatomical 
knowledge,  and  ignorant  of  the  right  way 
of  proceeding,  yet  the  propriety  of  perform- 
ing it,  under  the  circumstances,  which  have 
bee.n  specified,  is  universally  admitted. 
When,  however,  I refer  to  the  delicacy  and 
difficulty  of  the  operation,  1 arn  meaning  a 
case,  in  w hich  a deliberate  dissection  is  made 
down  to  (he  oesophagus,  without  any  gui- 
dance from  the  projection  of  the  foreign 
body  within  it;  a case,  in  which  my  views 
of  the  subject  lead  me  to  think,  contrarily  to 
Guattani,  that  the  experiment  would  gene- 
rally be  attended  with  no  practical  benefit ; 
which  is  also  the  sentiment  of  Baron  Boyer. 
For,  with  respect  to  opening  the  oesophagus, 
with  the  view  of  tracing  a substance  in  it,  not 
externally  perceptible,  and  either  of  taking 
hold  of  the  same  substance  with  forceps,  or 
pushing  it  down  into  the  stomach  with  other 
instruments,  introduced  through  the  incision, 
as  suggested  by  Guattani,  the  chances  of 
success  must  be  too  small  to  justify  a practice, 
in  which  it  is  above  all  things  of  consequence 
to  have  the  guidance  afforded  by  the  promi- 
nence in  the  throat,  as  a test  of  the  foreign 
body  being  actually  lodged  in  the  oesophagus, 
and  capable  of  being  removed  from  it  by  tbe 
proposed  operation.  Indeed,  the  uncertainty 
of  being  able  to  reach  and  extract  the  foreign 
body,  when  its  precise  situation  is  not  indi- 
cated by  any  external  swelling,  appears  to 
me  an  objection  of  greater  validity,  than  any 
consideration  either  of  the  increased  diffi- 
culty of  cutting  into  the  oesophagus  under 
these  circumstances,  or  of  the  usual  conse- 
quences of  such  an  incision,  after  it  has  been 
accomplished;  because  the  practicable  na- 
ture of  the  operation,  and  the  tendency  of 
wounds  of  the  oesophagus  to  heal  favourably , 
when  not  complicated  with  other  mischief 
of  too  serious  a description,  are  facts  proved 
beyond  the  possibility  of  dispute.  In  at- 
tempts at  suicide  and  murder,  and  in  cases 
of  gunshot  injury,  the  oesophagus  is  some- 
times wounded,  together  with  other  parts  in 
the  neck,  and  yet  the  patients  frequently  re- 
cover; and,  when  they  die,  their  fate  seems 
to  depend  rather  upon  other  unfavourable 
circumstances  in  their  cases,  than  upon  the 
accidental  injury  of  the  gullet.  The  cures 
of  wound?  of  the  neck,  involving  the  latter 
tube,  as  well  as  the  trachea,  are  reported  by 
numerous  writers,  B.  Bell,  Desault,  Bohnius, 
&c.  and  some  have  fallen  under  my  own 
observation.  If  it  w'erc  necessary  to  sub- 
stantiate this  point  further,  I might  cite  the 
instance,  recorded  on  the  authority  of  Dr. 
James  Johnson,  where  a man  recovered 
after  the  larynx  had  been  Completely  severed 
between  the  thyroid  and  cricoid  cartilages, 
and  one  half  of  the  calibre  of  the  oesophagus 
divided.  (See  llenncn's  Military  Surgery , p 
301,  Ed.  2.)  But,  supposing  a wound  of  the 


(ESOPHAGUS.. 


289 


oesophagus,  abstractedly  considered,  were 
more  dangerous,  than  it  really  is,  the  ques- 
tion of  the  propriety  of  oesophagotomy 
would  npt  be  materially  affected  by  it,  be- 
cause the  operation  is  never  recommended, 
except  as  a matter  of  necessity,  and  without 
which  the  patient  would  have  no  chance  of 
preservation. 

As  the  oesophagus  does  not  descend  ex- 
actly in  a straight  line,  between  the.  trachea 
and  vertebra;,  but  inclines  rather  to  the  left 
side  of  the  spine,  Guattani  directs  the  left 
side  of  the  neck  to  be  preferred  for  the  per- 
formance of  oesophagotomy.  But,  Boyer 
has  justly  remarked,  that  as  the  operation 
should  never  be  attempted,  unless  there  be 
projection  of  the  foreign  body,  the  place  for 
the  incision  is  always  to  be  determined  by 
the  situation  of  the  projection,  the  left  side 
being  chosen  only  when  the  prominence  is 
either  most  distinguishable  there,  or  at  all 
events  not  less,  than  on  the  opposite  side  of 
the  neck.  (Traiti  desMal.  Chir.  T.  7 .p.  192.) 

The  parts,  which  cover  the  oesophagus, 
from  the  middle  and  external  part  uf  the  neck 
to  the  upper  part  of  the  sternum,  are  the 
skin,  fat,  cellular  substance,  muscles  pro- 
ceeding front  the  sternum  to  the  larynx,  the 
thyroid  gland,  the  thyroid  arteries  and  veins, 
the  trachea,  the  recurrent  nerve,  &.c.  Guat- 
tani, who  preferred  the  left  side  of  the  neck, 
recommended  the  following  mode  of  opera- 
ting. The  patient  is  to  sit  on  a chair,  with 
his  bead  inclined  backward,  and  steadily  sup- 
ported by  an  assistant.  The  skin  having 
been  pinched  up  into  a transverse  fold,  an 
incision  is  to  be  made  in  the  integuments 
from  the  upper  part  of  the  sternum.  The 
cellular  substance,  between  the  sterno-hyoi- 
deus  and  sterno-thyroideus  muscles  and 
trachea,  is  next  to  be  divided.  With  two 
blunt  hooks,  the  lips  of  the  wound  are  to  be 
kept  open ; and,  on  separating  the  cellular 
substance  at  the  side  of  the  trachea  with 
the  aid  of  the  finger  and  a few  strokes  of 
the  knife,  the  oesophagus  will  be  seen.  The 
lower  part  of  this  tube  is  then  to  be  opened, 
and  the  wound  in  it  enlarged  with  a pair  of 
curved  blunt-pointed  scissors,  a director  being 
employed,  if  any  difficulty  arise.  With  a 
small  pair  of  curved  forceps,  similar  to  those 
used  for  the  extraction  of  polypi,  the  foreign 
body  may  then  be  removed.  According  to 
Guattani,  the  wound  will  serve  for  the  ex- 
traction of  the  foreign  body,  whether  this  be 
situated  above,  or  below  it,  and  he  asserts, 
that  the  opening  will  even  be  useful,  when  the 
extraneous  substance  bas  passed  so  far  down, 
that  it  cannot  be  taken  out,  as  it  can  now  be 
easily  pushed  into  the  stomach.  Guattani 
lays  great  stress  ou  the  usefulness  of  en- 
deavouring to  unite  the  wound,  and  adverts 
to  his  experiments,  proving  that,  in  animals, 
wounds  of  the  oesophagus  heal  very  favoura- 
bly. If,  says  he,  the  vein,  which  brings 
back  the  blood  from  the  inferior  parts  of 
the  thyroid  gland,  and  runs  into  the  subcla- 
vian, happen  to  be  cut,  the  hemorrhage  may 
be  stopped  with  a dossil  of  lint  held  upon 
the  aperture  in  the  vein  during  the  operation, 
and  afterward  if  the  bleeding  continue, 

Vm„  IT.  B7 


compression,  or  a ligature,  is  to  be  employed. 
The  recurrent  nerve,  if  at  all  likely  to  be 
touched  with  the  knife,  is  to  he  cautiously 
drawn  a little  out  of  the  way  with  the  blunt 
tenaculum.  Guattani  also  particularly  insists 
upon  opening  the  oesophagus  as  near  as  pos- 
sible to  the  trachea,  especially  at  its  upper 
part,  where  the  artery,  which  goes  from  the 
subclavian  to  the  thyroid  gland,  sometimes 
runs.  When  the  foreign  body  requires  an. 
ample  opening,  and  particularly  when  the 
thyroid  gland  is  enlarged,  Guattani  approves 
of  separating  this  part  a little  from  the  side 
of  the  trachea.  (See  Mini-  de  I'Acad.  Chir- 
T.  3,  4fo.) 

There  can  be  no  doubt,  that  Guattani’s  di- 
rections for  finding  the  oesophagus  are  very 
good  ; but  his  chief  defect  is  representing 
the  place  for  the  incision  as  beiugalways  the 
same,  whereas  it  ought  to  be  partly  regulated 
by  the  situation  of  the  foreign  body  itself. 
However,  his  advice  to  make  the  incisions 
close  to  the  trachea  -appears  to  me  more  ju- 
dicious, than  that  recently  delivered  by 
Boyer,  who  directs  them  to  lie  made  through 
the  cellular  substance  between  the  sterno- 
byoideus  and  sterno-thyroideus  muscles, 
and  the  omo-hyoideus,  (see  Traite  des 
Mai.  Chir.  T.  7,  p.  193,  8 vo.  Paris,  1821,) 
in  which  method,  he  quits  the  trachea, 
which  is  the  best  guide  to  the  oesophagus, 
and  approaches  unnecessarily  the  large 
blood-vessels  of  the  neck.  Yet,  I agree 
with  Boyer,  respecting  the  general  impro- 
priety of  attempting  oesophagotomy,  when 
the  situation  of  the  foreign  body  is  not  indi- 
cated by  any  prominence  in  the  neck,  and 
the  prudence  of  determining  the  place  of 
the  incision  in  a great  measure  by  such  pro- 
jection. Boyer  also  cautions  the  operator 
to  let  his  incisions  always  be  made  in  such 
manner,  as  to  leave  unhurt  the  trachea  and 
recurrent  nerve  at  the  inner  edge  of  the 
wound  ; the  carotid  and  internal  jugular  vein 
at  its  outer  edge  ; the  superior  thyroideal 
vessels,  above ; and  the  inferior  ones,  below. 
With  this  view,  the  cellular  substance  is  to 
be  slowly  divided  layer  by  layer,  and  the 
blood  repeatedly  absorbed  with  a sponge  ; 
but,  if  any  vessel  bleed  freely,  it  is  to  be 
immediately  tied. 

After  the  operation,  an  elastic  gum  ca- 
theter should  be  passed  from  one  of  the  nos- 
trils down  the  pharynx  and  oesophagus,  by 
which  means,  the  requisite  food  and  medi- 
cines may  be  injected  iuto  the  stomach, 
without  any  risk  of  their  passing  through 
the  incision,  and  retarding  the  cure.  But, 
a still  stronger  motive  for  this  practice  is  the 
avoidance  of  the  convulsive  action  of  the 
muscles  in  deglutition ; a source^  of  very 
hurtful  disturbance  to  the  parts.  Before  the 
advantages  of  this  contrivance  were  duly 
appreciated,  the  patient,  for  the  first  week, 
was  allowed  to  swallow  scarcely  any  thing, 
and  was  kept  alive  with  broths  injected  up 
the  rectum. 

(ESOPHAGUS,  Foreign  bodies  in  the . 
There  are  few  situations,  in  which  foreign 
bodies  lodge  more  frequently,  than  in  the 

oesophagus  ; a fact,  explicable  bv  the  eon- 


(ESOPHAGUS. 


sissr 


federation  of  Hie  iunclion  of  this  tube,  the 
Nearness  of  part  of  which  to  the  windpipe 
at  the  same  time  accounts  for  the  frequent 
danger  of  suffocation,  when  a substance, 
above  a certain  size,  is  lodged  in  it.  The 
lodgment  often  takes  place  at  the  lower  part 
of  the  pharynx,  or  beginning  of  the  oeso- 
phagus, and  sometimes  just  above  the  dia- 
phragm; hut  very  rarely  in  the  intervening 
portion  cm  i hat  canal. 

Foreign  bodies  liable  to  lodge  in  the  oeso- 
phagus, arc  not  only  articles  of  food,  such 
as  pieces  of  crust,  or  meat  imperfectly 
chewed,  the  yolk  of  an  egg,  boiled  very 
hard,  and  not  masticated,  a chesnut,  or  small 
apple,  &c. ; but  also  various  substances, 
which  are  accidentally  swallowed  either 
alone,  or  together  with  the  food,  such  as 
pieces  of  bone,  stones,  pins,  needles,  buttons, 
pieces  of  money,  knives,  forks,  scissors, 
spoons,  keys,  fcc.  - These  latter  articles,  by 
lodging  in  the  pharynx,  or  oesophagus,  may 
occasion  very  bad  and  fatal  symptoms,  and, 
if  forced  down  into  the  stomach,  may  pro- 
duce effects  of  a not  less  serious  description. 
Hence,  an  immediate  attempt  should  always 
be  made  to  extract  them.  For  this  purpose, 
the  lingers  may  be  employed,  and,  if  they 
will  not  reach  far  enough,  a pair  of  long 
curved  forceps  should  be  used.  But,  no 
instrument  seems  better  calculated  for  cases, 
in  which  the  body  lodged  in  the  oesophagus 
13  not  too  wide,  than  the  urethra-forceps, 
invented  by  Mr.  Weiss,  of  the  Strand,  and 
used  by  Sir  Astley  Cooper  for  the  re- 
moval of  calculi  under  a certain  size,  from 
the  bladder.  (See  Med.  Chir.  Trans.  Vol. 
31.)  Nooses  of  wire,  and  bunches  of  thread 
with  a multitude  of  nooses,  fastened  upon 
the  end  of  a probang,  and  a piece  of  sponge 
fixed  on  the  extremity  of  the  same  instru- 
ment, or  on  that  of  the  strong  wire  stilet  of 
a long  elastic  gum-catheter,  and  various  other 
contrivances  have  been  made  with  the  view 
of  extracting  different  articles  from  the  oeso- 
phagus. The  hunch  of  thread  seems  well 
calculated  for  catching  hold  of  small  sub- 
stances, like  fish-bones,  needles,  &,c. ; and 
the  sponge,  when  expanded  with  moisture 
and  withdrawn,  will  sometimes  bring  up  ar- 
ticles, which  on  its  introduction,  it  bed 
passed  in  its  dry  and  diminished  state. 
When  the  stomach  is  full,  the  excitement  of 
vomiting  has  sometimes  answered  ; but,  if 
the  foreign  body  be  sharp  and  pointed,  the 
method  is  not  free  from  danger,  and,  instead 
of  relieving  the  patient,  may  put  him  to  great 
pain,  and  bring  on  violent  inflammation  of 
the  passage,  and  the  most  distressing  symp- 
toms. 

When  the  substances  are  not  of  a very 
hurtful  kind,  and  cannot  be  extracted,  they 
must  be  pushed  down  into  the  stomach  with 
a large  bougie,  or  a whalebone  prohang, 
fifteen  or  sixteen  inches  long,  and  on  the  end 
of  which  a piece  of  line  sponge  is  securely 
fastened.  But  such  practice  is  not  ndviseabJe, 
when  the  foreign  bodies  have  a sharp,  point- 
ed form,  so  as  to  be  likely  to  prove  n source 
of  at  least  equal  danger  and  suffering,  if 
placed  in  contact,  willr  the  inner  surface  of 


the  stomach.  Experience  proves,  that  hardy 
angular  substances,  and  pointed  bodies,  like 
nails,  pins,  needles,  &c.  which  surgeons  have 
not  ventured,  or  not  been  ahle^to  force 
down  into  the  stomach,  have  often  made 
their  way,  after  a time,  to  the  surface  of  the 
body,  where  an  abscess  has  formed,  out  of 
which  they  have  been  discharged. 

When  very  hard,  irritating  bodies  have 
either  passed  of  themselves,  or  been  pushed 
with  a prohang  into  the  stomach,  their  ill 
effects  should  be  counteracted,  and  then- 
passage  through  the  bowels  promoted,  with 
mucilaginous  draughts,  containing  the  oleum 
amygdalarum,  or  oleum  ricine.  When  the 
substances,  lodged  in  the  oesophagus,  can 
neither  be  extracted,  nor  pushed  down  into 
the  stomach,  if  respiration  be  not  danger 
ously  obstructed,  and  liquids  can  yet  be 
swallowed,  the  wisest  plan  is  to  avoid  irrita- 
ting the  passage  with  the  further  use  of  in- 
struments, and  leave  the  case  to  nature,  that 
is  to  say,  as  far  as  manual  interference  is 
concerned  ; for,  bleeding,  and  macilaginous 
oily  draughts,  may  be  in  some  cases  useful. 
But,  when  the  lodgment  of  a foreign  body 
in  the  oesophagus  dangerously  obstructs  re- 
spiration, aud  the  substance  itself  can  be 
felt  externally,  the  patient  would  perish,  if 
some  means  of  facilitating  the  breathing 
were  not  immediately  adopted  ; and,  under 
these  circumstances,  perhaps,  the  most  pru- 
dent plan  would  be  to  make  an  opening  in 
the  trachea.  (See  Bronchotomy.)  The  sub- 
sequent treatment,  with  reference  to  the 
foreign  body  itself  might  be  determined  by 
the  circumstances  of  the  case. 

In  this  part  of  surgery,  one  fact  deserves 
to  be  particularly  remembered,  which  is, 
that  after  a sharp,  hard  substance  has  been 
either  ejected,  orpropelled  into  the  stomach 
b}7  nature,  or  art,  the  same  painful  sensations 
in  the  throat  frequently  continue  a certain 
time  afterward,  which  were  experienced 
while  the  foreign  body  was  actually  lodged 
in  the  passage.  These  sensations,  however, 
are  only  owing  to  the  manner,  in  which  the 
oesophagus  has  been  irritated,  and,  conse- 
quently, would  he  seriously  aggravated  by 
the  further  unnecessary  introduction  of  pro- 
bangs. and  other  instruments. 

There  may  be  cases,  in  which  the  patient 
would  lose  his  life  by  suffocation,  if  a 
foreign  body  of  considerable  size  were  not 
taken  out  of  the  oesophagus,  so  as  to  remove 
the  compression  of  the  iracbea.  Here,  if  it 
could  neither  be  extracted,  nor  pushed  into 
the  stomach  by  common  means,  and  its 
situation  were  indicated  by  any  hardness,  or 
prominence  in  the  neck,  an  operation  would 
be  necessary  for  its  removal.  (See  (Esopfia - 
gotomy.) 

A foreign  body,  not  large  enough  to  cause 
danger  ot  suffocation  by  pressure  on  the 
trachea,  may  yet  bring  on  fatal  symptoms, 
as  is  exemplified  in  a case,  which  fell  under 
the  notice  of  Guattani.  As  a man  was  throw- 
ing up  a boiled  chesnut  in  the  air,  and  catch- 
ing it  in  his  mouth,  it  passed  down  his  throat;, 
cud  he  was  immediately  seized  with  a difli- 
c ul tv  of  swallowing,  and  scut,  to  the  ho.- pda! 


i 


(ESOPHAGUS. 


29  i 


However,  as  lie  breathed  and  spoke  with 
facility,  and  had  vomited  since  the  accident, 
which  happened  when  he  was  tipsy,  the 
story  of  his  having  swallowed  the  chesnut 
was  disbelieved.  His  symptoms  grew  worse, 
and  he  died  on  the  19th  day.  Guattani 
made  an  incision  in  the  left  side  of  the  neck, 
below  the  larynx  and  thyroid  gland,  which 
was  considerably  swelled,  and  soon  came  to 
a large  abscess,  formed  around  the  portion 
of  the  oesophagus  enclosing  the  chesnut. 

When  the  extraneous  body  is  sharp  and 
pointed,  so  as  to  stick  in  the  mucous  mem- 
brane of  the  passage,  and  it  cannot  be 
removed,  nature  will  sometimes  expel  it 
herself,  without  any  dangerous  symptoms 
being  the  consequence.  The  foreign  body 
is  gradually  loosened  by  ulceration,  and  is 
then  either  ejected  by  vomiting,  or  descends 
into  the  stomach,  whence  it  is  voided  either 
through  the  bowels  with  the  feces,  or,  as  is 
more  common,  by  making  its  way  through 
some  part  of  the  alimentary  canal,  and 
approaching  the  surface  of  the  body,  where 
an  abscess  forms,  out  of  which  it  is  discharged. 
In  other  instances,  foreign  bodies,  like  pins 
and  needles,  which  cannot  be  removed, 
pierce  the  oesophagus  itself,  gradually  pass 
completely  out  of  this  canal,  and  afterward 
travel  to  remote  parts  of  the  body,  without 
exciting  much  inconvenience,  until,  perhaps, 
at  the  end  of  some  years,  they  come  near  the 
surface  of  the  body,  in  a very  remote  situa- 
tion from  the  throat ; and  an  abscess  is  pro- 
duced, in  which  they  are  unexpectedly  found. 
However,  this  transport  of  sharp-pointed 
substances  from  one  part  of  the  body  to 
another,  which  is  effected  by  a process,  in 
which  the  absorbents  have  a principal  share 
in  the  work,  is  not  conducted  in  every 
instance  with  so  little  disturbance,  and, 
when  foreign  bodies  of  this  description  come 
into  contact  with  particular  organs,  symptoms 
of  a dangerous  and  fatal  kind  may  be 
excited. 

The  great  art  of  passing  any  instrument 
down  the  oesophagus,  for  surgical  purposes, 
consists  in  putting  its  extremity  at  once 
directly  against  the  posterior  part  of  the 
pharynx,  and  keeping  it  closely  against  the 
vertebrae  so  as  to  avoid  touching  the  epiglottis. 
The  knowledge  of  this  circumstance  will  be 
found  extremely  useful  in  passing  probangs 
and  bougies.  When  elastic  gum-catheters 
are  intended  to  be  left  in  the  passage,  they 
are  introduced  down  the  pharynx  from  one 
of  the  nostrils,  and,  being  secured,  they 
serve  for  the  conveyance  of  liquid  food  and 
medicines  into  the  stomach  with  great  ad- 
vantage, in  many  cases,  either  where  the 
patient  cannot  swallow  at  all,  or  where  the 
disturbance  of  swallowing  would  be  attend- 
ed with  considerable  harm.  When,  however, 
the  plan  is  not  to  leave  the  instruments 
introduced,  as  Boyer  observes,  they  may  be 
passed  through  the  mouth. 

(ESOPHAGUS,  Strictures,  and  other  Dis- 
eases of  the.  Properly  speaking,  a difficulty, 
or  impossibility,  of  swallowing  should  not  be 
regarded  as  a disease  itself;  but  only  as  a 
symptom  of  different  affections,  to  which  the 


organs  of  deglutition  are  liable,  or  of  other 
diseases,  which  affect  parts  in  the  vicinity  of 
the  pharynx  and  oesophagus.  The  object  of 
the  present  article  is  not  the  consideration  of 
all  the  diseases,  which  may  produce  dyspha- 
gia, as  a symptom,  but  chielly  to  notice  this 
effect,  as  depending  upon  spasm,  paralysis, 
or  some  morbid  change  of  structure  affecting 
the  pharynx  or  oesophagus. 

Spasmodic  dysphagia,  as  Baron  Boyer  has 
remarked,  principally  occurs  in  nervous  in- 
dividuals, hysterical  females,  and  hypochon- 
driacal men.  It  is  sometimes  an  attendant  on 
fevers  ; it  is  declared  to  be  constant  in  hydro- 
phobia, and  epilepsy,  and  occasionally  pre- 
sent in  particular  forms  of  mania.  ( TraiU  deS 
Mai.  Chir  T.7,p.  151.)  However,  with  re- 
spect to  hydrophobia,  the  foregoing  assertion 
should  be  received  with  some  qualification, 
for  reasons  so  fully  detailed  in  another  part 
of  this  work  (see  Hydrophobia,)  that  it  is 
unnecessary  here  to  dwell  upon  the  subject.. 
Spasmodic  dysphagia  is  said  also  to  be  some-*, 
times  a consequence  of  taking  cold  drink, 
after  a violent  lit  of  anger;  of  strong  im- 
pressions on  the  imagination  ; of  worms  in 
the  stomach,  &.c. 

When  the  spasm  is  situated  in  the  pharynx 
and  upper  part  of  the  oesophagus,  and  is 
considerable,  neither  solids  nor  liquids  can 
be  swallowed,  and  the  patient  has  great  pain 
and  a sense  of  constriction  in  his  throat... 
When  he  tries  to  swallow  any  thing  soft,  or 
even  fluid,  he  is  seized  with  acute  pain,  insuf- 
ferable nausea,  and  violent  agitation  of  the 
whole  frame.  In  this  case,  the  spasm  is 
never  restricted  to  the  pharynx  and  upper 
portion  of  the  oesophagus,  but  extends  to 
other  organs,  the  inability  of  swallowing 
coming  on  in  the  midst  of  numerous  other 
spasmodic  symptoms,  exceedingly  compli- 
cated, and  sometimes  of  a very  alarming 
nature.  When  it  is  the  middle,  or  lower, 
part  of  the  oesophagus,  which  is  concerned, 
as  is  frequently  the  case  in  hysterical  women . 
the  food  passes  through  the  pharynx  and 
unaffected  portion  of  the  oesophagus  with 
tolerable  facility  ; but,  as  soon  as  it  reaches 
the  seat  of  the  spasm,  it  is  either  stopped,  or 
descends  further  with  great  difficulty  and 
effort.  Liquids,  especially  when  warm,  and 
swallowed  slowly  in  small  quantities  at  a 
time,  usually  pass  down  with  more  ease,  than 
solid  substances.  When  the  matterto  be  con- 
veyed into  tbe  stomach  reaches  the  point  of 
obstruction,  the  generality  of  patients  are 
attacked,  with  pain  extending  along  the 
spine  between  the  shoulders,  and  sometimes- 
shooting  to  the  stomach,  which  is  consider- 
ably disturbed,  and  often  discharges  jis  con- 
tents. In  some  cases,  however,  no  sucti 
pain  is  experienced,  and  whatever  the  pa- 
tients try  to  convey  into  their  stomachs 
regurgitates  quietly  into  their  mouths.  Al- 
though spasmodic  dysphagia  is  mostly  com- 
plicated with  other  marks  of  disorder  of  the 
nervous  system,  it  is  sometimes  unattended 
with  any  particular  impairment  of  the  health. 
{Boyer,  T.  7,  p.  152.) 

As  the  treatment  of  spasmodic  affection's 
of  the  pharynx  and  oesophagus  belongs  rat  her 


292  OESOPHAGUS. 


to  the  physician  than  the  surgeon,  [ shall 
be  very  brief  on  the  subject.  This  removal 
of  the  cause  of  the  infirmity,  that  is  to  say, 
of  the  particular  state  of  the  mind,  or  con- 
stitution, giving  rise  to  the  spasm,  is  the 
principal  thing,  at  which  the  practitioner 
should  first  aim.  Thus,  Boyer  cured  an 
hysterical  woman  of  a difficulty  and  dread 
of  swallowing  solid  food  attending  her,  at 
her  meals  twice  every  day  for  a month,  and 
gradually  convincing  her  of  the  absurdity  of 
her  apprehension  of  being  suffocated  by  at- 
tempting to  swallow  solid  aliment.  (Vol. 
cit.p.  154.)  Sauvages  makes  mention  of  an 
hysterical  female,  whose  difficulty  of  swal- 
lowing was  cured  by  a regimen  consisting 
of  regular  exercise,  cold  bathing,  and  milk- 
diet.  The  most  successful  remedies,  how- 
ever, are  said  to  have  been  camphor  in 
large  doses,  and  opium  taken  in  draughts, 
or  pills,  or  administered  in  clysters;  blisters 
and  cupping-glasses  applied  to  the  nape  of 
the  neck,  or  to  the  epigastrium.  Anodyne 
embrocations  are  also  stated  to  have  been 
useful.  At  the  present  day,  the  common 
idea,  that  many  anomalous  affections  depend 
upon  disorder  of  the  liver  and  digestive  or- 
gans, leads  to  the  frequent  employment  of 
the  compound  calomel  pill,  and  decoct, 
■sarsaparilla,  with  draughts  of  senna,  rhubarb, 
and  gentian  pro  re  nala. 

Dysphagia  may  originate  from  a weak- 
ened, or  paralytic  state  of  the  muscular 
fibres,  which  enter  into  the  structure  of  the 
pharynx  and  oesophagus.  The  affection  may 
be  either  symptomatic,  or  idiopathic.  The 
first  case  frequently  occurs  in  febrile  dis- 
eases, and  is  generally  set  down  by  writers, 
as  a very  unfavourable  omen.  The  idio- 
pathic form  of  the  complaint  may  be 
complete,  or  incomplete,  and  is  chiefly 
seen  in  persons  of  advanced  age,  though 
occasionally  the  patients  are  young  and  in 
the  prime  of  life.  The  causes  may  be  said 
to  be  little,  or  not  at  all  understood,  and  the 
only  remark,  which  can  be  safely  made  re- 
specting them,  is,  that  they  are  usually  con- 
nected with  constitutional  derangement. 

With  regard  to  the  symptoms  of  paralysis 
of  the  oesophagus,  when  the  disorder  is  com- 
plete, deglutition  is  absolutely  prevented, 
and,  if  the  patient  tries  to  swallow,  the 
food  lodges  in  the  pharynx,  and  sometimes 
produces  violent  fils  of  coughing.  Some  pa- 
tients eat  solid  substances  with  moderate 
facility  ; but,  find  more  or  less  difficulty  in 
taking  liquids.  Others  can  swallow  hastily  a 
large  quantity  of  fluid  at  a time,  yet,  cannot 
drink  slowly  and  a little  at  once.  Morgagni 
relates  an  instance  of  still  greater  singularity, 
which  was  an  ability  to  swrallow  all  kinds  of 
food  very  well,  except  the  last  mouthful, 
which  always  remained  in  the  oesophagus  until 
the  next  repast.  ( DeSed . et  Caus.  J\1orb.  Epist. 
28,  art.  14.)  In  cases  of  dysphagia  from 
paralysis  the  patient  suffers  no  pain,  nor 
sense  of  choking  ; if  the  neck  be  examined, 
no  hardness  nor  swelling  can  be  felt ; and  a 
probang  descends  down  the  gullet  without 
the  slightest  impediment.  (Boyer,  T.7,p.  158.) 

In  its  duration  and  termination,  dysphagia 


from  paralysis  presents  considerable  variety 
the  complete  paralysis  sometimes  proves  ra- 
pidly fatal,  not  however,  as  l conceive,  on 
account  of  the  affection  of  the  oesophagus 
alone,  but  other  complications,  and  the 
exhaustion  arising  from  inadequate  nutrition. 
Thus,  Tulpius  relates  an  instance,  in  which 
a woman  died  on  the  seventh  day  from  the 
commencement  of  the  inability  to  swallow, 
notwithstanding  every  endeavour  was  made 
to  support  her  with  nourishment  thrown  up 
the  rectum,  which  was  the  only  thing  that 
could  be  done,  as  she  would  not  allow  a tube 
to  be  passed  down  the  oesophagus.  In  other 
cases  the  patients  live  a considerable  time, 
and  afterward  perfectly  recover,  and  this 
sometimes  under  the  disadvantage  of  having 
been  entirely  supported  for  several  weeks 
with  broth-clysters,  as  we  find  exemplified 
in  a case  recorded  by  Ramazzini.  Certain 
examples  are  also  reported,  in  which  the 
patients  had  their  food  forced  into  the 
stomach  by  means  of  probangs,  for  years,  and 
either  ultimately  recovered  their  power  of 
swallowing,  or  in  this  manner  prolonged 
their  days,  without  any  cure  taking  place. 
(Stalpart  van  der  Wiel,  Vol.  2,  Obs.  28 ; 
Willis , Pharrti.  Rat.  Sect.  2,  cap.  1 ,p.  45.) 

Paralysis  of  the  oesophagus  is  to  be  treated 
on  the  same  principles,  as  other  paralytic 
affections  ; a subject,  which  I shall  not  be 
expected  to  discuss  ; but,  it  is  of  importance 
that  practitioners  recollect,  in  these  cases, 
the  very  essential  service  derived  from  the 
use  of  elastic  gum-catheters,  with  which  the 
requisite  food  and  medicines  may  be  in- 
jected into  the  stomach. 

Dysphagia  from  organic  disease,  or  mor- 
bid change  of  structure,  is  the  most  frequent 
case,  and  generally  the  most  difficult  of  cure. 
In  dissections,  the  parietes  of  the  oesophagus 
are  often  found  considerably  thickened, 
indurated,  and  scirrhous,  or  sometimes 
almost  cartilaginous,  and  even  ossified.  The 
parts,  where  the  pharynx  terminates  in  the 
(Esophagus,  and  where  the  latter  tube  joins 
the  stomach,  are  occasionally  converted 
into  thick  scirrhous  rings  with  or  without 
ulceration,  exactly  in  the  same  manner  as 
the  pylorus.  But,  such  diseases  are  not  re- 
stricted to  those  parts  of  the  (esophagus,  but 
sometimes  occupy  other  points  of  the  pas- 
sage. However,  the  organic  disease, 
producing  a difficulty,  or  impossibility  of 
deglutition,  is  not  always  situated  in  the 
coats  of  the  (Esophagus  itself ; for  the  parts, 
surrounding  this  canal,  are  subject  to  various 
diseases,  which  may  have  the  same  effect. 
Thus,  dysphagia  may  depend  upon  enlarge- 
ment of  the  thyroid  gland  ; tumours  formed 
between  the  trachea  and  oesophagus,  or  at 
some  other  point  near  the  latter  tube ; swell- 
ing and  induration  of  ^thc  thymus  gland  ; 
aneurism  of  the  aorta ; enormous  enlarge- 
ment of  the  liver  ; and  diseased  lymphatic 
glands  in  the  vicinity  of  that  portion  of  the 
oesophagus,  which  is  covered  by  the  perito- 
neum, and  the  largest  of  which  glands  are 
situated  near  the  fifth  dorsal  vertebra?,  just 
at  the  point  where  the  oesophagus  inclines* 


(ESOPHAGUS 


29.3 


little  to  the  right  side  to  make  way  for  the 
aorta.  (Boyer,  T.7,p.  162.) 

This  last  author  sets  down  every  case  of 
dysphagia,  depending  upon  organic  disease 
of  the  oesophagus,  as  incurable ; and  with 
respect  to  the  cure  of  other  examples,  in 
which  that  tube  is  compressed  by  swellings 
in  its  vicinity,  as  these  are  almost  always 
beyond  the  power  of  medicine  and  surgery, 
the  prognosis  is  nearly  as  unfavourable,  as 
where  there  is  a change  of  structure  in  the 
oesophagus  itself.  There  are  no  unequivocal 
symptoms,  by  which  a case  of  dysphagia 
from  enlargement  of  glands  in  the  vicinity 
of  the  oesophagus  can  be  known  from  seve- 
ral other  forms  of  the  complaint.  Hence, it  is 
difficultto  estimate  the  correctness  of  certain 
cases,  recorded  by  Ruyscb  (Advers.  Anat. 
Med.  Chir.  Dec.  1,  art.  10,  p.  24.)  anti  Haller 
( Opuscul . Pathol.  Obs.  78.)  where  .dysphagia, 
stated  to  have  been  produced  by  enlarged 
lymphatic  glands,  was  cured  by  mercurial 
frictions,  or  pills  composed  of  calomel,  aloes, 
and  camphor.  As  Boyer  justly  remarks, 
these  accounts  of  the  nature  of  the  diseases, 
thus  cured,  are  the  more  doubtful,  inasmuch 
as  the  resolution  of  chronic  swellings  of 
lymphatic  glands,  even  when  externally  situ- 
ated, is  very  difficult,  and  frequently  imprac- 
ticable, notwithstanding  the  use  of  topical 
applications  may  here  be  combined  with  the 
exhibition  of  internal  medicines  (T.7,p. 
169.)  However,  dismissing  the  question, 
whether  the  cases  really  arose  rrom  the 
pressure  of  enlarged  lymphatic  glands,  or 
not,  the  facts  ot  the  cures  having  taken 
place,  under  the  use  of  mercurial  medicines, 
are  of  themselves  interesting.  Several  wri- 
ters consider,  that  there  is  a great  analogy 
between  certain  forms  of  constriction  of  the 
oesophagus,  and  strictures  of  the  urethra,  and 
Mauchart  recommended  the  two  diseases  to 
be  treated,  on  the  same  principles,  u it h bou- 
gies, and  elastic  gum-catheters.  Baron  Boyer, 
however,  represents  this  doctrine  as  com- 
pletely erroneous,  declaring  that  the  affec- 
tion of  the  oesophagus  is  of  the  nature  of 
scirrhus,  and  absolutely  incurable.  He 
relates  one  case,  in  which  a woman’s  life 
was  prolonged  by  the.  use  of  an  elastic  gum- 
catheter,  though  it  proved  of  no  service  as  a 
means  of  permanently  dilating  the  diseased 
part  ; and,  notwithstanding  nourishing  li- 
quids were  plentifully  injected  into  the 
stomach,  the  patient  suffered  a good  deal 
from  hunger,  and  died  exhausted  about  three 
years  after  the  beginning  of  the  disorder. 
This  case,  however,  cannot  be  received,  as 
a proof  of  the  inefficacy  of  bougies  for  what 
is  commonly  implied  by  a stricture  of  the 
oesophagus,  because  the  nature  of  the  disease 
was  not  ascertained  by  an  in  pection  of  the 
oesophagus  after  death,  and  the  case  might 
have  depended  upon  some  organic  disease 
either  of  this  tube,  or  the  parts  in  its  vicinity 
not  classed  by  the  generality  of  modern 
writers  with  strictures  of  the  passage. 

The  following  are  some  of  Sir  Everard 
Home’s  sentiments,  respecting  these  last 
cases. 

As  the  oesophagus  is  required  to  be  wider 


at  one  time,  and  narrower  at  another,  in  or- 
der to  be  fitted  for  conveying  the  different 
kinds  of  food  into  the  stomach,  it  is  nearly 
under  the  same  circumstances,  with  respect 
to  the  formation  of  stricture,  as  the  urethra. 
For  obvious  reasons,  strictures  of  the  oeso- 
phagus are  much  less  frequent  than  those  of 
the  urethra.  However,  they  are  by  no 
means  uncommon,  and  produce  symptoms 
even  much  more  distressing  and  dangerous, 
than  those,  which  ordinarily  arise  from  ana- 
logous obstructions  in  the  passage  for  the 
urine. 

Of  course,  the  most  remarkable  symptom 
of  a stricture  in  the  oesophagus  is  the  diffi- 
culty of  swallowing,  which  must  be  greater 
or  less,  according  as  the  obstruction  is  more 
or  less  complete.  Sometimes  no  solid  food 
whatever  can  pass  down  into  the  stomach, 
and  fluids  can  only  descend  with  great  diffi- 
culty, and  in  very  small  quantities.  This  is, 
in  some  instances,  attended  with  considera- 
ble pain,  which  extends  along  the  fauces  to 
the  basis  of  the  skull,  and  through  the  eusta- 
chian  tube  to  the  ear.  The  pain  sometimes 
returns  at  intervals,  and  lasts  a considerable 
time,  even  when  no  effort  is  made  to  swal- 
low. If  a bougie  ot  proper  size  be  intro- 
duced down  the  pharynx,  it  will  often  be 
stopped  by  the  stricture  just  behind  the 
thyroid,  or  cricoid  cartilage;  for  from  Sir 
Everard  Home's  remarks,  it  appears  that  the 
obstruction  is  generally  as  high  up  as  this 
situation.  However,  there  are  other  cases, 
in  which  the  obstruction  is  only  of  a spas- 
modic nature,  and  in  these  a bougie  may  be 
passed  quite  own.  It  is  curious,  that  stric- 
tures high  up  in  the  cesophagus,  often  occa- 
sion ulceration  in  this  tube  very  low  down 
towards  the  stomach,  just  as  strictures  in 
the  urethra  occasion  ulceration  in  that  pas- 
sage towards  the  bladder.  This  is  most  apt 
to  occur,  when  strictures  of  (he  oesophagus 
have  been  of  long  continuance,  and  may 
arise  from  the  efforts  in  retching,  which 
frequently  come  on,  and  must  strain  the 
parts  already  deprived  of  their  natural 
actions,  and  of  the  benefit  of  the  secretions, 
with  w hich  they  are  lubricated  in  a healthy 
state.  When  such  ulceration  takes  place, 
the  characters  of  the  original  disease  are 
lost ; and  when  the  ulceration  extends  up- 
wards, the  stricture  itself  may  be  destroyed. 
A bougie,  introduced  under  such  circum- 
stances, will,  in  general,  have  its  point  en- 
tangled in  the  ulcer  ; and  when  so  skilfully 
directed  as  to  go  down  into  the  oesophagus, 
it  will  meet  with  a difficulty  while  it  is  pass- 
ing .the  commencement  ol  the  ulcerated 
part  of  the  oesophagus,  and  ano!her  impedi- 
ment where  it  leaves  the  ulcer,  and  enters 
the  sound  portion  ot  the  oesophagus  below. 
These  two  resistances  may  lead  to  the  sup- 
position, that  there  are  two  strictures,  while 
in  fact  there  is  not  one,  only  ulceration  as 
above  described. 

Strictures  in  the  oesophagus  are  sometimes 
so  complete,  that  swallowing  even  fluids  is 
utterly  prevented  ; the  patient  is  obliged  to 
have  nil* nourishment  injected  infra  anum , 


OLE 


294  CES.O 


and  in  general,  soon  perishes  in  a most  ema- 
ciated condition. 

Though  any  part  of  the  oesophagus  is 
liable  to  the  kind  of  contractions  forming 
strictures,  the  part  immediately  behind  the 
cricoid  cartilage,  where  the  pharynx  ends, 
and  the  oesophagus  begins,  is  the  most  fre- 
quent seat  of  the  obstruction.  Those  which 
are  situated  further  down  do  not  so  easily 
admit  of  being  examined,  and  relieved  by 
any  surgical  operation.  Strictures  of  the 
oesophagus  occupy  very  little  extent  of  the 
passage,  consist  of  a transverse  fold  of  the 
internal  membrane,  and  are  attended  with 
little  thickening  of  the  adjacent  parts. 
These  latter  circumstances  are  such  as  ren- 
der the  disease  capable  of  receiving  relief 
either  from  simple  or  armed  bougies. 

There  are  two  other  diseases  of  the  oeso- 
phagus, which  have  symptoms  similar  to 
those  of  strictures.  One  is  a thickening  of 
the  coats  of  the  oesophagus,  which  extends 
to  the  surrounding  parts,  and  generally  ends 
in  a cancer,  or  an  incurable  disease.  The 
other  affection  is  an  ulcer  of  the  lining  of 
the  passage,  commonly  situated  a little 
below  the  seat  of  the  stricture,  on  the  hack 
part  of  the  tube.  In  the  early  stale,  these 
diseases  can  only  be  distinguished  from  a 
stricture,  by  an  examination  with  a bougie; 
afterward  their  nature  becomes  clear 
enough  from  other  symptoms  which  arise. 
Strictures  also  take  place  more  commonly 
in  young  subjects ; the  other  two  diseases 
in  the  more  advanced  periods  of  life. 

Sir  E.  Horne  has  found,  that  a bougie  can 
be  more  easily  introduced  into  the  cesqpha- 
gus,  when  the  tongue  is  brought  forwards 
out  of  the  mouth.  This  gentleman  remarks, 
that  when  a bougie  is  passed,  with  a view  of 
learning  the  nature  of  the  case,  if  it  passes 
down  to  the  distance  of  eight  inches,  mea- 
suring from  the  cutting  edge  of  the  front 
teeth  in  the  upper  jaw,  its  extremity  has 
gone  beyond  the  usual  seat  of  stricture.  If 
it  he  withdrawn  without  any  resistance,  the 
aperture  in  the  oesophagus  must  then  be  lar- 
ger than  the  bougie  employed.  But  if  the 
bougie  stops  at  the  distance  of  six  inches 
and  a half,  or  even  lower,  it  must  be  re- 
tained there  with  a uniform  pressure  for 
halt  a minute,  so  as  to  receive  on  its  point 
an  impression  of  the  surface  by  which  it 
was  opposed.  If  the  end  of  the  bougie 
retains  its  natural  form,  or  nearly  so,  and 
there  is  an  indentation  on  one  side  of  it,  or 
all  round  it,  the  surgeon  may  conclude  there 
is  a stricture.  On  the  other  hand,  should  the 
bougie  descend  without  impediment,  as  far 
as  seven  inches  and  a half,  and,  when  with- 
drawn, the  surface  of  its  point  appear  irre- 
gular, and  jagged,  the  disease  is  an  ulcer  on 
the  posterior  part  of  the  oesophagus. 

The  mode  of  treatment  adopted  by  Sir 
E.  Home,  consists  either  in  passing  a com- 
mon bougie  occasionally  through  the  stric- 
ture, and  employing  one  of  a larger  size,  in 
proportion  as  the  dilatation  oT  the  obstruc- 
tion is  effected  ; or  else  in  introducing  an 
armed  bougie  at  convenient  intervals.  The 
\ views,  which  I take  of  the  disease,-  would 


lead  me  to  prefer  giving  a full  and  fair  tria. 
to  the  employment  of  elastic  gum-cathe- 
ters. Consult  Practical  Observations  on  the. 
Treatment  of  Strictures  in  the  Urethra  and 
(Esophagus,  3 Vols.  Edit.  3,  1805.  Vol.  2, 
1803,  and  Vol.  3,  1821,  by  Sir  E.  Home , 
Ph.H.Beuttelde  Struma  (Esophagi  ; hujusque 
coalitu  dijfficili  ac  abolitce  deglulitionis  Causis: 
(in  Haller's  Disp.  Chir.  2,  395,)  Tubing. 
1742,  Mauchart  de  Struma  (Esophagi , Tu- 
bing. 1742.  J.  Warner,  Cases  in  Surgery , p. 
130,  Ed.  4 F.  A.  J.  Zinckernagel,  de  Clyste- 
rum  JYutrienlum  Antiquit  ate,  el  Usu,  ( Trilleri 
Opusc.  1,399.)  A.  Vater , el  F.  A.  Zincker- 
nagel  de  Deglutitionis  difficilis  et  imp  edit  is, 
causis  abditis  : (Halleri  Disp.  ad  Morb.  1, 
577.)  E.  F.  Bulisius  de  Fame  lethali  ex 
callosa  oris  ventriculi  anguslia.  J.  M.  Ec - 
cardus , dc  his  qui  dm  vivunt  sine  alimento, 
4 to.  Kilice  Holsat.  1711.  Boyer  Trail6  de 
Mai.  Chir.  T 7,  8 vo.  Paris,  1821. 

OLEUM  CAMPHORATUM.  ft.  Olei 
oliv®.  Jb.i-  Camphor®  ^iv.  Misce  ut  solva- 
tur  camphora.  Sometimes  employed  for 
promoting  the  suppuration  of  indolent, 
particularly  scrofulous  swellings,  which  are 
to  be  rubbed  with  it  once,  twice,  or  thrice 
a day  according  to  circumstances. 

OLEUM  LINI.  In  surgery,  linseed  oil  is 
sometimes  used  as  an  application  to  hums, 
either  alone,  or  mixed  with  an  equal  quan- 
tity of  the  liquor  calcis.  It  has  also  been 
applied  to  cancerous  ulcers. 

1 OLEUM  ORIGAMI.  The  oil  of  marjoram 
is  often  used  for  dispersing  ganglions  : the 
tumours  are  to  be  rubbed  with  it  two  or 
three  times  a day. 

OLEUM  PALMiE  CAMPHORATUM. 
ft.  Camphor®  |ij.  Olei  palm®  jftj.  The 
camphor  is  to  be  reduced  to  powder,  and  the 
palm  oil,  being  melted,  and  suffered  to  be- 
come almost  cold,  is  to  be  mixed  with  it  in 
a mortar.  This  application  is  a mild  topical 
stimulant ; and  has  been  used  for  promoting 
indolent  suppurations,  especially  those  of  a 
scrofulous  nature,  which  take  place  under 
the  jaw,  and  are  attended  with  a good  deal 
of  chronic  induration. 

OLEUM  RICIJNI.  In  surgical  cases,  re- 
quiring the  bowels  to  be  opened  with  the 
slightest  degree  of  irritation  possible,  the 
oleiim  ricini  is  the  best  and  safest  medicine. 
The  usual  dose  is  one  large  table-spoonful, 
which  must  be  repeated  every  two  or  three 
hours,  till  the  desired  effect  is  produced. 

OLEUM  TERKBINTHINAT.  Oil  of  tur- 
pentine is  employed  externally  as  a stimula- 
ting liniment  and  a styptic.  In  the  article 
Liniment  may  be  seen  some  formul®,  in 
which  turpentine  is  the  most  active  ingre- 
dient. It  is  sometimes  exhibited  internally, 
for  the  cure  of  gleets. 

OLEUM  TEREBINTH! NATUM.  ft. 

Olei  arnygdal®  ^ss.  Olei  terebinthin®  gutt. 
xr..  Misce. 

In  deafness,  occasioned  by  defective,  or 
diseased  action  of  the  glandnl®  cerumine®, 
Mr.  Maule  directs  a little  of  this  oil  to  be 
dropped  into  the  patient’s  ear,  or  applied  at 
the  end  of  a small  dossil  of  cotton. 

WU*3U  a thin  secretion  takes  place,  the 


OPHTHALMY. 


cure  is  also  promoted  by  a small  blister, 
which  is  placed  as  near  the  ear  as  convenient, 
and  kept  open  with  the  savine  cerate.  The 
meatus  auditorius  externus  must  also  be 
cleansed  every  day  with  a lengthened  bit  of 
soft  cotton,  affixed  to  a probe.  (See  Phar- 
macop.  { shirurgica .) 

OMPI-fALOCE'LE.  (from  ojuyxkoc,  the 
navel,  and  a rupture.)  A rupture,  or 
hernia  at  the  navel.  (See  Hernia.) 

ONYCHlA.  (ovw|,  the  nail.)  An  abscess 
near  the  nail  of  the  finger.  (See  Whitlow.) 

ONYX.  (from  ovv%,  the  nail.)  A small 
collection  of  matter,  situated  in  the  anterior 
chamber  of  the  aqueous  humour,  and  so 
named  from  its  being  shaped  like  a nail.  It 
is  of  the  same  nature  as  Hypopium,  to  which 
word  I must  refer  the  reader.  Maitre-Jean, 
Mauchart,  and  several  other  oculists,  imply 
by  the  term  onyx,  a small  abscess  between 
the  layers  of  the  cornea. 

OPHTHALMY.  (from  opfla tx/aot,  the  eye.) 
Ophthalmia.  Ophthalmitis.  Inflammation 
of  the  eye.  This  is  not  only  a consequence 
of  several  affections  of  the  eye,  and  adjacent 
parts,  on  the  existence  of  which  other  dis- 
orders its  continuance  entirely  depends,  but 
is  frequently  the  primary  complaint,  and  too 
often  the  forerunner  of  such  irreparable 
mischief  as  for  ever  bereaves  the  patient  of 
vision.  The  determination  of  a preternatu- 
ral quantity  of  blood  into  the  organ,  and 
fulness  of  its  vessels,  or  a congestion,  as  se- 
veral writers  express  themselves,  is,  accord- 
ing to  Beer,  the  earliest  change  which  occurs 
in  ophthalmy  in  general.  The  next  symp- 
tom is  said  to  be  redness,  which  becomes 
more  intense,  as  the  disorder  makes  progress, 
and  if  the  complaint  be  protracted,  the  red 
assumes  a dark  hue,  then  a brownish,  and 
lastly  a bluish  tinge.  However,  when  the 
arteries  and  veins  affected  soon  return  to 
their  natural  state,  the  redness  of  the  textures 
of  the  eye  may  not  attain  the  greatest  in- 
tensity. Professor  Beer  seems  to  adopt  si- 
milar views  of  the  nature  of  the  process  of 
inflammation  to  those  which  are  taken  by 
Dr.  W.  Philip,  and  some  other  writers  alrea- 
dy mentioned,  (see  Inflammation ,)  for,  in 
consequence  of  the  small  arteries  and  veins 
being  deprived  of  their  propelling  power,  he 
considers  that  the  blood  in  the  texture, 
w hich  is  the  immediate  seat  of  inflammation, 
is  in  a state  of  actual  stagnation.  ( Lehre 
von  den  Jhigenkrankheiten , B.  1 ,p.  30.)  The 
third  general  symptom  of  ophthalmy,  des- 
cribed by  Beer,  as  closely  following  the 
redness,  is  a tense,  hard,  painful  -swelling  of 
the  texture,  directly  affected.  Lastly,  in 
proportion  as  the  pain,  redness,  and  swelling 
are  considerable,  the  more  obvious  is  ano* 
ther  common  effect  of  inflammation,  viz* 
an  increase  of  temperature  or  heat.  But 
although  the  disturbed  intercourse  between 
the  arterial  and  venous  systems  is  more  ob- 
vious than  the  effects  of  inflammation  in 
other  parts  of  the  organization  of  the  eye, 
yet,  that  the  secreting  and  excreting  vessels, 
and  the  absorbents,  are  also  affected,  is 
evinced  by  the  augmented  secretion  and 
excretion  in  the  early  stage  of  the  disorder, 


followed,  when  the  inflammation  has  be- 
come more  intense,  by  a suppression  of 
these  functions,  and  a dryness  and  want  of 
pliancy  in  the  inflamed  textures  of  the  eye. 
The  disturbance  of  the  connexion  between 
the  nerves  and  muscles  also  produces  first 
various  involuntary  movements,  which,  as 
the  inflammation  makes  progress,  become 
more  and  more  limited,  and,  at  length,  there 
is  a complete  loss  of  action  in  the  textures 
of  the  eye,  which  are  the  seat  of  inflamma- 
tion. 

But,  inasmuch  as  every  disease  of  the  eye 
presents  some  differences,  depending  upon 
the  nature  of  the  disorder  itself,  and  others 
arising  from  the  peculiar  organization  of  the 
texture,  which  happens  to  be  principally 
affected,  the  characteristic  appearances  of 
ophthalmy  must  be  subject  to  a vast  num- 
ber of  modifications,  according  as  this  or 
that  structure  of  the  eye  is  inflamed ; and 
hence,  sometimes  one  symptom  of  inflam- 
mation, sometimes  another,  chiefly  predo-  ** 
minates,  while  Others  are  less  conspicuous, 
and  often  scarcely  distinguishable.  Yet,  says 
Beer,  none  of  the  characteristic  marks  of 
inflammation  are  ever  entirely  absent.  This 
author  represents  the  degree  of  pain  as  be- 
ing proportioned  in  a great  measure  to  the 
tough  unyielding  nature  of  the  parts  imme- 
diately around  the  inflamed  texture  of  the 
eye,  to  the  firm  nature  of  the  inflamed  tex- 
ture itself,  and  to  the  quantity  of  nerves 
with  which  such  texture,  and  the  parts  in 
its  immediate  vicinity,  are  supplied.  In 
proof  of  the  truth  of  this  doctrine,  he  in- 
stances whitlows  and  internal  ophthalmy, 
where  the  .pain  is  very  severe  ; while  in- 
flammations of  the  conjunctiva,  not  extend- 
ing to  the  deeper  textures  of  the  eye,  are 
described  as  cases  in  which  the  pain  is 
slight,  because  the  structure  affected  is  loose 
and  yielding.  But,  without  scrutinizing 
every  reason  assigned  by  Beer,  for  the  va- 
rieties observable  in  the  symptoms  accord- 
ing to  the  texture  which  happens  to  be  most 
affected,  I shall  briefly  state  a few7  other  ex- 
amples quoted  by  the  same  author.  That 
the  degree  of  redness,  as  well  as  of  pain, 
varies  considerably  in  different  states  of 
ophthalmy,  is  a fact  universally  known.  In 
the  beginning  of  the  complaint,  such  red- 
ness is  generally  less  perceptible  than  when 
the  inflammation  has  attained  its  highest 
pitch  ; but  it  is  not  equally  great  in  every 
individual,  nor  in  every  species  of  ophthal- 
my, being  sometimes  more  intense  and  dif- 
fused,'sometimes  less  both  in  degree  and 
extent.  This  diversity  is  referred  by  Beer, 
and  probably  with  reason,  to  the  texture 
affected  in  the  eye,  being  furnished  with 
many  considerable  blood-vessels,  obvious  to 
the  sight,  or  only  containing  vessels,  more 
concealed  and  rather  filled  with  a colourless 
fluid  than  with  red  blood.  The  looseness 
or  unyielding  nature  of  the  texture  is  also 
represented  as  making  a difference  in  the 
degree  of  redness.  In  inflammation,  prin- 
cipally affecting  the  conjunctiva  and  sclero- 
tica, says  Beeivthe  redness  is  so  intense,  as 
to  give  the  eye  a frightful  appearance,  as  i- 


OPHTHALMY. 


296 


seen  in  ciiemosis  ; while  in  inflammations 
of  the  innermost  textures  of  the  organ,  the 
redness  is  scarcely  perceptible,  and,  in  the 
erysipelatous  inflammation  of  the  eyelids, 
the  redness  is  very  faint,  (j Beer,  Lehre  von 
den  Augenkrankheiten , B.  \,p.  34 — 36.) 

Dr.  Vetch  remarks,  that  the  conjunctiva  is 
capable  of  being  stretched  to  a great  extent, 
owing  to  the  loose  structure  of  the  cellular 
membrane  on  which  it  lies,  and  consequent- 
ly little  resistance  is  made  to  the  enlarge- 
ment of  its  vessels.  From  slight  irritation, 
they  soon  become  distended  with  red  blood, 
il  but  their  tone  or  power  of  reaction  is  spee- 
dily exhausted,  and,  if  the  exciting  cause  is 
not  kept  up  in  an  increasing  ratio,  they 
quickly  fall  into  a chronic  or  varicose  en- 
largement, or  again  contract  to  the  diame- 
ter of  the  serous  vessels.”  On  the  other 
hand,  (as  the  same  experienced  writer  has 
pointed  out,)  inflammation  of  the  sclerotic 
coat  is  slow  in  its  commencement,  and  often 
insidious  in  its  progress,  even  when  its  ulti- 
mate violence  is  great.  In  the  early  stage  of 
conjunctival  ophthalmia,  the  inflammation  is 
most  observable  at  a distance  from  the  cornea , 
round  which  the  membrane  often  preserves 
for  a length  of  time  its  natural  appearance. 
Precisely  the  reverse  takes  place  in  the  case  of 
sclerotic  inflammation , which  invariably  ap- 
pears at  the  circumference  of  the  cornea , 
forming  a zone , more  or  less  complete  around 
it , and  most  conspicuous  above  it , the  form  and 
colour  of  the  vessels  being  at  the  same  time 
wholly  different  from  those  which  appear  in 
the  course  of  conjunctival  inflammation. 
Intolerance  of  light  (says  Dr.  Vetch,)  in  va- 
riably accompanies  sclerotic  inflammation,  and 
is  entirely  unconnected  with  that  of  the 
conjunctiva.  (A  Practical  Treatise  on  the 
Diseases  of  the  Eye,  p.  10.)  If  the  latter  ob- 
servation be  strictly  correct,  it  is  to  be  in- 
ferred that,  in  all  common  cases  of  acute 
ophthalmy,  involving  the  conjunctiva  on 
the  front  of  the  eyeball,  the  sclerotica  is 
more  or  less  affected,  as  in  the  beginning  of 
the  disorder,  light  may  be  said  to  be  seri- 
ously annoying  to  every  patient. 

According  to  Mr.  Travers,  when  the  scle- 
rotica partakes  of  the  inflammation  of  the 
conjunctiva,  the  vessels,  which  pursue  a 
straight  course  to  the  margin  of  the  cornea, 
are  strongly  distinguished,  and  have  a some- 
what darker  hue, than  the  areol  ar  vessels  upon 
the  loose  portion  of  (he  conjunctiva.  ( Synop- 
sis of  the  Diseases  of  the  Eye,  p.  128.) 

Diversified  as  the  pain,  redness,  swelling, 
and  heat,  the  four  characteristic  symptoms 
of  inflammation,  may  be  in  cases  of  oph- 
thalmy, the  incidental  appearances  in  the 
eye  are  not  less  subject  to  numerous  modi- 
fications. Thus,  sometimes  an  extraordinary 
involuntary  action  of  the  muscles  of  the 
eyeball  and  eyelids,  or  of  the  secreting  and 
excreting  lachrymal  organs,  and  of  the  Mei- 
bomian glands  may  be  noticed  ; and  some- 
times the  action  of  all  these  parts  is  either 
diminished,  or  completely  stopped.  These 
differences  Beer  refers  to  the  latter  parts 
being  either  themselves  inflamed,  or  sympa- 
thizing with  the  inflamed  texture  of  the  eve 


lathe  first  case,  the  action  of  the  muscles,  and 
the  functions  of  the  lachrymal  organs,  and 
Meibomian  glands,  are  more  and  more  inter- 
rupted in  proportion  as  the  inflammation 
increases,  and  must  thus  remain,  while  the 
inflammation  lasts  in  its  genuine  form  ; but, 
in  the  second  case,  they  go  on,  and  this 
even  with  greater  activity,  while  the  inflam- 
mation continues,  and  until  it  has  ceased  to 
become  more  violent.  ( B . 1 ,p.  39.) 

Acute  ophthalmy  in  general,  when  at  all 
severe,  and  particularly  when  the  inner  tex- 
tures of  the  eye  are  affected,  produces  a 
febrile  disturbance  of  the  whole  constitution. 
This  change  from  a local  to  a general  indis- 
position takes  place  with  greater  certainty 
and  quickness,  in  proportion  as  the  focus  of 
inflammation  is  extensive,  the  constitution 
irritable,  the  disorder  of  the  eye  neglected, 
and  the  mischief  considerable,  which  is  ac- 
tually produced  in  the  organ,  whether  acci- 
dentally, or  in  consequence  of  unskilful 
treatment.  (Beer,  Vol.  cit.  p.  42.) 

Many  of  the  appearances  and  effects  of 
ophthalmy  are  different,  as  the  inflammation 
happens  to  be  of  an  acute,  or  chronic  na- 
ture. And,  as  Scarpa  has  taken  particular 
pains  to  impress  upon  the  minds  of  surgical 
practitioners,  every  acute  ophthal my, though 
treated  in  the  best  possible  manner,  is  never 
so  completely  resolved  as  not  to  be  followed 
by  a certain  period,  at  which  ail  active  dis- 
turbance ceases,  in  the  place  of  which  a 
degree  of  chronic  ophthalmy  remains  in  the 
conjunctiva,  or  lining  of  the  eyelids  ; the 
effect  either  of  local  weakness  in  the  vessels, 
or  of  the  continuance  of  a morbid  irritability 
in  the  eye,  after  the  removal  of  the  acute 
stage  of  the  inflammation.  As  it  occasions 
a diseased  secretion  in  the  organ,  and  a 
slow  accumulation  of  blood  and  coagulating 
lymph,  (he  inexperienced  are  apt  to  suppose,, 
that  the  acute  stage  is  not  yet  entirely  sub- 
dued, while  it  is  completely  so.  Now,  if  the 
inculcations  of  Richter  and  Scarpa  be 
correct,  immediately  the  critical  moment 
arrives,  when  the  acute  stage  changes  into 
the  chronic,  attended  with  local  weakness, 
it  is  of  the  highest  importance  to  alter  the 
treatment  without  delay,  and  to  substitute 
for  emollient  relaxing  applications,  such  as 
partake  of  an  astringent  corroborant  quality, 
as  the  former  only  protract  the  turgescence 
of  the  vessels,  and  the  redness  of  the  con- 
junctiva. “Quo  major  autem  fuit  inflam- 
mationis  vehementia  (says  Richter,)  eq 
major  pleruraque  sequitur  partiutn  affecta- 
rum  atonia,  eoque  major  opus  est  adstrin 
gentium  et  roborantiurn  longo  usu,  ut 
auferanlur  penitus  reliquiae  inorbi,  &,c." 

( Fasical . Obs.  Chir.  1 ,p.  109.) 

It  is  on  the  accession  of  the  second  stage 
of  ophthalmy,  that  one  may  remark  the 
sudden  increase  of  redness  in  the  inflamed 
texture,  with  a brown  and  afterward  a blue 
tinge  , actual  extravasations  of  blood  in  the 
chambers  of  the  aqueous  humour;  ecchy- 
mosis  of  the  conjunctiva ; a considerable  in- 
crease of  swelling;  the  decline  and  irregu- 
larity of  the  pain  ; the  decrease  of  the  in- 
flammatory heat  and  throbbing : a sensation 


OPHTHALMY 


297 


of  cold  and  heaviness  in  the  organ  ; and 
more  or  le$s  oedematous  swelling  of  the 
surrounding  parts.  It  is  also  in  the  second 
stage,  that  suppuration  is  liable  to  happen. 
(Beer,  Lehre,  fyc.  B.  1,  p.  46.)  And  in  an- 
other page  the  same  author  observes,  that 
the  characteristic  signs  of  the  second  stage 
of  ophthalmy  consist  in  the  following  ap- 
pearances : while  the  redness  and  swelling 
undergo  a sudden  and  striking  increase,  the 
hardness  manifestly  diminishes,  and  the  pain 
becomes  very  unequal,  and  not  continual  ; 
the  secretions  and  excretions  also,  which, 
during  the  first  stage,  were  completely  stop- 
ped, commence  again,  but  more  copiously, 
and  are  of  a very  different  quality  from  what 
they  were  in  the  state  of  health.  The  dis- 
order is  now  quite  in  its  second  stage,  and 
this  is  the  time  when  purulent  matter  may 
begin  to  be  formed.  (B.  1,  p.  50.)  Accord- 
ing to  Beer,  the  duration  of  idiopathic  oph- 
thalmy depends  upon  the  circumstances  of 
each  individual  case  ; first,  the  nature  of 
the  causes  giving  rise  to  the  affection  ; se- 
condly, the  irritability  of  the  patient  in  re- 
lation to  constitution,  sex,  and  age  ; thirdly, 
Avhat  may  be  termed  the  constitution  of  the 
affected  eye  itself,  and  the  texture  in  it  im- 
mediately inflamed.  Thus  ophthalmy  is  like- 
ly to  be  attended  with  great  severity,  when 
it  attacks  plethoric  individuals,  in  whom 
there  has  been  for  some  time  previously  a 
great  determination  of  blood  to  the  head 
and  eyes,  or  whose  sight  has  been  strained 
by  looking  at  shining  objects,  or  constitu- 
tions hurt  by  good  living  and  hard  drinking. 
Every  severe  ophthalmy  runs  through  its 
first  stage  much  more  rapidly  in  weak,  irri- 
table subjects  and  children,  than  in  robust 
individuals.  It  is  also  another  remark 
made  by  Beer,  that  every  inflammation  of 
the  eye,  at  all  considerable,  is  generally  of 
shorter  continuance  in  gray  or  blue-eyed, 
than  in  dark,  or  black-eyed  perstms ; and 
in  the  same  manner,  inflammation  of  the  in- 
ternal, sensible,  and  tender  textures  of  the 
eyeball  always  passes  through  its  first  stage 
more  quickly,  than  inflammation  of  the  eye- 
lids. 

With  respect  to  the  causes  of  ophthalmy  in 
general,  as  the  disorder  frequently  affects 
the  innermost  parts  of  the  eye,  and  when 
severe,  is  attended  with  some  risk  of  the  loss 
of  the  organ,  the  annihilation  of  its  func- 
tions, or  the  spoiling  of  some  of  its  textures  ; 
and  also,  as  inflammation  is  the  most  fre- 
quent complaint  to  which  the  eye  is  subject, 
il  is  important  to  learn,  as  far  as  possible, 
the  causes,  which  either  directly  or  indi- 
rectly give  rise  to  it. 

jThe  atmospheric  air  and  light  have  a di- 
rect and  powerful  operation  upon  the  eyes  ; 
and  in  order  that  the  former  may  have  no 
hurtful  effect  upon  these  organs,  it  should  be 
pure,  that  is  to  say,  its  regular  component 
parts  should  not  be  altered,  nor  blended 
with  extraneous  substances.  The  tempera- 
ture of  the  air  is  likewise  described  by  Beer, 
as  making  a good  deal  of  difference  in  the 
susceptibility  of  the  eyes  for  inflammation, 
either  a very  warm,  or  cold  air,  being,  in 
Vol.H.  3s 


this  respect,  hurtful.  The  observation,  how- 
ever, is  qualified  with  the  admission,  that 
the  terms  warm  and  cold  have  only  a rela- 
tive signification  to  individual  circumstances. 
The  effect  of  a blast  of  cold  air  on  the  eye, 
in  exciting  inflammation,  is  universally 
known,  and  needs  no  comment.  It  is  an 
opinion  of  Beer,  that  the  eye  is  much  affect- 
ed by  the  quantity  of  electricity  in  the  at- 
mosphere, and  he  says,  that  on  this  account, 
no  experienced  practitioner  would  under- 
take the  extraction  of  a cataract  during,  or 
on  the  approach  of  a storm.  ( B . 1,  p.  65.) 

Passing  over  many  interesting  observa- 
tions made  by  Beer,  on  the  contamination 
of  the  atmospheric  air  by  the  admixture  of 
other  gases,  and  the  injurious  effect  of  this 
change  upon  the  eyes,  I come  to  his  re- 
marks on  the  operation  of  light  upon  these 
organs.  Though  light,  he  observes,  is  indis- 
pensable to  the  functions  of  the  eye,  it  be- 
comes pernicious,  when  suddenly  increased 
beyond  what  the  organ  can  bear,  so  as  to  be 
a source  of  irritation  As  a proof  of  this 
fact,  he  cites  an  instance,  in  which  a young, 
plethoric,  strong  man,  whose  eyes  had  been 
for  some  time  unavoidably  strained  by  im- 
moderate exercise  of  them,  was  suddenly 
attacked  with  a violent  ophthalmy,  while 
looking  at  an  optical  representation  of  the 
rising  sun,  and  carried  home  in  great  agony. 
But  with  respect  to  the  influence  of  light^ 
Beer  observes,  that  every  statement  is  to  be 
received  only  in  a relative  sense  ; for  the 
degree  of  light  which  would  answer  very 
well  for  the  eye  of  an  African,  would  de- 
stroy many  European  eyes ; and  the  same 
light,  which  is  borne  without  inconvenience 
by  the  eye  of  an  adult,  would  excite  in  the 
eye  of  a new-born  infant  the  ophthalmia  neo- 
natorum, by  which  so  many  children  are  de 
prived  of  the  most  valuable  of  the  senses  in 
the  first  days  of  their  existence.  Beer  fur- 
ther explains,  that  the  same  degree  of  light 
produces  a stronger,  or  weaker  effect,  ac- 
cording to  the  greater  or  lesser  irritability 
of  the  eye  of  the  same  person  at  different 
times,  as  we  see  exemplified  in  every  indi- 
vidual in  the  tenderness  of  his  eye  to  light 
when  he  first  awakes  in  the  morning.  Light 
is  also  not  hurtful  to  the  eyes,  merely  ac- 
cording to  its  quantity  ; for  the  direction  of 
the  rays  makes  a great  deal  of  difference, 
the  eye  being  less  capable  of  bearing  them 
with  impunity  the  more  they  recede  from  a 
perpendicular  line,  and  strike  the  organ  slo- 
pingly,  or  horizontally.  Much  likewise  de- 
pends upon  the  kind  of  light ; that  which  is 
reflected  from  a scarlet  surface,  being  even 
more  prejudicial  than  the  sunshine  which 
is  reflected  from  a country  covered  with 
snow  ; another  convincing  proof,  that  the 
bad  effects  are  not  always  in  proportion  to 
the  quantity  of  rays.  The  light  of  burning- 
glasses,  concave  mirrors,  white  screens,  the 
full  moon,  &c.  and  the  shining  of  diamonds, 
are  well  known  to  render  the  eyes  weak, 
and  prone  to  inflammation.  Among  other 
occasional  causes  of  ophthalmy,  Beer  enu- 
merates the  custom  of  washing  the  eyes  im- 
moderately with  cold  water,  a renjark  in 


ophthalmy. 


2f  rs 


which  I do  riot  place  much  confidence  my- 
self; the  application  of  various  stimulating 
medicated  substances  to  them  ; compresses 
and  bandages  : the  badness  of  instruments 
employed  in  operations  upon  the  eyes  ; the 
employment  of  spectacles  unnecessarily,  or 
of  such  as  are  not  adapted  to  ibe  eyes  of 
the  individual  ; and  every  immoderate  ex- 
ertion of  the  eyesight. 

But,  among  the  most  important  and  fre- 
quent exciting  causes  of  ophthalmy,  are 
extraneous  bodies,  which  insinuate  them- 
selves between  tire  eyeball  and  eyelids,  and 
every  kind  of  wound  or  injury  of  the  eye. 

Foreign  bodies,  liable  to  enter  under  the 
eyelids,  are  of  three  kinds;  first,  they  may 
either  be  such  as  are  in  themselves  corn 
pletely  innoxious  to  the  eye  ; or  such  as  are 
likely  to  hurt  the  eye  only  when  strongly 
pressed  upon  by  the  spasmodic  closure  of 
the  eyelids,  or  by  the  patient's  imprudently 
rubbing  the  eye  ; or  they  may  be  of  a qua- 
lity which  injures  the  eye  the  moment  they 
come  into  contact  with  it.  Foreign  bodies 
of  the  first  description  lie  loose  under  one  of 
the  eyelids,  and,  for  the  most  part,  either 
immediately  behind  its  edge  in  the  groove 
destined  for  the  conveyance  of  the  tears,  or 
else  in  the  fold,  seen  when  the  eyelid  is 
everted,  exactly  at  the  line  where  the  pal- 
pebra  and  sclerotic  conjunctiva  join  toge- 
ther. They  never  actually  lodge  in  the 
coats  of  the  eye  ; but  they  irritate  it  either 
mechanically  or  chymically,  or  in  both  ways 
together,  according  to  their  size,  shape,  and 
chymical  properties. 

In  the  list  of  such  extraneous  substances 
are  inverted  eyelashes  ; particles  of  dust ; 
snuff  . pepper  . minute  insects  ; and  other 
small  things  generally  carried  under  the 
eyelids  by  the  wind. 

As  these  foreign  bodies  are  all  of  them 
more  or  less  irritating  to  the  eye,  they  mud 
Be  considered  as  a principal  exciting  cause 
©f  ophthalmy,  which  frequently  follows 
their  entrance  under  the  eyelids  with  extra- 
ordinary rapidity.  However,  the  redness 
and  effusion  ot  tears,  sometimes  instantly 
following  the  insinuation  of  extraneous  sub- 
stances under  the  palpebrre.and  as  suddenly 
ceasing  on  their  removal,  Beer  considers 
rather  as  preliminaries  to  inflammation,  than 
as  this  disorder  itself.  (B.  1 ,p.  92.) 

Wounds  and  other  injuries  of  the  eye, 
regarded  as  causes  of  ophthalmy,  Beer  di- 
vides into  three  kinds  ; viz.  mechanical,  chy- 
mical, and  mixed.  A prick  of  the  eye  with 
a fine  needle  is  an  example  of  a simple  me- 
chanical injury  ; the  action  of  quicklime 
upon  the  organ  is  an  instance  of  one  purely 
chymical ; and  the  violent  propulsion  of  a 
red-hot  bit  of  iron  against  the  eye  is  a le- 
sion, which  may  be  said  to  be  both  mecha- 
nical and  chymical.  The  same  author  makes 
a variety  of  original  reflections  upon  the 
differences  connected  with  the  extent  and 
intensity  of  such  injuries.  Their  intensity, 
be  views  only  as  something  relative  ; thus, 
either  the  force,  with  which  the  eye  is  inju- 
red, is  of  itself  too  great  ever  to  be  resisted,  as 
is  seen  in  a gunshot  wound  ; or  the  organic 


powers  of  the  patient  are,  from  age,  sex,  c/r 
constitution,  much  too  feeble  for  the  eye  to 
bear  favourably  any  considerable  injury,  as 
is  the  case  with  children  and  weak  unheal- 
thy females  ; or  the  organization  of  the  eye 
itself  may  Ire  weak,  and  the  effects  of  the 
violence  therefore  greater,  as  exemplified  in 
the  fact  of  a brown  or  black  eye  generally 
bearing  a wound  better  than  a gray  or  blue 
one  ; or,  lastly,  the  organic  powers  of  the 
texture  of  the  eye,  immediately  injured, 
may  be  too  feeble  to  bear  even  a slight  le- 
sion, as  is  the  case  with  the  retina.  (B.  1, 
p.9o.) 

Mechanical  injuries  of  the  eye  may  be 
made  either  with  sharp  or  obtuse  bodies. 
Sharp-pointed  and  cutting  instruments  are 
capable  of  readily  penetrating  the  eye, 
without  occasioning  at  the  moment  of  their 
entrance,  any  violent  compression,  or  lace- 
ration of  the  neighbouring  textures  ; and 
consequently  the  injury  inflicted  is  a simple 
puncture,  or  an  incision.  Sabre-cuts  of  t he 
eye,  however,  are  to  be  excepted  ; for, 
though  the  weapon  may  be  sharp,  the  blow' 
is  always  attended  with  more  or  less  con  - 
cussion, and  injury  of  the  textures,  adjoin- 
ing the  wound,  which  are  very  delicate  and 
readily  spoiled.  Blunt  weapons,  or  bodies, 
can  only  enter  the  texture  of  the  eye  by 
dint  of  great  force,  and,  in  this  case,  always 
cause  a serious  degree  of  compression, 
stretching,  and  laceration  ; but  sometimes 
when  they  do  not  penetrate  the  organ,  the 
contusion  is  such  as  is  productive  of  not  less 
mischief. 

In  the  case  of  a simple  puncture  or  inci- 
sion of  the  eye,  Beer  seems  to  think  that  the 
subsequent  ophthalmy  is  generally  more 
owing  to  the  incapacity  of  the  wounded  or- 
gan to  bear  the  effects  of  the  light,  air,  he. 
than  to  the  injury  itself  abstractedly  consi- 
dered. He  observes,  that  a proof  of  the 
truth  of  this  opinion  is  seen  in  the  extraction 
of  the  cataract ; for,  if  the  operator  is  care- 
less in  the  operation  itself,  opening  the  flap 
of  the  cornea  very  wide,  so  as  to  let  the  at- 
mospheric air  have  free  access  to  the  inner 
textures  of  the  eye  ; or  if  after  the  operation 
is  finished,  he  do  not  apply  the  dressings 
with  caution,  and  properly  darken  the  pa- 
tient’s chamber,  he  is  letting  the  eye  he  sub- 
jected to  some  of  the  most  active  causes  of 
inflammation.  But  though  Beer  is  unques- 
tionably correct,  in  regard  to  the  injurious 
effects  of  light  on  the  W'ounded  eye,  it  may 
be  doubted,  whether  his  theories  do  not 
make  him  attribute  too  much  to  the  irrita- 
tion of  the  air,  and  too  little  to  that  of  the 
mechanical  division  of  the  parts. 

Passing  over  many  of  Beer’s  observations 
on  injuries  of  the  eye  produced  by  blunt 
bodies,  and  substances  acting  chymically 
upon  it,  1 leave  the  topic  of  the  direct  exci- 
ting causes  of  ophthalmy,  and  come  to  the 
consideration  of  those  which  lie  regards  as 
indirect.  And  the  first  to  which  he  adverts, 
is  every  thing  that  has  a tendency  to  keep 
up  a determination  of  a large  quantity  of 
blood  into  the  small  vessels  of  the  head  and 
eyes.  Immoderate  bodily  exercise ; violent 


GJPHTHALM*. 


299 


emotions  of  the  mrnd ; injudicious  clothing ; 
and  high  living,  are  afterward  enumerated 
as  having  an  indirect  effect  in  the  produc- 
tion of  ophthalmy;  but  it  does  not  appear 
to  me,  that  Beer's  sentiments  upon  these 
points  are  entitled  to  much  attention.  With 
respect  to  infection  and  contagion,  as  causes 
of  inflammation  of  the  eye,  Beer  under- 
stands by  infection,  what  at  first  takes  effect 
only  upon  a small  point  of  the  body,  but 
never  the  whole  animal  economy  directly, 
that  is  to  say,  before  absorption  has  taken 
place.  Hence,  says  he,  infectious  diseases 
are  very  seldom  the  cause  of  ophthalmy, 
unless  some  of  their  matter  be  applied  im- 
mediately to  the  eye  itself;  but  he  admits 
that  they  often  dispose  this  organ  to  inflame 
from  slight  causes,  by  the  impairment  which 
they  produce  of  the  general  health  On  the 
other  hand,  he  considers  all  contagions  as 
very  quickly  affecting  the  whole  of  the  con- 
stitution directly  through  the  medium  of  the 
skin,  or  the  trachea,  lungs,  oesophagus,  &c. 
Hence,  contagion  is  set  down  as  being  much 
more  frequently,  than  infection,  the  indirect 
cause  of  ophthalmy.  Beer  conceives,  how- 
ever, that  as  the  contagious  principle  is 
blended  with  the  atmosphere,  it  may  also 
have  an  immediate  operation  upon  the  eyes, 
and  thus  he  attempts  to  account  for  the  or- 
gans not  unfrequently  exhibiting  a tendency 
to  inflammation  at  the  very  moment  of  the 
contagion  taking  effect.  (3.  l,p.  121.)  But 
this  is  a difficult  and  obscure  subject,  which 
can  be  viewed  to  more  advantage  when 
particular  kinds  of  ophthalmy  are  considered. 

In  Beer’s  general  observations  on  the 
treatment  of  inflammations  of  the  eyes,  the 
first  indication  specified,  is  to  remove  imme 
dialely  every  thing,  which  is  obviously  produ- 
cing an  irritating  effect  upon  the  eye  and  to 
take  care  that  no  fresh  source  of  irritation  to 
the  organ  incidentally  lake  place.  And,  as 
Itfrequently  happens,  even  in  healthy,  strong 
individuals,  that  ophthalmy  is  occasioned  by 
foreign  bodies,  either  lodged  under  the  eye- 
lids, or  inserted  in  some  part  of  the  eyeball, 
and  not  suspected  to  be  there,  the  earliest 
attention  should  always  be  paid  to  their 
gentle  and  skilful  removal.  Easy  as  this 
object  is  of  accomplishment,  when  not  de- 
layed, when  the  eye  has  not  been  seriously 
irritated  by  friction  and  pressure,  and  the 
patient  is  not  of  a weak,  irritable  constitu- 
tion, it  is  often  attended  with  great  difficulty 
under  one,  or  the  other  of  these  circumstan- 
ces, especially  the  last.  In  this  case,  strong 
convulsive  rotations  of  the  eyeball,  followed 
by  a violent  and  obstinate  spasmodic  closure 
of  the  eyelids,  render  it  impossible  to  sepa- 
rate them  ; and  the  spasm  is  the  stronger 
and  more  lasting,  the  more -the  extraneous 
substances  are  calculated  by  their  shape  and 
ehymica!  quality,  to  irritate  the  eye  ; and 
the  greater  the  irritability  of  the  patient  is. 
In  this  state  of  things,  every  attempt  forcibly 
to  open  the  eye,  or  to  examine  it  in  the  light, 
is  not  oniy  useless,  but  increases  and  keeps 
up  the  spasm,  which  nothing  will  lessen  and 
shorten,  except  darkness  and  perfect  repose. 
But,  as  timid  irritable  persons  are  exceeding- 


ly apprehensive  of  the  consequences  of  the 
lodgment  of  extraneous  substances  in  the 
eye,  the  surgeon  should  endeavour  to  lessen 
their  inquietude,  by  assuring  them  that  every 
thing  will  be  right  again,  which  is  strictly 
true  when  the  foreign  bodies  are  of  the  first 
class.  Then  the  spasmodic  closure  of  the 
eyelids  will  cease,  and  the  extraneous  sub- 
stance admit  of  being  properly  taken  away. 

Success,  however,  does  not  always  attend 
this  simple  method  ; for,  in  very  weak  sub- 
jects, the  spasm  of  the  orbicularis  palpebra- 
rum is  so  violent  and  obstinate,  especially 
when  a foreign  body  lodges  in  the  eye,  and 
at  the  same  time  mechanically  and  chymi-' 
cally  irritates  it,  (as  is  the  case  with  particles 
of  snuff,)  that  it  becomes  indispensable  to 
have  recourse  to  medicinal  applications.  For 
this  purpose,  Beer’s  experience  has  convin- 
ced him,  that  the  best  thing  is  a bread  poul- 
tice, made  either  with  milk  or  water,  and 
containing  some  of  the  vinous  tincture  of 
opium.  Care  is  to  be  taken,  however,  never 
to  let  it  become  quite  cold,  during  its  appli- 
cation ; for  then  the  spasm  would  only  be 
aggravate.!  by  it ; and  if  such  spasm  has 
been  of  long  continuance,  when  the  surgeon 
is  first  sent  for,  the  poultice,  according  to 
Beer,  may  be  rendered  more  efficacious  bv 
tlie  addition  of  hyosciamus  to  it.  In  very 
irritable  hysterical  and  hypochondriacal  per- 
sons, such  local  treatment  alone  is  frequently 
insufficient,  and  recourse  must  be  had  to  the 
internal  exhibition  of  antispasmodic  ano- 
dyne medicines.  At  length,  when  the  spasm 
of  the  orbicular  muscle  is  so  far  diminished, 
that  the  eyelids  can  be  effectually  opened 
without  any  force  for  the  extraction  of  the 
foreign  body,  great  caution  and  gentleness 
will  yet  be  necessary,  and,  in  particular,  the 
eye  should  be  kept  in  a very  moderate 
light,  as  the  spasm  would  be  immediately 
excited  again,  either  by  sudden  exposure  of 
the  eye  to  too  much  light,  or  rough  handling 
of  the  eyelids. 

Sometimes,  a person  rubs  his  eye  at  first 
awaking  in  the  morning,  and  if  the  eyelashes 
are  very  numerous  and  rigid,  one  of  them 
will  lodge  between  the  eyeball  and  lower 
eyelid  : it  may  readily  be  taken  away  with 
the  end  of  a fine  moist  sponge,  or  camei- 
hair  pencil,  the  eyelid  being  depressed  ns 
much  as  possible  and  the  eye  itself  turned 
upward,  so  that  the  hair  may  not  be  conceal- 
ed in  the  fold  of  the  conjunctiva.  When  the 
hair  is  situated  underthe  upper  eyelid  (which 
Beer  says  rarely  happens)  it  always  lodges 
in  the  fold  of  the  preceding  membrane, 
whence  it  may  be  extracted  in  the  manner 
above  directed,  with  the  difference  tiiat  the 
eyelid  must  be  raised  or  everted,  and  the  eve 
rotated  downwards.  (Lehre  von  den  Krankh. 
B.\,p.  128,  130.) 

For  directions  respecting  the  treatment  of 
redundant  and  inverted  cilia?,  see  Dislichiasis 
and  Trichiasis. 

Small  globular  smooth  extraneous  bodies, 
lodged  under  the  eyelids,  are  very  easily  ex- 
tracted, when  the  eyelid  is  gently  taken  hold 
of  both  byits  edg?  and  the  eyelashes, and  tiff, 
ed  up  from  the  eye,  while  the  patient  inclines 


OPIITHALMY. 


m 


hishead  forwards,  and  the  eye  is  turned  com- 
pletely downwards : the  effusion  of  tears, 
excited  by  these  manoeuvres,  will  now  gene- 
rally wash  these  extraneous  substances  out 
of  the  eye,  as  they  are  not  at  all  fixed. 
When  the  fissure  between  the  eyelids  is 
wide  and  open,  but  the  eyeball  at  the  same 
time  very  prominent,  the  object  may  also 
be  easily  accomplished,  when  the  upper 
eyelid  is  gently  and  repeatedly  stroked  with 
the  finger  from  the  outer  towards  tiie  inner 
canthus  ; in  which  case,  the  round  smooth 
foreign  body  soon  makes  its  appearance 
above  the  caruncula  lachrymalis,  whence 
it  falls  out  of  itself,  or  may  be  taken  with 
the  corner  of  a pocket  handkerchief.  The 
worst  cases  are  those,  in  which  the  eyes  are 
very  prominent,  and  the  fissure  of  the  eye- 
lids small,  as  ail  the  above  methods  are  then 
useless,  and  only  productive  of  irritation. 
In  this  circumstance,  therefore,  Beer  recom- 
mends the  surgeon  to  take  hold  of  the  eye- 
lid by  the  cilia;,  and  its  edge  with  the  thumb 
and  forefinger,  and  separate  it  from  the  eye- 
ball, w hich  is  to  be  tui  ned  downw  ards,  while, 
with  Daviel  s small  scoop,  or  the  head  of 
any  large  curved  needle,  introduced  straight 
under  the  eyelid,  at  the  outer  canthus,  as 
high  as  possible,  the  extraneous  substance  is 
to  be  extracted  with  a semicircular  move- 
ment, directed  towards  the  nose.  Though 
this  method  will  almost  alw  ays  succeed,  Beer 
confesses,  that  it  is  not  without  the  pro- 
duction of  a great  deal  of  mechanical  irrita- 
tion. 

In  consequence  of  the  detention  of  such 
substances  under  the  eyelids,  the*  conjunctiva 
sometimes  becomes  thickened  ; this  change, 
when  slight,  soon  disappears  of  itself  alter 
the  removal  of  the  foreign  bodies  ; but,  iu 
other  cases,  Beer  recommends  the  diseased 
part  of  the  membrane  to  be  removed  with  a 
pair  of  scissors  ; and,  after  the  bleeding  has 
ceased,  the  frequent  application  of  the  lotio 
plumbi  acetatis  to  the  eye. 

Particles  of  common  dust,  and  of  the 
sand  and  powders,  frequently  thrown  over 
letters,  and  very  apt  to  get  into  the  eyes  of 
persons  who  open  their  letters  carelessly, 
or  from  short-sightedness,  are  obliged  to 
bring  them  close  to  the  nose,  are  generally 
more  difficult  of  extraction.  In  the  attempt, 
however,  the  eye  must  never  be  subjected 
to  too  much  irritation.  According  to  Beer, 
these  extraneous  particles  of  dust,  or  sand, 
may  sometimes  be  removed  by  washing  the 
eye  well,  or  by  dropping  into  it  milk,  or 
some  other  viscid  fluid,  while  the  patient 
lies  upon  his  back,  and  the  eyelid  is  lifted 
up  from  the  eye.  But,  the  most  expeditious 
and  certain  plan  is  to  employ  a syringe,  the 
pipe  of  which  is  to  be  introduced  under  the 
upper  eyelid  near  the  outer  canthus,  and  the 
fluid  thrown  briskly  in  the  direction  towards 
the  nose.  If  all  the  extraneous  matter  can- 
not be  thus  removed,  the  rest  may  some- 
times be  taken  out  with  a camel-hair  pencil, 
dipped  in  some  viscid  fluid,  or  fresh  butter, 
and  the  eye  is  then  to  be  washed  again. 

When  particles  of  sugar,  or  other  soluble, 
not  very  irritating  substances,  happen  to  in- 


sinuate themselves  into  the  eye,  professional 
aid  is  seldom  required,  as  they  generally 
dissolve  in  the  tears,  and  are  voided  before 
a surgeon  can  arrive.  Snuff,  pepper,  and 
other  minute  irritating  bodies,  as  well  as 
small  winged  insects,  are  to  be  removed  in 
the  same  manner,  as  particles  of  dust  and 
letter-sand  ; but,  particular  care  is  to  be 
taken  afterward  to  wash  the  eye  well  with 
some  lukewarm  mucilaginous  coliyrium, 
until  the  irritation,  caused  by  the  chymical 
effect  of  such  foreign  bodies,  has  been  com- 
pletely obviated. 

The  removal  of  foreign  bodies  of  the 
second  class  is  usually  attended  with  more 
difficulty,  because  they,  as  well  as  those  of 
the  third  class,  more  frequently  produce  a 
violent  and  obstinate  spasmodic  closure  of 
the  eyelids,  and  are  seldom  loose,  being 
generally  fixed  in  the  cornea.  However, 
when  they  happen  to  be  detached,  they 
may  be  extracted  in  the  same  way,  as 
small  round  smooth  extraneous  bodies, 
except  that  the  stroking  of  the  eyelid  with 
the  finger  should  be  omitted,  not  only  as 
useless,  but  likely  to  press  any  of  these  sub- 
stances, which  are  of  a pointed  shape,  into 
the  loose  conjunctiva,  so  as  to  injure  the 
eye  itself,  which  would  otherwise  not  be 
hurt,  l he  nibs  of  pens,  the  parings  of  the 
nails,  and  s’inall  hard-winged  insects,  when 
lodged  in  a depression  of  the  cornea,  or 
white  of  the  eye,  Beer  says,  may  be  easily 
dislodged  by  means  of  a small  silver  spatula. 
Other  foreign  bodies  of  the  second  class  are 
not  only  fixed  in  a depression,  but  even 
penetrate  more  deeply  than  the  conjunctiva  • 
and,  in  old  subjects,  in  particular,  they 
often  insinuate  themselves  into  the  loose 
cellular  membrane  under  the  conjunctiva  in 
the  white  of  the  eye,  partly  in  consequence 
of  the  convulsive  motions  of  the  eyeball 
and  eyelids,  and  partly  by  reason  of  the 
attempts  made  to  loosen  them.  Hence, 
they  frequently  become  situated  a great 
way  from  the  place  of  their  entrance,  and 
are  complete!)  covered  by  the  conjunctiva. 
But,  even  when  they  lie  immediately  in  the 
wound,  they  are  so  intimately  connected 
with  the  subjacent  luose  cellular  membrane 
of  the  conjunctiva,  that  every  attempt  to 
remove  them  with  forceps  is  not  only  una- 
vailing, but  hurtful  to  the  eye,  inasmuch  as 
the  injury  is  thereby  rendered  deeper.  They 
may  be  taken  away  with  facility,  however, 
when  lifted  up  with  a pair  of  small  forceps, 
and  are  cut  away  withja  pair  of  scissors,  toge- 
ther with  the  piece  of  cellular  membrane, 
with  which  they  are  directly  connected. 
If  such  extraneous  substance  should  be  ac- 
tually underneath  the  sclerotic  conjunctiva. 
Beer  recommends  the  eyelids  to  be  well 
opened,  and  the  eye  to  be  brought  into  a 
position,  in  which  the  part  of  the  conjunctiva 
covering  the  foreign  body,  is  rendered  tense 
when  an  incision  is  to  be  made  with  a lancet 
down  to  the  extraneous  substance,  which  is 
to  he  taken  hold  of,  and  removed  with  a 
pair  of  scissors,  the  assistant  being  curetul 
to  keep  hold  of  the  eyelids  during  the  ope- 
ration,. On  the  other  hand,  when  the 


i 


OPHTHALMY. 


‘6i)L 


foreign  body  is  actually  lodged  between  the 
layers  of  the  cornea,  Beer  considers  that  its 
extraction  may  be  best  accomplished  with  a 
lancet-pointed  couching  needle.  But,  what- 
ever instrument  is  used,  its  point  must  be 
passed  with  great  caution  closely  and  ob- 
liquely under  the  foreign  body  ; and  care 
must  be  taken  not  to  introduce  it  too  deeply, 
lest  the  anterior  chamber  be  opened,  which 
may  readily  happen  in  young  subjects  ; and 
when  it  does,  the  aqueous  humour  flows  out, 
and  the  cornea  becomes  so  flaccid,  that  the 
removal  of  the  extraneous  substance  is  quite 
impracticable,  before  the  puncture  has  heal- 
ed, and  the  anterior  chamber  is  again  dis- 
tended. 

The  removal  of  foreign  bodies  of  the 
third  class  mostly  demands  very  great  cau- 
tion, first,  because,  as  Beer  observes,  no 
particles  of  them  should  be  allowed  to  re- 
main in  the  eye,  which,  without  the  utmost 
vigilance,  is  apt  to  be  the  case  ; and  second- 
ly, because  the  wound  of  the  eye,  already 
considerable,  should  not  be  made  larger 
than  can  be  avoided.  The  extraction  of 
small  bits  of  glass  is  particularly  difficult,  as 
they  cannot  be  seen,  but  must  be  found  out 
entirely  by  the  feelings  of  the  patient,  or 
the  tactus  eruditus  of  the  surgeon,  assist- 
ed with  a probe.  When  in  this  way,  a 
particle  of  glass  is  detected,  Beer  directs 
us  to  take  hold  of  it  with  a pair  of  forceps, 
and  cut  it  away  with  scissors.  The  place 
from  which  it  has  been  removed,  must 
then  be  carefully  probed,  in  order  that 
no  other  fragment  may  be  left  iri  it.  {Beer.) 

According  to  the  same  author,  pieces  of 
iron  and  steel,  which  strike  the  eye  so  forci- 
bly as  to  enter  it,  as  well  as  all  other  frag- 
ments of  metals,  which  are  readily  oxyda- 
ted,  should  be  as  carefully  removed  as  bits 
of  glass;  for  the  more  easily  they  combine 
with  oxygen,  and  the  longer  they  remain, 
the  more  brittle  they  become,  and  the  more 
apt  are  minute  particles  to  be  left  in 
the  eye,  especially  in  the  corneR.  A speck 
on  the  part  of  this  membrane,  where  the 
splinter  has  lodged,  is  the  least  serious  con- 
sequence of  such  an  event.  When  frag- 
ments of  steel,  which  have  quite  a black 
appearance,  remain  fixed  in  the  cornea 
several  hours,  it  is  found,  after  their  removal, 
that  the  whole  circumference  of  the  depres- 
sion, from  which  they  have  been  extracted, 
is  of  a reddish-brown  colour,  produced  by 
the  rust  left  behind,  and  firmly  adhering  to 
the  cornea.  Every  particle  of  rust  must  be 
carefully  removed  with  a couching  needle, 
or  else  a permanent  speck  will  ensue  ; but, 
caution  must  be  used  not  to  puncture  the 
anterior  chamber.  The  extraction  of  parti- 
cles of  lead  and  gunpowder  is  generally 
difficult,  as  they  have  mostly  been  project- 
ed with  great  force  against  the  eyelids,  so  as 
to  produce  not  only  a great  deal  of  spasm, 
but  instantaneous  swelling  of  those  parts. 
Hence,  Beer  says,  that  they  should  com- 
monly be  taken  hold  of  with  forceps,  arid 
cut  away.  Particles  of  cantharides  are  easi- 
ly removed  with  a small  silver  spatula,  or 
the  end  of  an  eye-probe  : but,  their  violent 


chymical  effect  must  be  obviated,  by  fre- 
quently applying  to  the  part  a little  fresh 
butter,  touching  it  with  a camel-hair  pencil, 
dipped  in  diluted  liquor  ammonia?,  or  drop- 
ping into  the  eye  lukewarm  mucilaginous 
collyria. 

The  attempt  to  wash  out  of  the  eye  parti- 
cles of  quicklime,  mortar,  he.  Beer  says, 
only  has  the  effect  of  rendering  the  violent 
chymical  operation  of  these  substances  more 
diffused,  and  he  recommends  them  to  be  ta- 
ken out  of  the  eye,  by  means  of  a fine  hair 
pencil,  dipped  in  fresh  butter,  or  oil.  This 
is  the  only  way  of  immediately  counteract- 
ing their  chymical  effect,  and,  after  their 
extraction,  the  application  of  unctuous  sub- 
stances to  the  part  should  still  be  continued. 

The  stings  of  small  insects,  when  lodged 
in  the  sclerotic  conjunctiva,  are  often  very 
difficult  of  detection  ; but  they  are  more 
readily  seen  on  the  skin  of  the  eyelids. 
Beer  directs  us  to  remove  them  with  a pair 
of  forceps,  or  a couching  needle,  and  then 
to  have  recourse  to  means  calculated  to 
diminish  the  ophthalmy,  which,  in  these  ca- 
ses, always  begins  on  the  first  occurrence  of 
the  accident.  Small  shots,  lodged  in  the 
loose  cellular  texture  of  the  conjunctiva, 
must  be  cut  out.  In  general,  says  Beer,  it  is 
necessary  to  divide  the  conjunctiva,  as  they 
are  mostly  situated  some  distance  from  the 
place  of  their  entrance,  and  of  course  are 
quite  covered  by  that  membrane. 

As  soon  as  a foreign  body  has  been  ex- 
tracted from  the  eye,  all  precursors  of  oph- 
thalmy diminish,  as  for  instance,  the  redness, 
intolerance  of  light,  and  the  increased  se- 
cretion and  effusion  of  tears.  Even  the  in- 
flammation itself,  when  already  developed, 
subsides;  but,  this  affection  is  slight,  if  the 
eye  has  not  itself  been  injured  by  the  extra- 
neous body.  On  the  other  hand,  when  the 
eye  has  suffered  more  or  less  irritation  from 
the  nature  of  the  substance  itself,  and  the 
treatment  requisite  for  its  complete  extrac- 
tion, the  inflammation  may  become  more 
severe,  unless  the  surgeon  pay  immediate  at- 
tention to  the  injury  left  on  the  eye.  (Beer.) 

According  to  the  principles  laid  down  in 
the  foregoing  columns,  the  first  indication  in 
the  treatment  of  wounds  of  the  eye  in  gene- 
ral is  to  remove  every  kind  of  extraneous 
substance,  which  might  impede  the  cure. 
Hence,  the  necessity  of  observing  whether 
the  instrument  with  which  the  wound  has 
been  inflicted,  or  any  part  of  it,  is  lodged  in 
the  eye.  When  this  is  the  case,  the  foreign 
body1"  should  be  quickly  extracted,  oreise  no 
recovery  of  the  organ  can  take  place.  But, 
says  Beer,  this  is  more  easily  said  than  done  ; 
for  in  many  instances,  it  is  very  difficult  to 
find  and  remove  the  fragments  of  instru- 
ments, on  account  of  the  great  delicacy  of 
the.  organ,  the  irritability  and  alarm  of  the 
patient,  and  the  bleeding  from  the  part. 
However,  the  attempt  must  be  made  with 
the  greatest  gentleness  possible  ; and  Beer 
particularly  advises  a fine  elastic  whalebone 
probe  to  be  used,  instead  of  a silver  one,  for 
the  purpose  of  detecting  the  fragment  He 
also  sanctions  making  an  incision,  for  facili- 


OPHTHALMY. 


tating  the  finding  of  the  extraneous  sub-  comes  both  unnecessary  and  impracticable., 
stance,  provided  it  is  certainly  lodged,  and  and  all  that  can  be  done  is  to  drop  frequent- 
cannot  otherwise  be  traced.  This  aulhor  ly  into  the  eye  a mucilaginous  colly rium, 
attaches  great  importance  to  the  fulfilment  and  cover  the  organ  with  a light  bandage, 
of  this  first  indication  n all  wounds  of  the  which  will  not  make  any  hurtful  pressure, 
eye,  and  relates  a case,  to  which  he  was  In  simple  contusions  of  the  eye,  unaccom- 
called  sixteen  years  ago,  where  a piece  of  panied  with  wound,  Beer  deems  a bandage 
tobacco  pipe  had  been  driven  so  forcibly  and  the  otdy  requisite  application ; but,  when 
deeply  at  the  external  can  thus  between  the  these  accidents  are  co  joined  with  effusion 
eyeball  and  orbit  of  a young  student,  aged  of  blood,  he  recommends  the  use  of  spiri- 
ts), and  of  delicate  make,  that  the  eye  was  tuous  aromatic  fomentations,  with  the  view 
immediately  pushed  out  of  its  socket,  and,  of  promoting  absorption, 
on  Beer’s  arrival,  it  lay  with  the  cornea  In  healthy  individuals  small  punctures  of 
quite  against  the  nose.  Its  very  position  led  the  eye,  made  with  instruments  like  needles, 
Beer  to  suspect,  that  some  extraneous  body  and  perforating  only  the  conjunctiva,  or 
was  lodged  in  the  orbit,  and,  notwilhstand-  cornea,  but  not  reaching  the  deeper  textures 
ing  the  assurances  of  all  the  bystanders  to  of  the  organ,  are  generally  followed  by  no 
the  contrary,  and  the  patient’s  being  affected  serious  consequences,  even  when  all  the 
with  violent  spasms,  he  part  was  examined  aqueous  humour  is  voided.  It  is  only  ne- 
Xvith  a fine  flexible  whalebone  probe,  by  cessary  to  keep  the  eye  quiet,  and  the  air 
which  means,  a piece  of  the  pipe,  nearly  an  and  light  excluded  from  it  by  means  of  alight 
inch  in  length,  was  felt,  and  immediately  compress,  suspended  over  it  from  the  fore- 
extracted  with  a pair  of  forceps.  Scarcely  head.  Under  this  treatment,  such  punctures 
had  this  substance  been  removed,  when  the  are  so  firtnlyclosed  in  twenty  four  hours,  with- 
©yeball  was  spontaneously  drawn  back  into  out  any  opacity,  that  the  chambersare  nearly 
the  orbit,  though  w ith  the  cornea  still  turned  filled  again  with  aqueous  humour,  and  the 
towards  the  nose,  and  the  twiichings  of  the  intoleranceof  light,  which  was  only  the  effect 
muscles  also  instantly  ceased  ; but  the  eye  of  the  loss  of  that  fluid  is  entirely  removed. 
Was  blind,  and  had  but  a very  faint  percep-  In  large  clean  cut  wounds  of  the  eye, 
tion  of  light.  By  very  careful  treatment,  the  whether  accidental  or  made  in  the  extraction 
eyesight  was  restored  in  five  weeks  ; but,  of  the  cataract,  the  prognosis  must  be  very 
the  eye  could  not  turn  towards  the  temple,  cautious,  and  the  treatment  conducted  with 
owing  to  the  considerable  injury,  which  the  the  utmost  care  ; for,  says  Beer,  it  too  readi- 
external  straight  muscle  had  sustained.  With  ly  happens,  that,  though  the  wound  is  not 
the  aid  of  electricity,  the  power  of  rotating  important  in  itself,  its  effects  become  from 
the  eye  about  half  its  natural  extent  out-  the  least  mismanagement  highly  dangerous 
wards  was  in  the  end  regained,  and  the  re-  to  the  eye.  Hence,  when  the  patient  is 
maining  infirmity  resisted  every  method,  known  to  be  either  an  individual  not  likely 
deemed  worthy  of  trial.  (Beer,  8.  1,  p.  146.  to  take  proper  care  of  himself,  or  one  too 
See  also  the  article  Exophthalmia.)  much  alarmed  about  tbe  fate  of  his  eye,  the 

Fragments  of  broken  instruments  are  not  prognosis  should  be  very  guarded,  even 
the  only  kind  of  extraneous  substances,  where  the  eonsitution  is  of  the  best  descrip- 
which  may  lodge  in  the  wounded  eye  ; for,  tion,  because  a violenl  and  dangerous  attack 
as  Beer  observes,  when  the  injury  is  exten-  of  ophthalmy  is  apt  to  ensue,  and  destroy 
sive,  contused,  and  lacerated,  there  may  be  the  eye,  sooner  than  effectual  succour  can 
splinters  of  bone,  or  pieces  of  membrane,  be  administered.  On  the  other  hand,  when 
cellular  substance,  muscle,  &.c.  so  detached  the  patient  is  steady  and  intelligent,  and  the 
as  to  be  quite  incapable  of  reunion,  on  case  is  properly  treated,  the  prognosis  is  very 
which  account,  this  author  sets  them  down  favourable. 

as  foreign  bodies  requiring  to  be  taken  away.  In  considerable  cuts  of  the  eye,  it  is  only 
However,  I conceive,  that,  with  respect  to  possible  to  promote  their  union  with  asuita- 
fhe  soft  parts,  the  advice  here  delivered  ble  bandage,  and  by  effectually  preventing 
should  be  received  with  much  limitation  all  motion  of  the  eye  and  eyelids,  which  is 
Wounds  of  the  eye,  like  those  of  most  best  accomplished,  when  the  sound  as  well 
other  parts  of  the  body,  may  be  healed  as  the  injured  eye  is  covered,  and  the  patient 
either  by  direct  union,  or  a slower  process,  kept  quiet  in  bed  until  the  sidesof  the  wound 
in  which  suppuration,  the  filling  up  of  the  have  grown  together.  (Beer,  B.  \,p.  164.) 
chasm,  by  granulations,  and  the  gradual  but  As  cases  of  deeply  penetrating  wounds  of 
not  complete  approximation  of  its  edges  to  the  eyeball  itself,  Beer  enumerates  the  punc- 
each  other,  are  the  most  conspicuous  effects,  tures  made  in  the  depression  and  reclination 
Clean  incised  wounds  may  be  cured  in  the  of  the  cataract,  and  in  every  mode  of  form- 
first  way,  (see  Cataract  ;)  and  lacerated,  ing  artificial  pupil ; and  lacerations  of  the 
contused  wounds,  or  such  as  are  attended  co  junctiva  with  ears  of  corn,  pointed  pieces 
with  loss  of  substance,  in  the  second.  But,  of  iron,  splinters  of  wood,  &.c.  In  these 
whichever  plan  be  attempted,  the  eye  must  cases,  the  prognosis,  he  says,  is  always  very 
be  kept  quiet,  and  excluded  from  the  air  and  favourable,  when  the  patient  can  put  him- 
light,  with  a light  suitable  bandage  As  in  self  under  all  t lie  conditions  which  the  treat- 
wounds  arid  chymical  injuries  of  the  eyeball  rnent  requires,  and  his  constitution  is  good, 
itself,  not  admitting  of  reunion,  tiie  eyelids,  The  first  thing  here  to  be  carefully  fulfilled, 
when  dosed,  completely  cover  the  wounded  is  the  removal  of  any  fragments  of  the  in- 
part, , the  application  of  dressings  to  it  be-  sfrument,  or  body,  with  which  the  injury  ha** 


OFHTHALMY 


been  inflicted,  and  it  should  be  recollected, 
that,  in  these  cases,  minute  splinters,  which 
are  scarcely  discernible,  frequently  lodge  in 
the  conjunctiva,  and,  if  not  immediately  tra- 
ced and  removed,  produce  the  very  worst 
consequences.  By  the  weapon  being  sud- 
denly withdrawn,  pieces  of  the  conjunctiva 
are  sometimes  nearly  torn  away,  and  hang 
from  the  eye  ; these  Beer  directs  to  he  cut 
off  with  scissors.  The  best  applications,  he 
says,  are  either  lukewarm  mucilaginous  lo- 
tions, or,  (when  blood  is  effused  under  the 
conjunctiva,)  vinous,  spirituous  collyria. 
To  these  cases,  he  thinks  fomentations 
scarcely  applicable.  When  the  quantity  of 
blood,  effused  in  the  loose  cellular  texture 
under  the  conjunctiva,  is  very  considerable, 
he  recommends  scarifications  but,  where 
this  practice  does  seem  likely  to  answer,  and 
vinous  spirituous  collyria  are  ineffectual, 
some  of  the  liquor  ammonia?  should  be 
added  to  them.  When  any  fragment  of  the 
instrument  has  been  overlooked,  and  remains 
in  the  part,  either  a copious  suppuration  en- 
sues, and  the  fragment  is  at  length  detached, 
or  else,  in  a patient  of  inferior  sensibility,  a 
soft,  spongy,  readily  bleeding,  pale-red  ex- 
crescence is  formed  all  round  the  extraneous 
body,  and  sometimes  even  projects  between 
the  eyelids.  Here,  according  to  Beer,  the 
first  requisite  step  is  to  cut  away  the  fungus 
with  a knife,  so  as  to  reach  the  irritating  frag- 
ment under  it,  and  then  the  rest  of  the  ex- 
crescence may  be  removed  by  touchingit  wit  h 
the  tinctura  thebaica,  or  vinous  tincture  of 
Opium. 

With  respect  to  lacerated  wounds  of  the 
cornea,  they  either  penetrate  the  anterior 
chamber,  or  not.  They  are  all  of  them  at- 
tended with  more  or  less  concussion,  lacera- 
tion, stretching,  and  partial  contusion  of 
the  delicate  anterior  textures  of  the  eyeball ; 
a consideration,  as  Beer  observes,  materially 
affecting  the  prognosis.  When,  in  such  in- 
juries of  the  cornea,  inflammation  and  sup- 
puration cannot  be  prevenied,  or  the  dis- 
charge is  protracted,  an  obvious  scar  is 
always  the  consequence,  which,  when  situa- 
ted in  the  centre  of  the  cornea,  is  a serious 
impediment  to  vision.  Every  endeavour 
should  therefore  be  made  to  unite  the  wound 
by  the  first  intention  ; and  the  best  chance 
will  be  afforded  by  treating  the  eye  precise- 
ly in  the  same  manner  ns  after  the  extraction 
of  the  cataract.  (See  alaract  ) And.  whi  n 
fortunately  the  plan  succeeds,  the  flow  of 
the  aqueous  humour  out  of  t he  eye  ceases 
in  about  36  or  48  hours,  and  the  anterior 
chamber  becomes  distended  again  ; but,  the 
site  of  the  injury  continues  visible  for  some 
time  afterward.  The  speck,  however,  ulti- 
mately disappears,  though  much  sooner  in 
young  healthy  subjects,  than  in  the  aged  and 
feeble.  When  the  opacity  does  not  go  off 
of  itself,  Beer  finds  a collyrium,  containing 
some  of  the  lapis  divinus,  (see  Lachrymal 
Organs ,)  and  the  vinous  tincture  of  opium, 
the  most  effectual  means  of  dispersing  it. 
Through  large  wounds,  penetrating  the  cor- 
nea near  its  edge,  a fold  of  the  iris  is  apt  to 
protrude,  and,  when  it  does,  it  should  be  re- 


30ii 

placed,  which  can  only  be  effected  without 
mischief  to  the  eye  by  gently  rubbing  the 
upper  eyelid,  and  then  letting  a strong  light 
suddenly  strike  the  organ.  In  this  case,  the 
employment  of\  instruments  is  < onsidered 
by  Beer  highly  objectionable.  When  the 
iris  is  not  immediately  reduced,  it  as  well  as 
the  cornea  is  attacked  with  inflammation; 
and  soon  becomes  firmly  adherent  to  the 
edges  of  the  wound.  (S  te  Iris,  Prolapsus  of 
the,) 

Large  wounds  penetrating  the  eyeball,  and 
reaching, to  the  ris,  are  always  of  a very 
serious  nature,  even  though  the  latter  part 
may  have  received  only  a prick,  or  cut,  be- 
cause as  tile  injury  iias  been  produced  by 
accident,  and  not  by  art,  the  wound  of  the 
iris  cannot  be  free  from  all  laceration  and 
contusion.  It  is  incredible,  says  Beer,  what 
extensive  injuries  the  iris  will  bear  in  healthy 
individuals  at  its  pupillary  and  ciliary  edges, 
especially  when  produced  bv  very  sharp" in- 
struments; nay,  rents  n ay  happen  at  noth 
its  edges,  without  any  ill  consequences,  if 
the  constitution  be  favourable;  a proof  of 
which  fact  is  seen  in  the  two  common  me- 
thods of  forming  an  artificial  pupil  viz.  tho 
excision  of  a piece  of  the  iris  and  the  de- 
tachment of  the  iris  from  the  ciliary  liga- 
ment, as  practised  both  by  Schmidt  and 
Scarpa.  But,  according  to  Beer,  all  violent 
pressure,  or  actual  contusion,  particularly 
when  it  affects  the  portion  of  this  organ  be- 
tween its  tw  o circles,  cannot  be  borne  even 
in  the  best  constitutions,  and  the  least  grie- 
vous consequence  is  inflammation,  oon  fol- 
lowed by  a partial  or  complete  closure  of 
the  pupil,  or  suppuration  in  the  eyeball. 
When  the  instrument,  causing  such  injury, 
passes  to  the  iris  through  the  cornea,  as  is 
mostly  the  case,  and  the  wound  in  the  latter 
tunic  is  extensive,  the  torn  iris  is  frequently 
pulled  between  the  edges  of  the  wound,  at 
the  moment  when  the  eapon  is  withdrawn, 
and  protrudes  in  a lacerated  state.  In  this 
case,  Beer  recommends  the  torn  projecting 
piece  of  the  iris  to  be  cut  away  with  scis- 
sors close  to  the  wound  in  the  cornea, 
when  the  rest,  he  says,  is  generally  retract- 
ed within  the  eye.  Thus  an  adhesion  of  the 
iris  to  the  cornea,  termed  synechia  anterior , 
may  often  be  prevented,  which,  when  the 
lacerated  iris  is  suffered  to  hang  out  of  the 
cornea,  is  inevitable,  surrounded  by  a large 
opaque  cicatrix. 

Some  violent  blows  on  the  eye,  though 
they  cause  no  woi  nd,  are  attended  with 
such  a concussion  of  the  anterior  hemis-- 
ph  re  of  the  organ,  that  more  or  less  of  the 
iris  is  instantaneously  separated  from  the 
part  of  the  ciliary  ligament,  where  the  force 
is  most  vehement.  The  consequence  of 
this  accident  is  either  a double  pupil,  or  the 
natural  pupil  closes,  and  the  artificial  one 
remains  open.  Such  injuries  may  be  pro- 
duced by  the  lash  of  a whip,  or  a horse’s 
tail,  (a  common  accident  in  the  narrow 
streets  of  Vienna)  or  the  thrust  of  any 
bluntish  weapon  against  the  outer  part  of 
the  cornea  ; and  they  are  purposely  inflict- 
ed in  the  method  of  forming  an  artificial. 


0PHTHALM5T. 


‘M 


pupil,  recommended  both  by  Schmidt  and 
Scarpa. 

Wounds  which  enter  the  eye  through  the 
sclerotica  near  the  cornea,  usually  produce 
a considerable  effusion  of  blood  in  the 
chambers  of  the  aqueous  humour;  but 
Beer  thinks  that  there  is  never  any  necessity 
for  making  an  opening  for  its  discharge  at 
the  lower  part  of  the  cornea,  except  when 
it  is  so  considerable  as  completely  to  hide 
the  iris,  at  the  same  time  that  the  eyeball  is 
affected  with  very  painful  tension  and  hard- 
ness. In  all  wounds  of  the  iris,  it  is  like- 
wise proper  to  follow  the  same  treatment 
as  applies  to  penetrating  wounds  of  the  cor- 
nea, with  this  difference,  that  when  the 
effusion  of  blood  in  the  chambers  of  the  eye 
is  considerable,  the  action  of  the  absorbents 
should  be  promoted  by  the  immediate  em- 
ployment of  vinous  aromatic  collyria,  and 
afterward  warm  spirituous  lotions. 

Wounds  of  the  eyeball,  affecting  the  cor- 
pus ciliare,  are  set  down  by  Beer  as  ex- 
tremely dangerous,  independently  of  the 
inflammation,  which  quickly  follows.  How- 
ever, such  injuries  are  most  serious  when 
they  consist  in  a real  contusion,  or  lacera- 
tion of  the  corpus  ciliare,  >vhich  can  hardly 
take  place  without  a severe  concussion,  or 
actual  disorganization  of  the  retina,  and 
laceration  of  the  principal  ciliary  nerves 
and  vessels.  Hence,  besides  an  effusion  of 
blood  in  the  chambers  of  the  aqueous  hu- 
mour, a partial  or  complete  amaurotic  blind- 
ness'is  instantly  produced,  and  the  iris,  in 
the  vicinity  of  the  place  where  the  instru- 
ment entered,  is  so  retracted  towards  the 
margin  of  the  cornea,  that  neither  of  its 
circles  can  be  seen.  In  cases  of  this  de- 
scription it  also  frequently  happens,  says 
Beer,  that  the  patient,  or  the  person  who 
inflicted  the  wound,  suddenly  and  roughly 
pulls  the  wreapon  out  of  the  eye  again,  and 
together  with  it  a part  of  the  corpus  ciliare, 
which  is  then  to  be  regarded  as  an  extrane- 
ous substance,  and  immediately  cut  off. 
With  respect  to  the  prognosis  and  treatment, 
the  observations  already  made  on  these 
topics,  in  reference  to  wounds  of  the  iris, 
are  here  quite  applicable,  excepting  that  as 
the  effused  blood  is  less  copious  than  in  the 
latter  cases,  there  can  never  be  here  any 
necessity  for  letting  it  out  by  a depending 
opening  in  the  cornea. 

Wounds  of  the  eye,  affecting  the  crystal- 
line lens,  are  not  unfrequently  follow  ed  by 
the  formation  of  a cataract,  and  so  are  blows 
on  the  eye,  which  may  be  supposed  to  pro- 
duce this  effect  by  destroying  some  of  the 
minute  nutrient  vessels  naturally  connect- 
ing the  capsule  w ith  the  lens.  (Beer,  B.  1, 
p.  218.)  The  treatment  of  these  accidents 
resembles  that  of  injuries  of  the  iris,  except 
that  the  surgeon  has  rarely  any  extravasation 
of  blood  to  deal  with.  However,  when  the 
lens  has  slipped  into  the  anterior  cham- 
ber, Beer  recommends  its  immediate  extrac- 
tion through  an  incision  in  the  cornea,  in 
order  to  prevent  the  eye  from  being  de- 
stroyed by  a violent  attack  of  traumatic 
inflammation  and  suppuration.  Nor -when 


inflammation  has  come  on,  should  this  mea 
sure  be  postponed,  as  Beer  has  constantly 
found  the  disorder  lessen,  after  the  lens  has 
been  taken  out. 

Considerable  w ounds  of  the  eye,  attend- 
ed with  loss  of  the  vitreous  humour,  are 
described  by  Beer  as  of  a very  serious  na- 
ture ; but  they  rarely  take  place  acci- 
dentally, being  almost  alwrays  the  conse- 
quence of  a surgical  operation.  Accidental 
injuries  of  this  kind  are  generally  combined 
with  so  large  or  complete  a discharge  of  the 
vitreous  humour,  and  with  such  mischief  to 
the  organization  of  the  eye,  thal  the  conse- 
quence is  a loss  of  the  eyeball,  or  such  a 
dwindling  of  it,  that  the  fissure  of  the 
eyelids  becomes  nearly  closed.  Accord- 
ing to  Beer’s  experience,  injuries  of  the 
foregoing  kind,  arising  from  accident,  are 
mostly  produced  by  the  horns  of  cows.  On 
the  contrary  , the  effusion  of  the  vitreous 
humour  in  operations  upon  the  eye,  he  ob- 
serves, is  seldom  followed  by  the  loss  of  the 
eye.  Kortum,  in  his  Manual  on  the  Disea- 
ses of  the  ftye,  adverts  to  some  instances 
which  he  had  seen,  or  fancies  that  he  had. 
seen,  wrhere  the  whole  of  the  vitreous  humour 
was  lost,  and  yet  the  eyesight  afterward  be- 
came as  strong  as  if  no  such  accident 
had  happened.  On  the  other  hand,  Beer 
has  never  met  with  any  of  these  fortunate 
cases  ; but  has  always  found  the  sight  to  be 
seriously  impaired  when  the  quantity  of  vi- 
treous humour  lost  has  amounted  to  nearly 
its  half,  and  that  complete  blindness  wras 
the  result  wrhen  the  loss  much  exceeded 
that  quantity.  He  conceives  also,  that 
Kortum  had  probably  seen  but  few  cases  of 
this  nature,  and  therefore  might  have  been 
mistaken,  as  to  the  proportion  of  the  vitre- 
ous humour  discharged,  which  to  the  inex- 
perienced seems  larger  than  it  really  is,  and 
he  cautions  surgeons  not  to  promise  too 
much  in  cases  of  this  description.  (B.  1 ,p. 
222.)  See  Cataract. 

Considerable  injuries  of  the  eyeball,  com- 
plicated with  a concussion,  bruise,  or  actual 
wound  of  the  retina,  produce,  either  gradu- 
ally or  immediately,  an  amaurosis,  which  is 
almost  always  incurable.  When  the  con- 
cussion of  the  retina  is  less  violent,  and  does 
not  affect  every  part  of  this  texture,  it  may 
occasion  only  an  amaurotic  weakness  of 
sight.  In  worse  cases,  the  surgeon  mny 
think  himself  very  successful  if  he  can  pre- 
vent the  figure  of  the  eye  from  being  de- 
stroyed by  the  subsequent  inflammation,  all 
idea  of  the  recovery  of  the  eyesight  being 
out  of  the  question.  The  treatment  is  the 
same  as  that  commonly  adopted  after  ope- 
rations for  the  removal  of  an  opaque  lens 
(see  Cataract ;)  but  there  is  one  particular 
circumstance,  sometimes  attending  injuries 
of  the  retina  and  ciliary  nerves,  claiming 
notice,  viz.  violent  vomiting;  a symptom 
which  Beer  says  may  even  attend  contu- 
sions of  the  sclerotica  and  of  the  ciliary 
nerves  and  retina,  without  any  wound.  In- 
juries of  the  ciliary  nerves,  he  observes,  are 
denoted  by  a very  peculiar  appearance  ; for, 
near  the  injured  part,  the  iris  is  drawn  up 


OPHTHALMY. 


0O0 

ao  close  10  the  edge  of  the  cornea,  that  its  strongish  mineral  acids.  And  even  in  these 
colour  can  scarcely  be  seen.  When  the  examples,  says  Beer,  the  prognosis  is  net 
surgeon  is  consulted  in  a case  of  this  kind,  unfavourable,  and  a complete  recovery 
though  some  inflammation  may  have  com-  may  be  effected  when  the  treatment  is  con- 
menced,  the  prognosis  is  yet  favourable,  in  ducted  according  to  the  directions  already 
regard  to  the  preservation  of  the  eye  ; for  a given  with  respect  to  such  accidents  in 


gentle  opiate  will  relieve  the  vomiting 
when  merely  a nervous  effect,  not  depend- 
ing upon  the  loaded  state  of  the  gastric 
organs  but,  if  the  case  be  of  this  last  de- 
scription, the  prima1  viae  should  first  be  emp- 
tied. However,  when  a traumatic  inflam- 
mation is  con.pletely  established,  before  the 
treatment  is  begun,  the  eye  is  generall)  de- 
stroyed,asthe  repeated  and  violent  vomiting 
cause  a great  determination  of  blood  to  the 
head  and  eyes,  and  increase  of  the  inflamma- 
tion ; an  effect  which  the  opiates,  given  for 
the  relief  of  the  vomiting,  also  tend  to  pro- 
duce 

Beer  has  seen  two  cases  in  which  the  eye 
was  pricked  with  a needle  n-ar  the  insertion 
of  the  external  straight  muscle  into  the  scle- 
rotica ; in  both  instances,  the  punctures 
were  so  small,  that  they  wrould  scarcely 
have  been  found,  had  not  the  patients  know  n 
their  situation  exactly  by  the  pain,  and  they 
were  then  only  perceptible  w ith  a magnify- 
ing glass.  The  punctures  were  soon  follow- 
ed by  a convulsive  rolling  of  the  eyeball, 
and  afterward  by  trismus,  which  continued 
severe  in  one  patient  a day  and  a half,  and 
in  another  two  days,  but  yielded  to  large 
doses  of  musk  and  opium  given  at  short 
intervals,  the  warm  bath,  and  the  applica- 
tion of  warm  poultices  containing  byos- 
ciamus. 

As  chymical  injuries  of.  the  eye  produce 
an  actual  loss  of  substance,  they  are  even 
more  serious  than  common  mechanical 
lesions.  However,  chymical  injuries  of 
little  extent  are  generally  repaired  with 
tolerable  facility  and  expedition.  Quietude 
of  the  organ,  and  moderating  the  outward 
noxious  effects  by  lukewarm  mucilaginous 
applications,  eithf  r in  the  form  of  fomenta- 
tions, or  eye  waters,  are  the  only  requisite 
measures.  If  the  cornea  itself  be  hurt,  as 
frequently  happens  w hen  boiling  hot  fluids 
strike  the  eye,  a kind  of  vesicle  arises  on 
the  injured  part,  which  becomes  more  and 
more  white.  The  vesicle  either  bursts  of 
itself,  or  subsides  without  breaking.  In 
both  cases,  the  production  of  the  conjunc- 
tiva, of  which  the  cyst  of  the  vesicle  is 
composed,  shrivels  up,  and  peels  off,  a new 
membrane  of  a similar  nature  being  regene- 
rated underneath.  An  opaque  speck  is  fre- 
quently apprehended  5 but,  says  Beer,  it  the 
surgeon  will  merely  avoid  being  too  much 
in  a hurry  to  open  the  vesicle,  and  not 
disturb  the  work  of  nature  by  applying 
various  remedies  to  the  eye,  there  will  be 
no  danger  of  such  an  occurrence. 

More  extensive  chymical  injuries  of  the 
«ye,  which  at  first  are  not  in  themselves 
very  severe,  frequently  become  dangerous, 
in  consequence  of  care  not  being  taken  to 
prevent  the  influence  of  external  stimuli. 
To  this  class  of  cases  belongs  the  accidental 
sprinkling  of  the  eve  with  boiling  fluids,  or 
Vor.  If.  ‘ 39 


general.  While  this  author  apjwove.s  of 
cutting  away  any  substance  which  is  dead 
and  partially  detached,  he  strongly  cau- 
tio.s  surgeons  not  to  remove  the  thin  layer 
of  the  conjunctiva,  nor  to  puncture  any 
vesicle  which  may  form. 

When  the  burning  or  corrosion  is  not 
limited  to  the  conjunctiva  of  the  eyeball, 
but  extends  to  the  lining  of  one  or  both  eye- 
lids, Beer  recommends  covering  the  injured 
parts  with  mucilaginous  applications,  and 
mildly  astringent  ointments,  containing 
tutty,  or  the  white  oxide  of  lead.  In  these 
cases,  keeping  the  eye  perfectly  motionless 
must  be  hurtful,  as  it  tends  to  promote  the 
formation  of  adhesions,  either  between  the 
eye  and  eyelids,  (Symblepharon)  or  be- 
tween the  eyelids  themselves.  (Ancbylo- 
blepharon.) 

Extensive,  deeply  penetrating,  chymical 
injuries  of  the  eyeball.  Beer -describes  as 
being  almost  always  followed  by  more  or 
less  impairment  of  the  functions  of  the 
organ,  or  of  some  of  its  particular  textures, 
because  such  accidents  never  happen  w ith- 
out  a loss  of  substance.  Thus  a part,  or  the 
whole,  of  the  cornea  may  be  entirely  de- 
stroyed, as  in  injuries  caused  by  quicklime  ; 
and,  frequently,  adhesions  between  the  eye 
and  eyelids,  or  betw  een  the  tw  o latter  parts, 
cannot  be  prevented  by  any  kind  of  skill. 
{Beer.)  These  serious  degrees  of  mischief, 
as  the  same  author  observes,  are  mostly 
occasioned  by  slaked  or  unslaked  lime,  con- 
centrated mineral  acids,  fire,  he.  Unslaked 
lime,  especially  when  extensively  diffused 
over  the  eye  by  the  immediate  application 
of  w ater,  not  unfrequently  produces  a sud- 
den destruction  of  the  whole  of  the  cornea, 
which  is  changed  into  a grayish,  pappy  sub- 
stance, capable  of  being  removed  from  the 
subjacent  iris  with  a camel-hair  pencil. 
Such  an  annihilation  of  texture,  however, 
is  generally  restricted  to  particular  points, 
or  the  surface  of  the  cornea.  Wherever 
this  membrane  has  been  so  much  decom- 
posed, that  a manifest  depression  is  directly 
perceptible  in  it  when  inspected  sidewrays, 
a snow-white  shining  speck  must  be  expect- 
ed to  be  the  consequence.  Slaked  lime 
never  operates  upon  the  cornea  with  so 
much  violence,  usually  causing  (as  Beer 
states)  only  a superficial  corrosion,  or  a 
coagulation  of  the  lymph  between  the  layers 
of  the  cornea.  Nor  are  mineral  acids, 
even  when  concentrated,  genera! ly  so  de- 
structive to  the  cornea  as  qu'cklime;  first, 
because,  as  fluids,  they  do  not  long  remain 
in  contact  with  the  eye ; and  secondly,  be- 
cause the  immediate  mixture  of  the  tears 
with  them  weakenstheir  operation ; whereas 
it  only  increases  that  of  unsiaked  lime.  Tfce 
local  treatment  here  consists  in  carefully 
removing  every  particle  of  the  hurtful  sub- 
stance, afterward  dropping  frequently  into 


OFHTHALUfir 


M 


the  eye  lukewarm  mucilaginous  decoctions 
or  collyrin,  or  covering  the  injured  place 
with  a mild  cerate,  and  excluding  the 
air  and  light  from  the  eye.  Every  endea- 
vour must  also  be  made  to  prevent  the 
formation  of  adhesions  between  the  injured 
surfaces. 

In  very  severe  burns  of  the  eyeball,  of 
course,  all  idea  of  restoring  its  functions  is 
out  of  the  question  i he  violence  of  the  in- 
jury is  the  greater,  the  more  numerous  the 
vesicles  are  upon  the  conjunctiva,  and  the 
more  the  eyeball  and  the  iris  are  incapable 
of  motion.  Here  the  only  indication  is  to 
moderate  the  inflammation,  and  avert  such 
additional  mischief,  as  might  otherwise  be 
produced  by  it.  With  this  view,  the  eye 
should  be  kept  at  rest,  and  excluded  from  the 
light  and  air.  According  to  Beer,  the  most 
common  injuries  of  the  eye,  partaking  both 
of  a mechanical  and  chymical  nature,  are 
those  caused  by  mortar,  or  the  accidental 
touching  the  eye  with  hot  curling  irons. 
When  the  mortar  contains  no  particles  of 
quicklime,  it  often  occasions,  at  particular 
points  of  the  cornea,  very  white  specks, 
which  Beer  describes  as  being  composed  of 
coagulated  lymph,  and  admitting  of  disper- 
sion. He  even  declares,  that  when  the 
whole  of  the  cornea  is  in  this  state,  its  trans- 
parency may  be  restored  by_  proper  treat- 
ment, as  has  been  frequently  exemplified  to 
the  gentlemen  attending  his  clinical  lectures. 
(B.  i,p.  234.)  The  pricking  of  the  eyeball 
with  a red-hot  needle,  and  the  stinging  of  i 
by  bees,  wasps,  and  other  insects,  are  also 
both  chymical  and  mechanical  injuries. 
Whether  the  sting  be  left  in  the  skin  of  the 
eyelid,  or  in  the  conjunctiva,  or  not,  a 
considerable  inflammatory  swelling  immedi- 
ately takes  place  ; and,  if  the  sting  be  lodged, 
and  not  now  taken  away,  the  inflamma- 
tion spreads,  and  the  eye  itself  is  endangered. 
In  two  eases,  where  the  stings  of  bees  were 
left  in  the  skin  of  the  upper  eyelid,  Beer  has 
known  gangrene  arise  in  the  short  space  of 
a day  and  a half,  and  the  patients  were 
saved  with  great  difficulty.  The  treatment 
of  such  cases  consists  in  immediately  ex- 
tracting the  sting,  if  lodged,  and  applying 
folds  of  linen  over  the  eye,  wet  with  cold 
water. 

After  noticing  the  destructive  effects  of 
burning  substances,  the  explosion  of  gun- 
powder, and  fulminating  silver  on  the  eve, 
(cases  in  which,  when  the  functions  of  the 
organ  are  annihilated,  the  only  indication  is 
to  diminish  the  subsequent  infiammat  o::  and 
its  consequences,)  Boer  inquires,  what  is  the 
reason  why  the  slightest  mechanical,  or 
chymical,  injuries  of  the  eye,  in  an  appa- 
rently healthy  subject,  are  sometimes  fol- 
lowed by  an  immoderate  degree  of  inflam- 
mation, and  even  the  loss  of  the  organ  from 
suppuration  ? It  is,  says  he,  an  observation 
made  by  Schmidt,  that  there  are  some  eyes, 
which  the  greatest  bunglers  may  abuse  for 
hours  at  a time,  without  being  spoiled,  their 
powerful  organization  defying  all  such  un- 
skilful disturbance ; while  other  eyes  are 
met  with,  which  the  most  skilful  opera- 


tors can  hardly  touch,  without  inducing  a*, 
destructive  degree  of  inflammation  and  sup- 
puration. It  was  to  this  peculiar  idiosyn- 
crasy that  Schmidt  applied  the  tevm  vulnera- 
bility ( Verwundharkeit.)  Patients  of  this  habit 
are  said  to  possess  an  exceedingly  fine  soft 
skin,  with  a reddish  polish  upon  it,  and  their 
cheeks  are  not  only  red,  but  exhibit  a net- 
work of  very  minute  vessels,  which  seem  as 
if  injected.  Such  individuals  appear  as  if 
they  were  in  the  bloom  of  health  ; and,  says 
B er,  in  some  respects  they  are  really  so. 
When  their  spirits  are  raised  by  the  slightest 
causes,  their  complexion  is  universally  red- 
dened ; but  the  least  fear  turns  them  as  pale 
as  a corpse.  Their  skin  is  described  as  being 
uncommonly  irritable,  sensible  of  every  im- 
pression. and  attacked  wiih  an  erysipelatous 
redness,  whenever  any  fatty  substance  touch- 
es it.  In  such  habits,  the  utmost  caution  is 
necessary  whenever  the  eyes  have  been  in- 
jured, and  the  prognosis  should  be  reserved. 
And,  when  an  operation  is  to  be  done  on 
their  eyes,  Beer  recommends  the  previous 
exhibition  of  opium,  and  the  application  of  a 
blister  to  some  part  of  the  skin,  at  a consi- 
derable distance  from  them.  As  a prophy- 
lactic measure,  he  also  directs  regular  fric- 
tion of  the  surface  of  the  body. 

In  severe  ophthalmies,  particularly  those 
which  affect  the  eyeball  itself,  all  mental 
emotions,  anger,  joy,  &,c.  should  be  avoided. 
Hence,  no  talkative  nor  quarrelsome  per- 
sons should  be  suffered  to  remain  with  the 
patient;  and  noisy  childien  ought  to  be  kept 
away  from  him.  The  apartment  should 
be  ventilated  at  least  once  a day,  without  the 
patient  being  exposed  to  any  current  of  w ind. 
All  touching  of  the  eye,  or  rubbing  it  with 
the  bed-clothes  during  sleep,  must  be  strictly 
prohibited.  Stimulating,  spicy  food,  spiritu- 
ous drinks,  and  great  bodily  exercise  are  like- 
wise to  b>-  forbidden.  In  the  list  of  things 
which  have  a hurtful  effect,  Beer  also  in- 
cludes all  exertions  of  the  lungs,  every  kind 
of  disturbance,  an  atmosphere  impregnated 
with  tubacco-smoke,  &.c. 

Having  fulfilled  the  first  general  indication 
by  removing,  if  possible,  every  kind  of  irrita- 
tion acting  upon  the  eye,  the  second  central  in- 
dication specified  by  Beeras  proper  in  the  first 
stage  of  ophthalmy,  is  to  be  observed,  which 
is  to  moderate , according  to  Ifv  degree  of  in- 
flammation, the  agem y of  several  things  to  the 
effect  of  which,  the  organ  is  naturally  subjected. 
Thus,  the  inflamed  eye  should  not  be  exer- 
cised, even  though  the  eyeball  itself  may  not 
be  immediately  inflamed  ; and  the  operation 
of  the  light  and  air  should  be  diminished 
partly  by  green  silk  eye-shades,  and  partly 
by  window  blinds.  Attention  to  this  rule 
is  still  more  necessary,  when  the  eyeball 
itself  is  affected.  With  respect  to  the  exclu- 
sion of  light,  it  is  to  be  well  remembered, 
that  it  is  only  adviseable,  as  Dr.  Vetch 
observes,  in  the  very  early  stage  of  inflam- 
mation, the  eye  becoming  more  irritable  and 
less  manageable,  w!  en  the  access  of  a 
moderate  degree  of  light  is  afterward  pre- 
vented. ( Vetch  on  Diseases  of  the  lyc,  p.  lb.) 

The  third  general  indication , mentioned 


OPHTHALMY. 


307 


by  Beer,  as  proper  in  tbe  first  stage  of 
ophthalmy,  when  the  disorder  threatens  to 
extend  to  the  whole  organ,  and  to  bring  on 
a febrile  disturbance  of  the  system,  is  to 
counteract  these  effects  by  covering  the  eye 
with  folded  linen  wet  with  simple  cold 
water,  or  vinegar  and  water;  and  having 
recourse  to  leeches,  or  when  the  nature  of 
the  case  allows,  to  scarifications  (B.  1,  p. 
242.)  Here,  however,  it  merits  particular 
notice,  that,  Beer,  in  expressing  a general 
preference  to  cold  lotions  in  the  first  stage 
of  ophthalmy,  differs  from  Richter,  Scarpa, 
and  Mr.  Travers,  ( Synopsis  of  the  Diseases  of 
the  Eye,p . 250,)  all  of  whom,  in  the  painfully 
acute  stage,  recommend  tepid  emollieut  ap- 
plications. 

With  regard  to  leeches,  also,  the  late  Mr. 
Ware  objected  to  their  being  put  on,  or  very 
near  the  e)  elids,  as  they  sometimes  cause  a 
cons.derable  swelling  of  these  parts,  and 
increase,  instead  of  lessening  the  irritation. 
In  ordinary  cases,  his  method  was  to  apply 
three  on  the  temple,  about  an  inch  and  a 
half  from  the  outer  part  of  the  orbit. 
Scarpa  recommends  applying  the  leeches  to 
the  vicinity  of  the  eyelids,  especially  about 
the  inner  canthus,  on  the  vena  angularis, 
where  it  joins  the  frontal,  deep  orbitar,  and 
transverse  vein  of  the  face.  Beer  prefers 
nearly  the  same  situation,  as  that»specified 
by  Scarpa,  viz.  the  inner  canthus, immediately 
below  the  under  eyelid  ; and  he  forbids  the 
application  of  leeches  above  either  canthus, 
as  likely  to  produce  a disagreeable  ecchy  mods 
in  the  cellular  membrane  of  the  upper  eyelid. 
The  number  of  leeches,  and  the  time,  which 
they  should  be  allowed  to  suck,  he  thinks, 
ought  to  depend  upon  the  severity  of  the 
inflammation.  According  to  Beer,  when  this 
mode  of  bleeding  is  to  be  of  any  service, 
the  patient  will  experience  a considerable 
abatement  of  the  throbbing  pain,  tension, 
&c.  in  the  affected  eye.  Hence,  when  any  of 
the  leeches  fall  off  prematurely,  the  bleeding 
from  the  bites  is  to  be  kept  up,  with  a sponge 
dipped  in  warm  water,  until  such  relief  is 
felt.  In  the  acute  stage,  Beer  considers  the 
abstraction  of  blood  by  means  of  scarifica- 
tions rarely  admissible.  (B.  \,p.  243.)  Mr. 
Travers  also  sets  down  scarifications  of  the 
conjunctiva  as  mostly  objectionable  in  the 
acute  stage  ; though  highly  beneficial  in  the 
chronic,  where  the  lining  of  the  eyelids  is 
thickened  and  over  vascular;  and  a con- 
siderable discharge  of  blood  may  be  thus 
obtained,  if  the  operation  be  briskly  done 
With  a sharp  lancet,  and  the  lower  lid  kept 
everted,  and  fomented.  The  same  gentle- 
man states,  that  cupping  has  a decided  supe- 
riority over  leeches,  but  that  both  are  well 
adapted  to  relieve  local  congestion.  Yet,  he 
deems  these  methods  too  indirect  to  answer 
as  substitutes  for  the  lancet,  where  it  is  de- 
sirable to  make  the  system  “ sustain  and  feel 
a reduction  of  power,”  in  which  case  blood 
must  betaken  from  a vein,  or  the  temporal 
artery.  ( Synopsis , fyc.  p.  249.)  While  inflam- 
mation of  the  conjunctiva  is  described  by 
Dr  Vetch,  as  not  much  affected  by  bleeding, 
unless  the  Quantity  of  blood  taken  away  be 


such  as  to  occasion  syncope,  he  states,  that 
the  abstraction  of  blood,  in  quantities  pro- 
portioned to  the  violence  of  the  symptoms, 
more  especially,  by  means  of  cupping  and 
leeches,  has  for  the  most  part  sufficient  con- 
trol over  the  various  states  and  individual 
symptoms  of  sclerotic  inflammation.  In 
some  obscure  cases  of  what  this  author 
terms  amaurotic  inflammation,  he  has  seen 
great  benefit  derived  from  the  application  of 
leeches  to  the  septum  nasi,  and  he  represents 
their  being  put  directly  on  ihe  conjunctival 
li  .ing  of  the  eyelids,  as  being  sometimes 
more  advantageous  than  on  the  adjacent 
integuments  the  orifices  bleeding  with  great 
freedom.  (On  Diseases  of  the  Eye,p  15.) 

If  some  of  the  above  remarks  are  correct, 
scarifications  are  rather  too  boldly  praised 
by  the  late  Mr.  Ware,  as  applicable  to  the 
acute  stage  of  ophthalmy.  But,  supposing 
the  first  violence  of  the  attack  past,  his  re- 
commendation of  the  practice  either  in  the 
vascular  and  turgid  state  of  the  lining  of  the 
eyelids,  or  in  the  eversion  of  the  lower  one 
from  a similar  cause,  seems  perfectly  unob- 
jectionable. When  the  upper  eyelid  was 
very  cedematous,  and  its  thickness  prevented 
the  application  of  proper  remedies  to  the 
eye,  Mr.  Ware  also  thought  a few  punctures 
near  the  cilite  useful,  by  causing  a discharge 
of  bloody  serum,  and  a quick  subsidence  of 
the  swelling.  And  he  speaks  of  the  excision 
of  a piece  of  the  excessively  tumid  lining  of 
each  eyelid,  in  cases  of  ophthalmy  with 
ev  ersion,  as  having  afforded  ;reat  and  speedy 
relief.  (Ware  on  Ophthalmy.  fyc. p.  39  ) 

The  fourth  general  indication , enumerated 
by  Beer,  is  that,  which  has  for  its  objects  a 
diet  and  reirimen  suited  to  the  state  of  the 
case,  after  it  has  attained  a degree,  in  which 
its  effects  begin  to  be  felt  throughout  the 
system.  When  therefore  the  plan  is  to  be 
rigorously  practised,  the  patient’s  ordinary 
diet  is  to  be  reduced,  and  he  is  to  be  allowed 
only  vegetable  food,  cooling  drinks,  water, 
weak  lemonade  &.c.  And  not  merely  the 
eye  itself  is  to  be  kept  at  rest,  but  the  whole 
body. 

Should  the  disorder  be  further  advanced, 
and  attended  with  a great  deal  of  inflamma- 
tory fever,  the  observance  of  the  foregoing 
indications  will  not  suffice  for  checking  the 
inflammation  and  preventing  suppuration, 
unless  the  fifth  indication,  laid  down  by 
Beer,  be  fulfilled,  which  is  to  employ  suck 
remedies  as  operate  upon  the  whole  constitution, 
1 Purgative  and  gently  aperient  medicines, 
which  will  empty  the  bowels  well,  and  lessen 
the  determination  of  blood  to  the  head  and 
eyes.  2.  Clysters,  which  are  useful  on  the 
same  principles.  3.  The  frequent  exhibition 
of  the  nitras  potassee.  4.  General  bleeding, 
the  efficacy  of  which  will  much  depend  upon 
the  blood  being  voided  in  a full  stream. 
Beer  seems  to  prefer  opening  a vein  on  the 
foot ; but,  in  England,  the  most  experienced 
practitioners  generally  open  a vein  in  the 
arm,  and  sometimes  the  temporal  artery. 
The  blood,  as  Beer  remarks,  should  be  allow- 
ed to  flow  until  the  hard  small  pulse  rises  and 
becomes  plainly  softer;-  for,  otherwise  tho 


OPHTHALMT. 


am 


operation  will  be  completely  useless.  Also, 
when  in  these  cases,  general  bleeding  is  no 
longer  indicated,  the  employment  of  leeches 
will  yet  be  advantageous,  and  afterward,  sca- 
rifications may  be  practised,  which,  at  any 
earlier  period,  would  have  aggravated  all  the 
inflammatory  symptoms. 

By  strict  attention  to  the  five  above  ex- 
pl  lined  indications,  either  without  precipita- 
tion. or  too  much  delay,  the  first  stage  of 
opVhalmy,  even  when  in  its  most  violent 
degree,  may  be  certainly  checked  and  re- 
solved ; and  all  suppuration  avoided,  so 
that  the  eye  may  be  restored  to  a perfectly 
sound  state  again,  provided  the  patient, 
previously  to  the  attack,  was  quite  healthy, 
and  of  course  the  affection  of  the  eye  a 
genuine  idiopathic  inflammation.  {Beer,  B. 

1. p.  246,  247.) 

Respecting  the  prognosis  and  indications  in 
the  second  stage  of  ophthalmy  in  general,  and 
of  idiopathic  cases  in  particular,  Beer  offers 
many  interesting  remarks.  He  observes, 
that  when  ophthalmy  has  reached  its  second 
stage,  which  may  be  known  by  circum- 
stances already  referred  to  in  the  preceding 
columns,  it  must  be  clear,  that  the  above 
indications  are  no  longer  valid,  and  the  ful- 
filment of  them  would  destroy  the  eye. 

In  the  second  stage,  every  thing  yv  hich  has 
a tendency  to  produce  further  weakness  of 
the  eye  must  be  avoided,  or  suppuration 
will  be  the  consequence  : the  first  indication, 
therefore,  specified  by  Beer,  is  to  let  the  eye 
he  cautiously  exposed  according  as  its  tendency 
will  allow , to  its  wonted  stimuli  again.  1. 
By  letting  fresh,  dry,  and,  if  possible,  a 
warmish  air,  have  free  access  to  the  organ. 

2.  By  exposing  the  eye  to  as  much  light  (not 
of  a reflected  description)  as  can  be  borne, 
not  only  without  difficulty,  but  with  pleasure, 

3.  By  moderately  exercising  the  organ, 
especially  in  the  inspection  of  agreeable 
diversified  objects  ; a plan,  which  is  of  infi- 
nite service,  when  the  eyeball  itself  has 
been  affected. 

The  second  indication,  proposed  by  Beer 
in  the  second  stage  of  ophthalmy  in  general, 
is  to  apply  tonic  remedies,  particularly  those  of 
a volatile  kind,  to  the  eye,  which  are  to  be  dis- 
continued in  the  event  of  suppuration.  1. 
Beer  praises  the  application  of  well-warmed 
linen  compresses,  which,  if  necessary,  may 
be  sprinkled  with  camphor ; or,  in  urgent 
cases,  he  uses  little  bags  of  aromatic  herbs 
and  camphor  ; a practice,  in  which  I am 
disposed  to  think  surgeons  here  will  have 
little  or  no  confidence  2.  However,  when 
the  eye  is  too  irritable  to  bear  the  applica- 
tion of  bags  of  aromatic  substances,  Beer 
sanctions  the  employment  of  poultices  nude 
of  bread  crum  and  warm  herbs,  or  the  pulp 
of  a roasted  apple.  But,  this  experienced 
author  is  very  particular  in  qualifying  his 
approbation  of  moist  applications  with  a 
caution,  that  they  must  never  be  allowed  to 
become  completely  cold  on  the  eye,  where- 
by they  would  do  more  harm  in  a quarter  of 
an  hour,  than  any  good,  which  may  have 
been  attained  in  many  hours  by  their  pre- 
vious use.  Hence,  Beer  employs  poultices 


only  in  cases  of  necessity.  In  this  country, 
“ when  the  extreme  vascular  congestion  and 
excessive  sensibility  are  reduced,  and  the 
inflammation  tends  to  become  chronic,  the 
U3c  of  cold  lotions,  of  a slightly  ton  c quality, 
is  substituted  with  great  advantage  for  ablu- 
tions of  warm  water.  The  sulphates  of 
alum  and  zinc  are  the  best.”  {Tracers,  Sy- 
nopsis, tyc.  p.  252.)  The  employment  of 
astringents  also  agrees  with  the  advice 
delivered  by  Richter  and  Scarpa.  Here 
then  we  find  a point  on  which  Beer  differs 
from  the  generality  of  writers  ; but,  nothing 
is  clearer  to  me,  than  that  his  alarm  about 
the  ill  effect  of  cold  upon  the  eye  in  the 
second  stage  of  ophthalmy  is  only  the  fruit 
of  some  theories,  which  he  entertains,  and 
not  of  impartial  experience  3.  When  there 
are  small  ulcers,  or  pustules,  on  the  eyeball 
itself,  Beer  assures  us,  that  great  benefit  is 
derived  from  dropping  between  it  and  the 
eyelids  a tepid  solution  of  the  lapis  divinus, 
the  composition  of  which  is  elsewhere  des- 
cribed (see  Lachrymal  Organs,)  and  bathing 
the  eye  with  the  same  application,  to  which 
a little  of  the  vinous  tincture  of  opium  is 
added.  Should  this  remedy  fail  in  checking 
the  progress  of  the  ulcers,  or  pustules,  Beer 
reeommends  the  addition  of  acetate  of  lead. 

4.  And,  says  the  same  author,  when  no  deci- 
ded amendment  is  produced,  within  twenty- 
four  hours,  the  suppurating  points  must  be 
touched  once  or  twice  a day,  according  to 
the  urgency  of  the  danger,  with  a camel-hair 
pencil,  dipped  either  in  a watery  solution  of 
opium,  or  the  vinous  tincture  of  opium.  In 
the  worst  cases,  he  even  directs  Hoffman’s 
balsam,  vitas,  naphtha,  or  the  Peruvian  balsam 
to  be  mixed  with  the  vinous  tincture  of 
opium. 

But,  Beer  observes,  that  when  these  reme- 
dies have  been  too  precipitately  employed, 
and  any  granulations,  or  excrescences  form, 
the  treatment  must  be  less  active,  and  then 
these  new  productions  will  frequently  recede 
of  themselves  ; but,  if  they  should  not  do  so, 
they  may  be  removed  with  burnt  alum,  or 
caustic.  {B.  I,  p.252.) 

The  third-rule,  laid  down  by  Beer,  in  the 
treatment  of  the  second  stage  of  ophthalmy , 
cautions  the  practitioner  not  to  apply  the 
caustic  or  the  knife,  to  any  of  the  morbid 
changes,  which  either  originate  during  the 
first  stage,  and  continue  in  the  second,  or 
make  their  first  appearance  at  the  period  of 
suppuration,  as,  for  instance,  opacities  of  the 
cornea,  eversion  of  one  or  both  eyelids,  &c. 
However,  as  exceptions  to  this  advice,  Beer 
adverts  to  the  treatment  of  new-growths 
under  the  circumstances  above  specified, 
and  to  that  of  abscesses  of  the  eyeball,  where 
the  matter  is  of  an  unhealthy  quality,  and 
so  copious  as  to  make  an  opening  ad\  iseable, 
which  practice,  however,  as  a general  one, 
he  condemns.  The  other  morbid  changes, 
already  alluded  to,  the  practitioner  must 
endeavour  to  remove  simply  by  proper  treat- 
ment of  the  second  stage.  {Beer,  B.  1,  p. 
254.) 

Beer’s  fourth  rule  in  the  treatment  of  the 
seebnd  stage  of  ophthalmy  in  general,  and  of 


OPHTHALM-l  . 


J0i> 


idiopathic  ophthalmy  in  particular,  when 
the  suppurative  process  is  extending  itself, 
and  threatening  to  impair  the  health,  is,  1st. 
To  allow  the  patient  such  food  as  is  both  easy 
of  digestion,  and  of  a very  nutritious  quality, 
and  even  a moderate  quantity  of  wine  and 
spirituous  drinks,  if  he  h s been  accustomed 
to  them.  2dly.  To  direct  the  patient  to  keep 
his  eye  exposed  the  greater  part  of  the  day, 
in  a fresh,  dry,  and  (if  possible)  mild  air,  and 
take  just  exercise  enough  in  various  ways 
to  p'roduce  a slight  degree  of  fatigue.  3dly. 
When  the  eye  itself  is  affected  with  suppura 
tion,  and  the  sight  is  either  thereby  much 
impaired,  or  quite  lost,  and,  of  course,  the 
patient  very  unhappy  and  depressed,  Beer 
considers  it  highly  beneficial  to  let  his  spirits 
be  improved  by  society. 

The  fifth  rule , or,  general  indication  in  the 
second  stage , laid  down  by  Beer,  refers  to  the 
necessity  of  supporting  the  constitution, 
when  the  suppurative  process  is  attended 
with  a general  febrile  disturbance.  For  this 
purpose,  he  recommends,  1st.  The  exhibition 
of  calamus  aromaticus,  naphtha,  and  cam 
phor.  2dly.  If  they  prove  ineffectual  alone, 
they  are  to  be  joined  with  other  tonics,  espe- 
cially bark.  3dly.  The  warm  bath,  which, 
in  consequence  of  the  sympathy  between 
the  skin  and  eyes,  is  particularly  efficacious. 
4thly.  Rubefacients,  applied  not  far  from  the 
eye  ; means,  which  are  exceedingly  bene- 
ficial in  the  second  stage  of  ophthalmy.  ( B . 
P-257.) 

As  an  appendix  to  these  general  remarks, 
delivered  by  Beer,  on  the  general  treatment 
of  ophthalmy  in  its  first  and  second  stages,  I 
annex  the  sentiments  of  some  other  writers, 
as  either  confirming,  or  rendering  question- 
able, some  of  his  statements. 

According  to  Scarpa,  when  bleeding  and 
other  evacuations  have  been  practised,  the 
next  most  useful  measure  is  the  application 
of  a blister  to  the  nape  of  the  neck.  He  ob- 
serves, that  the  skin  here  and  behind  the 
ears,  has  a stronger  sympathy  with  the  eyes, 
than  any  other  part  of  the  integuments. 
On  the  other  hand,  the  late  Mr.  Ware  pre- 
ferred blistering  the  temples,  and  says, 
“ When  the  leeches  have  fallen  off,  and  the 
consequent  hemorrhage  has  ceased,  I would 
advise  a blister  of  the  size  of  half  a crown  to 
be  applied  on  the  temples,  directly  over  the 
orifices  made  by  the  leeches,  and  I have 
found,  that  the  sooner  the  blister  has  followed 
th • b feeding , the  more  efficacious  both  have 
proved .”  He  adds,  that  when  ophthalmy  is 
very  violent,  and  resists  common  methods, 
the  most  beneficial  effects  are  sometimes 
produced  by  the  application  of  a blister 
large  enough  to  cover  the  whole  head.  ( P . 
43, 44.) 

With  respect  to  blisters,  another  modern 
writer  particularly  objects  to  their  being 
applied  near  the  eye,  or  on  the  temples, 
‘l  where  they  never  fail  to  prove  injurious.” 
There  is  (says  he)  “ but  one  exception  to  this, 
as  a general  rule ; for,  it  would  seem,  that 
blisters  applied  to  the  external  surface  of 
the  palpebra,  in  cases  of  purulent  ophthal- 
mia, tend  considerably  to  diminish  the  pum- 


lency  and  chemosis.”  ( Vetch  on  Diseases  of 
the  Eye,p.  17.) 

In  the  second  stage  of  acute  ophthalmy, 
the  vinous  tincture  of  opium  (the  tinctura 
thebaica)  has  been  very  extensively  used, 
as  a topical  application.  In  common  cases, 
two  or  three  drop-  may  be  insinuated  be- 
tween the  eyelids  and  globe  of  the  eye?  twice 
a day  ; but,  in  other  instances,  attended  with 
more  sensibility,  once  at  first  will  be  suffi- 
cient The  late  Mr.  Ware,  who  brought  this 
application  into  great  repute,  found,  that  in- 
troducing two,  or  three  drops,  of  this  medi- 
cine at  the  inner  canthus,  and  letting  them 
glide  gradually  over  the  eye,  by  gently 
drawing  down  the  lower  eyelid,  proved 
equally  beneficial,  and  less  painful  than 
letting  them  fall  directly  upon  the  eyeball. 
Immediately  the  application  is  made,  it  usu- 
ally creates  a copious  flow  of  tears,  a smart- 
ing, and  a sense  of  heat  in  the  eyes  ; which 
inconveniences,  however,  soon  cease,  and 
the  eyes  become  clearer,  and  feel  decidedly 
improved.  But,  notwithstanding  every  ex- 
aggeration, unbiassed  surgeons  are  now  fully 
convinced,  that  the  vinous  tincture  of  opium 
is  a proper  application  only  when  the  in- 
flammatory action  has  been  previously  di- 
minished by  bloodletting,  aperient  medi- 
cines, and  blisters,  and  when  the  action  of 
the  vessels  has  been  weakened  by  the  con- 
tinuance of  the  disease.  Nor  is  any  doubt 
entertained,  that  the  late  Mr.  Ware  went 
much  too  far,  when  he  recommended  the 
vinous  tincture  of  opium,  as  a most  effectual 
application  in  every  species  and  stage  of 
the  disorder,  from  the  most  mild  and  recent 
to  the  most  obstinate  and  inveterate.  (P, 
51.'  Scarpa  has  seen  the  necessity  of  limiting 
the  use  of  the  remedy  in  question,  and  has 
expressly  pointed  out,  that  it  is  useful  only 
when  the  violence  of  the  pain,  and  the 
aversion  to  light,  have  abated.  Indeed,  Mr. 
Ware  himself,  a little  before  sanctioning  its 
employment  in  all  cases,  has  acknowledged, 
that,  in  certain  instances,  in  which  the  com- 
plaint is  generally  recent,  the  eyes  appear 
shining  and  glossy,  and  feel  exquisite  pain  on 
exposure  to  the  light,  no  relief  at  all  was 
obtained.  (P  48,  49.)  Mr.  Travers  has  re- 
marked, that  “ there  are  inflammations, 
which  assume  a chronic  character  in  their 
commencement,  evidently  depending  on  a 
state  of  atony,  of  very  partial  extent,  void  of 
pain,  and  scarcely  possessing  any  sign  of 
inflammation,  except  the  congestion  of  the 
vessels,  or,  if  any,  so  feebly  marked,  as  to 
encourage  us  to  disregard  them  in  the  treat- 
ment. in  such  cases,  a single  stimulus  will 
often  restore  the  healthy  action  at  once. 
The  vinous  tincture  of  opium  has  acquired 
a nostrum-!ike  importance  from  its  restora- 
tive operation  in  such  casas  ; a virtue,  I be  - 
lieve, not  proper  to  it.  A drop  or  two  of 
the  zinc,  or  the  lunar  caustic  solution,  or 
water  impregnated  with  calomel,  or  a minute 
portion  of  the  citrine  ointment,  or  any  other 
stimulant,  would  do  as  much.”  ( Synopsis , 
fyc.  p.  252.) 

Whenever  the  patient  can  easily  bear  a 
moderate  degree  of  light,  Scarpa  directs  all 


orHTHALMY. 


aiy 

coverings  to  be  removed  irom  the  eyes,  ex- 
cept a shade  of  green,  or  black  silk.  A 
brighter  light  should  be  gradually  admitted 
into  the  chamber  every  day,  so  that  the  eyes 
may  become  habituated,  as  soon  as  possible, 
to  the  open  daylight ; for,  as  Scarpa  truly 
states,  nothing  has  a greater  tendency  to  pro- 
long and  increase  the  morbid  irritability  of 
the  eyes  than  keeping  them  unnecessarily 
long  in  a dark  situation,  or  covered  with 
compresses  and  bandages. 

Dr.  Vetch  has  such  a dislike  to  the  plan  of 
covering  the  eye,  that  he  never  suffers  a 
shade  to  be  worn,  conceiving  that,  in  con- 
junctival inflammation,  it  always  does  a great 
deal  of  harm  by  preventing  a free  exposure 
of  the  eye  to  a temperate  atmosphere.  (On 
Diseases  of  the  Eye,p  17.) 

Besides  the  common  remedies  for  inflam- 
mation, there  are  some  very  powerful 
means,  which  may  be  employed  for  the  re- 
lief of  particular  state*  of  ophthalmy  with 
great  effect.  Thus,  as  the  latter  author  has 
observed,  by  means  of  hysoscinmus,  bella- 
donna, and  stramonium,  (See  Belladonna) 
the  important  structure  of  the  iris  may  be 
secured  from  injury,  at  the  same  time  that 
other  measures  are  adopted  for  checking  the 
inflammation.  Such  medicines  may  even 
be  applied,  as  a mechanical  force,  for  de- 
taching any  recent  adhesion.  (Op.  cit.p.  18.) 

The  uses  of  the  argentum  nitratum  are 
also  very  extensive : “the  slightest  applica- 
tion of  it  in  substance  (says  D . Vetch)  can 
often  remove  the  highest  degree  of  morbid 
sensibility  to  light,  and  instantaneously  re- 
store quietude  to  the  organ;  it  can  prevent 
incipient  changes,  and  obviate  advanced 
ones;  and  may  also  be  used  io  solution,  as  a 
valuable  sedative.” 

The  mention  of  so  stimulating  and  active 
a substance  as  the  nitrate  of  silver  having  a 
.sedative  effect  may  excite  surprise  ; but  the 
fact  is  unquestionable,  and  well  illustrated  in 
the  treatment  of  several  diseases.  (See 
Cornea  and  Iris.)  As  another  modern  writer 
correctly  states,  it  is  remarkable  that  even 
the  weaker  forms  of  medicated  lotions  irri- 
tate, and  none  more  than  such  as  contain 
opium.  Tlie  relief,  afforded  by  anodyne 
fomentations  in  general,  is  very  various.  “ I 
have  known  them  (says  Mr.  Travel-*)  ob- 
jected to  as  painful,  and  patients  inquire  if 
they  might  not  substitute  warm  water  tor 
the  aqueous  solution  of  opium  and  infusions 
of  poppy  and  hemlock.  The  same  observa- 
tion applies  especially  to  painful  herpetic 
cutaneous  affections,  and  acutely  irritable 
ulcers.  Upon  these  a solution  of  opium 
often  acts  as  a stimulant,  and  augments  pain, 
while  the  lunar  caustic  solution  as  often  as- 
suages it.”  At  the  same  time,  Mr.  Travers 
admit*,  that  exceptions  occur,  and  that  lie 
has  met  with  case-,  “ in  which  no  other  ap- 
plication than  the  aqueous  solution  of  opium 
could  be  borne.”  He  has  also  known  the 
vapour  of  laudanum  afford  the  most  marked 
relief  to  the  irritability  to  light  accomtmny 
ing  strumous  opVhahny.  ( Synopsis  of  the 
Diseases  of  the  Eye,  p.  251.) 

.According  to  Dr.  Vetch,  it  is  impossible, 


in  cases  of  conjunctiva!  ophthalmia,  to  poj 
sess  an  application  of  greater  efficacy,  than 
the  undiluted  liquor  plumbi  subacetaii-,  for 
altering  the  morbid  and  purulent  state  of 
that  membrane;  he  also  describes  iico 
tiana.  externally  employed  as  a n r otic  and 
astringent,  as  being  of  singular  service  in 
lessening  the  pain,  and  turnelaction.  (P.  19.) 
However,  the  discordance  among  the  best 
writers,  about  the  effects  of  favourite  local 
applications,  would  lead  me  to  enjoin  rather 
attention  to  the  leading  principles  of*the 
treatment,  than  confidence  in  the  superior 
efficacy  of  any  particular  drug  or  composi- 
tion. As  also  the  local  applications  should 
vary  in  the  different  stages  of  purulent 
ophthalmy,  no  single  one  will  always  be 
right,  li  Bper  had  d -livercd  no  observa- 
tions of  greater  importance,  than  his  con- 
demnation of  Bates’s  camphorated  lotion, 
and  liis  praise  of  other  styptic  stimulating 
applications,  his  remarks  would  be  of  little 
value  ; but,  as  he  has  pointed  out  the  differ- 
ent stages  of  purulent  ophthalmia  in  a very 
correct  manner,  and  adapted  his  remedies  to 
these  various  states  of  the  disease,  his  infor- 
mation comprehends  scientific  principles, 
and  becomes  peculiarly  interesting.  The 
same  praise  belongs  also  to  Dr.  Vetch’s  ob- 
servations on  purulent  ophthalmy,  who  in 
some  points,  both  of  the  description  of 
the  complaint  and  its  treatment,  has  surpass- 
ed Beer. 

Of  the  different  Kinds  of  Ophthalmy . 
Beer’s  classification  is  very  comp  enensive. 
According  to  the  situations,  in  which  oph- 
thalmic iufiaminatio  first  originates,  he  pro- 
poses a general  division  ot  it  into  three  (qrms, 
as  suggested. bv  some  of  the  older  writers; 
viz  inflammation  of  the  eyelids , or  blepha- 
rophthalmitis ; inflammation  of  the  parts 
between  the  orbit  and  globe  of  the  eye ; and, 
lastly,  inflammation  of  the  eyeball  itself  or 
ophthalmitis.  He  observes,  however,  mat 
these  distinctions  seem  to  assign  a considera- 
ble extent  to  the  original  seal  of  th<-  aff  ct ion ; 
for  the  expression,  inflammation  of  the.  eye- 
lids, can  only  denote  a case,  in  winch  the 
disorder  begins  at  once  in  all  the  parts  com- 
posing the  eyelids.  In  the  same  way,  inflam- 
mation of  the  parts  between  the  eysbull  and 
orbit  appears  to  signifv,  that  all  those  parts 
constitute  the  original  sphere  of  th**  com- 
plaint; while  inflammation  of  the  eyeball 
seems  to  denote  that  the  disorder  has  begun 
at  once  in  all  the  textures,  of  which  this 
organ  is  composed.  But,  fortunately,  as 
Beer  remarks,  the  extent  of  the  original  seat 
of  genuine  idiopathic  inflammation  of  the 
eye  is  but  seldom  thus  considerable  ; being 
mostly  restricted  to  particular  textures,  from 
which  it  first  spreads  further  only  when 
neglected,  or  injudiciously  treated.  Hence, 
certain  subdivisions  of  the  complaint  are 
necessary ; and.  accordingly,  Beer  subdivides 
inflammation  of  the  eyelids , first,  into  the 
erysipelatous , or  blepharophthalmilis  erysipc - 
latosa , which  commences  in  the  integuments 
oi  these  parts.  Secondly,  into  that,  which 
originates  at  the  edges  of  the  pulpebrai,  in 
the  conjunctiva  lining  these  parts,  and  tbc 


OPIlTlIAUn 


Meibomian  glands,  and  which  Beer  denomi- 
nates glandular  inflammation  of  the  eyelid s 
or  blepkarophthalrnitis  glandulusa ; a case, 
described  by  writers  under  an  infinite  num- 
ber of  names,  and  often  confounded  with 
complaints  of  a totally  different  nature. 
Thirdly,  when  the  eff  ets  of  the  inflamma- 
tion ar  * confined  to  a -mall  portion  of  the 
eyelid  it  rnn-ti«ute»  the  disease,  termed  the 
inflammatory  stye,  or  hordeolum,  which  Beer 
say--  is  larely  a simple  inflammation,  but 
complicated  with  a scrofulous  habit  ; a pro- 
position, which,  I think,  will  not  receive  any 
credit  in  England.  Fourthly,  as  there  is  one 
more  form  of  inflammation  of  the  eyelids. 
Beer  xives  it  the  name  of  the  erysipelatous 
swelling  of  the  cornea  of  the  eye,  or  anchy- 
lups  erysiptlalosa , which  affects  the  skin  of 
the  inner  canthus,  immediately  over  the 
lachrymal  sac.  The  name,  here  suggested, 
expresses  precisely  the  seat  of  the  inflamma- 
tion, and,  as  Beer  thinks,  will  tend  to  prevent 
the  case  from  being  mistaken  for  inflamma- 
tion of  the  lachrymal  sac.  Inflammation  of 
the  parts  in  the  orbit  comprehends,  first,  in- 
flammation of  the  lachrymal  gland ; secondly, 
inflammation  of  the  lachrymal  sac,  a disorder, 
which  begins  in  the  lachrymal  sac  and  nasal 
duct,  and  generally  extends  with  great  ra- 
pidity over  all  the  excreting  parts  of  the  la- 
chrymal organs  ; and,  thirdly,  influrn  "'’on 
of  the  caruncula  lachrymalis,  or  the  erica,  this 
inflammetoria. 

I;  the  Same  way,  inflammations  of  tl 
eyeball  a lini'  of  a classification,  which  is  of 
the  high  .-t  practical  importance^  first,  into 
the  erysipelatous  inflammation  of  the  sclerotic 
conjunctiva , the  ophthalmitis  erysipelatosa, 
which  denotes  that  torm  of  the  disorder, 
which  is  first  entirely  confined  to  the  mem- 
brane connecting  together  the  eyelids  and 
eyeball.  Secondly,  into  inflammation  of  the 
outer  textures  of  the  eyeball , the  ophthalmitis 
externa , originating  in  the  cornea  and  sclero- 
tica. Thirdly,  into  inflammation  of  the  in- 
nermost textures  of  the  eyeball,  the  ophthal- 
mitis interna , which  has  two  forms  highly 
necessary  to  be  recollected  in  practice;  for 
the  inflammation  may  begin  immediately  in 
the  retina  ehoroides,  the  membrane  of  vi- 
treous humour,  &ic.  and  spread  from  these 
textures  t<>  all  the  rest  of  the  eyeball,  being 
n ined  true  internal  inflammation  of  the  eye- 
ball, or  ophthalmitis  interna  vera,  and  thus 
discriminated  from  another  case,  which  is 
originally  seated  in  the  iris,  the  adjoining 
corpus  ciliare,  the  lens,  and  its  capsule,  and 
afterward  extends  from  these  parts  to  the 
more  deeply  situated  coats,  and  to  the  texture 
of  t lie  vitreous  humour.  This  last  form  of 
internal  inflammation  of  the  eyeball  is  named 
both  by  Schmidt  und  Beer,  iritis.  The  clas- 
sification then  embraces  a view  of  the  dif- 
ferent form 5 of  ophthalmy,  as  modified  by 
constitutional  causes,  as  the  effect  of  con- 
tagious and  infectious  diseases,  measles, 
small-pox,  &c. ; and  as  a complication  of 
eeriain  cachexia;,  like  gout,  rheumatism,  and 
scurvy. 

Although  I have  thus  given  a brief  deline- 
ation of  Beer’s  classification  of  ophthalmic 


inflammation?,  it  Is  not  my  design  in  the  sub- 
sequent columns,  to  enter  into  a full  consi- 
deration of  every  particular  case,  above 
enumerated  ; first,  because  the  limits  of  this 
work  will  not  permit  me  to  do  so;  and  se- 
condly, because  some  of  these  cases  have 
been  already  considered  in  other  parts  of  the 
work.  (6ee  Lachrymal  Organs.) 

Common  Inflammation  of  the  Eyelids. 
This  form  of  disease  is  said  by  Beer  to  affect 
the  upper  much  more  frequently,  than  the 
lower  eyelid,  because  the  former  obviously 
has  a larger  surface  exposed  to  injuries  from 
without  ; nor  does  the  complaint  always 
spread  to  the  latter.  From  the  margin  of 
the  eyelid,  a very  red,  tense,  painful  swelling 
arises,  attended  with  heat,  throbbing,  and  a 
great  deal  of  tenderness,  when  touched.  It 
gradually  extends  over  the  whole  eyelid  : 
but  seems  to  be  plainly  bounded  by  the  edge 
of  the  orbit.  The  motion  of  the  eyelid  is 
always  more  or  less  obstructed,  and,  at 
length,  when  the  inflammation  has  reached 
its  greatest  degree,  it  is  completely  prevent- 
ed. Nor  is  there  any  difficulty  in  compre- 
hending why,  when  tiie  inflammation  has 
become  severe,  the  eye  should  he  excessively 
dry,  and  every  attempt  on  the  part  of  the 
patient  to  move  the  eyelid  should  be  produc- 
tive of  considerable  pain,  and  of  a sensation, 
ns  if  some  sharp  extraneous  substances  lay 
under  the  lid  ; for  at  this  period,  the  palpe- 
bral conjunctiva  is  already  severely  inflamed, 
and,  consequently,  the  secretion  of  mucus 
from  the  Meibomian  giands  is  immediately 
stopped  by  the  inflammation  itself,  while  that 
of  the  tears  is  interrupted  partly  by  the  ex- 
tension of  the  inflammation  to  the  sclerotic 
conjunctiva,  and  partly  by  the  effect  of  the 
sympathetic  connexion  existing  between  the 
conjunctiva  of  the  eyelid,  and  that  of  the 
eyeball.  To  this  last  cause,  viz.  sympathy. 
Beer  refers  the  supervening  dryness  and  shri- 
velling up  of  the  lachrymal  papilla;,  as  well 
as  the  apparent  closure  of  the  puncta  lachry- 
rnalia,  and  the  uneasy  dry  state  of  the 
edgvs  of  the  eyelids.  Hence,  also,  the  dry- 
ness of  the  adjacent  nostril,  and  a very  disa- 
greeable smell  of  dust  obliging  the  patient 
to  sneeze  repeatedly,  w hich  act  is  constantly 
attended  with  a great  increase  of  pain  in  the 
swelling,  a transient  shooting  of  it  to  the 
eye  and  bead,  and  a sensation  as  if  flashes  of 
light  we  e elicited  within  the  eyeball;  a 
kind  of  hallucination,  technically  named 
photopsia.  As  the  original  seat  of  the  in- 
flammation is  already  extensive,  one  may 
readily  understand,  says  Beer,  why  the  affec- 
tion in  its  first  stage,  particularly  when 
neglected, or  badly  treated,  should  frequently 
give  rise  to  some  febrile  disturbance  of  the 
system. 

In  the  second  stage  of  the  case,  or  that  of 
suppuration,  which  billows  when  the  inflam- 
mation is  violent  and  not  soon  dispersed, 
matter  forms  with  the  annexed  train  of 
-ymptoms.  The  redness  suddenly  increases 
very  much,  the  eyelid  becoming  of  a brown* 
i-b  red,  and  lastly  of  a purplish  red  colour. 
The  swelling  becomes  more  prominent,  and 
present?  a conical  eminence,  either  in  the 


OPHTHALMV 


3J.2 


middle  of  the  eyelid,  or  close  to  the  outer  or 
inner  canthus.  The  pain  is  irregular,  and  of 
a stinging,  burning  kind,  a throbbing  being 
felt  only  in  the  deeper  part  of  the  tumour. 
At  length,  the  swelling  becomes  somewhat 
softer,  and  Ies9  sensible  at  its  most  projecting 
point.  The  secretion  from  th<*  Meibomian 
and  lachrymal  glands,  which  in  the  first  stage 
of  the  disorder  was  suppress*  d,  is  now  quite 
re-established,  but  more  copiously,  than  in 
the  healthy  state.  During  sleep,  a quantity 
of  mucus  accumulates  between  the  edges  of 
the  eyes,  and  glues  them  together.  An  ex- 
traordinary sensation  of  cold  and  heaviness 
is  felt  all  about  the  eye.  Ultimately  the  most 
prominent  point  of  the  swelling  presents  a 
pale  red  colour,  followed  by  a yellowish 
livid  tinge.  As  the  abscess  is  now  com- 
pletely formed,  the  fluctuation  of  the  matter 
can  be  plainly  felt.  (Beer,  B.  1 ,p.  269,  fyc  ) 

According  to  the  same  author,  nothing 
very  particular  is  known  respecting  the 
causes  of  the  preceding  form  of  ophthalmic 
inflammation,  and,  with  the  exception  of 
blows,  he  has  not  been  able  to  discover  the 
precise  circumstances  which  give  rise  to  it. 

With  regard  to  the  prognosis,  if  the  treat- 
ment be  neglected,  or  injudicious,  the  in- 
flammation may  suddenly  become  so  violent, 
as  to  produce  in  weak  subjects  gangrenous 
mischief.  But,  when  the  case  is  properly 
managed  in  its  first  stage,  the  second,  or  that 
of  suppuration,  never  ensues;  yet,  says 
Beer, the  curative  measures  must  be  decisive, 
and  valuable  time  not  wasted  on  trifling 
means,  although  due  regard  must  be  paid  to 
the  constitution.  When  the  inflammation 
subsides  favourably,  it  le  -ves  no  vestiges  of 
it  behind,  and  even  the  redness,  which  is  the 
latest  in  disappearing,  completely  goes  off  in 
a few  days,  and  the  function  of  the  eyelid 
becomes  perfect  again. 

If  gangrene  and  sloughing  take  place,  the 
outer  coverings  of  the  eyelid  are  destroyed, 
and  the  consequences  are  an  incurable 
eversion  of  the  part.  (S  eo  Ectr opium)  ora 
hare-eye,  (see  Lagophihalmus.)  When 
suppuration  happens  favourably,  the  abscess 
sometimes  breaks  very  well  of  itself  on  the 
upper  eyelid;  but,  according  to  Beer,  this 
does  not  readily  occur  on  the  lower  one, 
nor  without  the  formation  of  sinuses,  which 
sometimes  run  quite  into  the  orbit.  After 
the  abscess  has  burst,  or  been  opened,  the 
part  heals  up  with  great  celerity  in  favour- 
able constitutions,  but  slowly  in  others ; 
vermilion  granulations  arise  from  the  bot- 
tom of  the  cavity,  and  a cicatrix  follows 
which  is  scarcely  perceptible.  When  the 
abscess  is  very  large,  however,  and  bursts  of 
itself,  the  upper  eyelid  continues  for  some 
time  very  much  weakened.  If  the  collec- 
tion of  matter  be  neglected,  or  wrongly 
treated,  or  the  subject  be  unhealthy,  or  the 
disease  be  aggravated  by  the  etFects  of  a 
damp  atmosphere,  hurtful  food,  severe 
mental  trouble,  wet  poultices,  or  too  long 
confinement  of  the  matter,  then,  says  Beer, 
fistulae  are  apt  to  be  produced,  sometimes 
complicated  with  necrosis  of  the,bone,  the 
certain  effects  of  which  are  some  perma- 


nent and  mostly  incurable  disease  of  the 
eyelid,  and  impairment  of  its  functions  : 1st. 
A closure  of  the  lachrymal  canals,  with  a 
permanent  stiilicidium.  2.  A complete 
obliteration  of  the  same  lubes,  with  an  in- 
curable stiilicidium-  3.  A prolapsus  of  the 
upper  eyelid,  from  distention  of  the  skin  by 
the  long  confinement  of  the  matter.  4. 
Inversion  of  the  edge  of  the  eyelid,  from  a 
shrinking  of  its  cartilage.  5.  Eversion  of 
the  eyelid,  and  hare-eye,  from  loss  <»f  kin. 
(Beer.) 

As,  in  this  species  of  inflammation,  says 
the  same  author,  the  organ  of  sight  cannot 
well  be  affected,  unless  the  disorder  after- 
ward extend  itself  very  much,  the  exclusion 
of  air  and  light  is  here  but  of  little  use 
Linen  compresses,  well  wet  with  very  cold 
water,  or  vinegar  and  water,  are  to  be  ap- 
plied ; and,  while  the  complaint  is  local, 
leeches  are  to  be  used  ; but,  if  the  constitu- 
tion be  threatened  with  febrile  symptoms, 
then  Beer  urges  the  necessity  of  venesec- 
tion, low  diet,  purgatives,  and  general 
antiphlogistic  measures.  (B.  \,p.  275.) 

In  the  second  stage,  with  the  exception 
of  a few  points,  Beer  states,  that  the  case  is 
to  be  treated  like  any  other  common  abscess. 
When  the  matter  is  situated  in  the  middle 
of  the  upper  eyelid,  not  far  beneath  the  skin, 
the  abscess  may  be  allowed  to  burst  of 
itself,  especially,  if  the  patient  have  a great 
dread  of  the  knife.  But,  if  the  matter  lie 
near  the  outer,  or  inner  canthus,  it  should  be 
let  out  w ith  a lancet  as  soon  as  its  fluctua- 
tion is  quite  distinct,  the  incision  being 
made  in  the  direction  of  the  fibres  of  the 
orbicular  muscle.  When  fistulae-  or  gan- 
grene, have  already  taken  place,  the  treat- 
ment should  be  like  that,  which  is  applicable 
to  the  s;im*j  kind  of  mischief  in  most  other 
parts  of  the  skin. 

Erysipelatous  Inflammation  of  the  Eyelids 
usually  affects  both  these  parts  together, 
very  seldom  only  the  upper  one,  and  never 
the  lower  alone.  When  also  both  are 
affected,  the  disorder  always  presents  itself 
in  the  greatest  degree  in  the  upper  eyelid 
A pale,  yellowish  red, seemingly  transparent, 
shining  swelling  arises  from  the  edges  of  the 
eyelids,  and  rapidly  extends  itself,  without 
any  determinate  boundary,  the  faint  red 
colour  being  gradually  lost  upon  the  eyebrow 
above,  and  not  unfrequently  upon  the  cheek 
below.  When  the  inflamed  part  is  gently 
touched,  the  redness  disappears,  but  only  for 
a moment.  At  length,  (be  swelling  towards 
the  margins  of  the  eyelids  becomes  exceed- 
ingly soft,  and  feels  like  a vesicle  that  has 
been  raised  by  a blistering  plaster.  The 
pain  is  inconsiderable,  not  attended  with 
throbbing, but  rather  with  a sense  of  heat  and 
stiffness;  when  the  part  is  slightly  touched,  the 
patient  experiences  a lancinating  sensation 
in  it.  Its  temperature  is  not  much  increased. 
The  secretions  from  the  Meibomian  glands, 
lachrymal  gland,  and  mucous  membrane 
of  the  nostrils,  are  much  augmented. — 
In  a strong  subject,  the  disorder,  if  genuine 
and  idiopathic,  is  not  productive  of  any 
constitutional  disturbance  '•  but,  in  bad 


OPHTHALM\ 


313 


habits,  and  weak  females  and  children,  it  is 
sometimes  attended  with  fever.  However, 
when  the  complaint  partakes  of  the  phleg- 
monous character,  and  is  badly  treated,  the 
general  symptoms  are  occasionally  very  se- 
vere at  the  change  from  the  first  to  the 
second  stage,  and  the  case  may  then  termi- 
nate in  a gangrenous  kind  of  suppuration. 
In  irritable,  delicate  children,  says  Beer, 
when  the  disease  spreads  over  the  face,  the 
case  requires  the  most  skilful  treatment  for 
the  prevention  of  a disastrous  termination. 

In  sirong  persons,  the  second  stage  of  this 
disorder  rarely  ends  in  a manifest  suppura- 
tion ; but  there  is  rather  an  exudation  of 
lymph,  which  becoming  dry,  forms  very 
small,  delicate,  branny  scales,  in  the  com- 
position of  which  the  desquamated  cuticle 
has  also  a considerable  share.  In  other 
instances,  vesications  of  various  sizes  are 
formed  on  the  erysipelatous  surface,  and 
burst,  and  discharge  a fluid,  which  is  con- 
verted into  yellowish  scabs. 

According  to  Beer,  the  skin  of  the  eye- 
lids is  particularly  prone  lo  erysipelatous  in- 
flammation, which  is  therefore  more  easily  in- 
duced in  it,  than  in  the  integuments  of  other 
parts.  Beer  considers  the  sudden  effect  of  a 
cold  blast  of  air,  or  of  very  cold  water,  upon 
the  skin  of  the  eyelid,  while  in  a slate  of 
free  perspiration,  as  the  most  common  cause 
of  its  being  attacked  with  erysipelas,  parti- 
cularly in  weak  subjects.  He  states,  how- 
ever, that  the  complaint  may  be  occasioned 
by  the  stings  of  bees,  wasps,  and  other 
insects  ; accidents,  which  when  the  stings 
are  not  extracted,  are  liable  to  be  followed 
by  a violent  and  dangerous  general  inflam- 
mation of  the  eyelid,  not  unfrequentiy 
extending  in  a perilous  degree  to  the  eyeball 
itself.  (B.  1,  p.  281.) 

With  regard  to  the  prognosis,  no  other 
case  of  ophthalmic  inflammation  so  fre- 
quently subsides  without  the  aid  of  surgery 
as  this,  provided  the  constitution  he  healthy 
and  strong;  and,  when  the  complaint  is 
resolved  in  its  first  stage,  the  vestiges  of  it 
afterward  are  as  little  as  those  consequent 
to  common  inflammation  of  the  eyelids. 

The  second  stage,  however  well  treated, 
is  followed  fora  long  time  by  a peculiar  sen- 
sibility of  the  skin  to  the  impression  of  cold 
damp  air,  and  a strong  propensity  to  relapses. 
If,  when  the  cuticle  peels  off,  a patient  of 
weak  constitution  sit  in  a current  of  damp 
cold  air,  or  try  to  wash  away  the  scales  and 
scabs  with  cold  water,  Beer  states,  that  an 
cedematous  affection  of  the  eyelid  will  be 
produced,  which  is  often  very  obstinate,  and 
apt  to  occasion  a temporary  inversion  of 
the  ciliae  ( Trichiasis ,)  or  a similar  state  of 
the  edge  of  the  eyelid  ( Entropium .)  And, 
he  observes,  that  when  from  neglect,  or 
bad  treatment,  an  erysipelatous  inflamma- 
tion of  the  eyelid  terminates  in  suppuration, 
the  abscess  is  not  like  a common  one,  hut 
the  matter  rapidly  makes  its  way  out  through 
several  openings  in  the  already  partially 
disorganized  skin,  and,  in  general,  this  state 
is  followed  by  ill-conditioned  tedious  ulce- 
rations, vvherebv  a good  deal  of  skin  is 
Yol.  IT  49 


always  destroyed.  Under  these  circum- 
stances, all  those  consequences  may  be 
produced,  which  have  been  described  as 
liable  to  take  place  from  the  second,  or 
suppurative  stage,  of  common  inflammation 
of  the  eyelid.  Gangrene  and  sloughing  may 
even  occur,  when  erysipelas  of  the  eyelids 
is  brought  on  hy  the  unremoved  sting  of  an 
insect,  and  efficient  treatment  is  delayed. 

The  treatment,  recommended  by  Beer  in 
the  first  stage,  consists  in  the  application  of 
cold  water,  and  he  remarks,  that  exposure 
of  the  part  for  a time  to  a cool,  moist,  hut, 
in  other  respects,  pure  atmosphere,  will  often 
suffice  for  the  removal  of  the  complaint. 
When,  however,  the  disorder  increases,  and 
assumes  a phlegmonous  character,  the  direc- 
tions given  for  the  treatment  of  blepharoph- 
thalmitis,  are  to  be  followed. 

In  the  second  stage  of  erysipelas  of  the 
eyelids,  Beer  praises  the  good  effects  of  a 
mild,  dry  air,  of  an  equal  temperature,  and 
recommends  covering  the  parts  with  a light 
bandage,  under  which  are  to  be  put  well 
warmed  linen  compresses,  which,  for ‘weak 
persons,  should  be  sprinkled  with  camphor  ; 
or  he  directs  the  eyelids  to  be  covered  with 
hags  of  aromatic  herbs;  generally  a very 
favourite  plan  with  Beer,  whenever  he  ob- 
jects to  moist  applications.  In  such  indivi- 
duals, he  observes,  that  the  cure  is  promoted 
by  keeping  up  the  function  of  the  skin  with 
gentle  diaphoretic  medicines,  with  which, 
when  the  debility  is  very  great,  camphor 
should  be  joined.  Should  an  abscess  form, 
the  same  treatment  is  proper  as  in  the  se- 
cond stage  of  common  inflammation  of  the 
eyelids,  or  (what  Beer  calls)  blepharophthal- 
mitis. 

Glandular  Inflammation  of  the  Eyelids,  or 
the  Blephar ophthalmitis  Glandulosa,  as  Beer 
terms  it,  is  considered  by  this  author  as  the 
disease,  of  which  all  the  various  cases  of  pu- 
rulent ophthalmy  are  only  modifications, 
which  he  describes  under  the  names  of  idio- 
pathic catarrhal  ophthalmy  ; idiopathic  catar- 
rhal-rheumatic ophthalmy ; and  blepharo-blen- 
norrhcen,  or  ophtlialmo-blennorhcea.  The  two 
latter  terms  comprehend  the  purulent  oph- 
thalmy of  infants,  the  Egyptian  ophthalmy, 
the  gonorrhoeal  ophthalmy,  &c. 

Glandular  Inflammation  of  the  Eyelids , 
Beer  knew  very  well  was  so  far  a defective 
term,  that  it  seemed  to  imply  merely  an  af- 
fection of  the  Meibomian  and  mucous  glands 
of  those  parts,  whereas  he  means  to  express 
by  this  name  the  kind  of  inflammation,  of 
which  all  the  cases,  usually  called  in  this 
country  purulent  ophthalmies , are  varieties 
and  modifications,  and  in  which  the  con- 
junctiva is  also  particularly  affected. 

Acute  suppurative  inflammation  of  the  con- 
junctiva, divisible  into  the  mild  and  severe 
forms,  as  proposed  by  Mr.  Travers,  appears, 
perhaps,  a better  name  ( Synopsis , fyc.  p.  96, 
&c.)  Dr.  Vetch,  who  also  prefers  the  gene- 
ral term  conjunctival  inflammation,  observes, 
that  from  many  internal  and  external  causes, 
the  membrane  of  the  conjunctiva  is  liable 
to  become  the  seat  of  inflammation,  more 
especially  that  portion  of  it,  which  gives 


314 


©phthalmy: 


a lining  to\the  inner  surface  of  the  eyelids. 
The  disease,  in  its  general  nature,  he  says, 
differs  little  from  that  which  is  met  with  in 
other  parts  having  a similar  surface,  as  the 
nose,  the  fauces,  the  bronchial  cells,  and  the 
urethra  ; but,  the  continuation  of  the  mem- 
brane forward  upon  the  anterior  portion  of 
the  eye,  and  the  consequent  liability  of  the 
inflammation  to  affect  this  important  organ, 
attach  much  interest  to  all  the  circumstan- 
ces. capable  of  producing  it.  (Vetch  on 
Diseases  of  the  Eye,p.  148.)  In  the  common 
glandular  inflammation  of  the  eyelids,  des- 
cribed by  Beer,  which  seems  to  me  to  cor- 
respond to  the  more  moderate  forms  of 
purulent  ophlhalmy  met  with  in  this  country, 
either  the  whole,  or pnly  that  part  of  the 
edges,  which  is  near  one,  or  both  canthi,  is 
affected  with  a very  red,  hardish,  sensible 
swelling,  attended  with  a violent  annoying 
degree  of  itching.  This  swelling,  Beer  ob- 
serves, does  riot  extend  far  over  the  outside 
of  the  eyelid  upwards,  or  downwards,  at 
most,  not  more  than  a few  lines ; but  it 
spreads  over  the  palpebral  conjunctiva,  es- 
pecially when  neglected,  or  badly  treated, 
and  the  constitution  is  w eak.  This,  he  says, 
can  only  be  discovered  when  the  eyelid  is 
everted.  The  further  the  swelling  extends 
over  the  inside  of  the  eyelid,  the  more  is 
the  motion  of  the  part  obstructed,  not  on 
account  of  any  want  of  power  in  the  orbi- 
cular muscle,  but  from  the  fear  of  the  pain, 
with  which  every  attempt  to  move  the 
eyelid  is  accompanied.  The  itching,  which 
continually  distresses  the  patient,  more  or 
less,  is  often  succeeded  by  an  irritating, 
burning  kind  of  pain,  which  is  particularly 
experienced  w?hen  the  eyelids  are  moved, 
and  hence,  the  patient  is  obliged,  as  it  were, 
to  keep  his  eye  closed.  While  the  inflam- 
mation is  restricted  to  the  edges  and  con 
junctiva  of  the  eyelids,  and  the  Meibomian 
glands  situated  under  it.  though  the  secretion 
from  these  glands  is  entirely  stopped,  that 
from  the  lachrymal  gland  is  much  augment- 
ed,, and  consequently,  the  disease  is- asso- 
ciated with  a true  epiphora , which  is  seri- 
ously aggravated  whenever  the  eye  is  ex- 
posed to  a strong  light.  As,  under  these 
circumstances,  the  tears  are  not  properly 
blended  with  the  Meibomian  secretion,  they 
must  of  course  be  very  irritating  to  the  eye 
and  its  surrounding  parts,  and  less  fitted  for 
properly  lubricating  its  surface.  Hence,  the 
pain  now  becomes  burning,  and  not  unfre 
quently  the  cheek,  over  which  the  tears 
run,  is  excoriated.  As  soon  as  the  inflam- 
mation of  the  eyelids  spreads  further,  and 
begins  to  affect  the  sclerotic  conjunctiva, 
the  effusion  of  tears  ceases  the  eye  becomes 
preternaturnlly  dry,  and  the  patient  con- 
stantly thinks  that  he  feels  sand  under  the 
eyelids,  which  sensation  is  rendered  almost 
intolerable  by  any  motion  of  the  eye,  or 
eyelids.  Children  and  women  have  so  great 
a dread  of  this  painful  feel,  that  much  per- 
suasion is  often  requisite  to  induce  them  to 
Jet  the  eye  be  properly  examined.  If  the 
glandular  inflammation  of  the  eyelids  attain 
a considerable  degree,  the  lachrymal  papilla; 


shrink,  and  the  puncta  seem  closed,  winch 
is  particularly  the  case  when  the  disorder 
begins  at  the  inner  canthus. 

In  the  second  stage  of  the  complaint,  Beer 
describes  the  itching,  burning  sensation,  and 
dryness  of  the  eye,  as  undergoing  a remark- 
able diminution,  as  either  the  canthi,  or  the 
whole  extent  of  (he  edges  of  the  eyelids, 
become  more  and  more  moist,  and  smeared 
with  mucus,  an  increased  secretion  of  a pu - 
riform  sebaceous  fluid  from  the  Meibomian 
glands  being  the  first  symptom,  denoting  the 
commencement  of  the  second  stage  of  the  in- 
flammation. As  this  mucous  secretion  is 
not  mixed  with  an  adequate  quantity  of 
tears,  it  inspissates  in  the  form  of  while, 
thin  delicate  layers,  which,  from  time  to 
time,  cover  the  cornea,  and  make  the  patient 
very  apprehensive  of  becoming  blind,  as  the 
flame  of  a candle  in  the  evening,  and  other 
objects  appear  to  him  more  or  less  conceal- 
ed by  a dense  mist  When,  under  these 
circumstances,  however,  the  eyelids  are 
repeatedly  and  briskly  moved,  or  the  eye 
is  wiped,  these  appearances  soon  go  off,  the 
flakes  of  mucus  being  removed  from  the 
cornea.  These  accumulations  of  thickened 
mucus,  Beer  remarks,  are  apt  to  be  most 
frequent  and  troublesome  some  time  after  a 
meal  ; and  the  eyelids  become  so  firmly 
glued  to  ether  during  sleep  with  yellowish 
crusts,  that,  when  the  patient  awakes  in  the 
morning,  it  is  not  till  after  a great  deal  of 
washing  and  bathing  of  his  eyes  with  warm 
water,  that  he  is  able  to  open  them  again. 
The  above  described  change  in  the  quantity 
and  quality  of  the  secreted  matter,  as  al- 
ready mentioned,  indicates  th e first  period  of 
the  second  stage ; for  Beer  wishes  it  to  be 
particularly  noticed,  that  here,  as  in  all  in- 
flammations of  mucous  membranes,  the  se- 
cond stage  of  the  disorder  has  three  periods, 
as  will  be  presently  seen,  to  which  the  prac- 
titioner cannot  be  too  attentive. 

This  morbid  secretion  of  a mucous  seba- 
ceous matter  does  not  continue  long  unat- 
tended with  other  efiects  ; and,  very  soon, 
the  peculiar  appearances  of  suppuration  are 
seen,  at  the  same  time  that  the  conjunctiva 
of  the  eyelids  becomes  more  considerably 
swelled,  and  a discharge  takes  place  not 
only  from  the  cantiii  or  margins  of  the  eye- 
lids, but  from  the  whole  of  the  thickened 
villous  surface  of  the  palpebral  conjuuctiva, 
and  which  discharge  is  distinguishable  at 
first  view  from  the  mucus,  which,  at  an  ear- 
lier period,  accumulated  in  much  smaller 
quantity  only  between  the  edges  of  the  eye- 
lids, and  at  the  canthi.  It  is  now  no  longer 
white,  but  ye!lowr,  completely  like  pus,  with 
which  it  is  in  reality  blended,  and  so  viscid 
is  it,  that  the  crusts  which  collect  on  the 
eyelids  in  the  nighttime  cannot  be  removed, 
without  pulling  the  eyelashes  away  with 
them.  Sometimes,  says  Beer,  at  the  moment 
of  suppuration,  minute  pustules,  which  are 
scarcely  distinguishable,  form  either  at  the 
canthi,  or  along  the  edges  of  the  eyelids, 
and  are  sooti  burst  by  the  constant  friction 
of  the  parts.  These  pustules  indicate  the 
second,  or  suppurative  period  of  the  second 


UPHTHALMY. 


315 


s* age  ot  the  case,  when  either  merely  the 
canthus,  or  the  whole  of  the  margin  of  the 
eyelid,  constantly  becomes  excoriated,  and 
secretes  mucus  and  purulent  matter,  the 
sore  fretted  places  smarting  so  severely  on 
exposure  to  the  airy  particularly  to  such  as 
contains  a large  proportion  of  carbonic  acid 
gasjind  nitrogen,  that  the  patient  is  afraid 
of  opening  his  eye.  When  the  patient  neg- 
lects himself,  and  continues  in  an  unhealthy 
atmosphere,  these  excoriations  of  the  skin, 
occurring  in  the  suppurative  stage,  are  al- 
ways more  extensive  ; nay,  they  sometimes 
spread  over  the  lower  eyelid,  and  down  the 
cheek 

At  length,  after  the  excoriations  have 
lasted,  perhaps,  several  weeks,  the  suppura- 
tive process  is  checked  and  suppressed,  ei- 
ther by  surgical  treatment,  or  accidental  fa- 
vourable circumstances,  as  change  of  regi- 
men, the  weather,  climate,  &lc.,  and  then 
the  excoriations  immediately  diminish. 
However,  a morbid  secretion  from  the  Mei- 
bomian glands  still  continues,  making  the 
third  period  of  the  second  stage,  and  is  apt  to 
become  habitual,  if  not  rectified  by  art,  or 
removed  by  the  effect  of  accidental  favour- 
able circumstances,  when  it  changes  into  a 
thin  serous  discharge,  and  then  terminates. 

Beer  refers  the  causes  of  glandular  inflam- 
mation of  the  eyelids , or  simple  purulent  oph- 
tha'.my , to  the  immediate  operation  of  va- 
rious stimuli  acting  chymically  upon  the 
edge  of  the  eyelid,  where  it  is  covered  with 
a very  delicate  cuticle,  and  upofi  the  ex- 
posed follicles  of  t e glands  of  the  eyelid 
towards  the  inner  canthus.  Hence,  says  he, 
when  many  men  are  living  together  in  a 
polluted,  noxious  air,  impregnated  with  ex- 
traneous substances,  this  form  of  inflamma- 
tion is  found  to  occur  even  in  the  strongest 
constitutions  with  such  frequency,  that  it 
seems  as  if  it  were  epidemic.  And,  accor- 
ding to  Beer,  the  principal  cause  of  the  dis- 
ease will  be  found  to  be  in  the  atmosphere, 
and  the  next  most  frequent  occasion  of  it, 
be  observes,  is  uncleanliness,  as  washing 
the  eyes  with  foul  water,  &.<■.  At  the  same 
time,  this  experienced  oculist  seems  aware 
that  this  explanation  would  not  of  itself  be 
always  quite  satisfactory  ; for,  he  adds,  that 
although,  under  the  above  circumstances, 
no  constitution,  no  sex,  nor  age,  is  spared, 
there  must  be  some  particular  condition 
which  is  conducive  to  the  disorder,  or  at  all 
events,  to  its  more  rapid  and  severe  course, 
and  the  quick  extension  of  the  inflamma- 
tion in  certain  individuals,  which  condition 
Beer  supposes  must  depend  either  upon 
weakness  of  constitution,  or  upon  excessive 
irritability,  or  as  he  terms  it,  vulnerability  of 
the  whole  surface  of  the  body.  Beer  makes 
•no  mention  of  the  effect  of  damp  nocturnal 
air  in  warm  countries  in  giving  origin  to  pu- 
rulent ophtbalmy.  so  much  insisted  upon  by 
Assalini  and  Dr.  Vetch,  but,  which  doctrine, 
in  reference  to  the  origin  of  purulent  oph- 
thalmies  in  England,  I think  completely 
fails  ; and  what  is  still  more  worthy  of  no- 
tice, Beer  never  attempts  to  explain  the 
propagation  of  the  disease  by  its  infectious 


nature.  It  is  observed  by  Dr.  Vetch,  that 
the  history  of  all  diseases,  originating  from 
some  particular  impression  received  from 
the  atmosphere,  but  capable,  when  formed, 
of  propagating  themselves  by  contagion,  is 
rendered  particularly  difficult;  because  the 
same  circumstances,  which  favour  the  com- 
munication by  contagion,  produce  also  a 
predisposition  to  be  acted  upon  by  the  more 
general  causes  existing  in  the  atmosphere. 
The  principal  cause  which  gives  force  and 
opportunity  to  the  action  of  contagion,  is 
the  crowding  individuals  together  into  too 
limited  spaces.  The  same  circumstance  Dr. 
Vetch  has  seen  give  a predisposition  to  dis- 
eases of  an  epidemic,  but  not  a contagious 
nature  ; and  hence  he  infers,  that  it  may 
produce  the  same  predisposition  to  diseases 
which  are  both  contagious  and  atmospheric. 
“ The  appearance  of  ophthalmia  among  the 
crews  of  ships  and  in  barracks  'was  often 
met  with  long  before  the  late  destructive 
and  virulent  disease  (presently  to  be  des- 
cribed.) In  the  army,  such  an  ophthalmia 
has  extended  to  whole  regiments,  without 
any  appearance  of  the  disease  among  the 
inhabitants  of  the  neighbourhood  ; and 
while  the  free  intercourse  which  subsists 
among  the  men.  as  to  washing  in  the  same 
water,  u-ing  the  same  towels,  and  sleeping 
more  than  one  in  a bed,  readily  accounts  for 
the  rapid  extension  of  the  disease  in  the 
same  corps,  yet  the  excessive  crowding  to- 
gether of  men  will  often  of  itself  engender 
inflammation  of  the  conjunctiva.”  {Fetch 
on  Diseases  of  the  Eyes.  p.  171.)  I be- 
lieve with  respect  to  the  causes  of  all  pu- 
rulent ophthahnies,  our  present  knowledge 
will  permit  us  to  venture  no  further  than 
the  tenor  of  the  preceding  observations, 
which  is,  that  they  originate  epidemically, 
but  probably  multiply  both  in  this  manner, 
and  by  the  infectious  matter  of  the  disease 
being  inadvertent  ly  applied  in  various  ways 
to  the  eyelids  of  other  persons.  This  spe- 
cies of  inflammation  of  the  eyelids  is  rarely 
met  with  by  the  surgeon  in  its  first  stage, 
because  only  very  timorous  patients  then 
seek  medical  advice,  and  most  individuals, 
who  feel  in  other  respects  well,  relieve 
themselves  by  washing  the  eyes  with  cold 
water,  and  applying  cold  poultices,  made  of 
bread  crum  softened  in  water.  Besides, 
when  the  disease  is  not  very  severe,  it  fre- 
quently subsides  of  itself,  as  in  a favourable 
constitution,  a better  air  is  sometimes  capa- 
ble of  restoring  the  healthy  state  of  the  eye. 
If,  however,  the  disease  at  its  very  com- 
mencement should  be  violent,  or  attack  an 
individual  of  very  wTeak  habit,  Beer  states 
that  it  may  immediately  affect,  not  only  the 
Meibomian  glands,  but  the  perichondrium 
of  the  cartilage  of  the  eyelid,  and  produce 
an  incurable  entropium,  which  is  also  sure 
of  taking  place  when  the  case  is  neglected, 
and  followed  by  deeply  extending  ulcerative 
mischief.  When  the  complaint  is  strictly 
idiopathic,  it  never  brings  on  any  general 
indisposition,  except  by  improper  treatment 
it  should  happen  to  be  converted  into  a 
violent  inflammation  of  the  whole  eyelid, 


OPHTHALMic . 


816 


or  what  Beer  terms  a complete  blcpharoph- 
Ihalmitis  ; which  he  says,  only  happens  in 
•weak  subjects,  and  women  and  children, 
whose  skin  is  in  a very  irritable  state,  or 
when  a person  of  apparently  good  consti- 
tution remains  under  the  influence  of  cir- 
cumstances which  tend  to  augment  the  in- 
flammation, as  for  instance,  exposed  to  the 
air  of  a stable,  privy,  foe.  in  which  event. 
Beer  describes  the  inflammation  of  the  eye- 
lids as  being  quite  of  a peculiar  description. 

As  for  the  prognosis  in  the  second  stage, 
Beer  observes,  that,  if  the  excoriations  at 
the  suppurative  period  should  spread  all 
over  the  edges  of  the  eyelids,  and  compel 
the  patient  to  keep  his  eye  incessantly  shut, 
a partial  adhesion  of  the  eyelids  to  each 
other  ( ancliyloblepharon ) may  be  the  result. 
Also,  when  at  either  of  the  periods  of  the 
secretion  of  mucus,  or  at  that  of  suppura 
lion,  the  patient  is  content  with  merely  sof- 
tening with  warm  water  the  thick  matter 
glueing  the  eyelids  together,  so  as  just  to  be 
able  to  open  his  eye  ; and  does  not  com- 
pletely free  the  eyelashes  from  the  crusts, 
clusters  of  the  hairs  will  project  inwards, 
(see  Trichiasis ) whereby  a secondary  in- 
flammation of  the  conjunctiva  of  the  eye- 
ball will  be  excited,  which,  Beer  says, 
should  be  carefully  discriminated  from  a 
mere  extension  of  the  glandular  inflamma- 
tion of  the  eyelid.  Such  a trichiasis,  he 
observes,  may  easily  become  incurable, 
when  the  edge  of  the  eyelid  is  seriously  in- 
jured by  the  depth  of  the  excoriations. 
But,  if  the  suppurative  process  be  restricted 
chiefly  to  the  canthus,  especially  the  outer 
one  (which  case,  according  to  Beer,  is  not 
unfrequent  in  old,  debiliated  subjects,  of  a 
relaxed  constitution)  and  if  the  excoriations 
should  deeply  penetrate  the  commissure  of 
the  eyelids  this  may  be  completely  destroy- 
ed, and  the  lower  eyelid  everted. 

As  the  state  of  the  atmosphere,  unclean- 
liness, crowded  and  close  places,  &c.  are 
considered  by  Beer  to  be  the  principal  causes 
of  the  glandular  inflammation  of  the  eye- 
lids, or  simple  purulent  ophthalmy,  one  of 
the  most  important  indications,  in  the  first 
stage  of  the  disorder,  seems  to  him  to  be 
the  removal  of  these  hurtful  circumstances. 
And,  he  declares,  that,  if  immediate  atten- 
tion be  not  paid  to  such  indication,  it  will 
be  quite  impossible  to  prevent  a dangerous 
increase  of  the  disorder.  A cool  fresh  air, 
and  bathing  the  eye  with  cold  water,  or  a 
weak  lotion  of  vinegar  arid  water,  Beer 
represents  to  be  means,  usually  adequate 
to  stille  this  inflammation  in  its  birth.  In 
the  second  stage,  he  says,  the  indication  is 
entirely  different. 

But,  also  in  the  beginning  of  this  stage, 
and  even  at  its  second  period,  namely  that 
of  suppuration  taking  place,  the  disorder, 
according  lo  Beer,  seems  for  a short  time  to 
be  benefited  by  the  employment  of  cold 
water,  but  the  consequences  are  rendered 
by  such  treatment  a great  deal  worse  ; for 
a fresh,  much  more  extensive  inflammation 
of  the  same  kind  again  takes  place.  At 
the  first  period  of  the  second  stage,  viz. 


while  the  secretion  is  a pure  mucous  au& 
sebaceous  matter,  Beer  says,  that  it  is  abso 
lutely  necessary  to  employ  such  external 
means,  as  are  calculated  to  promote  the  ac- 
tion of  the  veins  and  absorbents.  For  this 
purpose,  he  recommends  the  following  col- 
lyrium  : ]j^.  Aq.  rosa3  Z\v.  Hydrarg.  oxymur. 
gr.  j. vcl.gr. dimidium.  Mucil.  sem  cydori.  3j- 
Tinct  opii  vinos.  Qj-  Misce.  This  eyewater 
is  to  be  used  lukewarm  from  four  to  six 
times  a day,  and  the  eye  afterward  care- 
fully and  completely  dried.  JSo  eye,  in  this 
state,  he  says,  will  bear  more  than  the  pro- 
portion of  one  gr.  of  the  oxymuriate  of 
quicksilver,  and  only  seldom  more  than 
half  a grain. 

But,  as  soon  as  the  suppurative  period 
commences,  attended  with  excoriations, 
gentle  astringents,  like  the  liquor  plumbi 
subacetatis,  in  a solution  of  the  lapis  divinus 
(See  Lachrymal  Organs)  should  bt  added  to 
the  above  lotion,  for  which  they  may  at 
length  be  entirely  substituted.  And,  when 
the  suppurative  period  has  terminated,  but  a 
morbid  secretion  of  mucus  yet  obstinately 
continues,  and  threatens  to  become  habitual, 
recourse  should  be  bad,  without  the  least  de- 
lay, to  one  of  the  following  eyesalves,  a bit 
of  which,  about  the  size  of  a small  pea, 
Beer  directs  to  be  smeared  once  a day  over 
the  edges  of  the  eyelids.  Butyr.  recen  - 
tis  insulsi  ^ss.  Hydrargyri  nitrico-oxydi 
gr.  x.  Tutia?  ptt.  gr.  vj.  Misce.  This  oint- 
ment, he  says,  will  sometimes  answer  ; but, 
that  it  is  mostly  necessary  to  use  Janin’s 
salve,  composed  as  follows:  f^.  Butyri  re- 
centis  insulsi  ^ss.  Hydrargyri  praecipitati 
albi.  gr.  xv.  Boli  albi  3j.  Misce. 

According  to  Mr.  Travers,  the  mild  acute 
suppurative  inflammation  of  the  conjunctiva 
is  not  attended  w ith  that  excessive  swell- 
ing of  the  eyelids,  that  intense  pain,  nor 
that  profuse  secretion,  w ith  which  the  vehe- 
ment acute  form  of  the  disease  is  character- 
ized. In  the  treatment,  he  directs  a solution 
of  alum  to  be  early  substituted  for  emollient 
fomentations,  which  he  recommends  to  be 
freely  used  during  the  acute  period.  Simple 
purging  and  abstinence,  he  says,  are  gene- 
rally sufficient  to  allay  the  febrile  irritation, 
which  is  moderate.  Topical  bleedings,  and 
blisters,  kept  open  on  the  back  of  the  neck, 
are  also  stated  to  be  of  great  efficacy. 
“ When  the  pain  and  irritability  to  light 
subside,  and  the  discharge  becomes  gleety, 
the  conjunctiva  pale  and  flaccid,  tonics,  es- 
pecially the  extract  of  bark  and  the  acids, 
do  gri:at  good.”  ( Synopsis , fyc.  p.  264.) 

Catarrhal  uphlkalmy,  so  called  by  Beer,  is 
described  by  him  as  a species  of  glandular 
inflammation  of  the  eyelids,  attended  with 
a simultaneous  atfection  of  the  mucous  mem- 
brane of  the  nose,  trachea,  foe.  brought  on 
by  particular  states  of  the  weather,  and  at- 
tacking so  many  persons  at  once,  as  to  ap- 
pear epidemic.  The  prognosis  and  indica- 
tions are  the  same  as  those  in  common  glau 
dular  inflammation  of  the  eyelids,  with  this 
exception,  that  attention  must  be  paid  lo 
the  affection  of  other  organs,  and  both  at. 
the  first  and  second  periods  of  the  second 


dPHT'HALMV. 


Si  r 


Stage,  such  remedies  given  as  operate  power- 
fully on  the  mucous  membranes  and  skin, 
and,  in  general,  during  the  second  stage,  an 
equal  warm  temperature,  and  gentle  diapho- 
retics, with  camphor,  are  highly  beneficial. 

Severe  Purulent  Ophlhalmy. — The  Blepha- 
ro-blenorrhcea , and  Ophthnlmo-blenorrhcea , of 
Schmidt  and  Beer;  including  the  ophthalmia 
neonatorum;  the  Egyptian  ophlhalmy  ; the 
gonorrhoeal  ophlhalmy,  fyc.,  on  w hich  varie- 
ties, however,  1 shall  annex  to  this  account 
some  further  particulars,  as  they  relate  to 
each  of  these  cases  individually,  because, 
though  the  following  history  contains  an  ex- 
cellent general  description  of  the  severe 
forms  of  suppurative  inflammation  of  the 
conjunctiva,  it  leaves  unexplained  some  of 
the  circumstances  on  which  its  varieties  de- 
pend. 

The  vehement  acute  suppurative  inflam- 
mation of  the  conjunctiva  is  described  by 
Mr.  Travers  as  being  sudden  in  its  attack  ; 
a feature,  in  which  it  particularly  differs  from 
the  milder  cases  usually  met  with  in  schools. 
(See  Lloyd  on  Scrofula,  p.  321.)  It  is  accom- 
panied with  most  severe  darting  pains  ; and 
the  upper  eyelid  is  sometimes  in  a few  hours 
prolonged  upon  the  cheek,  owing  to  the  in- 
filtration and  enormous  swellingof  the  tissue, 
connecting  the  conjunctiva  to  the  tarsus. 
( Travers , Synopsis,  c %-c.  p.  265.) 

According  to  Beer,  the  modification  of 
glandular  inflammation  of  the  eyelids,  here 
to  be  considered,  consists  entirely  in  the  ra- 
pid extension  of  the  inflammation  and  sup- 
puration, the  disorder  affecting,  ere  it  is  sus- 
pected, not  only  the  whole  of  the  conjuncti- 
va of  the  eyelid,  but  also  that  of  the  eye- 
ball, and  the  sclerotica  and  cornea.  The 
swelling  of  the  palpebral  conjunctiva  is  de- 
scribed by  Beer  as  being  unusually  great  ; 
at  first,  soft,  somewhat  elastic,  smooth,  and 
readily  bleeding;  but,  afterward,  in  the  se- 
cond stage,  hard  and  granulated,  or,  as  ano- 
ther writer  says,  it  “ becomes  pi  eternaturally 
vascular,  thickened,  and  scabrous,  or  forms 
fleshy  eminences.”  ( Travers , Synopsis,  fyc 
p.  96.)  The  first  stage  is  rapidly  over.  At 
the  first  period  of  the  second  stage,  the  se- 
cretion both  of  mucus  and  pus  is  surprisingly 
copious.  First,  the  mucus  is  whitish  and 
thin  ; but,  as  soon  as  the  suppurative  pro- 
cess begins,  it  becomes  yellowish  and  thick, 
and  when  an  attempt  is  made  to  open  the 
eyelids,  it  gushes  out  with  such  force,  and 
in  so  large  a quantity,  as  frequently  to  cover, 
in  an  instant,  the  whole  cheek.  Sometimes, 
this  mixture  of  mucus  and  matter  contains 
light-coloured  streaks  of  blood  ; but,  in 
worse  cases,  these  streaks  are  dark  and 
brownish,  or  else  a thin  ichor  is  discharged, 
in  which  case,  the  progress  of  the  disease 
is  so  rapid,  that  the  eye  can  seldom  be  sa- 
ved. The  swelling  of  the  conjunctiva  of 
the  eyelids,  especially  of  that  of  the  upper 
one,  always  increases  during  the  first  period 
of  suppuration,  and,  when  the  discharge  is 
more  ichorous,  the  membrane  is  more  gran- 
ulated, so  that  if  the  eyelid  be  opened  care- 
lessly, or  during  the  child’s  crying,  fits  of 
pain.  &c.  the  whole  tumefied  conjunctiva  of 


the  upper  eyelid  is  immediately  thrown 
outward,  in  the  form  of  ectropium,  and  it  is 
sometimes  difficult,  and  even  impracticable 
to  turn  the  part  inward  again,  especially, 
when  the  conjunctiva  is  already  changed 
into  a hard  sarcomatous  substance.  While 
the  swelling  at  the  inner  surface  of  the  eye- 
lids continues  to  increase,  their  outer  sur- 
face, particularly  that  of,  the  upper  one, 
becomes  reddened  ; but  the  redness  is  dark- 
coloured,  inclining  to  brown,  and  when  the 
child  cries,  to  blue.  In  children,  the  w hole 
cheek  on  the  affected  s:de  is  very  often 
swelled,  and  sometimes  the  mucous  mem- 
brane of  the  lachrymal  sac  and  even  of  the 
nose,  participates  in  the  effects  of  the  dis- 
order. Sometimes,  at  first,  only  one  eye  is 
affected,  and  the  other  is  afterward  attack- 
ed And,  according  to  Beer,  just  before  the 
period  of  suppuration,  it  is  by  no  means  un 
common  for  rather  a profuse  bleeding  to 
to  take  place  from  the  eye  ; an  event, 
which  thou  h it  seriously  alarm  the  parents 
of  the  child,  or  an  adult  patient,  is  hailed  by 
the  experienced  surgeon  as  a favourable 
omen  ; for,  in  such  cases,  the  suppuration 
is  generally  very  mild,  and  not  of  a destruc 
five  kind,  and  the  swelling  of  the  « onjunc- 
tiva  of  the  eyelids,  as  well  as  that  of  the 
sclerotic^  conjunctiva,  if  already  present, 
soon  undergoes  a remarkable  diminution 
after  such  hemorrhage,  which  often  recurs 
two  or  three  times.  When  during  the  first, 
very  short  ami  transient  stage,  the  inflam 
mation  extends  also  to  the  sclerotic  con- 
junctiva, this  membrane  forms  a pale-red, 
soft,  irregular  swelling,  all  round  the  cor- 
nea, which  at  length  seems  so  buried,  that 
at  the  period  of  the  mucous  secretion,  its 
centre  can  hardly  be  discerned  ; and,  when 
suppuration  begins,  both  rnucus  and  pus 
are  discharged  from  the  conjunctiva  of  the 
eyeball  in  profust'  quantity,  particularly  ac- 
cumulating over  the  cornea,  and  not  unfre- 
quently  drying  into  a thick  pellicle,  when 
long  detained  in  the  eye.  Hence,  the  case 
looks  as  if  the  whole  eyeball,  or  at  least,  all 
the  cornea,  were  in  a state  of  complete  sup- 
puration. At  length,  the  tumefied  conjunc- 
tiva of  the  eyeball  becomes  sarcomatous, 
though  never  in  such  a degree  as  that  of  the 
eyelids.  hen  the  suppurative  period  cea- 
ses, and  with  it  the  most  urgent  danger  to 
the  eye,  the  secretion  of  mucus  alone  con- 
tinues, as  at  the  first  period  of  the  second 
stage,  the  swelling  of  the  conjunctiva  of 
the  eyelids,  and  of  the  sclerotic  conjuncti- 
va, when  this  has  also  been  affected,  dimi- 
nishes, and  the  disorder  ends  in  an  increased 
effusion  of  tears  or  true  epiphora.  When 
the  effects  of  the  suppuration  upon  the  con- 
junctiva of  the  eyeball  are  more  severe,  the 
corneal  production  of  this  membrane  in  the 
most  favourable  cases  is  raised  from  the  sub- 
jacent cornea,  and  so  opaque,  that  the  eye- 
sight is  lost,  or  at  all  events  seriously  impair- 
ed, until  the  transparency  returns,  which  is 
sometimes  late,  especially  when  efficient 
treatment  is  not  put  in  practice.  Should 
the  suppuration  be  very  deep,  the  cornea, 
which  always  turns  whiter  and  whiter,  pre- 


QPHTH  ALMV, 


318 


sents  near  the  edge  of  the  swelling  of  the 
conjunctiva  an  arrangement,  similar  to  that 
of  the  leaves  of  an  old  book,  and  at  length 
seems  converted  into  a mass  of  purulent 
matter,  which  projects  more  and  more  out 
of  the  depression  in  the  swelled  conjunc- 
tiva, and  then  bursts  in  its  centre  either 
quickly  and  with  very  violent  pain,  or  slow- 
ly without  any  suffering,  an  oval  hole  being 
left,  behind  which  the  yet  transparent  crys 
ta  1 line  lens  appears,  included  in  its  undama- 
ged capsule.  At  this  period,  adults  can  often 
see  very  plainly,  and  fancy  their  recovery 
near  at  hand,  or,  at  least,  all  danger  over. 
Already,  however,  every  part  of  the  cornea 
has  been  more  or  less  perforated  by  ulcera- 
tion, the  iris  protrudes  through  all  these 
apertures,  so  as  to  form  what  has  sometimes 
been  named  the  staphyloma  racemosum. 
In  a very  short  time,  not  exceeding  a few 
hours,  the  capsule  of  the  lens  is  affected, 
and  bursts  like  the  cornea,  when  it  is  dis- 
charged either  with,  or  without,  a portion 
of  the  vitreous  humour.  At  length,  the 
suppuration  subsides,  and  with  it  the  pro- 
trusions of  the  iris,  the  opening  in  the  cornea 
becoming  closed  with  a brown,  or  bluish, 
opaque  fiat  cicatrix  But,  if  in  this  destruc- 
tive form  of  suppuration,  nothing  is  done 
for  the  relief  of  the  disease,  the  whole  eye- 
ball suppurates,  theeyelids  become  concave 
instead  of  convex,  and  the  fissure  between 
them  closes  for  ever.  In  adults  of  feeble 
constitutions,  when  the  case  is  not  properly 
treated,  but  particularly  in  weak  children, 
this  excessively  violent  form  of  conjuncti- 
val inflammation  and  suppuration  spreads 
with  such  rapidity,  that  a considerable  ge- 
neral disturbance  of  the  system  is  occasion- 
ed. Indeed,  according  to  Mr.  Travers,  in 
the  common  course  of  this  vehement  form 
of  conjunctiva!  suppurative  ophthalmy,  the 
system  sympathizes  ; chilliness  is  succeeded 
by  a hot  and  dry  skin  ; and  the  pulse  is 
frequent  and  hard.  Yet,  it  is  particularly 
pointed  out  by  the  army  surgeons,  that  one 
peculiarity  of  the  Egyptian  purulent  oph- 
thalmy is  its  being  generally  attended  with 
little  constitutional  disturbance.  When  the 
above-described  annihilation  of  the  eyeball 
takes  place,  it  always  creates  violent  gene- 
ral indisposition  in  unhealthy  weak  chil- 
dren, and  even  leaves  adults  for  along  while 
afterward  in  an  impaired  state  of  health. 

According  1o  Beer,  who  appears  to  have 
no  idea  of  infection  being  concerned  the 
particular  cause  ot  this  unfortunate  exten- 
sion of  idiopathic  glandular  inflammation 
of  the  eyelids,  both  in  infants  and  adults, 
frequently  depends  altogether  upon  the  foul 
atmosphere,  in  which  they  are  residing,  and 
hence,  says  he,  the  disorder  is,  as  it  were, 
endemic  in  lying-in  and  foundling  hospitals, 
where  the  air  is  much  contaminated  by  ef- 
fluvia, from  the  lochia,  the  crowding  toge- 
ther of  many  uncleanly  persons,  dirty  clouts, 
&,c  The  unjustifiable  folly  of  exposing  the 
eyes  of  new-born  infants  to  every  degree 
of  light ; a tedious  labour,  in  which  the 
child’s  head  is  detained  a long  while  in  the 
vagina ; and  roughly  washing  the  eyes  after 


birth  with  a coarse  sponge;  are  other  cir- 
cumstances, supposed  by  Beer  to  be  condu- 
cive to  the  origin  of  the  complaint,  in  new- 
born infants.  The  reality  of  many  of  these 
causes  I regard  myself  with  a great  deal  of 
doubt ; and  nsfor  hisconjecture,  thatsprink- 
liug  cold  water  on  the  head  in  baptism, 
while  in  a state  of  perspiration,  may  pro- 
duce the  complaint,  it  is  too  absurd  to  need 
any  serious  refutation.  The  disorder,  he 
says,  is  always  more  rapid  and  perilous  in 
new-born  infants  than  adults;  ( B . 1,  p. 
318,)  a remark  which  does  not  agree  with 
the  statements  usually  made,  if  the  Egyp- 
tian ophthalmy,  as  seen  in  the  army,  be 
comprehended.  It  is  observed  by  Mr. 
Travers,  that  the  highly  contagious  nature 
of  the  suppurative  ophthalmia,  whether  in 
the  mild,  or  vehement  acute  form,  is  suffi- 
ciently proved.  For  one  person,  affected 
with  this  disease  above  three  months  old, 
he  thinks  at  least  twenty  are  attacked  under 
that  age.  “ The  mother  is  the  subject  of 
fluoralbus,  or  gonorrhoea,  and  the  discharge 
is  usually  perceived  about  the  third  day.’’ 
( Synopsis , fyc.  p.  97.)  Some  further  obser- 
vations on  the  causes  of  some  of  these  severe 
modifications  of  glandular  inflammation  of 
the  eyelids  will  be  introduced,  after  the 
prognosis  and  treatment  have  been  consi- 
dered. This  will  be  the  more  necessary,  as 
the  propagation  of  the  disorder  by  infection 
is  here  entirely  overlooked. 

According  to  Beer,  whenever  an  idiopa- 
thic inflammation  of  the  glands  of  the  eye- 
lids attains  the  severe  forms,  exhibited  in 
the  purulent  ophthalmy  of  infants,  the  Egyp- 
tian ophthalmy,  and  gonorrhoeal  ophthalmy, 
the  prognosis  must  naturally  be  unfavoura- 
ble, and  this  in  a greater  degree,  the  more 
the  inflammation  and  suppuration  have  ex- 
tended to  the  eyeball  itself.  The  cases  are 
still  more  unpromising,  when  they  happen 
in  poor,  half-starved,  distressed  individuals, 
whom  it  is  impossible  completely  to  extri- 
cate from  the  circumstances,  which  either 
cause,  or  have  a pernicious  effect  upon  the 
disease.  Should  an  incidental  ectropiurn 
not  be  immediately  rectified,  says  Beer,  it 
will  continue  until  the  end  of  the  second 
stage,  and  even  frequently  longer,  so  as  to 
require  particular  treatment.  When  at  the 
period  of  suppuration,  merely  the  layer  of 
the  conjunctiva,  spread  over  the  cornea,  is 
destroyed,  the  prognosis,  in  respect  to  the 
complete  recovery  of  the  eyesight,  is  fa- 
vourable, although  it  takes  place  but  slow- 
ly. If  the  effects  of  the  disease  at  this 
period  should  be  deeper,  yet  the  cornea 
not  destroyed,  only  rendered  flat  and 
somewhat  opaque  ; or,  if  the  cornea 
should  be  ulcerated  only  at  a very  lim- 
ited point;  there  will  remain  in  the  first 
case,  an  opacity  of  the  cornea  ; but,  in  the 
second,  a partial  adhesion  of  the  iris  to  the 
latter  membrane  (synechia  anterior)  is  apt 
to  follow,  with  a more  or  less  extensive  ci- 
catrix on  the  cornea,  covering  in  a greater 
or  lesser  degree  the  lessened  and  displaced 
pupil,  and  thus  diminishing,  or  preventing 
vision.  When,  during  the  inflammation 


OPHTHALMY. 


819 


aud  suppuration,  a considerable  part,  or  the 
whole  of  the  iris  adheres  to  the  cornea,  and 
this  is  not  penetrated  by  ulceration,  the  re- 
sult, in  the  first  case,  is  a partial , in  the  se- 
cond, a complete  staphyloma  of  the  cornea, 
which  does  not  fully  develope  itself,  until 
towards  the  decline  of  the  second  stage  of 
the  ophthalruo-blennorrhcea.  If  the  inflam- 
mation should  spread  to  the  tejitures  of  the 
eyeball  itself,  so  as  to  produce  severe  con 
Stitutional  disturbance,  the  eye  wastes  away 
in  the  midst  of  the  profuse  discharge,  the 
eyelids  sink  inwards,  and  the  fissure  between 
them  becomes  permanently  closed.  (Beer, 
B.  1,  p.  319.) 

Beer  notices  the  opinion  of  the  celebrated 
Schmidt,  which  was,  that  the  opthalmo- 
hlennorrhcea,  orpurulent  ophthalmy  involv- 
ing the  sclerotic  conjunctiva,  always  has  a 
fixed  duration  of  a mouth,  in  new-born  in- 
fants, and  of  six,  eight,  or  twelve  weeks,  in 
very  weak  individuals.  Beer  acknowledges 
the  correctness  of  this  opiuion,  only  in 
cases  where  the  surgeon  has  to  deal  with  a 
completely  formed  ophthalmo-blennorrhoea, 
and  not  in  a more  recent  case,  or  one  in 
which  the  disease  is  chiefiy  confined  to  the 
inside  of  the  eyelids.  ( Blepharo-blennor - 
rhoea.)  When  the  disorder  is  met  with  in 
the  first  period  of  the  second  stage,  or  it  is 
confined  to  the  palpebral  conjunctiva  and 
Meibomian  glands,  and  truly  idiopathic, 
Beer  asserts,  that  its  course  may  be  restrict- 
ed by  efficient  treatment  to  a few  days,  as 
he  has  often  proved  in  the  establishment  for 
foundlings  at  Vienna. 

It  is  further  remarked  by  Beer,  that,  in 
this  modification  of  genuine  idiopathic  glan- 
dular inflammation  of  the  eyelids,  the  in- 
dications have  something  peculiar  in  them. 
If,  by  chance,  the  surgeon  meet  with  the 
disease  in  its  first  stage,  it  will  be  most  bene- 
fited by  the  application  of  folded  linen  wet 
with  cold  water ; and  sometimes  a brisk 
purge  of  jalap  and  calomel,  and  putting  a 
leech  over  the  lachrymal  sac  at  the  inner 
canthus,  will  promote  the  subsidence  of 
this  dangerous  species  of  ophthalmy.  The 
case,  however,  jrarely  presents  itself  for  me- 
dical treatment  thus  early,  and,  in  hospitals, 
Beer  says,  antiphlogistic  treatment  is,  on  this 
account , hardly  ever  indicated. 

With  some  exceptions  of  importance,  the 
treatment,  advised  by  Beer,  for  the  second 
stage  of  these  severer  forms  of  purulent 
ophthalmy,  resembles  that  proposed  by  him 
for  the  second  stage  of  simple  glandular  in- 
flammation of  the  eyelids,  or  the  milder 
varieties.  These  more  severe  kinds  of  puru- 
lent inflammation  of  the  eye,  implied  by 
blepharo-blennorrhcea  and  ophthalmo-blen- 
norrhoea,  he  says,  should  never  be  viewed 
and  treated  merely  as  local  disorders  ; but 
that,  both  in  children  and  adults,  internal 
remedies  should  be  exhibited,  particularly 
volatile  tonic  medicines.  In  cases,  where 
the  cornea  is  already  attacked  by  a destruc- 
tive ulcerative  process,  manifold  experience 
has  convinced  him,  that  bark,  combined  with 
naphtha,  and  the  tincture  of  opium,  is  the 
only  means  of  saving  the  eye  : but,  that  if 


the  suppuration  be  confined  to  the  eye- 
lids, the  decoction  of  calamus  aromati- 
cus  with  naphtha  and  opium  will  mostly 
answrer.  When,  on  the  supervention  of 
suppuration,  the  pain  in  the  eye  and  neigh- 
bouring parts  is  excessively  severe,  Beer 
assures  us,  that  friction  with  a liniment  of 
opium  will  give  great  relief.  In  new-born 
infants,  the  maternal  milk  of  right  quality 
will  mostly  do  more  good,  than  internal 
medicines  : but  if  the  case  be  very  urgent, 
and  the  child  feeble,  Beer  thinks  volatile 
medicines  may  sometimes  do  good. 

With  respect  to  particularities  made  ne- 
cessary in  the  local  treatment  by  the  modified 
nature  of  the  inflammation.  Beer  otters  the 
following  information.  First,  in  new-born 
infants,  or  very  young  children,  the  oxymu- 
muriate  of  mercury  cannot  be  used  without 
danger,  though  blunted  with  mucilage;  and 
even  in  adults,  it  should  be  employed  in 
these  cases  with  great  circumspection.  Se- 
condly, the  mucus  and  purulent  matter 
should  not  be  allowed  to  remain  long  under 
the  eyelids,  as  such  lodgment  is  found  to 
promote  the  destruction  of  the  layer  of  the 
conjunctiva  situated  on  the  cornea;  but,  at 
the  same  time,  Beer  thinks,  that  leaving  any 
water  on  the  eyes,  after  cleaning  them,  and 
letting  it  become  cold  there,  will  have  quite 
as  pernicious  an  effect.  Hence,  he  is  very 
particular  in  directing  all  the  mucus  and 
purulent  matter  to  be  wiped  away  from  the 
eye  with  a bit  of  fine  sponge  moistened  with 
a warm  mucilaginous  collyrium,  but  not  so 
w et  as  to  let  the  fluid  drop  out  of  it ; or  when 
they  are  very  copious,  and  in  large  flakes, 
he  even  recommends  them  to  be  washed 
away  by  means  of  Anel’s  syringe  ; but.  he 
says,  that  every  part  about  the  eye  should  be 
immediately  afterward  well  dried  with  a 
warm  napkin,  and  then  covered  with  a w arm 
camphorated  compress.  Thir-ily , during  the 
suppurative  period,  according  to  Beer,  com- 
mon tincture  of  opium,  or  the  vinous  tincture 
is  the  best  local  application,  the  parts  being 
smeared  with  it  twice  a day,  by  means  of  a 
fine  camel-hair  brush.  It  is  only  in  a few 
instances,  that  a small  proportion  of  the 
lapsis  divinus  (see  Lachrymal  Organs ,)  mixed 
with  the  mucilaginous  collyrium,  can  be 
endured.  Beer  declares,  that  he  has  never 
seen  any  good  produced  by  Bates’s  campho- 
rated lotion,  w hich  was  so  highly  praised 
by  the  late  Mr.  Ware.  Fourthly,  when  the 
suppurative  period  has  terminated,  the  mu- 
cous secretion  again  becomes  vvliite  and  thin, 
as  at  the  very  commencement  of  the  second 
stage,  but  it  is  always  more  copious  ; now7  is 
the  time,  (as  in  the  last  stage  of  simple 
glandular  inflammation  of  the  eyelids)  when 
the  topical  use  of  mercury,  joined  w7ith 
styptics,  especially  in  the  form  of  an  eye- 
salve,  is  indicated.  Fifthly,  if  an  eversion 
of  the  upper  eyelid  should  happen  from 
washing  the  eye  carelessly,  or  the  mere 
crying  of  the  infant,  in  consequence  of  the 
thickened  granulated  state  of  the  palpebral 
conjunctiva,  the  position  of  the  eyelid  must, 
if  possible,  be  immediately  rectified  ; for 
afterward,  this  cannot  be  done.  In  order  to 


OPHTHALMY. 


mo 

avoid  this  ectropium,  the  eyelids  should  irritation  are  past,  and  the  cornea  retains  ite 
never  be  opened  while  the  child  is  crying,  or  tone  and  brightness,  Mr.  Travers  considers 
in  any  way  agitated;  for,  at  such  periods,  the  the  case  safe,  and  states,  that  the  prompt 
thickened  scabrous  conjunctiva  will  sudden  exhibition  of  tonics,  with  the  use  of  cooling 
ly  protrude,  and  cannot  be  kept  buck.  Beer  astringent  lotions,  will  prevent  its  lapsing 
says,  that  the  eyelid  should  be  replaced  in  into  a chronic  form.  “ But  if,  when  the 
the  manner  directed  by  Schmidt.  ( Ophthal - lowering  practice  has  been  pushed  to  the 
mo/  Bibl.  3.  R.  2.  Stuck,  p.  149.)  The  surgeon  extent  of  arresting  acute  inflammation,  the 
having  smeared  the  e^ds  of  the  thumb  and  patient  being  at  the  same  time  sunk  and  ex- 
forefinger of  each  of  his  hands  with  fresh  hausted.  the  cornea  shows  a lack  lustre  and 
butter,  is  to  take  hold  of  the  everted  raggedness  of  its  whole  surface,  as  if  shrunk 
cartilage  of  the  eyelid  at  the  outer  and  by  immersion  in  an  acid,  or  a gray  patch  in 
innercanthus,  draw  it  slowly  a little  upwards,  the  centre,  or  a line  encircling,  or  half  en- 
and  then  suddenly  downw  ards.  Thus,  the  circling  its  base,  assuming  a similar  appear- 
fhickened  conjunctiva,  if  not  too  fleshy  and  ance,  the  portion  so  marked  out  will  infalli- 
granulated,  may  be  quickly  reduced,  and  bly  be  deta*  bed  by  a rapid  slough,  unless  by 
the  ectropium  removed.  But,  if  the  swelling  a successful  rally  of  the  patient’s  powers,  we 
ot  this  membrane  should  he  already  very  can  set  up  the  adhesive  inflammation,  so  as 
considerable,  and  have  begun  to  be  hard  and  to  preserve  in  situ  that  which  may  remain 
studded  with  excrescences,  tiiethumbs  should  transparent.”  (Synopsis,  fyc.  p.  266.)  Here 
be  placed  so  as  to  compress  rather  the  we  find  some  approximation  of  practice,  be- 
middle  of  the  eyelid.  However,  if  the  ectro-  tween  Mr.  Travers  and  Professor  Beer  ; but 
piura  cannot  be  at  once  removed,  it  is  to  be  it  is  almost  the  only  point,  in  which  any  re- 
treated, after  the  termination  of  the  second  semblance  can  be  found  in  their  modes  of 
stage  of  the  purulent  opbthalrny,  as  a sequel  treatment. 

of  this  disorder.  (See  Ectropium .)  The  granulated,  or  fungous  state  of  the 

In  the  ophthal mo-blennorrhcea  the  altera-  palpebral  conjunctiva,  produced  by  puru- 
tion  of  the  sclerotic  conjunctiva  is  said  by  lent  ophthalmy,  sometimes  demands  parti- 
Beer  to  be  very  different  from  chemosis  ; a cular  treatment,  after  the  original  disease  is 
vemark,  which  is  strictly  correct,  inasmuch  subdued.  If  such  state  of  the  eyelid  be  not 
as  ordinary  chemosis  is  not  attended  with  rectified,  it  often  keeps  up  a “ gleety  dis- 
til at  change  in  the  surface  of  the  sclerotic  charge,  irritability  to  light,  drooping  of  the 
conjunctiva,  which  fits  it  for  the  secretion  upper  lid,  a pricking  sensation  as  of  sand  in 
of  pus.  But,  if  we  are  to  understand  by  the  eye,  and  a preternaturally  irritable  and 
chemosis,  a copious  effusion  of  lymph  in  the  vascular  state  of  the  sclerotic  conjunctiva  j 
loose  cellular  substance  between  the  con-  with  these  are  frequently  combined  opaci- 
junctiva  and  the  eyeball,  this  state  must  be  ties  of  the  cornea.”  (Travers,  op.  cit.  p.  271.) 
admitted  as  one  of  the  usual  effects  of  severe  The  affection,  as  conjoined  with  opaque 
purulent  ophthalmy.  cornea,  is  particularly  noticed  by  Dr.  Vetch, 

“ It  is  after  this  morbid  condition,  which  who  describes  the  disease  of  the  palpebrae  as 
is  characteristic  of  the  suppurative  ophthal-  consisting,  at  first,  in  a highly  villous  state  of 
mia  (says  Mr.  Travers)  that  the  conjunctiva  their  membranous  lining,  which,  if  not 
forms  fungous  excrescences,  pendulous  treated  by  appropriate  remedies,  gives  birth 
flaps,  or  hard  callous  rolls  protruding  be-  to  granulations,  which  in  process  of  time 
tween  the  palpebraS  and  globe,  and  everting  become  more  deeply  sulcated,  hard,  or 
the  former,  or,  if  not  protruding,  causing  the  warty.  Along  with  the  villous  and  fleshy 
turning  of  the  lid  over  against  the  globe,  appearance  of  the  lining  of  the  eyelids,  there 
The  tarsal  portion  takes  on  from  the  same  is  a general  oozing  of  purulent  matter,  which 
cause  the  hard  granulated  surface,  which  may  at  any  time  be  squeezed  out  by  press- 
keeps  up  incessant  irritation  of  the  sclerotic  ing  the  finger  on  the  part.  The  diseased 
conjunctiva, and  at  length  renders  the  cornea  structure  is  highly  vascular,  and  bleeds  most 
opaque.”  (Synopsis,  Q-c.' p.  9 8.)  profusely  when  cut.  It  possesses,  as  all 

The  treatment  recommended  by  Mr.  Tra-  granulated  surfaces  do,  a very  great  power  ' 
vers  for  the  vehement  acute  suppurative  of  growth  or  reproduction.  Dr.  Vetch  has 
inflammation  of  the  conjunctiva  consists  in  seen  many  cases  in  which  it  has  been  remo- 
a very  copious  venesection,  by  which,  be  ved  with  more  zeal  than  discretion,  twenty 
says,  the  pain  is  mitigated,  if  not  removed  ; or  thirty  times  successively,  without  this 
the  pulse  softened  ; and  the  patient  sinks  disposition  to  reproduction  having  suffered 
into  a sound  sleep  and  perspires  freely.  The  any  diminution.  Indeed,  he  assures  us,  that 
high  scarlet  hue  and  bulk  of  the  chemosis  the  operation  was  very  unfavourable  to  the 
are  sensibly  reduced,  and  the  cornea  is  ultimate  recovery  of  the  part ; “ a new  sur- 
brighter.  The  blood-letting,  if  necessary,  is  face  is  produced  of  a bright  velvety  appear- 
to  be  repeated,  and  the  patient  briskly  ance,  much  less  susceptible  of  cure  than  the 
purged,  every  dose  of  the  opening  medicine  original  disease,  and  which,  even  if  at  length 
being  followed  by  a lea-spoonful  of  a solu-  healed,  does  not  assume  the  natural  appear- 
tion  of  emetic  tartar,  so  as  to  keep  up  a ance  of  the  part,  but  that  of  a cicatrized 
stale  of  nausea,  perspiration,  and  faintness,  surface,”  not  attended  with  a return  of  the 
When  the  discharge  becomes  thin,  gleety,  transparency  of  the  cornea.  It  is  s&tisfacto- 
and  more  abundant,  the  swelling  of  the  eye-  l ily  proved,  by  the  observations  of  Dr. 
lid  subsides,  the  conjunctiva  sinks  and  be-  Vetch,  that  this  diseased  state  of  the  inner 
pale  and  fiebbv.  the  pain  and  febrile  surface  of  the  eyelid  was  not.  only  known  to 


©PHTHAUVTY. 


.321 


ilhases,  and  other  old  practitioners,  under 
the  names  of  sycosis,  trachoma,  scabies  pal- 
pebrarum, &c.  but  that  its  treatment  by  the 
actual  cautery,  excision,  and  friction,  was 
also  recommended  by  them.  The  honour 
of  having  introduced  the  preferable  mode  of 
cure  with  escharotics,  Dr.  Vetch  assigns  to 
St.  Ives.  No  substances  appear  to  Dr.  Vetch 
more  effectual  for  this  purpose  than  the 
sulphate  of  copper  and  nitrate  of  silver.  He 
says,  that  they  should  be  pointed  in  the  form 
of  a pencil,  and  fixed  in  a port-crayon. 
They  are  to  be  applied,  not  as  some  have 
conceived,  with  the  view  of  producing  a 
slough  over  the  whole  surface,  but  with 
great  delicacy,  and  in  so  many  points  only, 
as  will  produce  a gradual  change  in  the 
condition  and  disposition  of  the  part.  As 
long  as  any  purulency  remains,  Dr.  Vetch 
states,  that  the  above  applications  will  be 
much  aided  by  the  daily  use  of  the  liquor 
plumbi  subacetatis.  When  the  disease  re- 
sists these  remedies,  and  the  surface  is  hard 
and  warty,  he  applies  very  minute  quanti- 
ties of  finely  levigated  powder  of  verdigris, 
or  burnt  alum,  to  the  everted  surface,  with 
a fine  camel-hair  pencil,  but  carefully 
Washes  them  off  with  a syringe  before  the 
eyelid  is  returned.  The  caustic  potassa, 
lightly  applied  to  the  more  prominent  parts 
of  the  diseased  surface,  will  also  answer. 
(See  Vetch  on  Disease's  of  the  F.ye  p.  73, 
<y c.)  Mr.  Lloyd  also  gives  his  testimony  in 
favour  of  the  superiority  of  the  nitrate  of 
•silver,  which  he  lias  employed  in  the  form 
of  a saturated  solution  for  restoring  the 
healthy  state  of  the  inner  surface  of  the 
eyelid.  (On  Scrofula,  p.  328.)  Others, 
however,  still  adhere  to  the  practice  of  ex- 
cision, which,  as  already  observed,  was  fol- 
lowed by  the  ancients,  and  revived  of  late 
years  in  England  by  Mr.  Saunders,  who  did 
with  scissors  what  Sir  W.  Adams  and  others 
have  subsequently  performed  with  a knife 
or  lancet.  Mr.  Travers,  I may  observe,  is 
also  one  of  the  advocates  for  the  excision  of 
the  granulations  and  hardened  excrescences 
of  the  conjunctiva.  If  there  be  a nebula  of 
the  cornea,  with  a plexus  of  vessels  extend- 
ing to  it,  these  are  then  divided,  near  the 
edge  of  the  cornea,  in  the  manner  recom- 
mended by  Scarpa.  Mr.  Travers  afterward 
applies  a solution  of  the  sulphate  of  copper, 
the  liquor  plumbi  subacetatis,  or  the  vinous 
tincture  of  opium.  One  remark  which  he 
makes  tends  very  much  to  confirm  the  gene- 
pal  advantage  of  the  practice  inculcated  by 
Dr.  Vetch  ; for,  it  is  observed,  “ the  appli- 
cation of  the  bluestone,  or  of  the  lunar  caus- 
tic, is  often  useful  in  preventing  the  regene- 
ration of  the  granulations  after  their  exci- 
sion.” ( Synopsis , fyc.  p.  272.)  My  friend, 
Mr.  Law  rence,  whose  experience  in  diseases 
of  the  eye  is  very  considerable,  lately  in- 
formed me,  that  he  finds  caustic  the  sure 
mode  of  permanently  removing  the  granu- 
lated fungous  state  of  the  inner  surface  of 
the  eyelid,  and  that,  when  the  granulations 
are  cut  away,  they  are  frequently  reprodu- 
ced ; a fact  on  which  Dr.  Vetch  has  particu- 
larly insisted 
Vot,  II 


Egyptian  Ophlhalmy.  One  of  the  best 
accounts  of  this  disease,  as  it  appeared  iri 
the  army,  is  that  delivered  by  Dr.  Vetch. 
Although  there  can  be  no  doubt  that  the 
disorder,  in  all  its  general  characters, 
closely  corresponds  to  the  severe  form  of 
acute  suppurative  inflammation  of  the  con- 
junctiva, as  described  by  Beer;  yet  thero 
are  some  peculiarities  with  which  it  appears 
to  have  been  characterized.  Thus,  one 
thing  noticed  in  the  Egyptian  ophlhalmy, 
but  not  in  other  purulent  ophthalmies,  fs, 
that  the  firs'  appearance  of  inflammation  was 
observable  in  the  lining  of  the  lower  eyelid, 
(Peach  in  f din' . Med  and  Surgical  Journ. 
for  January,  1807.  Vetch,  on  Diseases  of  the 
Eye.  p 196.)  According  to  the  latter  wri- 
ter, the  feeling  of  dirt,  or  sand,  rolling  in 
the  eve  is  a symptom  requiring  particular 
attention,  as  its  accession  is  a certain  index 
of  the  disease  being  on  the  increase.  It  b 
subject  to  exacerbations  and  remissions,  the 
attacks  always  taking  place  in  the  evening, 
or  very  early  in  the  morning.  The  first 
stage  of  the  disease  is  said  by  Dr.  Vetch  to  be 
characterized  by  its  great  and  uniform  redress , 
ivithout  that  pain , tension,  or  intolerance  of 
light , which  accompanies  most  other  forms  of 
Ocular  inflammation  ; and,  in  particular,  that 
in  which  the  sclerotic  coat  is  affected.  From 
the  very  beginning  of  the  complaint,  there 
is  a disposition  to  puffiness  in  the  cellular 
texture  between  the  conjunctiva  and  the 
globe  of  the  eye,  often  suddenly  swelling 
out  into  a state  of  complete  chemosis,  and 
at  other  times  making  a more  gradual  ap- 
proach to  the  cornea.  While  effusion  is 
thus  taking  place  upon  the  eye,  cedema  is 
likewise  going  on  beneath  the  integuments 
of  the  eyelids.  This  enormous  tumefaction 
of  the  eyelids  is  said  to  be  generally  consen- 
taneous with  the  complete  formation  of 
chemosis;  entropium  is  produced,  and  the 
integuments  of  the  two  eyelids  meet,  lea- 
ving a deep  sulcus  between  them.  When 
the  external  swelling  begins,  the  discharge, 
w hich  was  previously  moderate,  and  consist- 
ed of  pus  floating  in  a watery  fluid,  changes 
into  a continued  stream  of  yellow  matter, 
which,  diluted  with  the  lachrymal  seer# 
tion,  greatly  exceeds  in  quantity  that  deri- 
ved from  any  gonorrhoea.  Although,  says 
Dr.  Vetch,  the  tumefaction  may  be,  at  first, 
farther  advanced  in  one  eye  than  the  other, 
it  generally  reaches  itsgreatest  height  In  both 
about  the  same.  The  patient  now*  begin?* 
to  suffer  attacks  of  excruciating  pain  in  the 
eve;  a certain  indication  of  the  extension 
of  the  mischief.  “ An  occasional  sensation, 
as  if  needles  were  thrust  into  the  eye,  ac 
companied  with  fulness  and  throbbing  of 
the  temples,  often  precedes  the  deeper  seat- 
ed pain  ” This  last  is  often  of  an  intermit- 
ting nature,  and  a period  of  excruciating 
torture  is  succeeded  by  an  interval  of  perfect 
ease.  Sometimes  the  pain  shifts  instanta- 
neously from  one  eye  to  the  other,  and  is 
seldom  or  never  equally  severe  in  both  at 
the  same  time  and  sometimes,  instead  of 
being  in  the  eye,  it  occurs  in  a circumscri- 
bed soot  of  the  head,  which  the  patient  <?e- 


41 


OPHTHALMT . 


W 


scribes  by  saying,  be  can  cover  the  part 
with  his  finger.  Sooner  or  later,  one  of 
these  attacks  of  pain  is  terminated  by  a sen- 
sation of  rupture  of  the  cornea,  with  a gush 
of  sc  liiirig  water,  succeeded  by  immediate 
relief  to  the  rye  ii  which  this  evtfnt  has 
happened,  bur  generally  soon  followed  by 
a increased  violence  of  the  symptoms  in 
the  other.  At  length  the  attacks  of  pain 
become  shorter,  and  less  severe,  though 
they  do  not  cease  altogether  till  after  the 
lapse  of  many  weeks,  and  even  months. 
During  this  stage  of  the  disease , according 
to  Dr.  Vetch,  then > is  seldom  the  slightist 
alteration  of  the  pulse,  unless  the  lancet  hare 
been  freely  employed.  The  patient’s  general 
health  is  little  impaired,  his  appetite  conti- 
nues natural,  but  sleep  almost  totally  for- 
sakes him. 

As  the  pain  abates,  the  external  tumefac- 
tion also  subsides,  and  a gaping  appearance 
of  the  eyelids  succeeds,  their  edges,  instead 
of  being  inverted,  now  becoming  everted. 
This  is  what  Dr  Vetch  designates  as  the 
third  stage  of  the  disease. 

After  the  swelling  of  the  second  stage  has 
subsided,  the  eyelids  are  prevented  from 
returning  to  their  natural  s ate  by  the  gra- 
nulated change  of  the  conjunctiva  which 
lines  them  ; and  an  eversion  of  them  now 
occurs  in  a greater  or  lesser  degree  ( Vetch 
on  Diseases  of  the  Eye , p.  196,  2<  2 ) Among 
other  interesting  remarks,  made  by  the  same 
author,  he  states,  that  there  is  no  reason  to 
warrant  the  idea  that  the  ulceration  ever 
proceeds  from  within  outwards.  He  ob- 
serves, that,  when  any  large  portion  of  the 
cornea  sloughs,  an  adventitious  and  vascu- 
lar membrane  is  often  produced,  which 
finally  forms  a staphyloma.  “In  some  few 
cases,  (says  he)  1 have  seen  the  lens  and  its 
capsule  exposed,  without  any  external  co- 
vering whatever,  and,  for  a short  time,  the 
patient  saw  every  thing  with  wonderful  ac- 
curacy; but,  as  soon  as  the  capsule  gives 
way,  the  lens,  and  more  or  less  of  the  vitre- 
ous humour,  escape,  the  eye  shrinks,  and 
the  cornea  contracts  into  a small  horn-co- 
loured speck.”  This  total  destruction  of 
the  globe  of  the  eye  is  said  generally  to  en- 
sure the  other,  and  renders  it  less  liable  to 
be  affected  by  future  attacks  of  inflamma- 
tion. 

A few  years  ago,  an  ophthalmy,  supposed 
to  be  of  the  same  nature  as  the  Egyptian, 
though  milder,  like  that  which  has  generally 
been  observed  in  schools,  occurred  to  a 
great  extent  in  the  Royal  Military  Asylum 
at  Chelsea,  and  Mr.  M ‘Gregor,  the  surgeon 
of  that  institution^  has  favoured  the  public 
with  an  excellent  description  of  the  disease, 
and  some  highly  interesting  facts  and  reflec- 
tions upon  the  subject.  In  the  Military 
Asylum  the  symptoms  of  this  species  of 
ophthalmy  generally  made  their  appearance 
in  the  following  order:  “A  considerable 
degree  of  itching  was  first  felt  in  the  even- 
ing; this  was  succeeded  by  a sticking  toge- 
ther of  the  eyelids,  principally  complained 
(>f  by  the  patient  on  waking  in  the  morning, 
’(the  eyelids  appeared  fuller  externally  than 


they  naturally  are  ; and  on  examining  their 
internal  surface  this  was  found  inflamed. 
The  sebaceous  glands  of  the  tarsi  were  con- 
siderably enlarged,  and  of  a redder  colour 
than  usual.  The  caruncula  lachrymalis  had 
a similar  appearance. 

“ In  24  or  30  hours  after  the  appearance 
of  the  above-mentioned  symptoms,  a viscid 
mucous  discharge  took  place  from  the  inter- 
nal surface  of  each  eyelid,  and  lodged  at  the 
inner  canthus,  till  the  quantity  was  sufficient 
to  be  pressed  over  the  cheek  by  the  motions 
of  the  eye.  The  vessels  of  the  tunica  con- 
junctiva, covering  the  eyeball,  were  distend- 
ed with  red  blood,  and  the  tunica  conjunc- 
tiva was  generally  so  thickened,  and  raised, 
as  to  form  an  elevated  border  round  the 
transparent  cornea.  This  state  was  often 
accompanied  with  redness  of  the  skin  round 
the  eye,  which  sometimes  extended  to  a con- 
siderable distance,  and  resembled,  in  colour 
and  form,  very  much  what  takes  place  in 
the  cow-pox  pustule,  between  the  9th  and 
12th  days  after  inoculation. 

“ When  the  purulent  discharge  was  con- 
siderable, there  was  a swelling  of  the  ex- 
ternal eyelids,  which  often  prevented  the 
patient  from  opening  them  for  several  days. 
The  discharge  also  frequently  excoriated  the 
cheeks  as  it  trickled  down  Exposure  to 
light  caused  pain  When  light  was  excluded, 
and  the  eye  kept  from  motion,  pain  was  sel- 
dom much  complained  of 

“These  symptoms,  in  many,  subsided, 
without  much  aid  from  medicine,  in  10,  12, 
or  14  days,  leaving  the  eye  for  a considera- 
ble time  in  an  irritable  state.  In  several, 
however,  the  disease  continued  for  a much 
longer  time,  and  ulceration  took  place  oa 
the  internal  surface  of  the  eyelids,  and  in 
different  parts  on  the  eyeball.  If  one  of 
those  small  ulcers  happened  to  be  situated 
on  the  transparent  cornea,  it  generally,  on 
healing,  left  a white  speck,  which,  however, 
in  the  young  subjects  under  our  care,  was 
commonly  soon  removed.  In  some  few 
instances,  an  abscess  took  place  in  the  sub- 
stance of  the  eyeball,  which,  bursting  ex- 
ternally, produced  irrecoverable  blindness.” 
(P  Gregor,  in  Trans,  of  a Socirty  for  the 
Improvement  of  Med.  and  Chirwg.  Knowledge, 
Tot.  3,  p.  3»— 40.) 

Whet!  the  local  symptoms  had  prevailed 
two  or  three  days,  some  febrile  disturbance 
occurred  ; but,  except  in  severe  cases,  it  was 
scarcely  observable. 

Mr  M ‘Gregor  considered  this  ophthalmy 
to  be  of  the  same  nature  as  that  which  has 
raged  with  such  violence  in  the  army  at  dif- 
ferent periods,  since  the  return  of  our  troop' 
from  Egypt  in  1800,  1801,  and  1802.  How- 
ever, he  has  found  that  its  consequences 
have  not  been  so  injurious  to  children  as  to 
adults;  for,  out  of  the  great  number  of 
children  that  were  afflicted  with  the  disease 
at  the  Military  Asylum,  only  six  lost  the 
sight  of  both  eyes,  and  twelve  the  sight  <n 
one  eye.  (Op.cit.p.  49.)  On  the  other  hand. 
Dr.  Vetch  informs  us,  that,  in  the  second 
battalion  of  the  52d  regiment,  which  con- 
sisted of  somowhat  more  than  TOO  m«n.  63f» 


OPHTHALMY. 


323 


eases  of  ophthalmy  were  admitted  into  the 
hospital  between  August,  18  5,  and  August, 
1806  ; and  that,  ‘‘  of  this  number,  fifty  were 
dismissed  with  the  loss  of  both  eyes,  and 
forty  with  that  of  one.”  And,  as  Mr.  M‘Gre- 
gor  observes,  it  is  a melancholy  fact,  as  ap- 
pears from  the  returns  of  Chelsea  and  Kil - 
mamham  Hospitals,  that  2317  soldiers  were, 
on  the  1st  of  December,  1810,  a burthen 
upon  the  public  from  blindness,  in  conse- 
quence of  ophthalmy.  The  cases,  in  which 
only  one  eye  was  lost,  are  not  here  included. 

The  attacks  of  the  disease  appear  to  be 
much  more  frequent,  severe,  and  obstinate, 
in  hot,  sultry  weather,  than  in  cold  or  tem- 
perate seasons.  (P  M Gregor,  op.  cit.  p.  37, 
64,  4,0.) 

This  gentleman  also  observed,  that  the 
ophthalmy  was  more  severe  and  protracted 
in  persons  having  red  hair,  or  a scrofulous 
habit,  than  in  others.  The  right  eye  was 
more  frequently  a d violently  affected  than 
the  left.  In  females  the  symptoms  are 
greatly  aggravated  for  some  days  previous 
to  the  catamenia;  but,  on  this  evacuation 
taking  place,  they  are  quickly  lessened.  Mr. 
M‘Gregor  further  remarks,  that  the  measles, 
cow-pox,  and  mumps,  go  through  their 
course  as  regularly  in  persons  affected  with 
this  species  of  ophthalmy,  as  when  no  other 
disease  is  present  ; a circumstance  whi  h, 
with  some  others,  proves  that  the  disorder 
is  entirely  local.  ( P . 54,  55.) 

With  respect  to  the  causes  of  the  Egyp- 
tian Purulent  Ophthalmy , much  difference 
of  opinion  has  prevailed,  and,  indeed,  there 
was  a time  when  the  disease  was  regarded 
by  the  majority  of  army  surgeons,  who 
alone  had  opportunities  of  judging  of  it,  as 
not  being  in  real ity  contagious,  but  dependent 
upon  local  epidemic  causes  ; the  irritation  of 
"and ; peculiarly  of  climate , fyc.  The  late 
Mr.  Ware  even  doubted  tiie  propriety  of 
calling  this  ophthalmy  Egyptian,  and  he  con- 
tended that  a disease  precisely  similar  in  its 
symptoms  and  progress  had  been  noticed 
long  ago  in  this  and  other  countries ; and 
that,  in  Egypt,  several  varieties  of  ophthalmy 
prevail.  He  preferred  calling  the  disease 
the  Epidemical  Purulent  Ophthalmy.  On 
the  other  hand,  'rir  W.  Adams  conceives, 
that  it  ought  rather  to  be  called  Asiatic 
Ophthalmy , as  recent  investigations  prove 
that  it  prevails  in  the  greater  part  of  Asia, 
and  was  long  ago  described  by  Avicenna. 
( Graefe , Journ.  der  Chir  1 B.  p.  170.) 

That  there  has  been  long  known  in  this 
country  an  infectious  species  of  purulent 
ophthalmy  cannot  be  doubted.  The  case, 
described  by  many  surgeons,  as  proceeding 
from  the  sudden  stoppage  of  gonorrhoea,  or 
the  inadvertent  application  of  gonorrhasal 
nr  tter  to  the  eyes,  which  disorder  will  be 
presently  noticed,  is  certainly  an  infectious 
purulent  ophthalmy.  It  is  also  admitted, 
that  it  resembles  Egyptian  ophthalmy,  by 
the  intensity  and  rapidity  of  its  svmptorns  ; 
but  the  latter  case  is  strongly  characterized 
by  the  quickness  with  which  it  causes,  espe- 
cially in  adults,  opacities  or  ulcerations  of 
cornea;  the  long  continued  irritability 


of  the  eves  after  the  subsidence  of  inflam- 
mation ; but,  more  particularly,  its  very  in- 
fectious nature,  by  which  it  spreads  to  an 
extent,  that  has  never  been  observed  with  re- 
gard to  any  other  species  of  purulent  oph- 
ih  dmy.  There  have  been  epidemic  oph- 
thalmies  of  other  kinds,  which  have  been 
known  to  affect  the  greater  part  of  the 
population  of  certain  districts  and  towTns  in 
England.  The  celebrated  ophthalmy,  which 
happened  at  Newbury,  in  Berks,  some  years 
ago,  is  an  instance,  that  must  be  known  to 
every  body.  But  1 know  of  no  purulent 
inflammation  of  the  eyes,  which  everspread 
to  a great  extent  in  England,  before  the 
return  of  our  troops  from  Egypt. 

The  reflections  and  observations  of  Mr. 
M‘Gregor,  as  well  as  those  of  Dr.  Vetch, 
and  Dr.  Edmondstone,  I think,  leave  no 
doubt  o two  facts  first,  that  this  ophthalmy 
.vasat  all  events  brought  from  Egypt;  and 
secondly,  that  it  is  infectious,  but  only  ca- 
pable of  being  co  imunicaled  from  one  person 
to  another  by  actual  contact  of  the  discharge. 
“ If  (says  Dr.  Vetch)  any  belief  were  en- 
t-  taine  I by  tlv  officers  of  Use  British  array, 
during  the  first  expedition  to  Egypt,  that  the 
disease  was  contagious,  it  was  of  a nature 
y<  rv  vague  and  indefinite.  Combined  as  its 
opt  rations  necessarily  must  be  in  tha  coun- 
try with  other  exciting  causis,  there  would  be 
more  difficulty  in  the'first  recognition  of  the 
fact.  But,  the  continuau  e of  thr- complaint 
with  the  troops,  fter  their  departure  from 
he  country,  could  scarcely  f 1 to  lead  to 
the  obvious  conclusion  of  its  posse-sing  a 
power  of  propagation.  Before  the  disease 
reached  this  country,  the  opinion  of  its 
being  contagious  was  adopted  by  many. 
Dr.  Edmund  done , in  the  account  which  he 
published  of  the  disease,  as  it  appeared  in 
the  regiment,  to  which  he  was  surgeon, 
after  its  return  to  England,  first  made  the 
public  acquainted  with  the  fad  of  the  disease 
being  communicable.  In  an  account  of  the 
Egyptian  ophthalmia,  as  it  appeared  in  this 
country,  print'  d in  the  early  part  of  1807,  / 
first  established , that  the  communication  of  Ike 
disease  was  exclusively  produced  by  the  appli- 
cation of  the  discharge  from  the  eyes  of  the 
diseased  to  those  of  the  healthy .”  ( Vetch  on 

Diseases  of  the  Eye,  p.  178.) 

The  opinion  that  the  disease  is  ever  com- 
municated from  one  person  to  another, 
through  the  medium  of  the  atmosphere,  is 
at  present  nearly  abandoned.  During  the 
whole  lime  that  Dr  Vetch  had  the  manage- 
ment oft  he  ophthalmic  hospitals,  there  never 
was  an  instance  of  any  medical  officer 
contracting  the  disease,  although  exposed 
to  what  might  be  supposed  to  be  the  greatest 
concentration  of  any  contagion  that  could 
arise  in  the  worst  stage  of  the  complaint. 
Two  orderlies  only  contracted  the  disease, 
and  both  in  consequence  of  the  accidental 
application  of  the  virus.  However.  Sir  YV. 
Adams  maintains,  that  he  has  seen  many 
cases  which  p^ove,  that  the  disorder,  like 
small-pox,  may  spread  contagiously,  without 
any  kind  of  inoculation.  (See  Graefe' s Journ, 
B l,p.  174.)  That  the  disease  rh  ay  also  •lie 


OPHTHAlMF 


partly  propagated  by  epidemic  chuses  in 
certain  places,  1 think  as  certain  and  clear, 
as  t hat  there  must  be  a cause  for  the  first 
commencement  of  the  disorder  in  situations 
Where  infection  by  contact  is  out  of  the 
question.  And,  as  Dr.  Vetch  has  observed, 
“ from  whatever  cause  inflammation  of  the 
conjunctiva  may  originate,  when  the  action 
is  ot  that  nature,  or  degiee  of  violence  as 
to  produce  a puriftmn  or  purulent  discharge  ; 
the  discharge,  so  produced,  operates  as  an 
animal  virus,  when  applied  to  the  conjunc- 
tiva. of  a healthy  eye  Considering  the 
various  modes,  by  which  such  a contact 
must  inevitably  occur  in  the  usual  relations 
of  life,  it  must  be  obvious,  that  wherever 
ophthalmia  prevails,  whether  it  be  the  effect 
of  local  conditions  of  the  soil,  or  of  the  at- 
mosphere, naturally  or  artificially  produced, 
this  contagious  effect  must  sooner  or  later 
mix,  or  unite  its  operation  with  that  of  the 
more  general  and  original  one  ; and  hence, 
without  regard  to  this  property  of  the  disease, 
Its  occurrence  must  often  remain  inexplica- 
ble, and  at  variance  with  the  more  general 
cause  existing  in  external  circumstances, 
And  further,  as  the  disease,  produced  by 
infection,  is  of  a nature  more  violent  and 
malignant,  than  that  produced  by  the  impres- 
sion of  atmospheric  causes,  it  will,  in  every 
instance  of  extensively  prevailing  ophthal- 
mia, occasion  two  different  forms  of  disease, 
which,  as  long  as  they  are  considered  as  one 
and  the  same,  w ill  produce,  according  as  the 
one  orthe  other  predominates,  very  discor- 
dant results.”  ( Vetch  on  Diseases  of  the  Eye , 
p.  175.) 

Mr.  McGregor  relates  three  cases,  which 
prove,  that  the  matter,  after  its  application, 
produces  its  effects  in  a very  short  time.  1 
shall  only  cite  the  following  example  : — On 
the  21st  of  October,  1809,  about  four  o’clock, 
e.  m.  Nurse  Flannelly,  while  syringing  the 
eyes  of  a boy,  let  some  of  the  lotion,  which 
bad  already  washed  the  diseased  eyes,  pass 
out  of  the  syringe  into  her  own  right  eye. 
She  felt  little  or  no  smarting  at  the  time  ; 
but,  towards  nine  o’clock  the  same  evening, 
her  right  eye  became  red,  and  somewhat 
painful,  and  when  she  awoke  next  morning, 
her  eyelids  were  swelled,  there  was  a puru- 
lent discharge,  pain,  &e.  {Op.  cit,  p.  51.) 

The  late  Mr.  Ware,  though  he  admitted, 
that  the  infection  was  brought  into  this  coun- 
try from  Egypt  by  the  troops,  conceived 
that  the  same  disease  also  sometimes  arose 
from  the  matter  of  gonorrhoea  being  applied 
to  the  eyes,  and  that  it  had  been  prevalent 
in  this  country  before  the  return  of  the  army 
from  Egypt.  He  thought,  however,  that 
the  infection  was  generally  communicated 
by  contact.  Mr.  Ware  observes,  some  of 
the  worst  cases  of  the  purulent  ophthalu  y of 
children  have  happened,  in  those  whose 
luotbers  were  subject  to  an  acrimonious  dis- 
charge from  the  vagina  at  the  time  of  partu- 
i-lti’./n.  Some  of  the  worst  forms  of  the 
virulent  oj  hthalmy  in  adults  have  occurred 
thoSe.  v ho,  either  shortly  before  the  at- 
tach of  the  opbthalmy,  or  at  that  very  time, 


laboured  either  under  a gonorrhoea,  or  & 
gleet.  Mr.  Ware  does  not  mean  to  impute 
every  purulent  opbthalmy  to  such  a cause  f 
but,  in  the  majority  of  adults,  whom  he  has 
seen  affected,  if  the  disorder  had  not  been 
produced  by  the  application  of  morbid  mat- 
ter, from  a diseased  eye,  it  could  be  traced 
to  a connexion  between  the  ophthalray 
arid  disease  of  the  urethra.  Other  causes, 
Mr.  Ware  acknowled  ges,  may  contribute  to 
aggravate,  and  perhaps  produce  the  disorder, 
and  the  purulent  opbthalmy  in  Egypt  has 
been  attributed  to  a great  number.  The 
combined  influence  of  heat  and  light,  of  a 
burning  dust  continually  raised  by  the  wind;, 
and  of  the  heavy  deWs  of  the  night,  may 
powerfully  tend  to  excite  inflammations  of 
the  eyes.  Yet  something  more  must  operate 
in  causing  the  malignant  ophthabny  now- 
under  consideration  ; for  the  same  causes 
operate  with  equal  violence  in  some  other 
countries,  besides  Egypt,  and  yet  do  not 
produce  the  same  effect ; and,  in  this  coun- 
try, (says  Mr.  Ware)  the  disorder  prevailed 
during  the  last  summer,  to  as  great  a degree, 
and  upon  as  great  a number  of  persons 
within  a small  district  of  less  than  a mile, 
as  it  ever  did  in  Egypt ; and  yet,  beyond 
t*his  space,  on  either  side,  scarcely  a person 
was  affected  with  it.  The  disorder  was  cer- 
tainly brought  into  this  country  by  the  sot- 
diers  who  returned  from  Egypt,  and  was 
probably  communicated  from  them  to  many 
others.  Now,  as  the  action  of  the  atmos- 
phere alone  cannot  account  for  the  spread- 
ing of  the  disease,  he.  Mr.  Ware  is  led  to 
believe,  that  this  particular  disorder  is  only 
communicable  by  absolute  contact ; that  is, 
by  the  application  of  some  part  of  the  dis- 
charge, which  issues,  either  from  the  con- 
junctiva of  an  affected  eye,  or  from  some 
other  membrane  secreting  a similar  poison* 
to  the  conjunctiva  of  the  eye  of  another 
person.  In  schools  and  nurseries,  in  conse- 
quence of  children  using  the  same  basins 
and  towels,  as  others  who  had  the  complaint, 
the  disease  has  been  communicated  to 
nearly  twenty,  in  one  academy.  Hence, 
Mr.  Ware  censures  the  indiscriminate  use  of 
those  articles,  in  schools,  nurseries, hospitals, 
ships,  and  barracks.  ( P . 14,  15.) 

That  in  Egypt  the  origin  of  the  disease 
cannot  rightly  be  imputed  to  the  effect  of 
the  sand  and  hot  winds  of  the  country,  is 
clearly  proved  ; 1st,  Because,  if  this  were 
the  case,  the  disease  would  not  be  most  pre- 
valent in  the  autumnal  season,  during  the 
inundation  of  the  Nile.  2dly,  The  inhabi- 
tants of  the  Delta  would  not  be  more  subject 
to  it,  than  the  Bedouin  Arabs,  who  live  ou 
the  sands  of  the  desert.  Not  only  the  Be- 
douin Arabs,  says  Dr.  Vetch,  remain  free 
from  the  disease,  but  Europeans,  who  are 
not  particularly  exposed  to  the  night  air , are 
also  safe  from  its  attacks . “ The  nature  of  mi 
litary  duty  prevented  our  soldiers  from 
using  this  precaution,  and  in  a particular 
manner  they  bec  ame  victims  to  the  com- 
plaint. The  men  suffered  more  in  propor- 
tion to  the  officers  of  the  English  army ; n« 


OPHTHALMY 


ale  Utter  eujoyed  a better,  though  often  an 
incomplete  defence  from  the  coldness  and 
dampness  of  the  night ; and  officers,  em- 
ployed in  strictly  military  duty,  suffered 
more  than  those  attached  to  the  civil  de- 
partments.” (Vetch  on  Diseases  of  the  Eyes, 
p.  157.)  And  \ssalini  remarks,  that  if  the 
dust  or  sand  were  the  sole  cause  of  ophthal- 
mia, we  ought  to  be  exempted  from  the 
disease,  where  the  cause  does  not  exist. 
The  contrary,  however,  was  the  case  in  the 
Delta,  and  principally  on  the  cultivated 
borders  of  the  Nile,  during  its  inundations. 
When  we  were  exposed  to  the  air  during  the 
flight,  we  were  immediately  attacked  with  oph- 
thalmia, though  the  dust  and  sand  were  then 
under  water.  Larrey  also  imputes  the  ori- 
gin of  the  disease  to  the  cold  damp  nocturnal 
air,  after  the  great  heats  of  the  day.  ( Graefe's 
Journ.  BA,  p.  179.) 

Whoever  reads  the  account  of  the  Egyp- 
tian ophthalmia,  as  given  by  Mr.  M‘Gregor 
and  Dr.  Vetch,  will  be  convinced  that  the 
disorder  is  only  communicable  from  one 
person  to  another  by  the  application  of  the 
infectious  matter  to  the  eyes.  Probably, 
the  common  mode  of  propagation  is  the  in- 
advertent use  of  the  same  towels,  or  even 
merely  touching  the  same  articles,  which 
have  been  in  the  hands  of  infected  persons, 
Who  must  be  supposed  occasionally  to  apply 
their  fingers  more  or  less  to  the  eyelids.  In 
this  last  way.  the  commencement  of  the 
disease  may  be  accounted  for  in  regiments 
upon  their  entering  into  barracks,  which 
have  been  quitted  by  other  infected  soldiers. 
“ Flics,  in  warm  weather,  (says  Mr.  McGre- 
gor) are  seen  in  great  numbers  surrounding 
patients  labouring  under  ophthalmia  ; and  1 
much  suspect  are  very  frequently  the  medium 
by  which  the  disease  is  communicated.” 
(P.  54.)  The  matter  is  observed  to  be  most 
infectious,  when  the  disease  is  in  an  acute 
state. 

Dr.  Vetch  adverts  to  two  important  ques- 
tions connected  with  the  history  of  the 
Egyptian  ophthalmy.  The  first  relates  to 
the  length  of  time  which  the  disease  has,  at 
different  periods,  lain  dormant,  and  espe- 
cially between  the  return  of  the  troops  from 
Egypt,  and  the  breaking  out  of  the  disease 
in  the  52d  regiment.  An  explanation  of  this 
fact  is  attempted  by  supposing,  that  the 
complaint  exists,  and  is  liable  to  a renewal 
of  its  infectious  quality,  long  after  the  eye 
seems  to  have  recovered  its  natural  and 
healthy  appearance.  Perhaps,  it  would  be 
as  well  to  be  content  with  the  fact,  that,  in 
Crowded  barracks,  under  particular  circum- 
stances, soldiers,  who  have  once  had  the 
disease,  are  very  liable  to  relapses.  The 
other  question  is,  why  has  the  disease  pro- 
duced such  ravage  in  the  array  in  England, 
and  not  in  that  of  France  P ft  is  well 
known,  that  the  French  soldiers  in  Egypt 
suffered  as  much  as  our  own  troops  from 
the  affection,  and  great  numbers  of  them  re- 
turned to  France  with  the  disease  in  a chronic 
form.  “In  many  (says  M.  Roux)  the  influence 
of  their  native  climate  has  sufficed  for  the 
removal  of  all  vertigo  of  the  disorder.  On 


the  contrary,  in  others,  it  has  continued  in 
a chronic  state,  either  attended  with  the  loss 
of  one,  or  of  both  eyes  ; and  many  of  oar 
invalids  remain  with  the  affliction.  But,  it 
has  not  been  found,  that  these  soldiers,  who 
returned  from  Egypt,  have  ever  communi- 
cated a contagious  ophthalmia,  either  in 
regiments,  in  which  many  of  them  have 
been  incorporated  ; or  in  invalid  houses, 
where  others  have  obtained  their  retire- 
ment ; or  in  the  individuals  belonging  to  the 
different  classes  of  society.  Such  is  the 
objection  that  has  been  made,  and  may 
always  be  again  urged,  against  the  opinions 
and  observations  of  the  English,  respecting 
the  Egyptian  ophthalmy.”  (Roux,  Voyage 
faite  a Londres  en  1814,  ou  Parall&le  de  la 
Chir.  Angloise , <^c.  p.  49.) 

Baron  Larrey,  who  admits  that  the  dis- 
ease may  be  communicated  by  application 
of  the  matter,  argues,  that  it  is  not  conta- 
gious in  any  other  way,  because,  in  Egypt, 
for  want  of  sufficient  hospital  room,  pa- 
tients with  this  and  other  diseases  were 
mixed  togelher,  without  the  ophthalmia 
being  propagated  to  any  of  the  patients, 
who  were  careful  to  avoid  the  above  mode 
of  infection.  (Graefe's  Journ.  B.  1 , p.  179.) 
Larrey)  however,  need  not  have  used  this 
rea-o- ing  with  us,  because  it  is  a mistake  in 
him  to  suppose,  that  the  disease  is  here  com- 
monly regarded  as  communicable  through 
the  medium  of  the  atmosphere.  While, 
however,  English  surgeons  chiefly  explain 
the  extension  of  the  disease  by  the  infec- 
tious nature  of  the  discharge  when  applied  to 
the  eyelids,  and  Larrey  admits  that  the  mat- 
ter is  thus  infection',  the  latter,  as  wTelI  as 
Roux,  assures  us,  that  none  of  the  healthy 
soldiers,  who  came  home  with  the  blind 
invalids  from  Egypt,  were  attacked  with  this 
species  of  ophthalmy.  A great  number  of 
those  invalids  were  received  in  the  hospital 
of  the  guards  at  Paris,  and  treated  there 
without  any  of  the  other  patients  bifing 
infected.  (Graefe's  Journ.  loc.  cit.)  On 
my  return  from  the  Mediterranean  through 
France  in  1802,  I saw  many  of  the  F.ench 
troops  in  a town  between  Marseilles  and 
Lyons,  with  bad  eyes,  contracted  in  Egypt, 
associating  with  other  soldiers,  whose  eyes 
were  perfectly  healthy, and  living  in  the  same 
barracks  ; a proof,  that  the  French  soldiers, 
with  the  exception  of  climate,  or  some 
other  protecting  cause,  were  placed  appa- 
rently in  circumstances,  in  which  the 
disease  here  made  such  extensive  ravages. 
This  is  a point  which  1 humbly  conceive,  is 
not  at  all  solved  by  Dr.  Vetch’s  belief,  that 
the  difference  is  explicable  by  the  French 
troops  being  sent  into  the  field  ; for,  in  fact, 
the  soldiers  with  diseased  eyes  were  in 
barracks,  or  hospitals,  as  well  as  our  own 
troops. 

But,  notwithstanding  it  seems  proved,  that 
the  discharge  from  the  eyes  in  the  Egyptian 
ophthalmy  is  so  actively  infectious  in  Eng- 
land, it  appears  from  an  experiment,  made 
by  Mr.  Mackesy,  that  its  application  mav 
sometimes  be  made  to  a healthy  eye,  without 
the  disease  followingas  aftiiatter  ot’ certainty 


OPHTHALMY. 


32b 


This  gentleman,  who  was  sitrgeon  to  the 
62d  regiment,  applied  to  his  own  eyes  linen 
impregnated  with  matter  discharged  from 
the  eyes  of  patients  in  the  fully  formed 
stage  of  the  disease,  and  even  allowed  so  ne 
of  the  matter  to  pass  under  the  eyelids  ; yet 
the  complaint  was  not  communicated. 
(See  Edinb.  Med.  and  Surg.  Journ.  Vol.  12, 
p.  411.) 

One  of  the  most  material  circumstances 
in  which  the  practice  of  English  surgeons 
differs  from  that  of  foreign  practitioners  in 
cases  of  severe  purulent,  and  especially 
Egyptian  ophthalmy,  is  the  freedom  and 
boldness,  with  which  the  former  attack  the 
disease  in  its  first  stage.  Mr.  Peach  recom- 
mends taking  away  a'  once  as  much  as  60 
ounces  of  biood  ; (Edinb.  Med.  and  Surg. 
Journ.  for  January,  1807)  and  Dr.  Vetch 
lavs  great  stress  on  the  striking  benefit  of 
bleeding  the  patient  till  syncope  is  produced. 
il  When  inflammation  has  its  seat  in  the 
sclerotic  coat,  (says  this  gentleman)  general 
blood  letting  may  for  the  most  part  be  dis- 
pensed with,  and  even  when  employed  to 
the  greatest  extent,  the  same  benefit  does 
not  ensue.  In  the  purulent  inflammat  ion  of 
the  conjunctiva,  however,  although  some 
good  may  be  derived  from  depletion,  yet  a 
perfect  command  over  the  disease  depends 
less  on- lowering  the  system,  than  on  the 
temporary  cessation  of  arterial  action  by 
syncope,  which  it  becomes  the  object  of 
tbe  operation  to  produce.  This  practice, 
besides  its  efficacy,  will  accomplish  the  cure 
with  a much  less  expenditure  of  blood,  than 
is  occasioned  by  the  repeated  bleedings 
generally  had  recourse  to,  u here  this  method 
of  rendering  one  equal  to  the  cure  of  the 
complaint  bas  been  neglected.  Some 
time  before  the  approach  of  faint  tie  g, 
the  redness  of  the  conjunctiva  for  the  most 
part  disappears;  but  this  is  no  security 
against  the  return  ol  the  disease,  if  the  flow 
of  blood  be  stopped,  without  «'eliquium 
animi  succeeding.”  (Vetch  on  Diseases 
of  the  Eye , p.  206.)  The  attacks  of  a pain- 
ful sensation,  as  if  gravel  were  in  the  eye, 
are  considered  by  this  gentleman  as  a proof 
of  the  disease  increasing,  and  are  regarded 
by  him,  in  the  early  stage  of  the  diease,  as 
a better  indication  of  the  necessity  for 
bleeding,  than  the  appearance  of  the  eye  it- 
self. 

With  respect  to  applications,  Dr.  Vetch 
speaks  very  highly  of  the  beneficial  effects 
produced  in  the  beginning  of  the  case  by 
dropping  into  the  eye  the  undiluted  liquor 
plumhi  subacetatis,  which  he  says,  dimi- 
nishes the  discharge,  lessens  the  inflamma- 
tion, and  is  incapable  of  doing  harm  in  any 
stage  of  the  disease.  He  places  great  con- 
fidence in  the  salutary  results  of  a free  ex- 
posure of  the  eye  to  the  atmosphere  ; and 
speaks  in  high  lerms  of  the  good  derived 
from  applying  at  night  to  the  eye  an  infusion 
of  tobacco,  I wo  drachms  of  the  leaves  to 
eight  ounces  of  water.  “ It  possesses  (says 
Dr.  Vetch)  the  valuable  properties  of  acting 
as  a powerful  astringent,  restraining  the  pu- 
: dent  discharge,  anddiirinjshiog  tbe  cedcuta, 


or  external  swelling  of  the  palpebrte  ; at  the 
same  time,  that  its  narcotic  qualities  often 
relieve  the  pain  and  the  perpetual  watchiul- 
ness,  which  the  largest  dose*  of  opium  can- 
not subdue.”  (P.  211  ) Bleeding,  however, 
is  the  c-  sheet  am  hor,”  and  the  only  means 
of  preventing  the  destruction  of  ihe  cornea, 
whenever  attacks  of  pain  in  the  eye,  or  or- 
bit, deno’e  the  unsubdued  slate  of  ihe  dis- 
ease. (P.212.)  When  I fie  di-ease  shifts  its 
violence  from  one  eye  to  the  other,  and  is  of 
long  duration,  Dr  Vetch  recommends  cup- 
ping, amt  the  eye  to  be  more  carefully  clean- 
ed by  the  injection  of  tepid  water,  or  any 
gentle  astringent  lotion,  and  afterward 
wiped  dry.  When  the  discharge  continues 
acrid  and  scalding,  he  directs  blisters  to  be 
applied  to  the  nape  of  the  neck,  and  beoind 
the  ears.  He  wishes  it  to  be  distinctly  kept 
in  mind,  that  the  time  for  the  employment 
of  bl -eding,  w ith  the  view  of  saving  he  eye, 
is  during  the  first  stage,  or  early  part  of  the 
second  ; and  when  ulceration  of  the  cornea 
has  commenced,  the  case  is  to  be  treated  on 
the  principles  applicable  to  sclerotic  inflam- 
mation. 

With  regard  to  the  plan  of  diminishing  in 
flammatory  action  by  medicines  which  ex- 
cite nausea  and  sickness,  instead  of  having 
recourse  to  the  lancet,  Dr  Vetch  states,  that, 
in  soldiers,  it  does  not  answer  so  well,  and  ia 
the  end  proves  more  debilitating. 

As  soon  as  the  external  oedema  of  the  eye- 
lids subsides,  and  they  begin  to  be  everted. 
Dr.  Vetch  begins  the  cure  of  the  gr  nutations 
and  general  villosify,  by  a very  light  and 
careful  application  of  the  argentum  nitratuua- 
The  everted  portion  is  then  to  be  returned, 
and  secured  in  its  place  with  a compress  and 
bandage.  This  method  is  to  he  repeated 
every  time  the  eye  is  cleaned,  and  in  the 
course  of  a fortnight,  the  tendency  to  ectro- 
pium  will  be  removed  (P.  229.) 

Assalini  found  venesection,  all  emollient 
applications,  and  eyewaters,  hurtful.  He 
first  purged  his  patients,  and  then  introduced 
into  their  eyes  a few  drops  of  a solution  of 
the  lapis  divinus,  (see  Lachrymal  Organs,) 
to  which  was  sometimes  added  a small  quan- 
tity of  the  acetate  of  lead.  He  speaks  fa- 
vourably of  leeches,  and  sometimes  he  put  a 
small  blister  on  Ihe  temple,  or  behind  the 
ears  (See  Manuale  di  Chirurgia  ; Milano , 
1812.) 

Perhaps  the  best  inode  of  putting  an  im- 
mediate stop  to  the  Egyptian  ophthalmy, 
when  it  prevails  ex  ensively  in  a regiment  in 
garrison,  ot  barracks,  is  to  put  the  men  actu- 
ally affected  into  a detached  hospital,  at  n 
considerable  distance  from  the  rest  of  the 
corps,  which  should  be  dispersed  as  much 
as  possible  in  separate  billets  and  villages. 
Purulent  ophthalmv  is  a disease  which  makes 
great  head  only  when  large  numbers  of  per- 
sons are  either  exposed  together  to  the  epi- 
demic causes,  which  first  give  birth  to  it,  or 
to  the  causes  which  occasion  the  disease  to 
be  communicated  from  one  individual  to 
another,  as  when  soldiers  are  crowded  to- 
gether in  the  same  building,  using  the  same 
towels  and  water,  fee  Notwithstanding  the* 


OPHTHALMY. 


reports  of  Koux  and  Larrey  prove,  that  tho 
disease  did  not  spread  in  the  French  army, 
after  the  return  of  unctired  soldiers  from 
Egypt  to  France,  though  these  were  freely 
mixed  with  their  comrade*  in  hospitals  and 
barracks  the  same  security  did  not  extend 
to  the  British  tr<>ops  lately  in  the  latter  coun- 
try, who  at  one  time  were  threatened  w ith  a 
very  extensive  renewal  of  the  Egyptian  nph- 
thalmy  among  Item,  but  which  was  w isely 
checked  by  attention  to  the  principles  above 
specified,  and  in  which  Dr.  Grant,  the  head 
of  tiie  medical  department  of  that  army,  had 
the  greatest  confidence. 

In  the  cases  under  Mr.  M‘Gregor,  local 
applications  were  found  most  advantageous. 
Dating  the  inflammatory  stage,  however, 
this  gentleman  also  had  recourse  to  antiphlo- 
gistic means,  spare  diet,  bleeding,  neutral 
salts,  &,c.  The  topical  treatment  was  as  fol- 
lows: Leeches  were  freely  and  repeatedly 
applied  near  the  eye.  But  while  there  was 
much  surrounding  redness,  instead  of  leeches, 
which  created  too  much  irritation,  fomenta- 
tions, with  n weak  decoction  of  poppy-heads, 
and  a little  brandy,  were  used.  A weak  so- 
lution of  acetate  of  lead,  and  sulphate  of 
zinc,  had  mostly  a good  effect  when  applied 
to  the  eye.  The  vinous  tincture  of  opium 
did  not  answer  the  expectations  entertained 
of  it.  But  of  all  the  remedies,  the  ung.  hy- 
drarg.  nitrat.was  found  most  frequently  suc- 
cessful. It  W'as  applied  by  means  of  a camel- 
hair  pencil  and  at  first  weakened  with  twice 
its  quantity  of  lard.  The  red  precipitate, 
well  levigated,  and  mixed  with  simple  oint- 
ment, sometimes  answered  when  the  ung. 
hydrarg.  nit  rat . failed.  Well  levigated  verdi- 
gris, and  a quack  medicine,  called  the  golden 
ointment,  proved  also  sometimes  efficacious. 
( P . 41 — 43.)  According  to  Mr.  M‘ Gregor, 
blisters  behind  the  ears,  and  upon  the  neck, 
ore  useful  ; but  hurtful  when  put  nearer  to 
the  eye.  In  cases  wdiere  the  disease  seems 
to  resist  antiphlogistic  means,  and  ulceration 
has  commenced  on  the  external  surface  of 
the  cornea,  thi-  gentleman  approve;  of  dis- 
charging t he  aqueous  humour  by  a puncture, 
os  advised  by  Mr.  Wardrop. 

When  the  violence  of  the  inflammation 
has  subsided,  Mr.  M Gregor  recommend-  the 
us**  of  Bates’s  camphorated  water,  diluted 
with  four,  five,  or  six  times  its  quantity  of 
wafer.  But  the  astringent  collyrium,  from 
which  he  saw  most  good  derived,  was  a so 
lution  of  the  nitrate  of  silver,  in  the  propor- 
tion of  half  a grain  to  every  ounce  of  dis- 
tilled water.  In  some  cases,  it  may  be  used 
stronger. 

Tepid  sea-w-ater  sometimes  proved  ser- 
viceable in  removing  the  relics  of  the  com- 
plaint. ( P . 56  tye.) 

The  late  Mr.  Ware  was  in  favour  of  bleed- 
ing ; but  he  rardy  carried  it  to  the  ex:ent 
which  has  been  done  in  the  army.  In  weak 
persons,  instead  of  repealed  venesection,  he 
preferred  topical  bleeding,  either  from  the 
vein  that  passes  on  the  side  of  the  nose,  or 
by  means  of  five  or  six  leeches  put  on  the 
temple.  Sometimes  he  thought  it  better  to 
scarify  the  inside  of  the  lower  eyelid  with 


the  point  of  a lancet,  carried  along  parallel 
to,  and  very  near  the  margin  of  this  part 
He  objects  to  pricking  the  eyelid  in  an  infi- 
nite number  of  places,  as  very  painful,  and 
likely  to  increase  the  irritation.  The  lancet 
(he  says)  never  need  be  applied  more  than 
twice,  and  rarely  more  than  once  ; and,  per- 
haps, less  pain  w ill  be  occasioned  by  making 
the  incision  with  the  edge,  rather  than  the 
point  of  the  lancet.  After  taking  away 
blood,  Mr.  Ware  says,  a large  blister  on  the 
h**ad,  or  back,  is  often  useful.  Anodynes 
should  be  given,  with  occasional  purgatives, 
and  an  antiphlogistic  regimen.  {Ware  on 
Purulent  Ophthalmy , ISOS  p.  26,  <^c-) 

As  a local  application,  Mr.  Ware  preferred 
tiie  aqua  camphorata,  which  was  used  exact- 
ly in  the  same  way,  as  will  be  described  i« 
speaking  of  his  method  of  treating  the  puru- 
lent ophthalmy  of  children.  When  the  in- 
flammation was  very  great,  he  only  put  four 
or  five  grains,  instead  of  eight,  of  the  sul- 
phate of  copper  to  eight  ounces  of  water. 
He  usually  employed  the  lotion  cold,  espe- 
cially in  children;  but  in  adults,  in  whom 
the  general  fever  and  local  inflammation 
were  considerable,  he  was  obliged  to  use  it 
warm.  In  cases  of  great  pain  and  swelling, 
it  should  be  very  weak,  less  often  applied, 
and  sometimes  only  warm  water  injected. 
In  such  circumstances,  Mr.  Ware  also  sanc- 
tions fomenting  the  eye  with  a flannel,  or 
sponge,  wet  with  a hot  decoction  of  poppy - 
li&nds,  or  mere  hot  water.  When  i he  cor- 
nea threatens  to  burst,  this  gentleman  ap- 
proves of  opening  it,  in  order  to  discharge 
the  aqueous  humour,  by  making  an  incision 
in  a place  where  the  scar  will  not  obstruct 
vision,  as  first  suggested  by  Mr.  Wardrop. 

Purulent  Ophthalmy  oj  Infants.  Dr.  Vetch 
describes  the  external  appearances  of  this 
case  as  not  materially  different  from  those  of 
the  purulent  ophthalmy  of  adults;  but,  he 
states,  that  its  nature  is  considerably  modi- 
fied by  the  more  delicate  texture  and  great- 
er vasculari'y  of  the  parts  affected,  and  the 
more  intimate  connexion,  subsisting  between 
the  vessels  of  the  conjunctiva  and  those  of 
the  scleiotic  coat.  Hence,  he  says,  the  in- 
flammation is  sooner  communicated  to  this 
coal,  and  sloughing  and  ulceration  of  the 
cornea  occur  earlier  in  infants,  than  adults. 
When  the  oedema  ceases,  the  inner  surface 
of  the  palpebrse  becomes  sarcomatous,  and 
this  diseased  surface,  when  the  eyelids  are 
opened;  forms  an  exterior  fleshy  circle,  be- 
yond which  the  relaxed  conjunctiva  of  the 
eye  comes  forward  as  a second  ; and  often 
the  caruncula  lachrymalis  adds  still  farther  to 
the  valvular  appearancp,  which  the  pmrt  pre- 
sents. (On  Diseases  of  the  Eye , p.  256— 
258.) 

According  to  the  late  Mr.  Ware,  the  prin- 
cipal difference  between  the  purulent  oph- 
th almy  in  infants  and  that  in  adults,  consists 
i'll  the  different  states  of  the  tunica  conjuncti- 
va: in  the  former,  notwithstanding  the  quan- 
tity of  matter  confined  within  the  eyelids  is 
often  profuse,  the  inflammation  of  the  con- 
junctiva is  rarely  considerable,  and  when- 
ever the  cornea  become?  impaired,  it  is  rather 


328 


OPHT 

owing  to  the  lodgment  of  such  matter  on  it 
than  to  inflammation  ; a statement,  which 
appears  to  me  very  questionable.  But,  in 
the  purulent  ophthalmy  of  adults,  the  dis- 
charge is  always  accompanied  with  a violent 
inflammation,  and  generally  wilh  a tumefac- 
tion of  the  conjunctiva,  by  which  its  mem- 
branous appearance  is  destroyed,  and  the 
cornea  is  nntde  to  seem  sunk  in  the  eyeball. 
( Ware  on  Epidemic  Purulent  Ophthalmy , p. 
123.)  In  children,  the  alfection  of  the  eyes 
is  occasionally  accompanied  with  eruptions 
on  the  head,  and  with  marks  of  a scrofu- 
lous constitution.  (See  Ware , p.  138,  fyc.) 
The  only  inference  to  be  drawn  from  this 
fact  is,  that  scrofulous,  as  well  as  other  chil- 
dren, are  liable  to  this  disorder  of  their  eyes. 

The  following  is  the  treatment  recommend- 
ed by  Mr.  Ware.  If  the  disease  be  in  its 
first  stage,  the  temporal  arteries  are  to  be 
opened,  or  leeches  applied  to  the  temples, 
or  neighbourhood  of  the  eyelids,  and  a Mis 
ter  put  on  the  nape  of  the  neck  and  temples. 
The  child  should  be  kept  in  a cool  room, 
not  covered  with  much  clothes,  and  if  no 
diarrhcea  prevail,  a little  rhubarb  or  mag- 
nesia in  syrup  of  violets  should  be  prescribed. 

A surgeon,  however,  is  seldom  called  in 
before  the  first  short  inflammatory  stage  has 
ceased,  and  an  immense  discharge  of  matter 
from  the  eyes  has  commenced  Of  course, 
(says  Mr.  Ware,)  emollient  applications  must 
generally  not  be  used.  On  the  contrary,  as- 
tringents and  corroborants  are  immediately 
indicated,  in  order  to  restore  to  the  vessels 
of  the  conjunctiva  and  eyelids  their  original 
tone,  to  rectify  the  villous  and  fungous  ap- 
pearance of  the  lining  of  the  palpebrae,  and 
thus  finally  to  check  the  morbid  secretion  of 
matter.  For  this  purpose  Mr.  Ware  strongly 
recommends  the  aqua  camphorata  of  Bates’s 
Dispensa  ory  : Capri  sulphatis,  bol.  ar- 

rnen.  a a |iv.  Camphorae,  Jj.  M.  &f.  pulvis, 
de  quo  projice  ^j.  in  aqua?  bullientis 
amove  ab  igne,  ef  subsidant  foeces.  Mr. 
Ware,  in  his  late  Remarks  on  Purulent  Oph- 
thalmy, 1803,  observes,  that  he  usually  directs 
the  aqua  camphorata  as  follows:  Cupri 

sulphatis.  bol.  armen.  a & gr  viij.  Camphorae 
gr  ij.  Misce,  et  affunde  aqua?  bullientis  ?viij. 
CCtm  lotio  sit  frigida,  effundatur  limpidus  li- 
quor, et  saepissirne  injiciatur  paululum  inter 
oculum  et  palpebras.  This  remedy  possesses 
a very  styptic  quality  ; but,  as  directed  in 
Bates’s  Dispensatory,  it  is  much  too  strong 
for  use  before  it  is  diluted;  and  the  degree 
of  its  dilution  must  always  be  determined 
by  the  peculiar  circumstance  of  each  case. 
Mr.  Ware  ventures  to  recommend  about  one 
dram  of  it  to  be  mixed  with  an  ounce  of  cold 
clear  water,  as  a medium  or  standard,  to  be 
strengthened  or  weakened  ns  occasion  may 
require.  (P.  143.)  The  remedy  must  be  ap- 
plied by  means  of  a small  ivory  or  pewter 
syringe*  the  end  of  which  is  a blunt-pointed 
cone.  The  extremity  of  this  instrument  is 
to  be  placed  between  the  edges  of  the  eye- 
lids, in  such  a manner,  that  the  m»  dicated  li- 
quor may  be  carried  over  the  whole  surface 
of  the  eye.  Thus  the.  matter  will  be  entirely 
washed  aw  ay,  and  enough  of  the  styptic  me- 
dicine left  behind  to  interrocf  and  diminish 


HAT  Ml. 

the  excessive  discharge.  According  to  the 
quantity  of  matter,  and  the  rapidity  with 
which  it  is  secreted,  the  strength  of  the  ap- 
plication, and  the  frequency  of  repeating  it, 
must  he  regulated.  In  mild  recent  cases,  the 
lotion  may  be  u-ed  once  or  twice  a day.  and 
rather  weaker  than  the  above  proportions  ; 
but,  in  inveterate  cases,  it  is  necessary  to  ap- 
ply it  once  or  twice  every  hour,  and  to  in- 
crease its  styptic  power  in  proportion  ; and 
when  the  complaint  is  somewhat  relieved, 
the  strength  of  the  lotion  may  bo,  lessened, 
and  its  application  be  less  frequent. 

“The  reasons  for  a frequent  repetilion  of 
the  means  just  mentioned,  in  bad  cases,  are. 
indeed,  of  the  most  urgent  nature.  Until 
the  conjunctiva  is  somewhat  thinned,  and 
the  quantity  of  the  discharge  diminished,  it 
is  impossible  to  know  in  what  state  the  eye 
is  ; whether  it  is  more  or  less  injured,  totally 
lost,  or  capable  of  any  relief.  The  continu- 
ance or  extinction  of  the  sight  frequently  de- 
pends on  the  space  ot  a fewr  hours  : nor  can 
we  be  relieved  from  the  greatest  uncertainty 
in  these  respects,  until  the  cornea  becomes 
visible.”  (Ware- p.  145.) 

This  author  condemns  the  use  of  emollient 
poultices,  which  must  have  a tendency  to  in- 
crease the  swelling  and  relaxation  of  the  con- 
junctiva. If  poultices  are  preferred,  he  par- 
ticularly recommends  such  as  possess  a tonic 
or  mild  astringent  property;  as  one  made  of 
the  curds  of  milk,  turned  with  alum,  and  an 
equal  part  of  the  unguentum  9ambuci,  or 
axungia  porcini.  This  is  to  be  put  on  cold, 
and  frequently  renewed,  without  omitting 
,he  use  of  the  injection.  (Ware,  p.  147.) 

When  the  secreted  matter  is  glutinous, 
and  makes  the  eyelids  so  adherent  together, 
that  they  cannot  be  opened,  after  being  shut 
for  any  length  of  lime,  the  adhesive  matter 
must  be  softened  with  a little  fresh  butter 
mixed  with  warm  milk,  or  by  means  of  any 
othersoft  oleaginous  liquor,  after  the  poultice 
is  taken  off,  and  before  using  the  lotion.  (P.. 
147.) 

If  the  eversion  of  the  eyelids  only  occurs 
when  the  child  cries,  and  then  goes  off,  no- 
thing need  be  done  in  addition  to  the  above 
means.  When,  however,  the  eversion  is  con- 
stant, the  injection  must  be  repeated  more, 
frequently  than  in  other  cases;  the  eyelids 
put  in  their  natural  position,  after  its  use  ; 
and  an  attendant  directed  to  hold  on  them, 
with  his  finger,  for  some  length  of- time,  a 
compress  dipped  in  the  diluted  aqua  camplio 
rata.  (P.  148.) 

In  some  cases,  when  the  inside  of  the  eye- 
lids has  been  very  much  inflamed,  the  tine- 
tura  thebaica,  insinuated  between  the  eye 
and  the  eyelids,  has  been  useful.  If,  after 
the  morbid  secretion  i3  checked,  nny  part 
of  the  cornea  should  be  opaque,  the  unguert- 
tum  bydrargyri  nitrati,  melted  in  n spoon, 
and  applied  accurately  on  the  speck,  with  u 
fine  hair  pencil ; or  Janin’s  ophthalmic,  oint- 
ment, lowered  and  used  in  the  same  mariner, 
may  produce  a cure,  if  the  opacity'  he  not  of 
too  deep  a kind.  When  the  local  disease 
seems  to  be  kept  up  by  a bad  habit,  altera- 
tives should  be  exhibited,  particularly 


tiPH'VH  ALM  \ . 


32l> 

black  sulpburet  of  mercury,  or  small  dosesof  eyes,  was  freely  applied  to  (be  orifice  of  (he 
calomel.  urethra.  No  effect  followed  (his  trial,  which 

The  treatment,  recommended  by  Dr.  was  repeated  on  some  other,  patients,  all  la- 
Vetch,  is  as  follows:  if  the  inflammation  has  bouring  under  the  most  virulent  state  of  the 
not  extended  to  the  conjunctiva  of  the  eye,  Egyptian  disease,  and  in  all  the  application 
its  further  progress  may  he  checked  by  re-  was  perfectly  innocuous.  But,  in  another 
moving  the  infant  to  a healthy  atmosphere,  case,  where  the  matter  was  taken  from  the 
and  washing  the  eye  with  any  mild  collyri-  eye  of  one  man,  labouring  under  purulent, 
um.  Leeches  are  commended  throughout  ophthalmia,  and  applied  to  the  urethra  of  ari- 
the  whole  course  of  the  complaint.  On  the  other,  the  purulent  inflammation  of  the  nre 
first  accession  of  the  tumefaction,  t he  best  thra  commenced  in  thirty-six  hours  after- 
effect will- often  be  produced  by  the  applica-  ward,  and  became  a very  severe  attack  of 
tion  of  a small  portion  of  ointment,  composed  gonorrhoea.  From  the  result  of  these  cases, 
of  lard,  or  butter  3yj.  and  x gr.  of  the  red  ni-  (says  Dr.  Vetch)  l could  no  longer  admit  the 
trate  of  mercury,  without  any  wax.  As  the  possibility  of  infection  being  conveyed  to 
purulency  advances,  the  liquor  plumbi  suba-  the  eyes  from  (he  gonorrhoeal  discharge  of  (he 
cetatis,  he  says,  will  be  found  not  less  ser-  same  person.  Some  time  after  this,  the  im 
viceahle,  than  in  other  instances  of  purulent  probability,  or  rather  impossibility  of  this  ef- 
ophthalmy.  For  promoting  the  separation  feet,  was  rendered  decisive  by  an  hospital 
of  any  slough,  he  recommends  a solution  of  assi-tant,  who  conveyed  the  matter  of  gonor- 
the  nitrate  of  silver:  and  for  curing  the  re-  rhcea  to  his  eyes,  without  any  affection  of  the 
laxed  state  of  the  conjunctiva,  a solution  of  conjunctiva  being  the  consequence.”  (See 
alum,  or  of  the  sulphate  of  copper.  (On  Vetch  on  Diseases  of  the  Eye , p.  242.) 
Diseases  of  the  Eye , p.  260.)  Hence,  this  gentleman  is  led  to  refer  the  con 

The  Purulent  Ophthalmy  arising  either  nexion,  between  gonorrhoea  and  ophthalmia, 
from  suppression  of  gonorrhoea,  or  from  the  in  the  same  person,  to  peculiarity  of  consti- 
ihadvertent  conveyance  of  gonorrhoeal  matter  tutiou;  but  the  theories  on  which  this  opi 
to  the  eyes,  is  said  to  produce  rather1 a swell-  nion  rests,  my  limits  will  not  allow  me  to 
ing  of  the  conjunctiva,  than  of  the  eyelids,  examine 

which  is  followed  by  a discharge  of  a yei-  If  it  be  actually  true,  that,  in  adults,  a spe  • 
low  greenish  matter,  similar  to  that  of  clap,  cies  of  purulent  ophthalmy  does  originate 
The  heat  and  pain  in  the  eyes  are  con-  from  the  sudden  suppression  of  a gonorrhoea, 
siderable  ; an  aversion  to  light  prevails,  and,  are  we  to  consider  the  complaint  so  pro- 
in some  instances,  an  appearance  of  hypopi-  ducedas  a metastasis  of  the  disease  from  the 
on  is  visible  in  the  anterior  chamber  oi  the  urethra  to  the  eyes  ? This  ophthalmy  does 
aqueous  humour.  When  the  complaint  pro-  not  regularly  follow  the  suppression  of  gonor- 
eeeds  from  the  secondcause.it  is  described  rhcea;  nay,  it  is  even  a rare  occurrence: 
as  being  less  severe,  than  when  it  arises  from  also,  when  it  is  decidedly  known,  that  the 
the  first.  However,  by  such  gentlemen,  purulent  ophthalmy  has  arisen  from  the  in- 
( Ware , Travers,  fyc.)  as  have  seen  unequivo-  faction  of  gonorrhoea,  namely,  in  those  in 
cal  instances  of  purulent  ophthalmy  excited  stances  in  which  the  matter  has  been  incau- 
in  the  second  way,  the  disease  is  said  to  be  tiously  communicated  to  the  eyes,  it  appears 
remarkable  for  its  violence  and  intensity,  that  such  an  affection  of  these  organs,  so  pro- 
The  reality  of  cases  of  purulent  ophthalmy  duced,  is  different  from  the  one  alluded  to, 
from  the  application  of  gonorrhoeal  matter  to  inasmuch  as  it  is  slower  in  its  progress,  and 
the  eyes,  seems  supported  by  such  a mass  of  less  threatening  in  its  aspect.  When  the 
evidence,  that  I believe  the  fact  must  be  ad-  eyes  are  affected,  the  disease  of  the  urethra 
mitted.  Yet,  from  some  statements,  lately  is  not  always  suspended.  (Vetch  on  Diseases 
published  b\  Dr.  Vetch,  it  would  appear,  that  of  the  Eye.  p.  239.)  Hence,  there  is  good 
the  frequency  of  this  mode  of  infection  must  reason  for  supposing  that  no  metastasis  takes 
be  very  much  lessened  by  the  circumstance  place  in  (his  species  of  purulent  ophthalmy, 
of  the  matter  taken  from  the  urethra,  not  supposed  to  be  connected  with  a suppressed 
being  capable  of  communicating  the  dis-  gonorrhoea:  but,  we  must  be  content  with 
ease  to  the  eyes  of  the  individual,  by  whom  inferring  that,  if  it  really  has  such  a cause,  it 
such  matter  is  secreted,  though  probably  originates  from  a sympathy,  prevailing  be- 
capable  of  doing  so  to  the  eyes  of  another  tween  the  urethra  and  eyes,  and,  that  the 
person.  difference  of  irritability,  in  different  people, 

In  the  same  way,  the  urethra  caunot  be  is  the  reason,  why  it  is  not  an  invariable 
affected  by  the  application  of  matter  taken  consequence  of  the  sudden  stoppage  of  a 
from  the  purulent  eyes  of  the  individual,  on  gonorrhoea. 

Whom  the  experiment  is  made.  At  least,  of  The  injection  of  warm  oil,  the  introduc 
these  circumstances,  there  is  a negative  proof  tion  of  a bougie  into  the  urethra,  and  the 
in  some  facts  recorded  by  Dr.  Vetch.  “ In  application  of  cataplasms  to  the  perinaeum, 
the  case  of  a soldier,  received  in  a very  ad-  with  a view  of  renewing  the  discharge  from 
vanced  stage  of  the  Egyptian  ophthalmia,  in  the  urethra,  form  the  outline  of  the  practice 
whom  destruction  of  the  cornea  had  to  a cer  of  those  who  place  implicit  reliance  in  the 
tain  extent  taken  place,  I took  occasion  to  suppression  of  gonorrhoea  being  the  cause 
represent  the  possibility  of  diverting  the  dis-  of  the  complaint.  The  rarity  of  the  occur- 
ca«e  from  the  eyes  to  the  urethra,  by  apply-  rence;  the  frequency  of  the  sudden  cessa- 
ing  the  discharge  1o  the  latter  surface.  Ac-  tion  of  the  urethral  discharge ; the  possibi- 
cordingly,  some  of  the  matter  taken  from  the  lity  of  an  ophthalmy  arising,  as  well  at  this 
V0L.  II.  42 


OPHTIIALMF 


particular  moment,  as  at  any  other,  totally 
independent  of  the  other  complaint ; cannot 
fail  lo  raise  in  a discerning  mind  a degree  of 
doubt  concerning  the  veracity  of  the  assign- 
ed cause.  Besides,  admitting  that  there  is  a 
sympathy  between  the  urethra  and  eyes, 
how  are  we  to  ascertain  whetherthe  suppres- 
sion of  gonorrhoea  be  the  cause  or  the  effect 
of  the  ophthalmy,  supposing  that  the  one 
ceases  and  the  other  commences  about  the 
same  time  ? Actuated  by  such  reflections,  I 
am  induced  to  dissuade  surgeons  from  adopt 
ing  any  means  calculated  to  renew  a dis- 
charge of  matter  from  the  urethra.  When 
the  purulent  ophthalmy,  in  adult  subjects,  is 
decidedly  occasioned  by  the  actual  contact, 
and  infection  of  gonorrhoeal  matter,  applied 
accidentally  to  the  eyes,  no  one  has  recom- 
mended this  unnecessary  and  improper  prac- 
tice. 

The  first  indication  in  the  treatment  of  the 
disease  from  either  cause,  is  to  oppose  the 
violence  of  the  inflammation,  and  thus  re- 
sist the  destruction  of  the  eye  and  opacity  of 
the  cornea.  A copious  quantity  of  blood 
should  be  taken  away  both  topically  and  ge- 
nerally ; mild  laxatives  should  be  exhibited, 
and  a blister  applied  to  the  nape  of  the  neck, 
or  temples.  The  eyes  ought  to  be  often  fo- 
mented with  a decoction  of  white  poppy- 
heads,  and  warm  milk  repeatedly  injected 
beneath  the  eyelids.  To  prevent  the  palpe- 
brse  from  becoming  agglutinated  together, 
during  sleep,  the  spermaceti  cerate  should 
be  smeared  on  the  margins  of  the  tarsi  every 
night. 

When  the  heat  and  pain  in  the  eyes,  and 
febrile  symptoms  have  subsided  ; when  an 
abundant  discharge  of  pus  has  commenced; 
all  topical  emollients  are  to  be  relinquished, 
and  a collyrium  of  Aq.  rosse  |x.  containing 
Ilydrarg.  oxy.  mur.  gr.  j.  used  in  their  place. 
Scarpa  slates,  that  in  the  ophthalmia,  origi- 
nating from  the  inadvertent  communication 
of  the  matter  of  gonorrhoea  to  the  eyes,  ap- 
plications, in  the  form  of  ointment,  such  as 
the  ung.  hydrarg.  and  Janin’s  salve,  to 
which  might  be  added  the  ung.  hyd.  nitrat. 
avail  more,  than  fluid  remedies. 

Inflammation  of  the  Eyeball  in  general. 
From  cases  in  which  the  eyelids  are  at  first 
chiefly  affected,  I pass  to  the  consideration 
of  inflammation,  as  commencing  in  the  eye- 
ball itself.  As  Beer  remarks,  fortunately  it 
is  only  very  seldom,  that  the  whole  ol  the 
organ  is  at  once  attacked  with  genuine  idio- 
pathic inflammation,  without  any  part  of  its 
texture  being  spared.  Although  this  kind  of 
ophthalmy  is  far  more  frequent  than  com- 
mon inflammation  of  the  orbit,  it  is  much 
more  rare  than  the  same  disorder  of  the  eye- 
lids. For  the  most  part,  healthy  inflamma- 
tion of  the  eyeball  has  a limited  point  of  ori- 
gin, from  which  it  spreads,  sometimes  quick- 
ly, sometimes  slowly  over  the  whole  organ. 
During  an  exceedingly  violent,  tense,  throb- 
bing pain,  affecting  not  only  the  eye  itself, 
but  extending  to  all  the  surrounding  parts, 
the  bottom  of  the  orbit,  and  within  the  head, 
the  white  of  the  eye  becomes  suffused  with 


an  uniform  redness,  which,  on  attentive  ex- 
amination, is  found  to  be  seated  not  only  in 
the  conjunctiva  of  the  eyeball,  but  also  in 
the  sclerotica,  and  to  exhibit  at  first  a very 
fine  vascular  network,  which,  as  the  redness 
grows  more  intense,  assumes  the  appearance 
of  scarlet  cloth,  forming  all  round  the  cor- 
nea an  uniform  circular  prominent  fold, 
which  has  a very  firm  feel,  and  is  so  tender, 
that,  when  touched  in  the  gentlest  manner, 
the  patient  cries  out  with  agony.  The  cir- 
cumference of  the  cornea  continues  to  be 
more  and  more  covered  by  this  increasing 
swelling  of  the  conjunctiva,  until  at  length 
only  a portion  of  its  centre  remains  visible. 
At  the  same  time,  the  pupil  is  very  much 
contracted  ; the  iris  motionless ; and  though 
vision  is  nearly  or  entirely  lost,  the  patient 
is  seriously  disturbed  by  fiery  appearances 
before  the  eye.  When  the  iris  is  naturally 
gray,  or  blue,  it  turns  greenish,  and  when 
brown,  or  black,  it  becomes  reddish.  Every 
movement  of  the  eyeball  and  upper  eyelid 
is  suspended,  and  the  orbit  feels  to  the  pa- 
tient, as  if  it  were  too  small,  which,  Beer 
says,  is  in  reality  the  case,  because  the 
whole  of  the  eyeball,  and  not  merely  the 
conjunctiva,  is  enlarged,  so  as  to  project 
like  a lump  of  raw  flesh  further  and  further 
between  the  edges  of  the  palpebrae,  and  com- 
pletely fill  every  part  of  the  orbit.  While 
the  eyeball  enlarges,  the  cornea  always  loses 
its  transparency,  and  the  inflammation 
spreads  to  the  eyelids,  the  lower  one  at 
last  becoming  everted  by  the  excessive 
and  firm  tumefaction  of  the  parts  behind 
it,  and  the  upper  one  presenting  the  most 
unequivocal  marks  of  phlegmonous  in- 
flammation. The  secretion  of  tears  and 
mucus  is  now  entirely  suppressed,  and  of 
course,  the  eye  preternaturally  dry.  At 
the  very  commencement  of  this  violent 
form  of  ophthalmy,  the  constitution  is 
disturbed  by  a t-vere  attack  of  inflam- 
matory fever,  and  irritable  patients  are 
not  unfrequently  seized  with  delirium. — 
Here,  says  Beer,  terminates  the  first  stage  of 
this  very  dangerous  disorder. 

When  the  disease  is  left  to  itself,  suppura- 
tion comes  on,  attended  with  fever  and 
constant  shiverings  ; the  swelling  of  the  scle- 
rotic conjunctiva  undergoes  a remarkable 
increase,  and  assumes  a dark  red  colour,  at 
the  same  time  that  it  becomes  softer.  The 
pain  becomes  irregular,  throbbing,  and. 
when  the  eye  or  eyelids  are  touched,  of  a 
lancinating  description.  As  a morbid  secre- 
tion now  begins  to  take  place  from  the  Mei- 
bomian glands,  the  swelled  conjunctiva  has 
a more  moist  appearance.  The  upper  eyelid, 
has  a purple  hue,  and,  on  account  of  the  con- 
tinually increasing  size  of  the  eyeball,  is 
pushed  further  and  further  outward.  The 
portion  of  the  cornea,  still  discernible  in  the 
middle  of  the  protuberant  conjunctiva,  ac- 
quires a snowy  whiteness,  which  afterward 
changes  to  yellow.  The  patient  feels  an  op- 
pressive sense  of  heaviness  in  the  orbit,  and 
a disagreeable  kind  of  coldness  all  round 
the  eye.  At  length  the  throbbing  and  ten 


OPIITHALMV. 


331 


sion  are  so  agonizing,  that  the  patient  often 
expresses  a wish  to  have  the  eyeball  extir- 
pated. If  no  effectual  treatment  be  adopted, 
the  eye  now  bursts,  and  a mixture  of  matter 
and  blood,  together  with  the  scarcely  per- 
ceptible remains  of  the  lens  and  vitreous 
humour,  is  discharged  with  considerable 
force  to  some  distance  in  front  of  the  pa- 
tient ; an  occurrence  sometimes  termed 
rhexis , or  rhegma  oculi.  From  this  moment, 
the  pain  all  at  once  subsides  into  a very  mo- 
derate feel  of  burning  in  the  eye  ; and  sup- 
puration goes  on,  until  all  the  textures  of  the 
organ  are  annihilated,  the  orbit  has  an  emp- 
ty appearance,  and  the  closed  eyelids  sink 
into  a concavity.  Thus  ends,  as  Beer  ob- 
serves, the  second  stage,  after  much  tedious 
and  general  indisposition.  But,  he  remarks, 
that  the  course  of  the  case  is  quite  different, 
when  it  has  been  wrongly  treated  in  its  first 
stage  with  stimulants,  or  exposed  to  the  ill 
effects  of  tobacco  smoke,  the  drinking  of 
spirits,  improper  diet,  immoderate  exercise, 
&.c.;  for,  under  the  operation  of  these  unfa- 
vourable circumstances,  the  second  stage 
may  commence  with  dreadful  gangrenous 
mischief,  every  vestige  of  the  organization 
of  the  eye  disappearing,  and  the  parts  at 
length  sphacelating,  while  large  abscesses 
form  around,  and,  unless  efficient  medical 
aid  be  promptly  given,  the  patient  loses  his 
life. 

With  respect  to  the  causes  of  such  an  at- 
tack of  the  whole  eyeball  at  once  by  com- 
mon inflammation  in  a healthy  subject,  they 
must  be  of  an  exceedingly  violent  descrip- 
tion, such  as  injuries  produced  by  gunpow- 
der, burns,  and  lesions  either  of  a mechani- 
cal kind,  or  acting  both  chymically  and  me- 
chanically together,  a subject  already  fully 
treated  of  in  the  foregoing  columns. 

The  following  are  the  observations  which 
Beer  delivers  on  the  prognosis  : While,  in 
the  first  stage  of  this  dangerous  form  of  oph- 
thalmy,  the  eyesight  yet  remains,  and  the 
eyeball  itself  is  not  enlarged,  if  the  patient 
can  be  properly  taken  care  of,  some  hope 
may  be  entertained  of  dispersing  the  inflam- 
mation so  favourably,  that,  with  the  excep- 
tion of  a weakness  of  sight,  of  longer  or 
shorter  continuance,  no  ill  effects  will  be 
left.  It  is  manifest,  however,  that  under 
these  circumstances,  the  surgeon  should  not 
be  too  bold  in  promising  a perfect  cure;  for, 
the  very  commencement  of  such  an  inflam- 
mation of  the  whole  eyeball,  even  when  the 
disorder  is  purely  idiopathic,  is  unavoidably 
attended  with  some  risk,  not  only  of  perma- 
nent blindness,  but  of  the  eye  itself  being 
destroyed  in  the  most  painful  manner; 
and,  when  things  turn  out  rather  better,  a 
tolerably  favourable  termination  of  the 
case  is  uncommon.  But,  as  soon  as  the 
power  of  seeing  is  quite  lost,  the  pupil  nearly 
closed,  and  the  eyeball  prodigiously  swelled, 
it  will  be  fortunate,  if  the  inflammation  can 
be  resolved,  so  as  to  preserve  the  shape  of 
the  organ ; for  the  restoration  of  the  eye- 
sight is  entirely  out  of  the  question.  But, 
besides  the  irremediable  loss  of  vision,  the 
disorder  under  these  circumstances  always 


produces  a greater  ®r  lesser  closure  of  the 
pupil,  which,  however,  lias  no  share  in  caus- 
ing the  blindness. 

In  the  second  stage  of  the  case,  of  course, 
the  hope  of  restoring  vision  is  quite  past , 
and  if  the  eyeball  itself,  and  not  merely  the 
conjunctiva,  has  been  considerably  swelled 
in  the  first  stage  of  the  case,  the  chance  of 
preserving  the  natural  shape  of  the  organ 
extremely  unpromising.  But,  when  the  eye 
bursts,  the  latter  desideratum  is  impossible. 
If  the  first  stage  should  have  been  so  violent 
as  to  have  induced  gangrene,  the  practition- 
er will  have  enough  to  do  in  preventing 
sphacelus,  and  death,  the  danger  of  which 
is  considerable,  on  account  of  the  intimate 
connexion  between  the  eye  and  parts  in  the 
orbit,  and  the  brain  and  its  membranes. 

In  the  first  stage,  antiphlogistic  treatment, 
in  the  general  sense  of  the  expression,  is 
indicated,  and  the  case  is  not  to  be  re- 
garded merely  as  a local  disorder.  Howe- 
ver, with  respect  to  topical  bleedings,  the 
surgeon,  says  Beer,  should  be  more  active, 
than  in  other  examples  of  ophthalmy,  and, 
after  copious  venesection  and  the  use  of 
leeches  have  produced  some  relief,  the  pro- 
tuberant conjunctiva,  round  the  cornea, 
should  be  deeply  scarified  with  a lancet.  If, 
in  the  first  stage,  delirium  come  on,  as  it 
sometimes  does  during  the  violence  of  the 
inflammatory  fever,  Beer  directs  one  of  the 
external  jugular  veins  to  be  opened:  or 
blood  might  be  taken  from  the  temporal 
artery. 

In  the  second  stage  of  the  case,  when 
the  re-establishment  of  vision  is  quite  im- 
impossible,  and  the  objects  are  to  endeavour 
to  keep  the  eye  of  a good  shape,  and  quick- 
ly lessen  the  suppuration,  warm  emollient 
poultices,  and  particularly  those  made  of 
apples,  are  the  applications,  on  which  Beer 
bestows  his  praises.  This  topical  treatment 
is  to  be  assisted  with  internal  means,  as  ex- 
plained in  the  preceding  pages,  because  the 
disorder  is  attended  with  a general  disturb- 
ance of  the  constitution.  When  matter  is 
fully  formed,  and  its  fluctuation  can  be  dis- 
tinctly felt,  Beer  approves  of  opening  the 
abscess  with  a lancet;  for,  it  is  only  by  this 
means,  that  the  annihilation  of  the  eyeball 
can  be  prevented.  If  the  eye  has  already 
burst,  the  preservation  of  its  form  is  no  lon- 
ger possible,  and,  according  to  Beer,  both 
the  topical  and  general  treatment  should  be 
partly  of  a tonic  description.  When  gan- 
grenous mischief  has  occurred,  the  practice 
ought  to  conform  to  the  principles  explain- 
ed in  the  article  Mortification. 

External  Ophthalmy.  Inflammation  of  the 
Outer  Coats  of  the  Eye.  Ophthalmitis  Externa 
Idiopathica , of  Beer.  The  modifications  of 
this  common  species  of  ophthalmy,  as  the 
latter  author  observes,  have  a variety  of 
names  applied  to  them,  as  ophthalmia  levis , 
ophthalmia  angutaris,  tar  axis,  and  sotnetim*  £ 
chemosis,  and  ophthalmia  sicca.  Together 
with  a preternatural  dryness  of  the  eye,  and 
a sensation,  as  if  the  eyeball  were  compress- 
ed on  every  side,  the  white  of  the  eye  be- 
jeoeaes  covered  with  a general  rednejs.Sj 


OPHTHALMV. 


332 


which,  though  it, affect  both  the  sclerotica  and 
the  conjunctiva,  will  be  found  on  attentive 
examination  to  be  much  more  considerable 
in  the  former,  than  the  latter  membrane,  in 
which  only  a delicate  plexus  of  blood-ves 
sels  is  at  first  perceptible.  The  motions  of  the 
eye  and  eyelids  are  not  absolutely  prevent- 
ed ; yet,  the  patient  never  moves  these  parts 
except  when  he  is  actually  obliged  to  do  so, 
as  every  motion  of  them,  if  not  actually 
painful,  occasions  a good  deal  of  annoy- 
ance. Though  the  cornea  cannot  be  said 
to  become  opaque,  its  clearness  is  always 
much  diminished,  and  this  change  is  the 
greater,  the  redder  the  white  of  the  eye  ap- 
pears. These  effects,  which  occur  almost 
simultaneously,  are  followed  by  pain,  which 
increases  every  moment,  at  first  extending 
over  the  whole  eyeball,  and  then  to  the  sur- 
rounding parts,  and  to  the  top  of  the  head. 
As  the  pain  grow  s more  severe,  every  move- 
ment of  the  eyeball  and  palpebraj  becomes 
more  distressing,  the  dryness  of  the  eye 
greater,  and  the  redness  of  the  sclerotic 
conjunctiva  augments,  either  more  slowly, 
or  quickly,  according  to  the  degree  of  in- 
flammation until  the  network  of  blood-ves- 
sels, which  was  at  first  distinguishable,  en- 
tirely disappears,  and  the  conjunctiva  looks 
like  a piece  of  red  cloth,  quite  concealing 
the  sclerotica,  and  forming  round  the  cor- 
nea a very  painful,  firm,  uniform  circular 
projection.  Thus,  the  cornea  seems  as  if 
it  lay  in  a depression,  with  its  margin  partly 
covered  by  this  inflammatory  swelling  of 
the  conjunctiva.  At  the  period,  when  the 
protuberance  of  the  latter  membrane  takes 
place,  the  cornea  itself  always  becomes  less 
and  less  clear,  and  of  a reddish  gray  colour, 
so  that  neither  the  iris  nor  the  pupil  can  be 
any  longer  distinguished,  and  the  power  of 
vision  is  reduced  to  a faint  perception  of 
light.  The  pain,  which  was  that  of  heavi- 
ness and  tension,  now  becomes  of  a throb- 
bing description,  and  the  eyelids,  which 
now  begin  to  participate  in  the  effects  of 
the  inflammation,  are  no  longer  capable  of 
covering  properly  the  swelled  conjunctiva. 
The  eyeball  and  eyelids  are  perfectly  mo- 
tionless ; and,  if  an  attempt  be  made  by 
the  patient  to  move  them,  the  efforts  of 
the  muscles  may  be  perceived,  but  still  no 
movement  of  the  parts  intended  is  perform- 
ed. The  orbit  feels  as  if  it  were  too  small 
for  the  eye,  and  the  constitution  suffers  a 
severe  attack  of  inflammatory  fever.  Thus, 
says  Beer,  does  the  first  stage  of  this  form 
of  ophthalmv  gradually  rise  to  its  highest 
degree,  to  which  he  applies  the  name  of 
true  chemosis. 

However,  it  is  observed,  that  idiopathic 
external  ophthalmy  does  not  always  be- 
come so  violent,  as  for  instance,  when  the 
complaint  has  been  excited  merely  by  the 
lodgment  of  some  small  foreign  body  under 
tbe  eyelids  ; for  though  in  such  a case  the 
conjunctiva  and  sclerotica  are  both  redden- 
ed together,  yet  even  when  no  aid  is  afford- 
ed, if  no  other  sources  of  greater  irritation 
are  present,  the  redness  does  not  readily 
increase  so  as  quite  to  conceal  the  sclero- 


tica, or  to  be  attended  with  an  inflamma- 
tory swelling  all  around  the  cornea.  This 
milder  form  of  external  ophthalmy  has 
sometimes  received  the  name  oi  tar  axis.  It 
is  the  mild  acute  ophthalmy  of  Scarpa,  cha- 
racterized, as  this  author  says,  by  redness  of 
the  conjunctiva  and  lining  of  the  eyelids, 
an  unnatural  sensation  of  heat  in  the  eyes, 
uneasiness,  itching,  and  shooting  pains,  as  if 
sand  w ere  lodged  between  the  eye  and  eye- 
lids. At  the  place  where  the  pain  seems 
most  severe,  Scarpa  remarks,  that  some 
blood-vessels  appear  more  prominent  and 
turgid  than  other  vessels  of  the  same  class. 
The  patient  keeps  his  eyelids  closed  ; for  he 
feels  a weariness  and  restraint  in  opening 
them,  and  by  this  means  be  also  moderates 
the  action  of  the  light,  to  which  he  cannot 
expose  himself,  without  increasing  the  burn- 
ing sensation,  lancinating  pain,  and  effusion 
of  tears.  If  the  constitution  be  irritable, 
the  pulse  w ill  be  a little  accelerated,  parti- 
cularly towards  the  evening  ; the  skin  dry  ; 
and  sometimes  slight  shiverings,  and  nausea 
and  sickness  take  place. 

According  to  Scarpa,  mild  acute  ophthal- 
my is  often  the  consequence  of  a cold,  in 
which  the  eyes,  as  well  as  the  pituitary  ca- 
vities, fauces,  and  trachea,  are  affected.  It 
is  not  unfrequently  occasioned  by  change 
of  weather,  sudden  transitions  from  heat  to 
cold,  the  prevalence  of  easterly  winds,  jour- 
neys through  damp  unhealthy,  sandy  coun- 
tries, in  the  hot  season  of  the  year,  exposure 
of  the  eyes  to  the  vivid  rays  of  the  sun., 
draughts  of  cold  air,  dust,  &c.  Hence,  it 
does  not  seem  extraordinary,  that  it  should 
often  make  its  appearance  as  an  epidemic, 
and  afflict  persons  of  every  age  and  sex. 
As  additions  to  the  list  of  remote  causes, 
authors  enumerate  the  suppression  of  some 
habitual  evacuation,  as  bleedings  from  the 
nose,  or  piles,  the  menses,  he.  a disordered 
state  of  the  prima*  viae,  worms,  dentition, &c. 

Between  Beer  and  some  late  w riters,  there 
is  either  one  point  of  difference  in  their  de- 
scriptions of  external  ophthalmy,  or  else 
they  mean  different  cases  ; for  while  Beer 
represents  the  redness  as  affecting  the  scle- 
rotica at  first  more  than  the  conjunctiva, 
other  writers  describe  the  affection  of  t he  scle- 
rotica as  generally  secondary,  when  it  hap- 
pens at  all  ; for  according  to  modern  obser- 
vations, it  is  not  unavoidably  either  an  at- 
tendant upon,  or  an  effect  of  simple  inflam- 
mation of  the  conjunctiva. 

As  the  second  stage  of  external  ophthal- 
my comes  on,  the  symptoms  vary,  accord- 
ing to  the  degree  of  the  complaint  in  its 
first  stage  ; but  when  what  Beer  calls  a true 
chemosis  is  produced,  the  following  are  de- 
scribed by  him  as  llie  usual  appearances. 
The  circular  prominent  fold  of  the  conjunc- 
tiva round  the  cornea,  becomes  of  a dark 
red  colour,  and  the  swelling  increases,  but 
it  becomes  softer  and  less  painful.  The 
hardly  visible  portion  of  the  cornea,  situated 
iu  the  depression  formed  by  the  circular 
protuberance  of  the  conjunctiva,  seems  at 
first  perfectly  white,  and  afterward  yellow- 
ish, being  the  seat  of  more  or  less  purulent 


matter.  Though  the  swelled  conjunctiva 
is  every  where  moistened  with  a thin  whi- 
tish mucus,  this  secretion,  says  Beer,  is  never 
so  copious  as  to  run  over  the  face,  as  in 
the  case  of  ophthalmo-blennorrhcea.  In 
this  stage,  the  lower  eyelid  is  turned  some- 
what outwards,  in  consequence  of  its  lining 
becoming  more  swelled.  While  suppura- 
tion is  taking  place  in  the  cornea,  attended 
with  the  febrile  symptoms  which  usually  ac- 
company the  formation  of  acute  abscesses, 
little  collections  of  matter  sometimes  occur 
at  different  points  of  the  conjunctiva,  and 
after  they  have  burst,  a probe  may  easily 
be  passed  rather  deeply  into  them,  without 
any  particular  pain.  (Beer,  B.  1,/).  412.) 
The  suppuration  continually  advancing,  the 
swellingof  the  conjunctiva,  and  of  the  whole 
eyeball  now  diminishes,  the  effects  of  the 
inflammation  penetrate  deeply  into  the  or- 
gan, and  the  structure  of  the  eye  is  so  alter- 
ed as  not  to  be  cognizable,  the  part  shrivel- 
ling up,  as  Beer  says,  into  a motionless, 
whitish  mass.  However,  according  to  this 
author,  these  deep  effects  of  suppuration 
are  sometimes  produced  only  in  a certain 
part  of  the  eyeball,  especially  when  the 
chemosis  is  the  consequence  of  an  external 
injury,  and  in  this  circumstance,  the  rest  of 
the  circumference  of  the  globe  of  the  eye 
exhibits  its  natural  organization,  while  in 
the  part  above  alluded  to,  there  is  a funnel- 
like  depression,  attended  with  a considera- 
ble diminution  in  the  size  of  the  organ. 

But,  says  Beer,  when  an  idiopathic  exter- 
nal inflammation  of  the  eye  has  only  attain- 
ed the  milder  degree,  expressed  by  the  term 
taraxis ; as,  for  instance,  when  the  com- 
plaint is  principally  owing  to  the  lodgment 
of  some  mechanically,  or  chyriucally  irrita- 
ting substance  under  the  eyelids  . the  red- 
ness of  the  conjunctiva  and  sclerotica  un- 
dergoes a remarkable  increase  on  the  ac- 
cession of  the  second  stage ; the  first  of 
these  membranes  becomes  somewhat  swell- 
ed ; the  pain  is  lancinating  and  irregular ; 
and  the  secretion  of  tears  unusually  pro- 
fuse ; but  at  the  point  where  the  extraneous 
substance  lodges,  an  open  superficial  sup- 
puration occurs,  and  according  to  Beer,  the 
case  both  in  the  first  and  second  stage,  is 
generally  accompanied  with  no  febrile 
symptoms. 

In  the  first  stage,  Beer  represents  the 
prognosis  as  very  favourable,  provided  the 
disorder  does  not  exceed  that  degree,  to 
which  the  name  of  iaraxis  is  applied;  for 
with  the  aid  of  proper  treatment,  the  in- 
flarnmaiion.  when  of  a healthy  kind,  may 
be  soon  so  favourably  removed,  as  not  to 
leave  a vestige  of  it  behind.  If  the  cause  of 
the  disorder  be  not  greater  than  a moderate 
injury  or  wound  of  the  eve,  any  traces  of 
the  lesion,  which  are  perhaps  still  remain- 
ing, will  disappear  as  soon  as  the  inflamma- 
tion subsides.  On  the  other  hand,  when 
this  kind  of  ophthalmy  presents  itself  in 
the  form  of  true  chemosis,  the  prognosis  is 
serious,  and  must  be  made  with  great  re- 
serve, especially  when  the  patient  is  of  a 


weak  irritable  constitution,  a child,  very- 
stubborn  and  unmanageable,  or  incapable 
of  following  strictly  the  advice  which  he 
receives  froth  his  medical  attendant ; for, 
under  these  circumstances,  it  will  not  be  in 
the  power  of  the  latter  to  prevent  the  com- 
plaint from  advancing  unremittingly  to  its 
second  stage,  in  which  event  the  ill  conse- 
quences of  suppuration  w ill  be  incalculable. 
But  if  these  unfavourable  conditions  are  not 
present,  though  the  genuine  idiopathic  che- 
inosis  may  really  have  attained  a violent, 
and  almost  its  highest  degree  in  the  first 
stage,  not  only  the  eye  may  be  saved  by 
prompt  and  judicious  treatment,  but  als© 
the  eyesight ; nor  will  the  result  be  differ- 
ent, even  when  the  cornea  continues  for 
some  time  deprived  of  its  transparency,  and 
the  power  of  vision  impaired  by  a slight 
varicose  affection  of  its  conjunctival  cover- 
ing. These  effects,  says  Beer  at  length 
completely  disappear,  less  in  consequence 
of  the  aid  of  medicine,  than  of  a proper 
regimen,  the  uninterrupted  enjoyment  of 
a fresh,  dry  air,  &c. 

The  prognosis  in  the  second  stage,  is  un- 
der very  different  circumstances  ; for,  a^ 
Beer  observes,  though  the  inflammation,  in 
the  first  stage  may  really  not  exceed  that 
degree  which  is  implied  by  the  term  iaraxis, 
yet  if  any  suppurating  point,  occasioned  by 
some  slight  preceding  injury,  be  not  effi- 
ciently treated,  or  if  there  be  any  loss  of 
substance,  already  produced  by  the  injury 
itself,  a more  or  less  opaque,  white  cicatrix 
is  apt  to  remain  on  the  cornea,  and  cause  a 
permanent  impediment  to  vision  in  a degree 
determined  by  the  situation  and  extent  of 
the  opacity.  And  in  addition  to  this  risk  it 
is  to  be  remembered,  that  if  the  suppurating 
point  be  entirely  neglected,  or  erroneously 
treated,  the  cornea  or  sclerotica  may  be 
penetrated  by  ulceration,  and  in  the  first 
case,  a prolapsus  of  the  iris,  an  adhesion  of 
this  organ  to  the  cornea,  (synechia  anterior,) 
a disfigurement  of  the  pupil,  or  an  irregu- 
larity of  the  cornea,  be  produced  ; while, 
in  the  second,  the  consequences  may  be  a 
partial  wasting  away  of  the  eyeball,  attend- 
ed with  loss  of  sight,  and  of  the  natural 
shape  of  the  part.  (Beer.  B.  1,  p.  417.) 

Beer  further  observes,  that  when  this 
species  of  ophihalmy  presents  itself  in  its 
first  stage  in  the  form  of  true  chemosis,  the 
prognosis  in  the  second  stage  is  very  unfa- 
vourable ; for  when  the  cornea  is  generally 
pervaded  by  suppuration,  the  eyesight,  and, 
in  some  degree,  the  form  of  the  eyeball,  are 
for  ever  lost,  and  it  will  be  lucky,  if  the 
case  can  be  brought  to  a conclusion  with 
the  mere  destruction  of  the  cornea.  Br?t 
when  the  matter  points  at  once  in  several 
places  of  (he  conjunctiva,  round  the  cornea, 
all  idea  of  preserving  (he  shape  of  the  eye 
sufficiently  for  the  application  of  an  artifi- 
cial eye  is  out  of  the  question,  and  the  sur- 
geon will  be  very  successful,  if  he  can  now 
check  in  moderate  time  the  suppuration, 
which  continues  with  a good  deal  of  gene- 
ral indisposition.  An  extraordinary  relaxa- 
tion of  the  con  junctiva  of  the  lower  eyelid, 


OPHTHALMY. 


334 

and  a consequent  ectropium,  are  the  least 
disastrous  effects  of  the  abscesses  of  the  eye 
thus  produced.  Lastly,  Beer  remarks,  that 
when  chemosis  is  in  the  second  stage,  that 
is  to  say,  attended  with  suppuration  of  the 
eye,  it  rarely  happens,  under  the  most  fa- 
vourable circumstances,  that  the  eyesight 
and  shape  of  the  organ  can  be  preserved 
entirely  free  from  permanent  injury.  ( B . 1, 
j V • 418.) 

Let  us  next  consider  the  treatment  of  idio- 
pathic external  ophthaliny  in  its  modifica- 
tions of  simple  inflammation  of  the  con- 
junctiva, mild  acute  ophthalray,  or  taraxis, 
and  severe  acute  opi.thalmy,  with  che- 
tnosis. 

According  to  Mr.  Travers,  simple  inflam- 
mation of  the  conjunctiva  unconnected 
with  injury  of  tiie  eye,  and  neither  depend- 
ing upon  any  established  disorder  of  the 
system,  nor  modified  by  a scrofulous  dia- 
thesis, may  be  easily  and  speedily  reduced, 
even  in  its  most  acute  form,  by  bleeding 
and  some  brisk  doses  of  purgative  medicine. 

( Synopsis  of  the  Diseases  of  the  Eye,  p.  247.) 
For  the  relief  of  mild  acute  ophthaliny, 
Scarpa  recommends  low  diet,  gentle  purging 
with  small  repeated  doses  of  aritimonium 
tartarizatum,  the  removal  of  any  extraneous 
body  lodged  under  the  eyelid,  and  frequently 
washing  the  eye  with  a warm  decoction  of 
mallow  leaves,  and  covering  it  with  a very 
soft  emollient  poultice,  included  in  a fine 
little  muslin  bag.  Mr  Travers  also  expresses 
his  decided  preference  to  a tepid  application 
in  the  painfully  acute  stage  of  inflammation, 
and  considers  simple  warm  water  generally 
better  than  medicated  lotions,  like  the  aque- 
ous solution  of  opium,  or  infusions  of  poppy 
and  hemlock. 

When  the  disease  presents  itself  in  its  first 
stage,  in  the  mild  form  of  taraxis,  says  Beer, 
it  usually  runs  its  course,  quite  uncomplica- 
ted with  any  general  indisposition,  and  may 
be  cured  by  moderate  antiphlogistic  treat- 
ment, in  which,  indeed,  since  the  eyeball  it- 
self is  affected,  particular  attention  must  be 
paid  to  lessening  the  action  of  the  light  and 
air  upon  the  organ.  But  when  a true  che- 
mosis is  present,  every  antiphlogistit  means 
must  be  promptly  and  rigorously  put  in 
practice,  internal  as  well  as  external  reme- 
dies being  employed,  and  besides  common 
measures,  the  conjunctiva,  round  the  cor 
nea,  is  to  be  scarified  ; a proceeding  never 
necessary  in  the  case  of  taraxis.  Such  sca- 
rifications, Beer  observes,  have  a wonderful 
effect  when  practised  at  the  proper  period, 
aft  r veneseci  ion  and  topical  bleeding  with 
leeches  have  been  fully  put  in  execution, 
and  when  the  cuts  are  made  deep,  so  as 
to  produce  immediately  a copious  discharge 
of  blood.  “ By  means  of  such  scarifica- 
tions (says  he)  I have  seen  the  inflam- 
mation and  all  its  threatening  effects  re- 
cede, as  it  were,  before  my  face,  when  no 
material  relief  could  be  effected  by  other 
measures.”  ( B . 1,  p.  419.) 

According  to  the  late  Mr.  Ware,  there 
cannot  be,  in  chemosis,  an  easier  or  more 
effectual  remedy  than  set  her.  A few  drops 


are  to  be  poured  Into  the  palm  of  the  hand., 
and  diffused  over  it,  which  may  be  imme- 
diately done  by  pressing  the  other  hand 
against  it  The  hand  is  then  to  be  applied 
to  the  eye,  and  kept  so  close  to  it  that  the 
spirit,  as  it  evaporates,  may  insinuate  itself 
into  the  part  affected,  and  act  on  the  extra- 
vasated  blood,  so  as  to  disperse  it.  In  a few 
instances  of  chemosis,  in  which  the  swelling 
and  inflammation  have  been  considerable, 
this  gentleman  found  the  following  applica- 
tion of  singular  service  : f^.  lnteriorum  fo- 

liorum  recentiurn  Lactucae  Sissilis  ^iij. 
Coque  cum  aq.  pur.  3-ss.  in  balneo  mariao 
pro  semihora ; tunc  exprimatur  succus,  et 
applicetur  paululum  ad  oculos  et  ad  palpe- 
bras  saepe  indie.  (Ware,  p.  54)  As  these 
applications  are  not  noticed  by  the  genera- 
lity of  modern  writers,  I infer,  that  the  supe- 
rior efficacy  imputed  to  them  by  the  late 
Mr.  Ware,  is  not  such  as  to  obtain  the  con- 
fidence of  all  other  ophthalmic  practitioners. 

General  and  local  bleeding,  and,  if  chemo- 
sis be  present,  scarifications  having  been  put 
in  practice,  the  treatment  is  to  be  continued 
by  administering  purgatives  of  the  mildest 
description,  and,  after  their  operation,  apply- 
ing blisters,  according  to  the  directions 
given  in  a preceding  part  of  this  article.  Ia 
the  first  stage  of  severe  acute  ophthalmy, 
Scarpa  considers  topical  emollient  applica- 
tions to  the  eye  most  beneficial,  such  as 
mallows  boiled  in  new  milk;  bread  and 
milk  poultices;  or  the  soft  pulp  of  a baked 
apple  ; all  included  in  fine  little  muslin  bags. 
Remedies  of  this  description  should  be  re- 
newed at  least  every  two  hours.  The  pa- 
tient should  be  directed  to  observe  perfect 
quietude,  and  to  lie  with  his  head  in  an 
elevated  position.  To  keep  the  eyelids 
from  adhering  together  in  the  night-time, 
the  spermaceti  cerate  is  proper.  When 
ophthalmy  is  accompanied  with  a violent 
pain  in  the  head,  the  late  Mr.  Ware  recom- 
mended a strong  decoction  of  poppy-heads 
to  be  applied  as  a fomentation.  (P.51.) 

Under  the  preceding  plan  of  treatment, 
the  first  stage  of  severe  ophthalmy  com- 
monly abates  in  about  a week  The  burning 
heat  and  darting  pains  in  the  eyes,  and  the 
febrile  disturbance  of  the  constitution  sub- 
side. The  patient  is  comparatively  easy, 
and  regains  his  appetite.  The  eyes  become 
moist  again,  and  can  now  be  opened  without 
experiencing  vast  irritation  from  a moderate 
light.  In  this  state,  notwithstanding  they 
may  continue  red,  and  the  conjunctiva 
swelled,  all  evacuations  are  to  be  left  off, 
as  well  as  the  use  of  topical  emollients,  for 
which  iatter  astringent,  corroborant  collyria 
are  to  be  substituted.  Scarpa  recommends 
the  following  application  : f^.  Zinci  sul- 

phatis  gr  vj.  Aquae  distillate  ^vj.  Mucil. 
sein.  cydon.  mali  j.  Spiritfis  vini  cam- 
phor guttas  paucas.  Misce  et  cola.  This 
collyriutn  maybe  injected  with  a syringe, 
between  the  eye  and  eyelids,  once  every 
two  hours;  or  the  eye  may  be  bathed  in  it 
by  means  of  an  eye-cup.  Such  persons  as 
cannot  bear  cold  applications  to  the  eye, 
must  have  the  same  hind  ef  collyriutn  a little 


OPHTHALMY 


ib& 


unarmed ; but  as  soon  as  the  irritability  is 
lessened,  it  may  be  used  cold. 

Scarpa  then  speaks  of  the  good  effects 
produced  in  the  second  stage  of  ophthalmy 
by  the  application  to  the  eye  of  two  or  three 
drops  of  the  vinous  tincture  of  opium,  once 
or  twice  a day  ; a subject  already  consider- 
ed in  the  foregoing  columns.  The  utility 
of  letting  the  eye  be  habituated  to  the  light, 
as  soon  as  it  can  bear  it,  is  next  strongly 
commended;  a rule  of  great  importance, 
but  on  which  1 need  not  here  dwell,  be- 
cause it  has  been  already  insisted  upon  in 
the  general  observations. 

When  idiopathic  external  ophthalmy  has 
terminated  in  suppurations  of  little  extent, 
Beer  speaks  highly  of  the  benefit  derived 
from  a solution  of  the  lapis  divinus,  (see 
Lachrymal  Organs)  containing  the  liquor 
plumbi  subacetatis,  or  from  smearing  the 
suppurating  points  with  a little  laudanum. 
In  worse  cases,  Beer  states,  that,  when  such 
local  treatment  is  combined  with  the  inter- 
nal exhibition  of  bark  and  naphtha,  and  a 
diet  and  regimen  conducive  to  the  support 
of  the  system,  its  efficacy  is  very  great.  And 
here,  says  he,  it  is  worth  observing,  that 
while  the  solution  of  the  lapis  divinis  is  of 
great  service  in  the  second  stage  of  true 
chemosis,  it  is  more  or  less  detrimental  in 
the  kind  of  chemosis  which  accompanies 
purulent  ophthalmy,  especially  if  not  blend- 
ed with  mucilage,  and,  even  w hen  thus  qua- 
lified, it  cannot  be  endured  by  weak  and 
irritable  subjects,  affected  with  the  latter 
complaint ; a fact  not  observed  in  other  in- 
stances of  chemosis.  (B.  1,  p.  42u.)  To 
Mr.  Ware’s  use  of  ajther  in  chemosis,  1 have 
already  adverted. 

When  pustules,  or  abscesses  in  the  swell- 
ed conjunctiva  point  round  the  cornea,  a 
free  outlet  to  the  matter  must  be  immedi- 
ately made  in  each  of  them  with  a lancet; 
for,  if  this  be  not  done,  as  Beer  observes, 
the  matter  will  spread  extensively,  and  the 
eyeball  be  in  danger  of  being  destroyed. 
For  an  account  of  the  method  of  treating  the 
eversion  of  the  lower  eyelid,  sometimes  re- 
maining as  a consequence  of  the  disorder, 
see  Eclropium. 

Inflammation  of  the  Sclerotica.  Sclerotitis. 
- — The  modern  attempts  to  class  ophthal- 
mies,  according  to  the  texture  of  the  eye 
first  or  chiefly  affected  promises,  I think,  to 
load  to  clearer  views  of  the  subject,  and 
sounder  practice.  One  circumstance,  par- 
ticularly adverted  to,  both  by  Dr.  Vetch  and 
Mr.  Travers,  in  inflammation  of  the  sclero- 
tica, is  the  appearnuce  of  a vascular  zone 
at  the  margin  of  the  cornea.  By  the  latter 
gentleman,  this  effect  is  ascribed  to  the  par- 
ticular distribution  of  the  vessel's.  “Branches 
from  the  straight  vessels  of  the  conjunctiva, 
penetrate  Ihe  sclerotica  obliquely  towards 
the  margin  of  the  cornea,  and  the  long  ci- 
liary vessels  pass  in  sulci  of  this  membrane 
to  the  plexus  ciliaris  at  the  root  of  the  iris. 
At  the  interior  border  of  the  sclerotica, 
where  the  annulus  ciliaris  is  adhering  closely 
to  this  tunic,  the  ciliary  communicate  with 
the  : muscular  branches,  and  being  in  deep- 


seated  inflammation  fully  injected  with  red 
blood,  the  condensation  of  colour  gives  the 
well-known  and  remarkable  appearance  of 
a vascular  zone  at  the  margin  of  the  cornea.” 

( Synopsis , tyc.  p.  126.)  According  to  Dr. 
Vetch,  only  a few  interspersed  trunks  are 
posteriorly  observed,  “which  do  not  affect 
the  natural  appearance  of  the  intermediate 
space,  but  these,  diverging  as  they  come 
forwards.  produce  a zone  more  or  less  com- 
plete, of  minute  hair-like  vessels,  distin- 
guished by  their  rectilinear  direction,  and 
their  uniform  concentration  towards  the 
margin  of  the  cornea  ; their  colour  advances 
w ith  the  progress  of  the  disease,  from  that 
of  a delicate  pink,  or  damask  rose,  to  a 
deeper  hue,  and  imparting  a faint  blush  to 
the  part  immediately  surrounding  it.”  (On 
Diseases  of  the  Eye.  p 27.)  There  appears, 
however,  to  be  a good  deal  of  variety  in  the 
symptoms  of  sclerotitis  ; for  rheumatic  in- 
flammation of  the  eye,  described  by  Pro- 
fessor Beer  and  Mr.  Ward rop,  as  particularly 
affecting  the  sclerotica  in  common  with 
other  fibrous  membranes,  is  not  noticed  by 
these  authors  as  characterized  by  the  red 
zone  round  the  edge  of  the  cornea.  Indeed, 
instead  oi  there  being  posteriorly  only  a few 
interspersed  trunks,  Mr.  Wardrop  states, 
“that  (in  rheumatic  ophthalmy)  the  blood- 
vesseis  are  generallv.  equally  numerous  over 
the  whole  white  of  the  eye,  passing  forwards 
in  nearly  straight  lines  from  the  posterior 
part  of  the  eyeball,  and  advancing  close  to 
the  cornea  ; but  neither  passing  over  it  nor 
leaving  the  pale  circle  around  it , which  is  so 
striking  when  either  the  choroid  coat  or  iris  is 
inflamed.  If  the  vessels  be  closely  exami- 
ned, the  genera!  redness  will  be  found  pro- 
duced more  from  numerous  small  ramifica- 
tions than  a few  large  trunks.”  (Med.  Chir. 
Trans.  Vol.  10,  p.  3.)  However,  as  if  there 
must  be  no  harmony  on  this  subject,  Beer 
describes  the  blood  vessels,  in  rheumatic 
ophthalmy,  not  as  being  equally  numerous 
over  the  whole  white  of  the  eye,  but  as  be- 
ing in  some  places  collected  in  larger  numbers 
or  clusters,  and  he  differs  again  from  Mr. 
Wardrop,  in  describing  the  redness  as 
coming  on  with  considerable  intolerance  of 
light,  ( Lehre  von  den  Angenkr.  B.  1,  p.  397 
— 398,)  while  the  latter  :-uthor  distinctly 
mentions,  that  “ the  eye  does  not  seem  to 
suffer  from  exposure  to  lights”  (Med.  Chir. 
Trans.  Vol.  10,  p.  6.)  I can  only  reconcile 
these  accounts  by  concluding,  that  sclero- 
tic inflammation,  like  that  of  other  textures 
of  the  eye,  has  stages  and  modifications 
which  account  for  these  seeming  contradic- 
tions. And,  with  respect  to  the  vascular 
zone  round  the  edge  of  the  cornea,  it  would 
appear,  at  all  events,  to  belong  to  iritis,  as 
well  as  sclerotic  inflammation.  The  vessels 
of  the  sclerotic  coat  are  observed  by  Dr. 
Vetch  tu'follow  the  motion  of  the  eye,  and 
he  says,  that  they  may,  by  this  circumstance, 
be  distinguished  from  those  of  the  conjunc- 
tiva, “ the  vessels  of  the  latter,  independent 
of  their  darker  colour,  their  more  tortuous 
form,  and  varying  size,  have  likewise  a more 
longitudinal  direction,  and  as  they  proceed 


336 


OPHiHALMV 


from  the  angles  ot  the  orbit,  they  form  radii 
of  a larger  circle.  The  distinction  between 
the  inflamed  vessels  of  the  conjunctiva  and 
the  sclerotica,  (says  Dr.  Vetch)  I consider 
to  be,  therefore,  obvious  ; but,  that  any  dif- 
ference can  be  observed  in  the  arrangement  - or 
appearance  of  the  vessels  of  the  I, alter,  suffi- 
ciently distinct  to  indicate  the  peculiarity  of  the 
exciting  came , or  specific  nature  of  the  case, 
is  more  than  l have  been  uole  to  perceive.  The 
general  character,  as  it  arises  out  of  the 
structure  of  the  part,  will  be  found  the  same, 
whether  the  cause  be  gout,  rheumatism,  or 
syphilis.  The  vessels,  such  as  l have  de- 
scribed them,  will  always  be  most  observa- 
ble on  the  upper  portion  of  the  eye,  as  it  is 
in  that  place  that  the  inflammation  is  most 
intense,  except  when  its  locality  is  affected 
by  any  external  exciting  cause,  in  which 
case  it  will  be  greatest  near  the  injured 
part.”  {On  Diseases  of  the  Eye,  p.  29.) 

While  Dr.  Vetch  describes  the  vessels  of 
the  conjunctiva  as  exhibiting  in  sclerotic 
inflammation  a darker  colour  than  that  of  the 
vessels  of  the  sclerotic  coat  itself,  Mr.  Tra- 
vers represents  the  vessels  of  the  latter  mem- 
brane, which  pursue  a straight  course  to  the 
margin  of  the  cornea,  as  having  a somewhat 
darker  hue  than  the  areolar  vessels  upon  the 
loose  portion  of  the  conjunctiva. 

It  should  be  mentioned,  however,  that 
by  sclerotic  inflammation.  Dr.  Vetch  signi- 
fies inflammation  of  the  eye  itself,  as  con- 
trasted with  conjunctival  inflammation ; 
but,  how  far  this  will  account  for  the  differ- 
ences, above  pointed  out,  between  his  des- 
cription and  that  of  Mr.  Travers,  1 am  not 
prepared  to  say.  According  to  Mr.  Travers, 
ordinary  inflammation  of  the  sclerotica  is 
secondary,  that  is  to  say,  this  membrane  is 
usually  affected  only  as  intermediate  to  the 
conjunctiva  and  the  other  tunics.  How- 
ever, he  has  occasionally  observed,  in  a re- 
cent ophthalmia,  a turgescence  of  the  ves- 
sels, which  pur&ue  a straight  course  to  the 
cornea,  unaccompanied  with  any  affection 
of  the  iris,  and  so  slight  a vascularity  of 
the  loose  conjunctiva,  that  he  was  disposed 
to  regard  the  case  as  a primary  sclerotitis. 
The  inflammation  he  says,  is  not  acute,  and 
the  motions  of  the  eyeball  are  painful.  It 
sometimes  accompanies,  and  sometimes  fol- 
lows rheumatic  inflammation.  If  continued, 
it  presents  the  vascular  zone  and  a pupil 
contracted,  or  drawn  a little  to  one  side. 
It  is  often  seen  in  company  with  eruptions, 
or  sorethroat,  of  a pseudo-syphilitic  cha- 
racter, oris  secondary  to  gonorrhoea.  ( Tra- 
vers, Synopsis,  tyc.p.  123.) 

The  practice,  recommended  by  this  gen- 
tleman, is  as  follows  : obtuse  pain  in  the 
eyeball,  he  says,  may  he  materially  relieved 
by  blood-letting,  and  by  antimony  and  ipeca- 
cuanha with  opiates.  Mercury  is  stated  to 
have  much  less  power  over  this  case,  than 
iritis.  In  general,  the  patient  is  seriously 
reduced,  and  very  irritable,  from  suffering, 
rheumatic  inflammation  in  the  elbow,  knee, 
or  ankle;  a state,  to  the  produc  ion  of 
which  the  previous  use  of  mercury  has  com- 
monly contributed  but  though  such  is 


stated  to  be  the  case,  the  moderate  ana  cau- 
tious employment  of  this  mineral  is  set  down 
as  generally  indispensable  in  the  treatment 
And  in  the  interval  of  the  mercurial  action, 
the  nitric  acid  is  alleged  often  to  be  of  great 
service.  The  preparations  of  mercury  pre- 
ferred by  Mr.  Travers  in  these  cases,  are  the 
oxymuriate  in  doses  of  one  1-12  or  1-8  of  a 
grain,  and  the  hydrargyrus  cuin  crela,  in 
doses  of  from  five  to  ten  grains,  twice  or 
thrice  a day.  As  auxiliaries  for  allaying  ir- 
ritation, he  prescribes  the  pulv.  ipecac,  comp, 
hemlock,  hyosciamus,  and  the  extract  of  sar- 
saparilla; either  dissolved  in  the  decoction, 
or  taker*  solid.  (Vol.  cit.p.  289.) 

On  rheumatic  inflammation  of  the  eye,  a 
few  observations  will  be  hereafter  inserted. 
Idiopathic  Inflammation  of  the  Internal  Tex- 
tures of  the  Eyeball,  or  Internal  Ophthalmy 
in  general.  According  to  Beer,  internal  in  - 
flammation of  the  eye  does  not  always  ori 
ginate  in  one  particular  texture,  but,  in  some 
instances,  commences  in  the  retina,  choroi 
des,  &.c.  ; while,  on  other  occasions,  its  prin  - 
cipal seat  is  in  the  iris,  from  which  mem- 
brane it  quickly  extends  itself  to  the  corpus 
ciliare,  and  the  crystalline  lens  and  its  cap- 
sule. or  else  in  another  direction  to  the  scle- 
rotica, cornea,  &.c.  These  differences  in  the 
seat  of  the  disorder  obviously  depend  upon 
the  way  in  which  the  exciting  causes  have 
operated  ; for,  when  they  are  such  as  imme- 
diately affect  the  retina  only,  the  inflamma- 
tion must  have  Us  origin  in  this  texture,  as 
when  the  disorder  is  produced  by  the  effect 
of  the  sudden  entrance  of  any  very  strong 
vivid  or  reflected  light  into  die  organ.  This 
case  Beer  denominates  ophthalmitis  internet 
idiopathica,  proprie  sic  dicta. 

The  exciting  causes,  however,  may  not 
affect  directly  the  retina,  and  parts  immedi- 
ately next  to  if,  but  may  operate  chiefly  upon 
the  iris,  in  which  event,  this  part  is  the  chief 
seal  of  the  inflammation  and  the  complaint 
i-  named  both  by  Schmidt  and  Beer,  iritis 
idiopathica.  This  form  of  inflammation,  Beer 
say-,  i seen  after  the  extra*-  ion  of  the  cata- 
r i t,  and  accidental  injuries  of  the  eye,  where 
the  w upon,  with  which  they  were  produced, 
has  either  penetrated  directly  to  the  iris,  and 
more  or  less  caused  it,  or  roughly  entered 
the  eyeball  near  the  ciliary  edge  of  this 
membrane,  without  actually  wounding  it. 
( Lehre  von  den  Jingenkrankh.  B.  1 ,p.  421.) 

Symptoms  of  the  first  stage  of  idiopathic 
internal  ophthalmy,  properly  so  called.  While 
a very  uneasy  sensation  of  general  constric 
tion  and  tension  affects  the  whole  eyeball, 
and  soon  changes  into  an  obtuse,  deep  throb 
bing  pain,  increasing  every  instant,  and 
quickly  propagating  itself  over  the  eyebrows 
to  the  top  of  the  head,  as  Beer  observes,  the 
power  of  vision  gradually  declines,  and,  at 
the  ‘•arne  time,  the  pupil,  which  pi  only  loses 
i.s  dear  shining  blackness,  contracts  without 
bring  deprived  of  its  circular  figure, or  drawn 
out  *it  its  natural  position,  until,  at  length,  it 
i,>  so  completely  closed,  that  the  iris  seems 
as  it  it  had  no  aperture  w hatever.  But  long 
before  this  periect  closure  of  the  pupil  lias 
taken  place,  the  power  of  seeing  is  entity 


OPHTHALMY. 


437 


gone,  though  after  the  faculty  of  perceiving 
the  external  light  is  extinguished,  fiery  ap- 
pearances, which  trouble  the  patient  serious- 
ly are  seen  at  each  pulsation  of  the  blood- 
Ves-els  within  the  eye.  As  the  developernent 
ol  these  symptoms  is  going  on,  the  iris  evi- 
dently loses  its  natural  colour,  becoming,  ns 
Bo  r says,  greenish,  when  it  vvas  gray,  or 
blue  ; and  reddish,  when  its  was  brown,  or 
black.  In  consequence  of  the  iris  swelling, 
and  projecting  towards  the  cornea,  the  ante- 
rior chamber  becomes  considerably  diminish- 
ed. Immediately  the  least  mark  of  the  swell- 
ing of  the  iris  is  seen,  together  with  a mode- 
rate degree  of  contraction  of  the  pupil,  the 
whole  sclerotica  assumes  a pink-red  colour ; 
f»  plexus  of  innumerable  blood-v  essels  is  seen 
in  the  conjunctiva  ; and  the  cornea  loses  a 
good  deal  of  its  natural  brilliancy,  without 
being  actually  opaque.  The  lattersymptoms 
of  this  form  of  ophthalmy  are  attended  with 
manifest  general  indisposition,  and  intolera- 
ble headach.  Sometimes  in  the  first  stage 
of  the  case,  the  pupil,  though  much  lessened, 
is  not  absolutely  closed,  but  thickish,  and  if 
examined  with  a magnifying  glass,  it  has  a 
red  ish-gray  appearance,  and  the  power  of 
vision,  notwithstanding  the  continuance  of 
the  aperture,  is  quite  lost.  (Beer.) 

Symptoms  in  the  second  stage.  According 
to  the  same  author,  while  the  eye  is  snffernig 
very  irregular  throbbing  pain,  attended  with 
a sensation  of  heaviness  and  cold  in  the  eye, 
an  increase  of  the  redoes*  of  the  conjuncti- 
va, severe  constitutional  disturbance,  and 
constant  shivering,  there  is  suddenly  formed 
at  the  bottom  of  the  anterior  chamber  a col- 
lection of  matter  which  above  presents  a 
horizontal  line,  but  on  every  inclination  of 
the  head  sideways,  changes  its  position.  This 
matter  continues  to  accumulate  more  and 
more,  until  it  not  only  teaches  the  pupil,  but 
fills  the  whole  of  the  anterior  chamber,  con- 
stituting the  case  termed  Hypopium.  If  the 
disease  be  left  to  itself,  says  Beer,  the  matter 
collects  in  such  quantity,  that  the  cornea  is 
rendered  more  prominent,  and  afterward 
conical,  very  like  an  abscess,  ultimately 
bursting  during  an  aggravated  attack  of  pain, 
when  the  eye  shrinks,  and  the  sufferings  gra- 
dually cease.  This  kind  of  hy  opium  Beer 
names  true,  in  order  to  distinguish  it  from 
the  case,  in  which  the  matter  passes  into  the 
anterior  chamber  out  of  an  abscess  in  the 
cornea,  and  which  he  terms  a false  hypopj- 
um.  When,  at  the  end  of  the  first  stage,  the 
pupil  is  not  entirely  dose.),  one  may  discern 
in  the  second  slags,  at  the  period  of  matter 
presenting  itself  hi  the  bottom  of  the  anterior 
chamber,  (though  not  easily  wiilj  the  unas- 
sisted eye)  whitish  filaments,  extending  from 
the  edge  of  that  opening  towards  its  v-ntie, 
produced  by  the  coagulahle  lymph  effused  in 
the  aqueous  humour,  the  secretion  of  which 
was  interrupted  in  the  first  stage,  but  now 
commences  again.  And,  continues  Beer, 
one  may  perceive,  with  a good  magnifying 
glass,  a very  delicaie  cobweb-like  mem 
brane,  which,  when  the  matter  collected  lies 
over  the  pupil,  and  remains  fora  good  while 
unabso.bed,  at  length  becomes  unite  ye!- 
?ol.  IL  ~ * -13 


low,  the  matter  being  really  encysted  by  it  in 
the  form  of  a small  lump,  which  remains  in 
the  pupil,  nd  partly  projects  into  the  ante- 
rior chamber,  forming  the  case,  which  Beer 
de nominates  a spurious  purulent  cataract , to 
which  the  edge  of  t lie  iris  is  so  closely  adhe- 
rent, that  sooner  than  a separation  could  be 
effected,  the  whole  of  the  iris  would  be  torn 
in  pieces.  W en  the  pupil  has  been  t om- 
pletely  closed  in  the  first  stage,  these  effects 
of  course  cannot  take  place. 

Beer  remarks,  with  respect  to  the  causes  of 
this  form  of  ophthalmy,  tha  , as  there  are 
not  many  circumstances  which  can  produce 
it,  the  case  belongs  rather  to  the  less  fre- 
quent kinds  of  inflammation  of  the  eye. 
As  predisposing,  he  mentions  plethora  and 
irritabilityof  the  eyes,  occasioned  by  little  ex- 
ercise of  them.  Experience  has  convinced 
him,  however,  that  by  far  the  most  usual 
ca  se  of  this  internal  ophthalmy  is  an  extra- 
ordinary, long-continued  straining  of  the  eye 
in  the  inspection  of  small  microscopic  objects 
in  a strong  reflected  light. 

Respecting  the  prognosis,  it  is  remarked 
by  Beer,  that  this  is  not  unfavourable,  when 
the  inflammation  of  the  eyeball  is  moderate, 
proper  treatmentcan  be  immediately  employ- 
ed, the  pupil  is  not  yet  very  much  contracted, 
and  the  power  of  seeing  not  considerably 
impaired.  But  if  the  power  of  vision  should 
seem  as  it  it  were  abolished,  the  prognosis  is 
extremely  uncertain.  And  if  the  pupil  should 
close  after  the  entire  stoppage  of  vision,  no 
hope  can  he  entertained  of  the  recovery  of 
the  sight  ; for  if  the  pupil  open  again  on  the 
subsidence  of  the  inflammation,  it  will  yet 
continue  very  small  and  motionle-s,  and  the 
eye  blind.  When  the  case  is  mistaken  in  its 
first  s age,  and  neglected  or  erroneously 
treated,  Beer  says,  it  changes  into  a very 
perilous  general  inflammation  of  the  whole 
eyeball  ; a disorder  already  consider'  d. 

In  the  second  stage  the  prognosis  is  al~ 
ways  unfavourable;  for  the  eyesight  has  I- 
ways  been  already  destroyed  at  the  end  of 
the  first  one,  and  the  only  expectation  of  t he 
practitioner  can  now  be  to  preserve  e 
shape  of  the  eye,  while  as  speedy  a check  as 
possible  is  put  to  the  suppuration.  If  the 
case  has  been  so  mismanaged  in  its  first 
stage,  that  a violent  inflammation  of  the 
whole  eyeball  is  inevitable,  and  traces  of 
chemosis  are  already  present,  the  chances  of 
the  figure  of  the  eye  being  lost  in  the  second 
stage  are  still  greater,  and  as  Beer  observes, 
the  surgeon  will  be  fortunate,  if  he  can  now 
prevent  afrigiitful  morbid  change  of  the  organ. 

In  t he  trea  inent  of  the  first  stage,  Beer 
describes  the  indications  is  being  exactly  the 
same  as  in  common  ophthalmy,  except  that 
no  scarifications  are  necessary,  unless  the 
case  change  into  a violent  inflammation  of 
the  whole  eyeball.  However,  great  promp- 
titude in  the  applica’ ion  of  proper  curative 
measures  is  here  particularly  called  for,  as 
the  least  delay  is  apt  to  cau-e  either  a total 
loss  of  sight . or  at  least  a serious  impairment 
off.  (Beer.) 

Wi  h tew  exceptions,  the  treatment  of  the 

second  stage  is  also  !:ka  that  of  ophthalmy 


OPHTiSALMi. 


in  general.  Warm  poultices,  Beer  says,  can 
only  he  employed  with  great  circumspection. 
When  matter  collects  in  the  anterior  cham- 
ber, Beer  strongly  condemns  making  an 
opening  in  the  cornea,  hv  which  practice,  he 
states,  tliat  th*  eye  would  certainly  he  ren- 
dered quite  deformed.  He  recommends 
leaving  every  thing  to  the  absorbents,  the 
action  of  which  is  to  he  invigorated  hy  gene- 
ral and  local  remedies.  Poultices  are  now 
to  be  laid  entirely  aside,  and  the  effect  of 
warmth  tried.  Blisters  are  to  he  applied  al- 
ternately behind  the  ear  and  on  the  temple. 
The  eye  is  to  be  smeared  with  the  vinous 
tincture  of  opium,  two  or  three  time-  a day, 
by  means  of  a camel-hair  brush,  or  even 
four  times,  when  the  anterior  chamber  is 
filled  to  the  extent  of  one  half  of  it.  Beer’s 
experience  leads  him  to  approve  of  opening 
the  cornea  only  in  very  urgent  cases,  that  is 
to  say,  when  the  eye  is  so  distended  with 
matter,  that  the  cornea  is  in  a state  of  an  ab- 
scess, which  threatens  to  bur-t.  In  one  part 
of  his  observations,  Beer  describes  the  mat- 
ter in  these  instances  as  fluid;  a point  on 
which  he  differs  from  Scarpa:  but  he  alier- 
ward  confesses,  that  when  an  opening  is 
practised,  the  matter  mud  not  he  expected 
to  flow  out  immediately  like  that  of  a com- 
mon abscess  For  furt'.er  information  on 
this  subject,  see  Hyp  opium. 

Idiopathic  Iritis.  The  following  is  Beer's 
description  ot  the  disease.  Together  with 
an  obtuse,  heavy,  deep  pain  in  the  eye.  pro- 
ducing a position,  as  if  the  eyeball  were 
continually  pressed  upon  by  one  of  the  fin- 
gers, a manifest  and  incessantly  increasing 
uniform  contraction  of  the  pupil  takes  place, 
as  well  ,v>  a gradual  diminution  of  the  move- 
ments of  the  iris;  yet  the  pupil  neither  loses 
its  circular  shape,  nor  changes  its  position  in 
the  eye,  and  at  ihesame  time,  an  intolerance 
q!  1 bt  commences.  When  the  pupil  is  ex- 
omi  ed  v ii h a glass,  it  is  found  to  have  al- 
ready 'os-  he  shining  blackness,  which  is 
peculi  r to  the  healthy  state.  While 

these  changes  "curring  in  the  pupil,  the 
col  ur  ■!  the  iris  undergoes  a mate  i d altera- 
tion, first  at  its  le -:«»  Ircie,  which  grows 
much  darker,  and  afterward  at  its  greater 
circle,  which  turns  greenisn,  i n it  was  gray 

or  blue,  but  reddish  whet,  it  wn=  brown  or 
black.  At  the  same  time,  the  margin  of  the 
pupil  becomes  mdi  !inc»,and  ep(,ears  not  so 
sharp  a n eural.  A -oon  as  tin-  greater  ring 
of  the  iris  S s under.*  me  a considerable 
change  of  colour,  this  membrane  becomes 
evidently  swelled,  nd  p, ojects  towards  the 
cornea,  so  hut  In-  interior  chamber  is  very 
much  lessened.  As  * !y  as  the  period  when 
th  contraction  of  >h"  pu  ;'!.  and  the  1 1 n m > • 
bilitv  of  the  "i  are  oh  err  , »ie,  a serious  di- 
minution <>f  the  p.iwfrr  of  vision  occurs;  be- 
cause, in  all  cases,  the  iuflarnmat  on  extends 
more  or  less  over  the  anterior  i r of  (lie 
crystalline  capsule,  and  after u ai  , the. 

Case  is  somewhat  m >re  advanced,  - '■■■>  B er, 
one  may  perceive  quit*-  plainly,  with  he 
unassisted  *ye,  those  ••ff-,  - f infl -intimation 
on  the  r.apsub , which  live  b e so  ex<:«  I- 
lentJ|f  described  by  Professor  Walt  her-  (/. lb - 


handl.  aus  dan  G&bielhe  der  Vraciist’ttn  Me  ■ 
dicin,  1 B.  Landshut , 1810.)  In  proportion  a; 
the  inflammation  makes  progress,  the  pain 
grows  more  severe  and  exterfsive,  and  to- 
wards the  end  of  the  first  stage,  it  shoots  par- 
ticularly up  to  the  top  of  the  head;  a cir- 
cumstance strikingly  proved  whenever  any 
tiling  like  slight  pressure  aggravates  the  pain 
in  the  eye.  The  redness  perceptible  in  the 
eye  during  the  whole  of  the  first  stage  is  in- 
considerable, and  seems  to  be  not  at  all  pro- 
portioned to  the  violence  and  danger  of  the 
inflammation  ; for  the  sclerotica  is  only  of  a 
rose-red  colour,  and  even  this  pale  redness 
fades  towards  the  circumference  of  tlie  eye- 
ball (B.  1,  p 434.) 

According  to  Beer,  idiopathic  iritis  is  al- 
ways attended  with  a corresponding  general 
disturbance  of  the  system  ; but  a good  deal 
depends  upon  whelher  the  inflammation 
spends  immediately  'o  the  deeper  textures 
o |f  the  eye.  or  to  its  outer  coats,  or  in  both 
directions  at  once.  In  the  first  case,  the 
constitutional  indisposition  is  always  more 
severe,  and  the  danger  of  the  disease  in- 
creases every  moment;  in  the  second  in- 
stance,the  augmentation  of  the  general  symp- 
toms is  less  striking;  but  in  the  third,  the 
inflammation,  and  the  corresponding  febrile 
symptoms  soon  rise  to  such  a pilch  that  the 
possibility  of  preserving  the  eyesight  be- 
comes very  doubiful.  The  continued  ope- 
ralion  of  hidden  exciting  causes,  neglect, 
and  erroneous  management  of  the  disease, 
also  produce  considerable  differences  ; and, 
as  Beer  observes,  it  not  unfrequent  ly  hap- 
pens that  a genuine  idiopathic  iritis,  which 
does  not  appeal*  at  first  very  dangerous,  nor 
rapid  in  its  progress,  vvi  l suddenly  change, 
under  the  unfortunate  concurrence  of  tfie 
circumstances,  above  alluded  to,  into  a com- 
plete inflammation  of  the  whole  eyeball,  de- 
stroying the  organ  in  a tew  days,  unless  the 
most  efficient  treatment  be  speedily  adopted. 

In  the  second  stage,  says  Beer,  in  c.o  junc- 
tion with  a corresponding  still  more  mani- 
fest general  indisposition,  the  pain  in  the 
eye  grows  very  irregular  ; luminous  appear- 
ances flash  within  the  organ,  and  seriously 
annoy  the  patient,  especially  in  the  dark, 
vvhi'e  the  power  of  seeing  the  external  light 
undergoes  a great  decrease;  the  redness, 
even  in  the  conjunctiva,  .increase^ ; and  the 
pupil,  which  hitherto  has  been  perfectly  cir- 
cular, becomes  more  or  less  angular.  At 
Miese  angles,  something  of  a light  grayish  co- 
lour mav  be  seen  projecting  behind  the  pu- 
pillary edge  of  the  iris,  and  on  examination 
with  a glass,  plai*  !>  appears  to  be  a very  de- 
licate layer  of  coagulating  lymph,  by  which, 
fi  st  the  lesser  ring  of  the  uvea,  and  (if  pro- 
per treatment  be  not  expeditiously  employ- 
ed) also  its  greater  ring,  are  soon  rendered 
adherent  to  the  an'erior  po  tion  • »f  'he  cap- 
sule >1  the  lens.  ( synechia  posterior ,)  which 
membrane,  a*-  ill  di-u  a <■  advances,  becomes 
more  arid  more  deprived  ol  its  transparen- 
cy. Under  llie-e  circumstance*,  it  is  evident, 
that  the  pov\er  of  vision  must  dailv  decline, 
and  that  if  this  process  of  the  effusion  ot 
lymph  and  its  organization  be  not  jjpvHcd  by 


0PHTHA1MY 


339 


powerful  measures,  (he  patient  will  suon  be 
Heft  just  capable  of  faintly  distinguishing  the 
light.  While  the  above-described  changes 
an  taking  place  between  the  uvea  at  dante- 
terior  position  of  the  capsule,  very  pec  uliar 
effects  are  occurring  in  the  anterior  cham- 
ber, for,  ns  the  iris  continues  to  project  fur- 
ther towards  the  cornea,  the  latter  mem- 
brane grows  less  and  less  transparent,  and 
the  iris  seems  as  if  concealed  in  a mist,  at 
the  same  time  that  a small,  yellowish,  red, 
round  prominence  is  formed  at  one  or  more 
places  together,  generally  hptween  the  great- 
er and  lesser  rings  of  the  iris,  and  proves  af- 
terward to  be  a small  abscess,  which  ulti- 
mately bursting,  pours  its  contents  into  the 
anterior  chamber,  and  thus  occasions  n true 
Hypopium.  For  several  days,  the  flakes  of 
(he  burst  little  cyst,  still  connected  with  the 
Iris,  may  be  seen  floating  in  the  aqueous  hu- 
mour, until  they  gradually  disappear.  When 
there  is  not  merely  one,  hut  several  of  these 
little  abscesses,  says  Beer,  the  greater  part  of 
the  anterior  chamber  may  be  filled  with 
matter,  so  that  little  more  of  the  iris  can  be 
distinguished.  In  weak  subjects,  at  this  pe- 
riod ol  suppuration,  blood  may  not  unlre- 
quenlly  be  perceived  in  the  chamber  of  the 
eye  ; a circumstance  regarded  by  Beer  as  a 
very  unfavourable  omen,  in  respect  to  the 
recovery  of  sight,  as  in  such  cases,  portions 
of  blood  and  matte:  are  • pt  to  lie  in  the  pos- 
terior chamber  entangled  in  the  lymph.  Ac- 
coiding  to  the  same  author,  the  matter  in 
the  anterior  chamber  is  at  last  absorbed  ; the 
pupil,  if  it  has  been  concealed,  can  again  be 
seen,  but  it  appears  angular  and  very  turbid  ; 
and  in  consequence  ol  the  layer  of  lymph 
in  the  posterior  chamber,  the  eyesight  is  ex- 
ceedingly dimim-hed,  or  even  re  dinted  to 
the  mere  power  ot  knowing  light  horn  dark- 
ness Su<  h,  says  Bee  , is  the  course  ot  the 
second  stage  oi  idiopathit  iritis,,  w hen  the 
inflammation  has  not  extended  tar  beyond  its 
proper  locu',  and  has  been  principally  con- 
fined to  the  iris,  corpus  ciliare,  the  lens  and 
its  capsule,  and  the  anterior  part  of  the  scle- 
rotica. But  if  it  should  spread  more  deeply 
to  the  vitreous  humour,  the  retina,  the  mem- 
brane Ruyschiana,  and  the  chorotdes,  symp- 
toms ot  internal  ophthidmy  (strictly  so  call- 
ed) then  occur  with  great  vehemence  in  the 
first  stage,  and  at  the  termination  of  the  se- 
cond, the  eyesight  is  for  ever  certainly  de- 
stroyed in  such  a degree,  that  not  the  least 
perception  of  light  remains  ; and  even  it  the 
patient  should  think  that  he  can  distinguish 
it,  the  feel  is  only  a deception  ; a develope- 
ment  ol  light  v\  ithin  the  eye  itself ; of  w Inch 
the  surgeon  may  i usriy  assuie  himself  by 
placing  the  patient  with  his  back  towards 
the  light,  and  asking  him  to  point  out  where 
it  is;  or  by  putting  him  directly  opposite  a 
window,  and  moving  the  hand  slowly  along 
before  his  eyes;  of  which  proceeding  the 
patient  will  be  quite  unconscious.  The  ef- 
fects left  in  the  eye  after  such  an  iritis,  and 
indicating  its  mischievous  extension,  ate  so 
characteristic,  that,  on  the  first  inspection  of 
the  eye,  no  surgeon  can  entertain  a doubt  of 
(ha  deeper  textures  of  the  eye  having  been 


involved  in  the  inflammation.  But  when 
idiopathic  iritis  extends  rather  to  the  exter- 
nal, than  the  deep  textures  of  the  eye,  the 
swelled  iris,  as  early  as  the  end  ol  the  first 
stage,  approaches  so  near  the  cornea,  which 
grows  le.-s  and  less  clear,  that  they  seem  as 
if  they  were  adherent,  ere  the  second  stage 
has  commenced.  And,- indeed,  on  the  ac- 
cession of  this  stage,  they  actually  adhere 
together  at  every  point,  either  directly,  or 
with  the  intervention  of  a mass  of  coagula- 
ting lymph.  In  the  first  event,  at  the  end 
of  the  second  stage,  the  cornea  forms  a co- 
nical protuberance,  and  a total  staphyloma 
arises  ; (se>  Staphyloma  ;)  but  in  the  second, 
the  cornea  is  said  not  to  undergo  this  change. 
On  the  contrary,  it  becomes  rather  flat,  and 
on  account  of  the  layer  of  organized  lymph, 
which  fill-  up  the  space  between  the  cornea 
and  iris,  little  of  the  Idler  membrane  can 
be  discerned,  and  what  can  be  seen,  appears 
to  have  its  organization  entirely  subverted. 
When  idiopathic  iritis  in  its  first  stage  ex- 
tends its  effects  directly  over  the  whol*  eye- 
ball, the  eye  becomes  nearly  or  quite  de- 
stroyed in  the  same  manner  as  in  cases  of  vi- 
olent acute  ophthalmy. 

The  causes  which  give  rise  to  idiopathic 
iritis,  mut  always  be  such  as  operate  direct- 
ly upon  the  iris;  and,  hence,  the  disorder 
is  usually  a consequence  of  injuries  and 
wounds  of  the  eye,  produced  by  accident, 
or  in  operations.  And,  says  Beer,  although 
rheumatic  inflammation  of  the  eye,  when 
neglected,  or  w rongly  treated,  may  at  length 
aff  ct  the  iris,  and  adjacent  textures,  yet 
such  an  iritis  is  but  a secondary  effect,  deri- 
ved from  the  pre-existing  rheumatic  oph- 
thalmy. All  injure-  in  which'  the  weapon, 
or  in-trumenl,  has  more  or  les-  pre-sed 
against,  pushed,  irritated, < r v iolently  brui  ed, 
or  torn,  the  iris  itsel,.  and  ail  largish  wounds 
of  the  cornea,  are  to  tie  accoun  t'd  the  prin- 
cipal exciting  causes  ot  idiopathic  iritis. 
Hem  e,  extra  ion  ol  the  cataract  is  not  un- 
Irequentlv  followed  by  this  i flammation, 
when  t hr  flap  of  the  cornea  i-  kept  too  long 
opened,  and  the  iris  is  hurt  with  any  blunt 
instrument  ; when  the  incision  in  the  cor- 
nea is  too  small,  and  a hard  cataract  pushes 
the  iris  between  I tie  lips  of  the  wound,  and 
is  slow  ly  pressed  out  of  the  eye  ; when  many 
pieces  of  the  cataract  break  off,  and  it  is  ne- 
cessary repeatedly  to  introduce  Dniel’s 
scoop  for  their  removal  ; or  when,  notwith- 
standing the  operator  proceed  with  the  ut- 
most delicacy,  the  patient  is  excessively 
timid,  and  unmanageable,  or  particularly  ir- 
ritable ar.d  prone  to  inflammation.  This 
torm  of  iritis  is  also  produced  by  couching, 
reclmation  through  the  sclerotica  kerato- 
nyxis,  and  operations  for  artificial  pupil.  Nor, 
as  Beer  observes,  is  it  at  all  surprising,  that 
iritis  should  follow  these  last  operations,  as 
the  surgeon  has  often  to  meddle  w ith  an  irid 
that  has  been  already  violently  inflamed. 

Prognosis  in  the  first  stage.  Serious  as  the 
disorder  always  is;  important  as  the  textures 
are,  in  which  the  inflammation  is  most  se- 
vere ; and  quickly  as  vision  may  be  for  ever 
annihilated  by  it;  yet,  says  Beer,  the  prog- 


OPHTHALMY. 


mo 


nosls,  in  tho  first  stage,  is  very  favourable, 
when  the  true  nature  of  the  caso  is  at  once 
understood,  and  treated  as  it  ought  to  be. 
The  prognosis  is  the  most  favourable  when 
the  inflammation  is  not  extensive  ; but  it 
must  be  very  reserved,  when  the  inflamma- 
tion extends  either  deeply  backward,  for- 
ward, or  in  both  directions.  Beer  remarks, 
that,  when  iritis  is  purely  idiopathic,  ami  ju- 
diciously treated  in  its  first  stage,  it  is  mere- 
dible  with  what  rapidity  its  effects  re  ede. 
When  it  is  produced  immediately  by  an  in- 
jury of  the  iris  us  if,  and  some  part  of  this 
membrane  i torn,  the  risk  of  the  inflamma- 
tion is  not  the  only  thing  for  consideration  ; 
for  the  chance  of  the  function  oi  the  iris  be- 
ing permanently  impaired  by  the  injury 
must  also  be  taken  into  the  accoun*.  And, 
says  Beer,  as  in  these  severe  injuries  of  the 
eyeball,  it  is  impossible  to  foretell  what  may- 
be the  result  of  the  traumatic  inflammation, 
it  is  a good  maxim  always  either  to  deter 
making  any  prognosis,  or  to  deliv  r only  a 
doubtful  one.  When  idiopathic  iritis  has  al- 
ready changed  either  into  a complete  inter- 
nal ophthalmy,  m*  into  a violent  inflamma- 
tion of  the  whole  eyeball, no  incautious  pro- 
mises shonid  be  made  about  the  recovery  of 
the  eyesight,  or  even  about  preserving  the 
shape  of  tbeeje.  {Beer.) 

Prognosis  in  the  second  stage.  Though, 
says  Beer,  this  is  much  les-  favourable  than 
in  the  first  stage,  yet  il  proper  measures  be 
riot  deferred,  <>  perfect  recovery  of  she  eye 
may  often  be  effected.  Here  a great  deal 
depends  upon  the  state  of  the  layer  of  lymph 
effused  in  the  po-terior  chamber,  and  of  sup- 
puration. If  it  be  plain  to  the  naked  eye, 
that  no  coagulating  lymph  lies  in  that  cham- 
ber behind  the  contracted  pupil,  but  slight 
grayish  filaments  are  discernible  with  a mag- 
nifying glass,  projecting  only  a little  way 
from  behind  the  pupillary  edge  of  the  iris; 
if  the  colour  merely  of  the  lesser  circle  of 
the  iris  be  changed,  while  no  little  cyst  of 
matter  is  yet  formed  on  the  latter  membrane, 
a d the  sight  is  lessened  only  in  a small  de- 
gree, being  somewhat  cloudy ; the  com- 
plaint may  be  so  completely  cured  by  pro- 
per means,  that  not  a vestige  of  it  wiil  re- 
main. How  ever,  for  some  time  after  theter- 
jni  atiou  of  the  second  stage,  the  motions  of 
the  iris  will  be  more  sluggish  th  in  natural, 
though  the  pupil  effectually  adapt  itsell  to 
the  variations  of  light.  On  he  other  hand, 
when  a considers  le,  though  fine,  web-like 
membrane  can  be  plainly  seen  behind  the 
pupil ; when  the  colour  of  the  larger  circle 
of  tile  iris  is  somewhat  altered  ; and  the 
power  of  vision  is  seriously  lessened;  though, 
by  effectual  treatment,  the  sight  may  be  re- 
established sufficiently  to  enable  the  patient 
to  read  and  write;  yet,  says  Ben*,  it  will 
for  ever  continue  weak;  the  pupillary  edge 
of  the  iris  will  never  regain  its  perfect  free- 
dom, but  constantly  remain  more  or  less  an- 
gular ; and  the  pupil  never  assume  again  the 
clear  shining  blackness,  which  in  persons 
not  of  gr  at  age  it  naturally  exhibits.  Still 
moie  remarkable  are  the  sequelae  of  idiopa- 
thic iritis,  when  a small  cyst  of  matter  has 


been  formed  on  the  iris,  and  discharged- ihr 
contents  into  the  anterior  chamber  ; for,  in 
this  case,  under  the  best  circumstances,  the 
former  colour  of  the  iris  never  entirely  re- 
turns. According  to  Beer,  when  at  the  first 
visit  of  the  surgeon,  vision  is  quite  interrupt- 
ed by  the  effusion  of  lymph  in  the  posterior 
cha  thee  so  that  the  patient  can  no  longer 
perceive  any  object  with  the  affected  eye, 
though  capable  of  distinguishing  the  light, 
and  th>*  outlines  of  <orne  things  ; when  the 
pupil  is  at  the  same  time  very  contracted, 
and  the  cm  our  of  the  greater  circle  of  the 
iris  entirely  changed  ; there  is  no  hope  of 
recovery  of  the  sight  at  first,  though  some 
chance  of  benefit  may  he  subsequently  af- 
forded by  the  formation  of  an  artificial  pu- 
pil. If,  says  Beer,  in  such  a case,  matter  lias 
been  - ffused  from  several  lit* le  suppurating 
points  of  the  iris,  so  copiously  into  the  an- 
terior chamber,  that  nearly  all  this  cavity,  or 
at  least  the  half  of  it,  tS  filled  up,  though  after 
absorption  some  power  of  distinguishing 
light  may  return,  little  or  no  hope  can  be  en- 
tertained of  any  effectual  benefit  from  a fu- 
ture operation  for  an  artificial  pupil.  When, 
at  I he  termination  of  the  first  stage,  the  cor- 
nea is  so  severely  inflamed,  that  the  iris  al- 
most touches  this  membrane  in  its  outruns- 
parent  thickened  state,  all  prospect  of  saving 
th  eyesight  is  over,  and  it  will  bi*  fortunate 
if  the  natural  shape  of  the  eye  can  now  be 
preserved,  and  the  formation  of  a staphylo- 
ma of  the  cornea  prevented.  When  the 
layer  of  lymph  between  the  cornea  and  the 
iris  is  extensive,  and  considerable  blood-ves 
sels  can  be  seen  proceeding  into  it  from  the 
iris,  Beer  says,  nothing  will  succeed  in  re- 
establishing vision.  And  he  observes,  that, 
\ hen  an  idiopathic  iritis,  at  the  close  of  its 
first  stage,  has  changed  into  a true  internal 
ophthalmy,  and  the  pupil  is  already  quite 
blocked  ip,  so  that  even  the  light  cannot  be 
distinguished,  tbe  recovery  of  sight  is  quite 
impossible,  and  the  surgeon  must  make  every 
exertion  to  prevent  the  shape  of  ihe  organ 
from  being  destroyed.  In  this  disease,  says 
Beer,  a relapse,  even  w hen  the  inflammation 
has  not  been  very  considerable  in  the  first 
attack,  almost  constantly  nds  in  partial  or 
complete  blindness  ol  the  affecied  eye,  as 
the  progress  of  the  tvise  is  so  rapid,  that  there 
is  not  time  enough  to  render  effectual  assist- 
ance. 

Beer  directs  idiopathic  iritis  to  be  treated 
in  its  first  stage  like  a case  of  pure  internal 
ophthalmy,  (he  practice  being  somewhat  mo- 
dified, however,  according  to  the  direction 
and  degree  in  which  the  inflammation  has 
spread,  when  the  surgeon  is  first  consulted. 
When  the  inflammation  continues  a good 
while  limited,  or  spreads  but  very  gradually 
to  the  outer  texture  of  the  eyeball,  general 
and  local  antiphlogistic  remedies  are  to  be 
employed  with  moderation  ; ut  if  it  imme- 
diately extend  itself  to  the  innermost  parts 
of  the  eye,  or  both  inwards  and  outwards  to- 
gether, and  threatens  to  end  in  an  universal 
inflammation  of  the  eyeball,  antiphlogistic 
treatment  must  be  most  rigorously  adopted. 
(Beer.)  This  author  then  notices  the  unfnr* 


OTHTHALMY . 


tunafe  state  of  the  case,  when,  towards  the 
end  of  (be  first  stage,  the  eyesight  happens  to 
be  entirely  destroyed,  the  iris  is  close  to  the 
cornea,  and  there  is  danger  of  a staphyloma. 
In  this  desperate  state  of  things,  his  appre- 
hensions of  this  Iasi  disease  lead  him  to  sug- 
gest a plan,  (the  propriety  of  which  1 re- 
gurd  with  much  suspicion ,)  which  is  nothing 
less  than  actually  trying  10  increase  the  in- 
flammation, by  stimulating  the  eye  several 
times  a day  with  laudanum,  sulphuric  aether, 
&, c.  with  the  view  ol  doing  what  ? Why,  of 
obliterating  the  sources  of  the  aqueous  hu- 
mour ! the  continuance  of  the  secretion  of 
which  is  set  down  as  one  of  the  essentials  to 
the  production  ot  staph)  loma.  (B.  1 . p.  447.) 

The  treatment  of  idiopathic  iritis  in  its 
second  stage,  as  recommended  by  Beer,  is 
on  the  whole,  both  generally  and  locally, 
like  what  has  been  advised  for  the  same 
stage  of  pure  internal  ophtbalmy  ; but  here, 
he  says,  it  is  necessary  to  pay  particular  at- 
tention to  the  direction,  in  which  the  in- 
flammation extends  itself  in  the  fi  st  stage, 
so  that  the  treatment  may  be  regulated  with 
greater  precision.  Beer  also  advises  great 
attention  to  be  paid  to  the  effusion  of  lymph 
in  the  posterior  chamber  ; as  towards  the 
end  of  the  second  stage  much  may  fie  done 
which  would  afterward  be  too  late.  Thus, 
when  the  surgeon  perceives  towards  the 
end  of  the  second  stage,  that  the  layer  of 
lympu  in  the  posterior  chamber  does  not 
completely  prevent,  though  it  seriously  di- 
minisues  vision,  and  that  it  is  likely  to  re- 
main in  the.  same  state,  after  the  termination 
of  the  second  stage,  Beer  recommends  to- 
pical applications  to  the  eye,  and  if  these 
prove  unavailing,  internal  alterative  medi- 
cines, and  even  mercury,  which,  he  says, 
when  the  treatment  is  judiciously  conduct- 
ed, ought  not  to  be  omitted.  Here,  also,  he 
observes,  another  deviation  must  be  made 
from  the  usual  practice  in  the  second  stage 
of  ophtbalmy:  calomel  joined  with  opium, 
is  to  be  exhibited  w7ith  calamus  aromaticus, 
bark,  &c.  Externally,  Beer  speaks  highly 
of  the  benefit  of  a collyrium,  containing 
the  oxymuriate  of  mercury,  without  any 
mucilage,  but  with  a considerable  addition 
of  the  vino  s tincture  of  opium.  When 
these  remedies  cease  to  be  efficacious,  or 
the  eye  ca  .not  bear  fluid  applications,  as  is 
sometimes  tiie  case,  Beer  recommends  a bit 
of  the  following  salve  to  be  smeared  once 
a day,  between  the  edges  of  the  eyelids, 
and  allowed  slowly  to  melt  there,  and  be- 
come diffused  over  the  eye  : Butyri  re- 

ceutis  iusulsi  3ij  Hydrargyri  nitrico-oxydi 
rubri  gr.  vj.  Extract  opii  gr.  viij.  JVl  Beer 
also  states  that  rubbing  a little  mercurial 
ointment,  with  w hich  some  opium  is  blend- 
ed, once  a day  into  the  eyebrow,  w'ili  great- 
ly promote  the  removal  of  the  lymph  effu- 
sed in  the  posterior  chamber.  (B.  1,  p. 
450.) 

Excellent  as  Beer’s  description  of  idiopa- 
thic iritis  certainly  is,  there  are  some  im- 
perfections in  his  method  of  treatment.  1st, 
?t  docs  not  appear  to  me,  that  he  insists  suf- 
ficiently upon  the  necessity  of  taking  away 


341 

a very  large  quantity  of  blood  at  the  com- 
mencement ot  the  case,  and  of  repeating 
the  general  and  topical  bleeding,  until  the 
circulation  is  duly  lowered,  and  the  violence 
of  the  inflammation  checked.  2dly,'l  hough 
his  recommendation  of  rigorous  antiphlo- 
gistic treatment  implies  the  approbation 
both  of  bleeding  and  cathartics,  he  says 
nothing  of  ttie  use  of  moderate  doses  of 
tariarized  antimony,  in  weakening  the 
pulse  ; a practice  highly  praised  by  the  late 
Mr.  Saunders.  (On  some  Practical  Points 
relating  to  Diseases  of  the  Eye,  p.  26,  8 vo. 
Land.  181 1.)  3dly,  If  mercury  has  the  pow- 
er of  arresting  acute  inflammation  of  the  iris, 
“ both  prior  to,  and  after,  the  effusion  of  ad- 
hesive matter,”  and  of  rapidly  removing,  “by 
an  excitement  of  the  absorbing  system, 
peculiar  to  itself,  the  newly-effused  mat- 
ter, ( Travers , Synopsis , <^c.  p.  2b  1,)  then 
Beer  must  delay  too  long  the  employment 
of  this  powerful  medicine,  since  he  does 
not  commence  its  use  until  the  close  of  the 
second  stage,  when  he  has  found,  that  the 
absorption  of  the  effused  lymph  cannot  be 
effected  by  other  means.  4thly,  Beer  en- 
tirely overlooks  the  important  utility  of  bel- 
ladonna and  byosciamus  in  producing  a 
dilatation  of  the  pupil,  whereby  adhesions 
of  the  iris  to  the  capsule  oi  the  lens,  or  to  the 
cornea  itself,  may  frequently  be  prevented, 
or  their  ill  effects  considerably  lessened. 
Belladonna,  (says  Mr.  Saunders,)  “ if 
properly  applied  to  the  eye,  during  the  ad- 
hesive process  of  inflammation,  will  cause 
the  inner  margin  of  the  iris  to  expand,  and 
recede  from  the  axis  of  the  pupil,  and  will 
thus  overcome  the  restraint  arising  trom  the 
agglutination  of  lymph,  by  elongating  the 
organized  bands,  which  connect  the  iris  and 
capsule,  if  they  have  not  been  of  long 
duration.  Thus,  the  adhesions  are  drawn 
out  t.,  a degree  of  tenuity,  and  consequently 
transparency,  and  a considerable  quantity 
of  light  is  admitted.  If  the  effect  of  the 
inflammation  has  been  slight,  the  adhesions 
will  be  trivial,  and  tne  pupil  only  slightly 
irregular.  The  iris  will  retain  a certain 
power  of  action,  and  vision  will  be  very 
little  injured.  In  general,  the  pupil  is 
misshapen,  and  the  iris  perfectly  fixed  ; but, 
if  the  aperture  be  of  sufficient  size,  and  the 
capsule  not  rendered  too  opaque,  the  patient 
will  e.ijoy  a very  useful  degree  of  sight.” 
(Saunders,  p.  32.)  Respecting  belladonna, 
it  is  observed  by  Langenbeck,  that,  as  all 
applications  directly  to  the  inflamed  eye 
itself  are  frequently  hurtful,  and  render  it 
still  more  painful  and  irritable,  it  is  a good 
plan  to  let  the  extract  of  belladonna  be 
smeared  upon  the  eyebrow,  instead  of 
putting  a solution  of  it  immediately  in 
contact  w ith  the  conjunctiva.  (JVeue  Bibl. 
B.  2,  p.  236.)  The  same  author  expresses 
his  attachment  to  Beer’s  method  of  rubbing 
mercurial  ointment  with  opium  into  the 
eyebrows ; and,  after  dwelling,  with  due 
force,  on  the  necessity  of  copious  and  re- 
peated bleedings,  leeches,  evacuations,  &c. 
he  cautious  practitioners  not  to  be  led  into 
the  supposition,  that  the  efficacy  of  beHa- 


342 


©PHTHALMY. 


donna  will  supersede  the  occasion  for  taking 
away  blood.  He  even  dec  lares,  that,  during 
the  first  vehemence  of  the  inflammation, 
the  application  is  quite  inefficient,  and  that 
it  frequently  will  not  succeed  in  producing 
a dilatation  of  the  pupil,  before  bleeding 
has  been  practised.  “ If,  (says  Langenbeck,) 
bleeding  is  to  be  useful  in  iritis,  it  must  be 
copious,  and  often  repeated.” 

Specific  Cases  of  Iritis.  The  foregoing  ob 
servations  refer  to  idiopathic  iritis,  or  in- 
flammation of  the  iris  uncomplicated  with 
any  specific  disease.  But  there  is  an  iritis, 
which  “ appears  in  company  with  rheuma- 
tism of  the  chronic  form  ; sometimes  with 
gout ; with  the  constitutional  signs  of  the 
lues  venerea  ; and  during,  or  following,  the 
action  of  mercury  upon  the  system.”  (Tra- 
vers, Surgical  Essays,  Part  1,  J>-  59.) 

Mr.  Hunter  entertained  doubts,  whether 
any  inflammations  of  the  eyes  are  syphilitic, 
and  he  appears  to  found  his  opinion  upon 
two  circumstances  ; one  is,  that,  if  such 
cases  be  venereal,  the  disease  is  very  diffe- 
rent from  what  it  is  when  it  attacks  other 
parts,  and  is  attended  with  more  pain  than 
venereal  inflammation,  arising  from  an  af- 
fection of  the  constitution  : the  second  is, 
that  he  never  sa  these  cases,  attended  with 
such  ulceration,  as  occurs  when  the  com- 
plaint invades  the  mouth, throat,  and  tongue. 
(Hunter  on  the  Venereal  Disease,  p.  324.) 
On  the  other  band,  the  generality  of  modern 
surgeons  believe  in  the  reality  of  venereal 
ophtiialmy,  though  their  accounts  of  the 
symptoms  and  appearances  of  the  com- 
plaint are  in  some  respects  discordant. 
Scarpa  says,  the  venereal  ophthalmy  is  pe- 
culiar in  not  discovering  manifest  signs  of 
inflammation,  stealing  on  clandestinely, 
without  much  uneasiness.  It  afterward  re- 
laxes the  vessels  of  the  conjunctiva  and 
lining  of  the  palpebrse,  and  changes  the  se- 
cretion of  Meibomius’s  glands.  In  time  it 
causes  ulceration  of  the  margins  of  the  eye- 
lids ; the  ciliae  fall  off,  and  the  cornea  grows 
opaque.  In  the  worst  stage  it  excites  itch- 
ing in  the  eyes,  which  is  exasperated  at 
night,  and  abates  in  violence  tow  ards  morn- 
ing, as  do  almost  all  the  effects  of  syphilis. 
It  never  attains  the  state  of  chemosis. 
With  the  exception  of  the  venereal  oph- 
thalmy, in  the  form  of  iritis,  1 cannot  dis 
cover,  that  any  thing  very  certain  has  yet 
been  made  out.  By  this  observation,  how- 
ever, it  is  not  meant  to  assert,  that  cases, 
corresponding  to  Scarpa’s  description,  do 
not  present  themselves,  and  may  not  be 
relieved  by  his  method  of  treatment  ; but, 
that  their  venereal  character  is  not  fairly 
proved.  In  examples,  like  those  described 
by  Scarpa  thedecoct.sarsap.theqxymuriaie 
of  mercury  ; mezereon  ; guaiacum  ; and 
even  mercurial  frictions,  may  be  employed, 
with  leeches  and  blisters.  Scarpa  particu- 
larly recommends  a collyrium,  made  with 
the  oxy muriate  of  mercury.  When  the 
eyelids  are  ulcerated,  the  unguenturn  hv- 
drargyri  nitratri,  weakened  at  first  with  twice 
or  thrice  its  quantity  of  the  unguenturn  ce- 
taepurn,  is  the  best  topical  application. 


The  iris  is  now  supposed  to  be  more  lia- 
ble than  any  other  part  ot  the  eye,  to  vene- 
real inflammation.  ( Wardrop's  Essays  era 
the  Morbid  Anat.  of  the  Eye,  Vol  2,  p.  36.) 
The  case  is  mentioned  by  Mr.  Sounders, 
who  recommends  the  vigorous  exhibition  of 
mercury,  and  the  use  of  belladonna.  Us 
symptoms  and  treatment,  however,  have 
been  more  particularly  detailed  by  Beer. 
(Lehre  von  den  Augenkr  B.  1,  p.  553.)  As 
this  case,  and  some  other  specific  forms  of 
iritis,  are  described  in  the  first  vol.  of  the 
last  edition  of  the  First  Lines  of  Surgery, 
1 need  here  only  refer  the  reader  to  that 
volume,  and  to  a few  works  containing  ad- 
ditional information  on  iritis  in  general;  aat 
Sounder's  Treatise  on  some  Practical  Points, 
relating  to  Diseases  of  the  Eye  p.  21,8t'o. 
1811 ; and  particularly  the  latter  editions,  in 
which  the  utility  of  mercurials  is  noticed. 
Beer's  Lehre  von  den  Augenkr.  B.  1,  8ro, 
Wien.  1813. 

In  the  article  Hypopium , I have  referred 
to  an  early  case,  in  which  the  quick  exhibi- 
tion of  mercury  and  its  good  effects  were 
exemplified  in  Germany.  But  whatever 
claims  the  continental  surgeons  may  have 
respecting  the  first  administration  ot  mer- 
cury in  iritis,  1 believe  it  a justice  due  to  Dr. 
Farre  and  Mr.  Travers  to  state,  that  these 
gentlemen  have  undoubtedly  given  notonly 
the  best  practical  directions  on  the  subject, 
but  laid  the  greatest  s ress  upon  the  neces- 
sity of  the  practice,  establishing  the  efficacy 
of  mercury,  as  a means  as  well  of  resisting 
the  effusion  of  lymph  in  the  eye,  as  of  exci- 
ting the  absorption  of  it,  after  it  has  been 
effused.  (See  Travers,  in  Surgical  Essays, 
Part  l.)  Consult  also  J.  l etch , A Practical 
Treatise  on  the  Diseases  of  the  t.ye.  p.  88,  fyc. 
S vo.  Lond.  1820.  Weller’s  Manual  of  the 
Diseases  of  the  Human  Eye,  Trans  by  Mon- 
teath,  8 vo.  Glasgow,  1821.  J.  War  drop  j 
Morbid  Anatomy  o the  Eye,  Vol.  2,  chap 
20,  8 vo.  Lond.  1818.  H.  B.  Schindler,  de 
Jrilide  Chronica,  Vralislacice,  lb  19.  J.  A. 
Schmidt  liber  Nachstaar  und  Iritis  nach  Staar - 
Opera  ionen,  4 to.  Wien.  1801  ; a work  of 
high  repute.  Carmichael  in  Obs.  on  the  Spe- 
cific Distinctions  oj  Venereal  Diseases,  p.  31* 
Quarterly  Journ.  of  Foreign  Medicine , JYov. 
1818. 

Rheumatic  Inflammation  of  the  Eye.  Ac- 
cording to  Mr.  VVardrop,  the  albuginea  ac- 
quires a brick-red  tinge,  or  an  admixture  of 
yellow  w ith  crimson  red,  which  colour,  be 
supposes,  is  probably  caused  by  the  serous 
part  of  the  blood  being  tinged  with  bile* 
“ an  effect,  likely  to  take  place  from  the 
marked  derangement  of  the  biliary  organs, 
which  usually  acco  • panics  this  disease.” 
Contrary  to  the  statement  of  Beer,  who  de- 
scribes the  blood  vessels  as  being  in  clusters, 
Mr.  Wardrop  observes,  that  they  are  gene- 
rally equally  numerous  over  the  whole 
white  of  the  eye,  passing  torwards  in  near- 
ly straight  lines  from  the  posterior  part  ot 
the  eyeball,  and  advancing  close  to  the  cor- 
nea ; but  neither  passing  over  it,  nor  leaving 
the  pale  circle  around  it,  which  is  so  striking 
when  cither  the  choroid  coat,  or  the  iris  k 


OPHTHALMY. 


unilaraed.  If  the  v essels  be  closely  examin- 
ed, the  general  redness  will  be  found  produ- 
ced more  by  numerous  small  ram  ideations, 
than  a few  large  trunks.  There  is  frequent- 
ly a little  swelling  of  the  conjunctiva, 
which  sometimes  forms  a slightly  elevated 
ring  round  the  cornea.  In  mild  cases,  little 
change  takes  place  in  the  anterior  chamber 
in  the  early  stage  ; but,  as  the  disease  ad- 
vances, the  cornea  becomes  dull  and  turbid. 
Upon  close  examination,  one  or  more  of 
the  layers  of  the  conjunctiva  on  the  cornea 
will  generally  be  found  to  be  abraded  espe- 
cially towards  its  circumference.  At  the 
commencement  of  the  disease,  there  is  of- 
ten a disagreeable  feeling  of  dryness  of  the 
eye  ; but  sooner  or  later,  a very  copious 
secretion  of  tears  takes  place.  The  eyelids 
are  observed  to  be  very  little  affected.  At 
first,  the  chief  seat  of  pain  is  generally  in 
the  head,  though  sometimes  in  the  eyeball 
itself.  Mr.  Wardrop  describes  the  pain  as 
usually  most  severe  in  the  temple  of  the  af- 
fected side,  but,  he  says,  that  it  is  often  seat- 
ed in  the  brow,  the  cheek-bone,  the  teeth, 
or  the  lower  jaw.  “ Sometimes  the  pam  is 
precisely  confined  to  one  half  of  the  head, 
and  sometimes  there  is  a severe  pain  in  the 
cavity  of  the  nose,  or  in  the  ear.  The  pains 
are  more  of  a dull  agonizing  kind,  than 
acute,  and  though  unceasing,  they  vary 
much  in  degree,  coming  on  at  times  in  very 
severe  paroxysms,  and  with  great  violence, 
when  the  head  is  bent  downwards.  Some- 
times the  pain  is  excited  by  merely  touch- 
ing the  scalp,  and  the  patient  is  unable  to 
rest  his  head  on  the  affected  side,  or 
even  lean  it  on  a pillow.  In  most  cases, 
the  pain  is  said  to  be  remittent,  the 
paroxysm  coming  on  in  the  evening, 
continuing  during  the  night,  being  most 
severe  about  midnight,  and  abating  towards 
morning. 

In  the  eyeball,  says  Mr  Wardrop,  the  pa- 
tient generally  complains  more  of  a sense  of 
fulness  and  distention,  than  of  pain  ; and, 
though  there  is  a great  degree  of  external 
redness,  the  eye  does  not  seem  to  suffer  from  ex- 
posure to  light ; a point,  on  which  Professor 
Beer  delivers  a directly  opposite  statement, 
at  least,  in  relation  to  the  first  stage  of  the 
disease.  However,  these  authors  both  agree 
in  considering  the  sclprotica,  as  generally  the 
chief  seat  of  rheumatic  inflammation  ; but 
Beer  sets  down  the  iris  as  likewise  a subject 
to  be  attacked.  He  admits  also,  that  in  the 
second  stage,  the  aversion  to  light  under- 
goes a considerable  diminution  According 
to  Mr.  Wardrop,  rheumatic  ophthalmy  is 
always  accompanied  with  more  or  less 
symntomatic  fever,  severe  paroxysms  of 
which  take  place  toward  evening,  and  the 
functions  of  the  prim®  vise  are  much  de- 
ranged, “ the  appetite  being  impaired,  and 
the  evacuation  always  changed  in  quality.” 
In  severe  cases,  the  pain  in  the  head  soon 
becomes  agonizing,  the  r^d  mss  of  the  eye- 
ball increases,  the  whole  white  of  the  eye  is 
crowded  with  blood  vessels,  and  the  con- 
junctiva swelled.  At  length  ulceration  com- 
mence* in  the  cornea,  through  which  the 


aqueous  humour  is  discharged,  and  the  eye- 
ball collapses,  when  all  pain  ceases  ; or 
abscesses  may  form  within  the  posterior 
chamber,  and  burst  through  the  sclerotic 
coat.  ( Wardrop , in  Med.  Chir.  Trans  Vol. 
10.)  Beer  describes  small  watery  vesicles 
as  forming  on  the  cornea,  or  white  of  the 
eye,  and  changing  during  severe  pains  into 
small  ulcers,  which  occasion  an  appearance, 
as  if  a small  piece  were  torn  out  of  the  sur- 
face of  the  cornea.  He  adds,  that  they 
seldom  leave  scars  behind  ; but  generally 
little  pits,  which  are  soon  filled  up  in  healthy 
subjects.  (See  Weller  on  Diseases  of  the  Eye, 
Vol.  2,  p.  217.) 

The  causes  of  rheumatic  ophthalmy.  enu- 
merated by  writers,  are  change  of  weather, 
vari  ation  of  temperature,  exposure  to  damp, 
a cold  current  of  air  directly  striking  the 
eye,  and  a constitution  disposed  to  rheuma- 
tism. Mr.  Wardrop  states,  that  both  sexes 
are  equally  subject  to  the  disease  ; but  that 
he  has  observed  it  most  frequently  in  adults, 
and  persons  of  rather  advanced  age.  Only 
one  eye  is  usually  affected  ; and  when  the 
second  is  attacked,  the  disease  is  almost 
always  less  severe  in  it,  than  that  which  is 
first  inflamed. 

According  to  Mr.  Wardrop,  rheumatic 
ophthalmy  resembles  syphilitic  more  than 
any  other  kind  of  inflammation  of  the  eye. 
But,  he  notices,  that,  in  rheumatic  ophthalmy , 
th°  proper  vessels  of  the  sclerotic  coat  are 
enlarged,  which  is  the  cause  of  the  redness 
being  generally  diffused  over  the  whole 
albuginea,  whereas  in  syphilitic  inflammation, 
it  is  the  anterior  ciliary  arteries , passing  along 
the  sclerotica  on  thnr  way  to  the  iris , which 
are  ch  efiy  affected ; and  hence  the  pale  ring, 
which  is  always  observed  between  the  cor- 
nea and  the  enlarged  vessels.  Mr.  Wardrop 
further  explains,  that  though  these  diseases 
resemble  each  other  in  the  pains  round  the 
orbit,  and  their  evening  exacerbation,  pa- 
tients , with  syphilitic  ophthalmy.  aluays  have 
the  constitutional  symptoms  of  syphilis. 

When  the  disease  has  made  much  progress, 
and  the  symptoms  have  not  yielded  to  other 
remedies,  Mr.  Wardrop  recommends  the 
evacuation  of  the  aqueous  humour,  as  a prac- 
tice, from  which  the  most  beneficial  effects 
may  be  expected.  After  the  operation,  fo- 
mentations are  the  only  necessary  applica- 
tions ; but,  if  the  eye  continue  long  irritable, 
the  vinous  tincture  of  opium  is  to  be  used. 

Mr.  Wardrop  enjoins  attention  to  the  state 
of  the  biliary  organs  in  every  stage  of  the 
disease,  and  speaks  highly  of  the  sudden  relief 
sometimes  afforded  by  an  emetic,  care  being 
taken  to  empty  the  bowels  afterward  with 
calomel  and  rhubarb,  or  other  purgatives. 
If  t ie  functions  of  the  skin  were  suddenly 
interrupted  by  a -hill  just  before  the  attack, 
this  author  prescribes  a couple  of  grains  of 
aniimoniai  powder,  alone,  or  combined  with 
opium,  to  be  taken  every  four  or  six  hours. 
Little  advantage,  ne  says,  is  derived  from 
local  bleeding,  and  where  venesection  may 
become  necessary,  on  account  of  the  com- 
plaint resisting  other  means,  it  to  be  prr.c 
ticed  with  moderation 


344 


OPHTHALM**. 


In  the  early  stage,  Mr.  Wardrop  has  found, 
that  the  pain  in  the  eye  and  eyebrow  are 
sometimes  much  alleviated  by  a fomentation 
with  the  decoction  of  poppy-heads.  He  also 
praises  blisters  to  the  nape  of  the  neck,  or 
behind  the  ear;  but,  disapproves  of  their 
being  put  near  the  eye  itself.  The  vinous 
tincture  of  opium,  he  says,  is  the  only  local 
application  which  he  has  ever  seen  deci- 
dedly beneficial ; but,  its  use  is  to  be  deferred, 
till  a late  stage  of  the  inflammation,  when 
all  febrile  symptoms  have  been  subdued. 
“ After  the  primae  viae  have  been  well 
evacuated,  the  tongue  may  still  remain  very 
white,  and  the  pulse  quicker  than  natural.” 
In  this  state,  small  doses  of  bark,  either  alone, 
or  with  the  mineral  acids,  will  be  most 
serviceable.  ( Wardrop  in  Med.  Chir.  Trans. 
Vol.  10.)  The  outlines  of  Beer’s  practice  may 
be  given  very  briefly : in  the  first  stage,  he 
applies  a leech  to  the  inner  canthus,  and 
covers  the  eye  with  a cold  poultice,  with  a 
small  proportion  of  vinegar  in  the  water, 
with  which  it  is  made.  Diaphoretics  are  also 
prescribed.  In  the  second  stage,  guaiacum, 
camphor,  arnica,  antimonials,  blisters  to  the 
neck,  or  behind  the  ears,  frictions  with 
opium  over  the  eyebrows,  and  covering  the 
eyes  with  bags  of  aromatic  herbs  and  cam- 
phor, are  the  means  of  the  relief.  When 
abrasions,  or  ulcerations  exist  on  the  con- 
junctiva, sclerotica,  or  cornea,  a collyrium 
of  the  lapis  divinus.  with  a large  addition  of 
the  vinous  tincture  of  opium, is  commended ; 
or  if  the  ulcers  are  large,  and  on  the  cornea 
itself,  they  may  be  touched  with  the  latter 
tincture  by  means  of  a camel-hair  pencil. 
After  each  use  of  the  collyrium,  Beer  covers 
the  eye  again  with  the  bags  of  aromatic  herbs 
and  c .mphor.  (See  Weller  on  Diseases  of  the 
Eye,  Vol.  2,  p.  218.)  Respecting  the  last 
application,  I have  already  expressed  my 
belief,  that  it  is  one  which  is  not  likely  to 
obtain  credit  among  English  surgeons. 

Scrof  l ous  Ophthalmy.  According  to  Mr. 
Travers,  the  inflammation  of  the  conjunctiva, 
termed  strumous,  when  it  has  not  proceeded 
to  a eba*  ge  of  texture,  is  not  marked  by  any 
prominent  local  character.”  The  vascularity 
is  inconsiderable  This  inflammation  some- 
times accompanies  pustule  of  the  sclerotic 
conjunctiva,  in  which  case,  the  vascularity 
is  diffused,  instead  of  being  partial,  as  in 
pure  puslular  inflammation,  and  the  intole- 
rance of  light,  characteristic  of  ike  strumous 
inflammation , is  present  in  a greater  or  lesser 
degree.  It  accompanies  also  (he  morbid 
secretion  of  the  lids,  when  the  eyeball 
becomes  affected  by  the  acuteness  and  dura- 
tion of  that  disease,  and  the  pustule  on  the 
cornea,  especially  the  variolous  pustule.  In 
its  simplest  form,  it  is  almost  peculiar  to 
voting  children,  stationary,  marked  by  a 
very  slight  redness  of  the  sclerotic  conjunc- 
tiva, and  the  greatest  possible  degree  of 
intolerance  (of  light  ”)  The  same  author 
attributes  the  disease  to  n morbid  sympathy 
of  the  retirm  with  the  secreting  surfaces  of 
he  primae  vice  and  skin.  The  following  is 
*he  treatment  proposed  by  Mr.  Travers  for 
each  form  of  scrofulous  ophthalmy  ■ 


1.  Strumous  inflammation,  without  chaugt 
of  texture,  vascularity  more  or  less,  intole- 
rance (of  light)  excessive.  Calomel  and  opium, 
at  night  ; emetic  tartar  to  continued  nausea  , 
gentie  alvine  evacuants  ; diaphoretic  drinks  ; 
large  open  blister  on  the  nape  of  the  neck  ; 
leeches  ; tppid  bath  ; tepid  or  cold  water 
washes,  as  must  agreeable ; vapour  of  opium  ; 
large  bonnet  shade  ; no  bandages  ; spacious 
airy  apartments  ; and  light  bed-clothing. 

2.  With  recent  diffused  opacity  of  the  corneal 
conjunctiva , and  vessels  raised  upon  and  over- 
shooting the  corneal  margin.  Calomel  and 
opium  to  slight  ptyalism  ; purgatives  on 
alternate  days ; leeches;  blisters  alternated 
behind  the  ears  and  on  the  nape  of  the  neck 
and  temples.  As  the  acute  stage  passes  off, 
repeated  circular  sections  of  the  vessels  on 
the  sclerotica,  near  the  margin  of  the  cornea. 

3.  With  herpetic  ulcers  of  the  corned.  The 
same  ; blisters  on  the  temples ; as  the  in- 
flammation yields,  solut.  argent,  nitrat.;  vin. 
opii ; solut.  cupr.  sulph. ; dilute  zinc  lotion. 

4.  With  pustules.  If  partial,  weak  zinc, 
or  alum  lotion  ; ung.  hydrarg  nitrat. ; occa- 
sional brisk  purgatives ; infusion  of  roses 
with  additional  acids  ; tonic  bitters  ; colum- 
ba ; gentian,  he.  blisters  behind  the  ears, 
repeated  if  necessarv  ; if  the  vascularity  is 
diffused  by  the  multiplication  of  pustules, 
or  the  duration  of  inflammation,  with  irrita- 
bility to  light,  treatment  as  in  strumous  in- 
flammation without  breach.  Ung.  sub-acet. 
plumbi. 

5.  With  inflammation  of  the  follicles  and 
puriform  discharge.  Active  measures  at  first, 
but  not  long  continued.  Blisters;  when  be- 
coming chronic,  with  thickened  lids,  scarifi- 
cations ; zinc,  alum,  or  copper  wash,  dilute  ; 
ung.  hydr.  nitrat.;  hydr.  nitr.  oxid.;  sub-ncet. 
cupri ; tonics  and  sedatives ; if  obstinate, 
issue  or  seton. 

6.  Convalescent  state.  Infusion  of  roses  ; cas- 
carilla  ; columba  ; decoction  of  bark  . with 
dilute  sulphuric,  or  nitric  acid  : steel,  rhu- 
barb, and  soda  ; or  magnesia,  as  aperients  ; 
tonic  collyria  and  gently  stimulant  oint- 
ments; nutritive  diet ; country  air  ; shower, 
or  sea-balh,  in  the  warm  months.  (Travers's 
Synopsis,  fyc.  p.  92 — 260,  fyc. 

When  I look  at  the  discordant  accounts 
of  what  are  called  scrofulous  affections  of 
the  eye,  and  the  difference  of  practice  laid 
down  by  different  writers  I leave  the  subject 
with  an  impression,  that  the  terms  scrofu- 
lous and  strumous  are  here  employed  as  much 
at  random  as  in  any  other  cases,  which  ran 
be  specified.  Indeed  the  attempt  to  recon- 
cile the  various  statements  and  descriptions 
of  scrofulous  ophthalmy,  would  puzzle  the 
most  able  man  in  the  profession  : and  it  is 
with  this  belief,  that  I avoid  contrasting  the 
sentiments  of  Beer,  Weller,  Lloyd,  and 
other  modern  writers  with  those  already  de- 
livered. (See  particularly  Beer's  Lehre  vou 
den  Augenkr.  B.  1,  p.  588-  fyc.;  Weller's 
Manual  of  the  Diseases  of  the  Eye , Vol. 
2,  p.  265,  <^c. ; and  Lloyd  on  Scrofula , p. 
312,  <^c.) 

The  following  observations  explain  the 

Practice  of  Scarn?.  and  the  late  Mr.  Wan* 


OPHTHALMY. 


Sip 


No  specific  being  known  for  scrofula, 
the  treatment,  in  this  instance,  rather  con- 
sists in  preventing  the  aggravation,  than  in 
attempting  the  radical  cure  of  the  complaint. 
Every  thing  debilitating  is  hurtful,  as  all 
evacuations  ; indigestible  food;  intense  study ; 
a sedentary  life  . damp  marshy  habitations  ; 
uncleanliness  ; frequent  transitions  from  heat 
to  cold.  On  the  other  hand,  observing  to 
regulate  the  action  of  the  bowels  with  the 
mildest  laxatives  ; and  the  administration  of 
bark,  either  alone  or  conjoined  with  the 
tinct.  guaiaciammoniata,do  good.  Alterative 
medicines,  and  especially  aethiops  mineralis, 
from  gr.  ss.  to  gr.  xx.  in  the  day,  taken  for  a 
few  weeks  uninterruptedly  ; liquor  calcis,  in 
broth  or  gruel,  at  first,  in  the  dose  of  Jiij. 
at  breakfast,  and  atterward  the  same  quan- 
tity, twice  daily  for  a few  months  ; together 
with  the  uniform  observance  of  a good  regi- 
men ; may  tend  much  to  abbreviate  the  du- 
ration of  this  obstinate  species  of  the  dis- 
ease. (Scarpa.) 

Mr.  Ware  found,  that  the  addition  of  xx  to 
xxx  gr.  of  the  potassai  sulphas  to  each  dose 
of  bark,  suffices  to  keep  the  bowels  in  a re- 
gular state,  when  there  is  a tendency  to  cos- 
tiveness. In  some  cases,  in  which  there 
was  little  appearance  of  inflammation,  this 
gentleman  found  the  eyelids  so  relaxed,  and 
the  eyes  so  irritable,  that  children  would  not 
open  their  eyes,  even  in  the  darkest  room. 
In  some  of  these  relaxed  cases,  very  benefi- 
cial effects  were  produced  by  administering 
internally  small  doses  of  opium,  night  and 
morning,  to  abate  the  irritability.  Sea-bath- 
ing is  always  serviceable  in  scrofulous  oph- 
thalmy,  and,  probably  the  mere  residence  on 
the  seacoast,  and  the  respiration  of  the  sea- 
air,  may  bring  about  some  of  those  advan- 
tages, which  have  been  exclusively,  attri- 
buted to  bathing.  Friction  of  the  body  with 
a fresh  brush  or  flannel,  should  be  employed 
morning  and  evening. 

With  regard  to  topical  applications,  those 
of  a soft  relaxing  kind  prove  injurious,  as 
also  retirement  in  dark  situations.  Slightly 
astringent  collyria  ; the  ung.  tutiag,  and  the 
ung.  hyd.  nitrat.  are  proper  when  there  are 
excoriations  upon  the  eyelids,  and  when, 
from  their  occasional  adhesion  to  each  other, 
there  is  reason  to  suspect,  that  the  sebaceous 
gffinds  secrete  an  acrimonious  fluid.  Mr. 
Ware  also  found  that  one  drop  of  the  thebaic 
tincture,  dropped  into  the  eye,  once  or  twice 
in  the  course  of  the  day,  contributed  greatly, 
both  to  abate  the  irritability  and  to  increase 
the  strength  of  the  relaxed  vessels.  (On 
Scrofulous  Ophthalmy  p.  26.)  The  same 
gentleman  occasionally  mixed  old  verjuice 
with  cold  spring- water,  at  first,  in  the  pro- 
portion of  one  part  of  the  former  to  six  of 
the  latter,  and  sometimes  increased  the 
quantity  of  verjuice,  until  its  quantity  equal 
led  that  of  the  water.  All  coverings  should 
be  removed  from  the  eyes,  except  a shade 
of  green  silk,  and  patients  should  be 
gradually  habituated  to  a stronger  light. 
Good  air  and  exercise  always  tend  to  im- 
prove scrofulous  constitutions,  and  thus, 
V'jj,  u 44 


indirectly,  the  disease  under  consideration. 
Scrofula  often  disappears  spontaneously,  as 
children  approach  the  adult  state,  and,  if 
we  only  have  it  in  our  power  to  check  its 
progress  in  the  early  stage"  of  life,  it  seems 
to  wear  itself  out  afterward,  and  whatever 
local  effects  it  may  have  produced,  often 
disappear 

Chronic  Ophthalmy.  Unfavourable  pecu- 
liarities are  met  w'ith  in  practice,  which 
prevent  the  complete  cure  of  the  second 
stage  of  acute  ophthalmy,  or  that  connected 
with  a weak  vascular  action  in  the  part 
affected  ; whence  the  protracted  disease 
becomes  purely  chronic,  and  threatens  the 
slow  destruction  of  the  eye. 

These  peculiarities  may  be  chiefly  re- 
ferred to  three  causes : 1.  To  an  increased 
irritability  continuing  in  the  eye  after  the 
cessation  of  acute  inflammation.  2.  To 
some  other  existing  affection  of  the  eye,  or 
neighbouring  parts,  of  which  the  chronic 
ophthalmy  is  only  an  effect.  3.  To  consti- 
tutional disease. 

1.  That  chronic  ophthalmy  may  depend 
upon  a morbid  irritability  of  the  eye  is 
evinced,  not  only  from  its  resisting  topical 
astringents  and  corroborants,  to  which  the 
disease  from  simple  relaxation  and  weakness 
yields,  but  from  its  being  exasperated  by 
them,  and  even  by  cold  water.  The  patient 
complains  of  a sense  of  weight  in  the  upper 
eyelid,  and  restraint  in  opening  it ; the  con- 
junctiva has  a yellowish  cast,  and  when 
exposed  to  the  damp  cold  air,  or  a brilliant 
light,  or  wffien  the  patient  studies  by 
candlelight,  its  vessels  become  injected 
and  turgid  with  blood.  If,  in  combination 
with  such  symptoms,  the  habit  of  body 
be  weak  and  irritable  ; subject  to  spasms  ; 
hypochondriasis,  &c.  then,  it  is  manifest, 
that  the  chronic  ophthalmy  is  connected 
with  a general  impairment  of  the  nervous 
system. 

2 Besides  extraneous  bodies,  lodged  be- 
tween the  palpebras  and  eyeball,  the  inver- 
sion of  the  ciliae  and  hairs,  growing  from 
the  caruncula  lachrymalis  ; ulcers  of  the 
cornea ; prolapsus  of  the  iris  ; herpetic 
ulcerations  of  the  margins  of  the  eyelids ; 
a morbid  secretion  from  the  Meibomian 
glands ; a diseased  enlargement  of  the  cor- 
nea, or  of  the  whole  globe  of  the  eye,  &c, 
may  occasion  and  maintain  chronic  ophthal- 
my.— it  is  only  my  part  here  to  mention  such 
remote  causes ; for,  the  particular  treatment 
of  them  is  described  in  other  articles.  (See 
Cornea , Ulcers  of;  Iris,  Prolapsus  of ; Lippi - 
tudo  ; Staphyloma  ; Hydrophlhalmy ; Tri- 
chiasis, fyc.) 

3.  The  cure  of  thp  second  stage  of  acute 
ophthalmy  may  be  retarded  by  the  preva- 
lence of  scrofula  in  the  system  ; or  by  the 
small-pox  affecting  the  eyes.  According  to 
Scarpa,  chronic  ophthalmy  isalso  sometimes 
a consequence  of  lues  venerea;  but  l know* 
nothing  certain  on  this  subject,  in  addition 
to  what  has  been  stated  in  the  foregoing 
columns. 

When  chronic  ophthalmy  depends  upo'n 


OPHTHaLMY. 


316 


preternatural  irritability,  the  internal  exhi- 
bition of  bark  with  valerian  is  proper ; 
animal  food  of  easy  digestion  ; gelatinous 
and  farinaceous  broths;  wine  in  moderation  ; 
gentle  exercise;  living  in  salubrious  and  mild 
situations  ; are  all  severally  productive  of 
benefit.  Externally , the  applications  should 
be  of  a sedative  and  corroborant  kind  ; such 
as  aromatic  spirituous  vapours  (from  the 
spiritus  ammon.  comp.)  applied  to  the  eye 
through  a funnel,  for  half  an  hour,  three  or 
four  times  a day  ; and  the  eyelids  and  eye- 
brows may  also  be  rubbed  with  the  linimen- 
tutn  camphors?. 

Patients,  both  during  the  treatment  and 
after  the  cure,  must  refrain  from  straining 
the  eye,  and,  immediately  the  least  uneasi- 
ness is  felt,  must  desist  from  exercising  it. 
When  they  write  or  read,  it  should  con 
stantly  be  in  a steady,  uniform  light,  and  too 
little,  as  well  as  too  much  exercise  of  the 
organ,  aggravates  the  disease.  Having  once 
begun  to  wear  spectacles,  they  should  never 
study  orsurvey  minute  objects  without  them. 
{Scarpa.) 

Intermittent  Ophthalmy.  It  is  the  charac- 
ter of  certain  forms  of  ophthalmy,  like  the 
rheumatic  and  venereal,  to  be  liable  to 
periodical  exacerbations ; but  I am  not 
certain  that  there  are  any  cases  specifically 
claiming  the  name  of  intermittent  ophthalmy . 
The  late  Mr.  Ware,  however,  ha-  noticed 
some  examples,  which  intermitted,  or  at 
least,  remitted  at  stated  periods.  In  these, 
he  did  not  find  bark  so  useful,  as  in  scrofu- 
lous ophthalmy;  but  he  had  seen  the  most 
beneficial  effects  produced  by  the  oxy mu- 
riate of  mercury,  sometimes  joined  with  the 
compound  decoction  of  sarsaparilla.  (See 
IVare  on  Intermittent  Ophthalmy .) 

Variolous  Ophthalmy . As  the  small  pox 
inoculation  has  at  present  almost  generally 
been  abandoned  by  the  faculty  in  favour  of 
the  vaccine  disease,  there  seems  less  occasion 
now  for  detailing  circumstantially  a very 
obstinate  species  of  ophthalmy,  induced  by 
the  former  complaint.  When  the  small-pox 
eruption  is  very  abundant  in  the  face,  it 
causes  a considerable  swelling  of  this  part 
of  the  body  ; the  eyelids  become  tumefied, 
the  eyes  redden,  and  there  ensues  a dis- 
charge of  a very  thick  adhesive  matter, 
which  agglutinates  the  palpehra?  together  ; 
so  that  if  no  steps  be  taken,  the  eyes  will 
continue  closed  for  several  days  in  succes- 
sion. The  matter,  confined  between  the 
eyelids  and  globe  of  the  eye,  being  per- 
haps of  an  irritating  quality,  and  injurious 
from  the  pressure  it  occasions  on  the  sur- 
rounding parts,  seems  capable  of  exciting 
ulceration  of  the  cornea,  and  even  of  irre- 
mediably destroying  vision.  When  the 
pustules  of  the  small-pox  in  other  parts  of 
the  body  have  suppurated,  they  cicatrize  ; 
but  those,  which  happen  within  the  margin 
of  the  cartilage  (if  the  eyelids,  are  prevented 
from  healing  by  the  diseased  secretion, 
which  is  then  made  from  the  Meibomian 
glands,  and  such  ulcers  result,  as  will  some- 
titpes  last  for  several  years,  and  even  during 


life,  if  unremedied  by  art.  {St.  Yves  sur  Us 
Mai.  des  Yeux,  p.  216,  Edit.  12 mo.)  After 
the  employment  of  the  antiphlogistic  treat- 
ment. should  the  disease,  when  treated  with 
topical  astringents  and  corroborants,  yet 
baffle  the  efforts  of  the  surgeon,  setons  in 
the  nape  of  the  neck,  kept  open  for  a long 
while,  prove  one  of  the  most  useful  reme- 
dies. Scarpa  has  experienced  much  advan- 
tage from  giving  every  morning  and  evening, 
to  a child,  ten  years  old,  a pill,  containing 
one  grain  of  calomel,  one  grain  of  thesulph. 
aur.  antun.  and  four  grains  of  cicuta  in 
powder.  It  is  obvious,  that  so  potent  an 
alterative,  if  ever  serviceable  in  this  case, 
will  soon  evince  its  efficacy  ; nor  would  it 
be  justifiable  to  sport  with  the  patient’s 
constitution  by  continuing  its  use  beyond  a 
certain  period,  unless  sanctioned  by  evident 
signs  of  its  salutary  effects  on  the  disease  of 
the  eyes. 

When  great  irritability  prevails,  a mixture 
of  three  drams  of  the  vinum  antimoniale, 
and  one  dram  of  the  tinctura  thebaica, 
given  in  doses  of  five  or  six  drops,  in  any 
convenient  vehicle,  and  at  the  same  time, 
applying  externally  the  vapours  of  the  spiri- 
tus amnion,  comp,  to  the  eye,  constitute  an 
excellent  plan  of  treatment.  In  othei  cases, 
saturnine  collyria,  with  a little  camphorated 
spirit  of  wine,  or  white  wine,  in  which  a 
little  sugar  is  dissolved  ; tinct.  thebaica  ; 
Janin’s  ointment.  &c.  avail  most.  This 
treatment  is  also  applicable  to  the  chronic 
ophthalmy  from  measles.  - 

When  inveterate  ulcers  remain  upon  the 
edges  of  the  palpebral,  the  disease  may  then 
be  regarded  as  the  psorophthalmy,  described 
by  Mr.  Ware,  and  will  demand  the  same 
method  of  cure.  (See  Psorophthalmy.) 

Operation  of  discharging  the  aqueous  hu- 
mour. To  this  practice,  some  allusion  has 
been  already  made  in  the  preceding  co- 
lumns ; and  as  the  proposal  is  intended  to 
apply  to  several  forms  of  inflammation  of 
the  eye,  1 have  not  given  any  particular 
account  of  it  in  treating  of  the  various  cases. 
Mr.  Wardrop  remarked,  that  if  the  eye  of  a 
sheep,  or  ox,  be  squeezed  in  the  hand,  the 
whole  cornea  instantly  becomes  cloudy,  and 
whenever  the  pressure  is  removed,  this  mem- 
brane regains  its  transparency.  From  this  cu- 
rious phenomenon  in  the  dead  eye,  it  was  evi- 
dent that,  in  the  living  body,  the  transparen- 
cy of  the  cornea  might  vary  according  to  the 
degree  of  its  distention  ; and  that,  in  cases 
of  opacity  of  the  cornea,  accompanied  with 
fulness  of  the  eyeball,  its  transparency  might 
be  restored  by  the  evacuation  of  the  aque- 
ous humour.  The  cornea  is  little  sensible, 
and,  as  every  body  knows,  its  wounds  are 
free  from  danger.  Mr.  Wardrop  soon  met 
with  a case,  favourable  for  making  the 
experiment;  the  cornea  was  milky  and 
opaque,  and  the  eyeball  distended  and  pro- 
minent, attended  with  acute  inflammatory 
symptoms.  The  aqueous  humour  was  dis- 
charged by  a small  incision,  and  the  operation 
produced  not  only  a removal  of  the  cloudiness 
of  the  cornea,  but  an  abatement  of  the 


OPHTHALMY. 


347 


pain,  anda  sudden  check  to  ail  the  inflamma- 
tory symptoms.  From  the  successof  this  case, 
Mr.  YVardrop  was  led  to  perform  the  opera- 
tion on  others,  not  only  with  a view  of 
diminishing  the  opacity  of  the  cornea,  but 
also  of  alleviating  the  inflammation.  Four 
interesting  cases  are  related  by  this  gentle- 
man, very  much  in  favour  of  the  practice, 
when  the  eye  is  severely  inflamed,  attended 
with  fulness  of  the  organ,  a cloudy  state  of 
the  cornea,  and  a turbidness  of  the  aqueous 
humour.  Mr.  YVardrop  also  advises  fhe  ope 
ration,  whenever  there  is  the  smallest  quan- 
tity of  pus  in  the  anterior  chamber,  ac- 
companied with  violent  symptoms  of  inflam- 
mation. He  thinks,  that  the  great  and  im- 
mediate relief,  which  the  method  affords,  is 
imputable  to  the  sudden  removal  of  tension  ; 
and  he  performs  the  operation  with  a small 
knife,  such  as  is  used  for  extracting  the 
cataract.  The  instrument  is  to  be  oiled,  and 
introduced  so  as  to  make  a wound  of  its 
own  breadth,  at  the  usual  place  of  making 
an  incision  in  the  extraction  of  the  cataract. 
By  turning1  the  blade  a little  on  its  axis,  the 
aqueous  humour  flows  out.  (See  Edinb 
Med.  and  Surg  Journal.  Jan.  1807 ; also 
Med.  Chir.  Trans.  Vol.  4.)  The  late  Mr. 
Ware  approved  of  Mr.  YVardrop’s  operation 
in  the  epidemic , purulent , or  Egyptian  oph- 
thalmy , when,  notwithstanding  general  eva- 
cuations topical  bleeding,  mildly  astringent 
lotions,  and  a strict  antiphlogistic  regimen, 
the  symptoms  still  continue,  and  especially 
if  the  cornea  begin  to  lose  its  transparency, 
and  a white  rim  appear  round  its  circumfer- 
ence. Mr.  Ware  did  not  object  to  using  a 
small  knife,  of  the  kind  employed  in  extract- 
ing the  cataract ; but  preferred  a lancet,  or 
a sharp-pointed  couching  needle,  writh  a 
blade  somewhat  wider  than  usual,  and  a 
groove  in  its  middle.  The  instrument,  he 
advises,  to  be  introducedabout  one-tenth  of 
an  inch  before  the  connexion  of  the  cornea 
with  the  sclerotica,  and  pushed  gently  on, 
parallel  to  the  plane  of  the  iris,  until  the  aque- 
ous humour  makes  its  escape.  ( Ware  on  the 
Purulent  Ophthalmy, p.  41,  1808.)  As  alrea- 
dy explained,  Mr.  YVardrop  also  recommends 
this  practice  in  certain  states  of  rheumatic  oph- 
thalmy. Consult  Avicenna,  Canon  L.  3,  Fen. 
3,  Tract.  1 , cap.  6.  Maitre-Jun  Traite  des  Mai . 
de  VCEil,  12 mo  Paris  1722.  St.  Yves , Traitd 
des  Mai.  des  Yeux,  p 170,  fyc.  Janin,  Mem 
sur  VCEil.  fyc.  8 vo.  Paris , 1772.  L F.  Gendron , 
Trait 6 des  Mai.  des  Yeux . 2 T.  12mo  Paris , 
3770.  C.  F.  Reuss,  Dissertation es  Med.  Selectee 
Tubingenses  Oculi  Humani  Affect  us  Medico- 
chirurgice  consederatas  sislenles,  3 Vo  Is.  8 vo. 
Tub.  1783.  Trnka  de  Krzowitz,  Hist  Ophthal- 
mia omnis  aevi  observata  medica  continens,  8ve. 
Vindob.  1 783.  G.  Power,  Attempt  to  investigate 
the  causes  of  the  Egyptian  Ophthalmy;  with 
obs.  on  its  nature  and  cure,  8 vo.  Load.  1803.  H. 
Read,  An  Essay  on  Ophthalmia,  8vo.  Portsea , 
1806-7.  J.  B Serney,  Treatise  on  Local  In- 
flammation, more  particularly  applied  to  Dis- 
eases of  the  Eye,  fyc.  8 vo.  Land.  1809  J.  P. 
Marat,  An  Inquiry  into  the  Nature.  Cause, 
and  Cure  of  a singular  Disease  of  the  Eyes, 
hitherto  unknown , and  yd  common,  produced 


by  the  use  of  certain  mercurial  preparations , 
4lo.  Land.  1770.  James  Ware,  Chir.  Ob- 
servations relative  to  the  Eye,  2 Vols.  8vo. 
Loud.  1805.  Richter,  Anfangsgr.  der  Wun- 
darzn.  B.  3.  G.  Peach  and  J.  Wardrop  in 
Edinb.  Med.  Surg.  Journ.for  January,  1807. 
Also  J.  Wardrop,  in  Med.  Chir.  Trans. 
Vols.  4 and  10;  and  Essays  on  the  Morbid 
Anatomy  of  the  Eye,  2 Vols.  8 vo.  1808 — 
1818.  John  Vetch , An  Account  of  the  Oph- 
thalmia, which  has  appeared  in  England  since 
the  return  of  the  British  Army  from  Egypt , 
8 vo.  Loud  i807.  Also  Obs.  relative  to  the 
Treatment  by  Sir  Wm.  Adams  of  the  Oph- 
thalmic Cases  of  the  Army,  8 vo.  Loud.  1818. 
Letter  on  the  Ophthalmic  Institution  for  the 
Cure  of  Chelsea  Pensioners,  4to.  Lond.  1819. 
And  A Practical  Treatise  on  the  Diseases  of 
the  Eye,  8 vo.  Lond.  1820.  W.  Thomas,  Obs. 
on  the  Egyptian  Ophthalmia, and  Ophthalmia 
Purulenta,  8 vo.  Lond.  1805.  P.  Assalini  on 
the  Plague,  Dysentery,  and  Ophthalmy  of 
Egypt,  &/-c.  Transl.  by  A.  Neale,  Lond.  1804. 
Also  Manuale  di  Chirurgia,  8 vo.  Milano , 
1812.  F.  Vasani  Sloria  daV  Ottalmia  con- 
tagiosa dello  Spedalt  Mililare  d' Ancona,  8vo. 
In  Verona,  1816.  Also  Risposta  a do  che  la 
riguarda  nei  Cenni  del  D, f.  Omodei  sulV 
Ottalmia  d'Egitto  et  sulla  sua  propagazione  in 
Italia,  12 mo  In  Verona,  1818.  T F Balfz, 
de  Ophthalmia  Catarrhali  Bellica,  4 to.  Hei- 
delb.  1816  Arthur  Edmonstone,  A Treatise  on 
the  Varieties  and  Consequences  of  Ophthalmia , 
with  a preliminary  inquiry  into  its  conta- 
gion nature,  8 vo.  Edinb.  18(»6.  De  Wenzel , 
Manuel  de  VOculiste , 2 T Svo.  Paris,  1808. 
C.  Farrell,  On  Ophthalmia  and  its  conse- 
quences. 8vo.  Lond.  1811.  On  the  Utility  of 
Blisters  in  the  Ophthalmia  of  Infants,  in  Ed. 
Med.  Surg.  Journ.  No.  58,  p.  156.  R.  C. 
Graefe,  Journ.  der  Chir.  B.  1.  Also  Re- 
pertorium  augenarzlicher  Heiformeln , 8 vo. 
Berlin , 1817.  G.  Benedict,  De  Morbis  Oculi 
Humani  Inflammatoriis,  4 to.  Lips.  1811 
J.  C.  Saunders  on  Same  Practical  Points  re- 
lating to  Diseases  of  the  Eye,  edited  by  Dr. 
Farre,  Lond.  181 1,  or  rather  the  later  editions. 
Karl  Himly  Ophthalmologische  Beobachtun- 
gen,  fyc.  12»i0.  Bremen,  1801.  Also  his  Ein- 
leitung  in  die  Auge nhtilkunde,  12 mo.  Jena , 
1806,  and  his  Bibliothek  fur  Ophlhalmologie , 
fyc.  12 mo.  Hanuov.  1816.  F.  J.  Wallroth , 
Syntagma  de  Oahihalmologia  Veterum,  8 vo. 
Halve , 1818.  C.  J M.  Langenbeck  in  Bibl. 
and  Neue  Bibl.  far  die  Chirurgie,  in  various 
places.  Ant.  Scarpa,  suite  Principali  Malatiie 
degli  Occhi ; Venez.  Ediz.  5ta. : or  the  Transl. 
by  Mr.  Briggs  2 d Ed.  Roux,  Voyage  fait  tn 
Angleterre  en  1814,  ou  Parallele  de  la  Chirur- 
gie Angloise  avec  la  Chirurgie  Francoise,  p. 
37,  <^c.  P.  Ml  Gregor  in  Trans  of  a Society 
for  the  Improvement  of  Med  and  Chirurgiral 
Knowledge,  Vol.  3,  p.  30  fyc.  Larrey,  Me- 
moiresde  Chir  Militaire,  T.  1 ,p.  202,  fyc. 

A.  Schmidt,  iiber  Nachslaar  und  Iritis,  4to. 
Wien.  1801.  G.  J.  Beer,  Lehre  von  dem 
Augenkrarikheiten,  2 B.  8 vo  Wien.  1813-~ 
1817.  C.  H Weller,  A Manual  of  the  DiSr 
eases  of  the  Human  Eye,  Transl.  with  Notes 
by  G C Monteat h,  2 Vols  Svo.  Glasg.  1821. 

B.  Travers  on  Iritis , in  Surgical  %s$ays} 


348 


OSTEOSARCOMA 


Part  1.  Also  a Synopsis  of  the  Diseases  of 
the  Human  Eye , Svo.  Loud.  1820.  Eusebius 
A.  Lloyd  on  Scrofulous  and  Purulent  Oph- 
thalmia, in  a Treatise  on  Scrofula , Svo.  Lond. 
1821. 

OSCHEOCELE,  (from  oer%eov,  the  scro- 
tum, and  km a tumour.)  A hernia  which 
has  descended  into  the  scrotum. 

*OSTEOSARCOM A,  or  Osteosarcosis. 
(from  oo-Ttov,  a bone,  and  era />%,  flesh.)  This 
term  signifies  the  change  of  a bone  into  a 
substance,  of  the  consistence  of  flesh.  Bones 
are  sometimes  converted  into  a soft,  lardy, 
homogeneous  substance  resembling  a can- 
cerous gland,  and  it  is  this  affection,  to  which 
Boyer  thinks,  that  the  appellation  ought  to 
be  confined, 

Callisen  seems  also  to  regard  the  osteosar- 
cosis as  a disorder  by  which  the  texture  of 
the  bones  is  converted  into  a fleshy  or  fatty 
substance,  accompanied  with  a tendency  to 
carcinoma.  ( System . Chirurgice  Hodiernce , 
p.  204.  Vol.  2.  Edit.  1800.)  We  are  to  un- 
derstand by  osteosarcoma,  says  Boyer,  an 
alteration  of  the  osseous  structure,  in  which, 
after  more  or  less  distention,  the  substance 
of  the  bone  degenerates,  and  is  transformed 
into  a diversified  mass  but,  more  or  less 
analogous  to  that  cancer  of  the  soft  parts ; 
while  the  local  and  general  symptoms  still 
more  strikingly  resemble  those  of  the  lat- 
ter disease.  (See  Traite  des  Mol.  Chir.  T. 
3,  p.  587.) 

According  to  this  writer,  all  the  bones  are 
liable  to  such  a disease  ; but  it  has  been 
more  frequently  observed  in  the  bones  of 
the  face,  those  of  the  base  of  the  skull,  the 
long  bones  of  the  limbs,  particularly  the 
ossa  irinorninata,  which  are  perhaps  oftener 
affected  than  any  other  bones  of  the  body. 
{Op.  cit.  p.  588.) 

Foreign  surgeons  do  not  appear  to  enter- 
tain precisely  the  same  ideas  respecting 
cancer,  which  prevail  in  England  : at  least, 
they  apply  the  term  to  many  complaints  in 
which  there  are  no  vestiges  of  a carcinoma- 
tous structure,  and  numerous  diseases  of  an 
incurable  nature  receive  abroad  very  indis- 
criminately the  name  of  cancer.  Thus, 
the  French  surgeons  have  not  yet  distinguish- 
ed the  strongly  marked  differences  between 
carcinoma  and  fungus  haematodes  (See 
JRoux , ParalWe  de  la  chir.  Angloise,  fyc. ; 
and  the  article  Fungus  Hcematodes.) 

Fungous  diseases  in  the  antrum  expand 
the  bones  of  the  face,  make  their  way  out, 
and  present  a frightful  specimen  of  disease. 
This  change  of  the  bones,  though  known  to 
have  nothing  to  do  with  cancer,  (see  An- 
trum,) is  considered  by  Boyer  as  a kind  of 
osteosarcoma,  proceeding  from  carcinoma- 
tous mischief  in  the  neighbouring  soft  parts  ; 
and  this  he  adduces  as  an  example  of  his 
first  species  of  osteosarcoma,  or  that  arising 
in  consequence  of  previous  disease  in  other 
parts.  In  the  second  species,  the  disorder 
commences  in  the  bones,  and  the  soft  parts 
are  secondarily  affected.  In  all  cases, 
osteosarcoma  comes  on  with  deeply-seated 
pain,  which  sometimes  lasts  a considerable 
time  before  any  swelling  is  manifest.  Some- 


times the  pain  becomes  more  and  more 
afflicting,  and  of  the  lancinating  kind,  im 
pairing  the  health  even  before  there  is 
any  change  in  the  form  of  the  limb.  At 
length,  the  swelling  takes  place,  occupying 
the  whole  circumference  of  the  member. 
Its  nature  and  situation  are  in  some  measure 
indicated  by  its  hardness  and  depth.  It  is 
unequal  and  tuberculated,  as  it  were.  Pres- 
sure does  not  lessen  its  size,  nor  make  the 
pain  worse.  The  soft  parts  are  still  in  their 
natural  state.  The  tumour,  however,  grows 
more  or  less  rapidly  and  the  lancinating 
pains  become  more  severe.  In  time,  the 
soft  parts  themselves  inflame,  and  become 
painful.  Sometimes,  the  skin  ulcerates,  and, 
in  this  very  uncommon  case,  the  sore  pre- 
sents a cancerous  appearance.  Hectic 
symptoms  are  induced,  the  patient  gradually 
loses  his  strength,  and,  at  length,  falls  a vic- 
tim to  the  disease. 

The  alteration,  which  the  structure  of 
the  bones  undergoes  in  the  osteosarcoma, 
(says  Boyer)  deserves  great  attention.  Most 
frequently,  when  the  disease  has  made  con- 
siderable progress,  and  the  tumour  has  exist- 
ed a long  while,  the  bony  texlure  has  disap- 
peared more  or  less  completely  ; in  lieu  of 
it,  an  homogeneous  grayish, yellowish,  lard- 
like substance  is  found,  the  surface  of  a slice 
of  which  is  smooth,  much  like  that  of  a 
very  hard  white  of  egg,  or  old  cheese,  the 
consistence  varying  from  that  of  cartilage 
to  that  of  very  thick  bouillie.  The  sur- 
rounding soft  parts,  which  have  participated 
in  the  disease  of  the  bones  are  converted 
into  a similar  matter;  muscles  tendons, 
periosteum,  ligaments,  vessels,  cellular  sub- 
stance, all  are  confounded  in  the  same 
homogeneous  mass,  and  have  undergone  the 
same  degeneration. 

In  some  examples,  the  disease  is  less  ad- 
vanced : portions  of  the  bone  are  then  met 
with  hose  texture  and  consistence  are 
nearly  natural,  and  which  are  merely  some- 
what enlarged.  But  in  proceeding  towards 
the  centre  of  the  disease,  the  substance  of 
the  bone  is  found  softened,  and  its  consist- 
ence less  than  that  of  cartilage,  still  mani- 
festly retaining,  however,  a fibrous  texture  ; 
while  more  deeply,  it  is  converted  into  a 
lard-like  substance,  resembling  (says  Boyer) 
that  of  parts  affected  with  carcinoma.  In 
these  tumours,  cysts  are  often  found,  some- 
times containing  a fetid  ichor, — some- 
times a matter  like  clear  bouillie ; and,  in 
certain  cases,  a quantity  of  semi-transpa- 
rent, tremulous,  gelatinous  matter  is  found 
in  the  middle  of  the  lard-like  substance. 
Boyer  records  an  instance,  in  which  nearly 
the  whole  humerus  was  changed  into  a 
gelatinous  mass.  (See  Lecqns  sur  les  Mai, 
des  Os,  T.  1.  Chap.  22.) 

The  prognosis  of  this  disease  must  always 
be  unfavourable  ; for.  it  is  equally  incurable, 
and  disposed  to  bring  on  fatal  consequences, 
whether  Boyer’s  opinion,  concerning  its 
being  cancer  of  the  bones,  be  true  or  not. 
This  author  notices,  that,  even  after  ampu- 
lation,  the  complaint  almost  always  recurs. 
(P.591.)  The  only  chance  of  relief, how- 


PAR 


PAR 


249 


ever,  obviously  depends  upon  the  possibility 
and  success  of  the  operation.  In  the  Traitt 
des  Mai.  Chir.  T.  3,  p.  594—605,  Boyer  re- 
cords two  cases  of  osteosarcoma  ; one  of 
the  thigh  ; the  other,  of  the  os  innominatum 
The  first  patient  was  saved  by  amputation. 
Some  further  particulars  relative  to  osteo- 
sarcoma may  be  found  in  Boyer,  Traile  des 
Maladies  Chir , T.  3;  Haller's  Element.  Phy- 
siol. T.  8,  p.  2,  pag.  5;  S.  A.  Kulmus,  Diss 
de  Exoslosi  Sleatomaiode  Claviculee  ; Gedan. 
3732;  S.  F Hundertmark,  Diss.  sistens  Os- 
teostealomatis  Casum  rariorem ; Lips.  1752; 
5.  G.  Hermann,  Hiss,  de  Ost<  osteatomate , Lips. 
1767:  S.  C.  Plenck , de  Osteosarcosi : Tub. 
1781  fyc.  B.  C.  Brodie  in  Pathol,  and  Surgi- 
cal Obs.  on  the  Joints,  p.  301. 

OZiENA.  (from  o?»,  a stench.)  An  ulcer 
situated  in  the  nose,  discharging  a fetid  pu- 
rulent matter,  and  sometimes  accompanied 
with  caries  of  the  bones.  Some  authors  have 
Sig-nified  by  the  term,  an  ill-conditioned  ulcer 
in  the  antrum.  The  first  meaning  is  that 
which  mostly  prevails.  The  disease  is  des- 
cribed as  coming  on  with  a trifling  tumefac- 
tion and  redness  about  the  ala  nasi,  accom- 
panied with  a discharge  of  mucus,  with 
which  the  nostril  becomes  obstructed.  The 
matter  gradually  assumes  the  appearance 
of  pus,  is  most  copious  in  the  morning,  and 
is  sometimes  attended  with  sneezing,  and  a 
little  bleeding.  The  ulceration  occasionally 
extends  round  the  ala  nasi  to  the  cheek,  but, 
seldom  far  from  the  nose,  the  ala  of  which, 
also,  it  rarely  destroys.  The  ozaena  is  often 
connected  with  scrofulous  and  venereal 
complaints.  In  the  latter  cases,  portions  of 
the  ossa  spongiosa  often  come  away.  After 
the  complete  cure  of  all  venereal  complaints, 
an  exfoliating  dead  piece  of  bone  will  often 
keep  up  symptoms,  similar  to  those  of  the 
ozama,  until  it  is  detached.  Mr.  Pearson 
remarks,  that  the  ozaena  frequently  occurs, 
as  a symptom  of  the  chachexia  syphyloidea. 
It  may  perforate  the  septum  nasi,  destroy 
the  ossa  spongiosa,  and  even  the  ossa  nasi. 
Such  mischief  is  now  more  frequently  the 
effect  of  the  chachexia  syphyloidea,  than  of 
lues  venerea.  The  ozaena  must  not  be  con- 
founded with  abscesses  in  the  upper  jaw- 
bone. (See  Antrum.) 

The  constitutional  disease,  on  which  the 
ozaena  generally  depends,  and  which  acts  as 
the  remote  cause,  must  be  relieved,  before  a 
cure  of  the  local  effect  can  be  expected. 
The  internal  medicines,  which  may  be  ne- 
cessary, are  preparations  of  mercury,  and 


antimony  ; sarsaparilla,  elm  bark,  Peruvian 
bark,  muriated  barytes,  and  muriate  of  lime 
Sea-bathing  may  also  do  good, by  improving 
the  health.  The  best  external  applications 
are  said  to  be,  preparations  of  copper,  zinc, 
arsenic,  mercury,  the  pul  vis  sternutatorius, 
and  diluted  suphuric  acid.  ( Pearson's  Prin- 
ciples of  Surgery,  Chap.  12  F.  A.  Mayer t 
Commentatio  de  Ozaena,  Frank.  Del.  op. 
11.) 

OYYMURIATIC  ACID.  Besides  the  ni- 
trous and  nitric  acids,  other  medicines,  con- 
taining alarge  proportion  of  oxygen, and  easy 
of  decomposition,  have  been  recommend- 
ed to  be  tried  as  remedies  for  the  venereal 
disease ; viz.  oxygenated  vinegar,  oxalic  acid, 
oxygenated  muriate  of  potash,  &c.  (See 
Caldwell's  Medical  Theses.  Vol.  T p.  111.) 
But,  perhaps,  nothing  has  been  put  to  the 
test  of  experiment  with  greater  expectation 
of  success,  than  the  oxygenated  muriatic 
acid.  Mr.  Cruikshanks  made  a very  early 
trial  of  it  in  syphilitic  cases,  and,  as  is  al- 
leged, w ith  the  utmost  benefit..  He  also  em 
ployed  the  nitric  acid,  and  the  oxygenated 
muriate  of  potash,  and  found  them  eligible 
remedies  The  latter  medicine  wras  likewise 
given  by  M Alyon  in  cases  of  chancre  and 
secondary  ulcers,  who  found  the  good  ef- 
fects from  it,  more  expeditious,  and  more 
certain,  than  those  of  any  mercurial  prepa- 
ration. (Essai  sur  les  Pr  opr  Hies  Mcdicinales 
de  rOxyaene,  fyc.  8 vo.  Paris,  an  7 me.)  On 
the  other  hand,  as  much  contrariety  of  sen- 
timent respecting  the  real  and  permanent  ef- 
ficacy of  all  these  medicines  prevails  in  the 
numerous  reports  about  them,  as  in  the  ac- 
counts delivered  of  the  effects  of  the  muria- 
tic and  nitric  acid;  and,  therefore,  I do  not 
think  that  the  reader,  after  the  copious  state- 
ments given  in  this  book  concerning  the 
nitric  and  nitrous  acids,  (see  these  words) 
would  be  pleased  to  hear  again  a repetition 
of  very  similar  contradictions,  respecting  the 
oxygenated  muriatic  acid.  I may  observe, 
however,  that,  if  oxygen  be  the  principle, 
on  which  the  efficacy  of  many  antisyphili- 
tic remedies  truly  depend,  this  acid  must 
possess  greater  virtue  than  the  common  mu- 
riatic acid.  From  3SS.  to  3'j-  mixed  in 
^viij.  of  water,  sweetened  with  syrup,  may 
be  taken  in  divided  doses  in  the  course  of 
the  day. 

Oxygenated  muriatic  acid  was  strongly- 
praised  by  Guyton  de  Morveau,  as  a means 
of  disinfecting  sick-rooms,  and  purifying  the 
air  of  crowded  hospitals. 


P. 


PANA  RIS,  (from  zrapn,  uear,  and  cvw|, 
ihe  nail.)  See  Whitlow. 

PANNUS.  (from  •■srsva.  lo  labour.)  When 
two  or  three  pterygia,  of  different  sizes  oc- 
curred on  the  same  eye,  with  their  points  di- 
rected towards  the  centre  of  the  cornea, 
where  they  met  and  covered  all  the  surface 
of  this  transparent  membrane  with  a dense 


pellicle,  the  ancients  named  the  disease, 
pannus.  (Scarpa,  Chap.  14.) 

PaRACEN  1 E'SIS.  (from  ftrcipctzsvTea),  to 
perforate.)  The  operation  of  tapping  or 
making  an  opening  into  the  abdomen,  tho- 
rax, or  bladder,  for  the  purpose  of  discharg- 
ing th»  fluid  confined  in  these  parts  in  cases 
of  ascites,  empyema,  bydrothorax,  and 


PARACENTESIS. 


'5*50 

retention  of  urine.  Eft*u«ed  blood  may  also 
require  an  opening  to  be  made  into  the  chest; 
and  so  may  confined  air  in  the  instance  of 
emphysema. 

TAPrr'G,  OH  PARACENTESIS  ABDOMINIS. 

When  the  swelling  extends  equally  over 
the  whole  abdomen,  tin*  fluid  is  usually  diffu- 
sed atnongall  the  viscera, and  is  only  circum- 
scribed by  the  boundaries  of  the  peritonae- 
um. The  water  is  occasionally  included  in 
different  cysts,  w hich  are  generally  formed 
in  one  of  the  ovaries  ; and  in  this  ca^e,  the 
tumour  which  is  produced,  is  not  so  uniform, 
the  fluctuation  is  noi  so  distinct  as  in  the 
former  instanc-,  at  least  this  is  the  case 
while  the  disease  has  not  made  very  great 
progress.  The  difference,  also,  in  the  con- 
sistence of  the  fluid,  may  render  the  fluctua- 
tion more  or  less  difficult  of  detection. 
When  the  water  is  contained  in  different 
cysts,  it  is  frequently  thick  and  gelatinous; 
but  when  it  is  uniformly  diffused  all  over  the 
cavity  of  the  peritonaeum,,  it  is  generally 
thinner,  and  even  quite  limpid.  Sometimes 
a con  iderable  number  of  hydatids  are  found 
floating  in  the  fluid,  discharged  in  cases  of 
ascites. 

Whatever  may  bp  the  efficacy  of  digitalis, 
mercury,  diuretics,  and  other  evacuants  in 
ascites,  they  are  rarely  of  any  service  in 
cases  of  focal  and  encysted  dropsies.  When 
such  swellings  continue  to  enlarge,  notw  ith- 
standing  the  adoption  of  a few  measures 
which  wifi  presently  be  suggested,  the  soon- 
er the  fluid  is  evacuated  the  better.  It  is 
also  well  known,  that  all  efforts  to  produce 
a radical  cure  even  of  dropsies,  which 
ar<  not  encysted,  too  frequently  fail.  I am 
decidedly  of  opinion,  however,  with  Dr 
Fothergill,  that  physicians  u'ould  meet  with 
much  more  success  in  the  treatment  of  asci- 
tes, if  they  were  to  recommend  paracentesis 
to  be  done  sooner  than  they  generally  do. 
This  operation  is,  for  the  most  part,  much 
too  long  delayed;  and  during  a long  space, 
the  bowels  are  continually  suffering  more 
and  more,  from  the  effect  of  the  large 
quantity  of  fluid  which  oppresses  them. 
What  ought  to  render  the  practice  of  eaily 
tapping  more  entitled  to  approbation  is,  that 
the  operation,  when  done  in  the  situation 
which  will  be  presently  advised,  is  perfectly 
free  from  danger,  attended  with  very  little 
pain,  and  need  not  interrupt  the  further  trial 
of  such  medicines  as  the  physician  may 
place  confidence  in.  Paracentesis  only  be- 
comes a serious  measure  when  the  disease 
has  existed  for  a great  length  of  time,  and 
the  patient  has  been  much  weakened  by 
it.  Indeed  there  seems  much  reason  to 
suspect  that  the  operation  should  be  done  as 
soon  as  the  tension  of  the  abdomen,  and  the 
fluctuation,  leave  no  doubt  concerning  the 
nature  of  the  malady  ; especially  when  the 
first  t rials  which  have  been  made  of  internal 
remedies,  seem  to  promise  no  success.  Dr. 
Fothergill  has  demonstrated  by  facts  the  ad- 
vantages of  this  method.  On  the  commence- 
ment of  an  ascites,  this  celebrated  practi- 


tioner advises  the  trial  of  diuretics  and  other 
evacuants*  He  then  adds,  that  “ if  by  a 
reasonable  perseverance  in  this  course,  no 
considerable  benefit  accrues  ; if  the  viscera 
do  not  evidently  appear  to  be  obstructed, 
and  unfit  for  the  purposes  of  life;  if  the 
complaints  have  not  been  brought  on  by  a 
long  habitual  train  of  intemperance,  and 
from  which  there  seems  little  hope  of  re- 
claiming the  patient ; if  the  strength  and  time 
of  life  are  not  altogether  against  us  ; I desist 
from  medicine,  except  of  the  cordial 'kind  : 
and  let  the  disease  proceed  til!  the  operation 
becomessafely  practicable.  When  this  isdone 
by  the  moderate  use  of  the  warm  diuretics, 
chalybeates,  and  biiters,also  the  preparations 
of  squills,  in  doses  below  that  point  at  which 
the  stomach  would  be  affected,  I endeavour 
to  prevent  (he  abdomen  from  filling  again.” 
(Med.  Obs.  and  Inq.  Vol.  4,  p.  112.)  The 
same  author  remarks,  with  regard  to  encyst- 
ed dropsies,  that  tapping  sometimes  effects  a 
radical  cure. 

The  operation  should  not  only  be  per- 
formed in  as  early  a stage  of  the  disease  as 
is  compatible  with  the  safety  of  the  parts 
within  the  abdomen,  it  should  also  he  repeat- 
ed as  soon  as  the  quantity  of  fluid  accumu- 
lated again  is  sufficient  to  make  the  puncture 
practicable  without  danger.  Desault  used 
to  tap  dropsical  patients  once  a week,  and 
in  many  ca^es,  after  he  had  performed  the 
operation  two  or  three  times,  the  disease  was 
stopped. 

The  great  number  of  times  that  the  ope- 
ration has  been  repeated  in  some  individu- 
als is  surprising;  for  in  tance,  twenty  nine 
times  (Schmucker,  J¥ahrnehmungen,2  B.  p 
102;)  fort\-<>ne  times  (Med.  Communica- 
tions,, Vol.  2;)  fifty-two  times  (Schmucker, 
Vol..cit.  p.  187;)  sixtv-five  times  (Mead ;) 
one  hundred  times  (Callisen,  Syst.  Chir.  Ho- 
diernal Vol.  2,  p.  55;)  one  hundred  and 
fifty-five  times  (Phil.  Trans.  Vol.  69 ;)  and 
if  it  be  possible  to  credit  Bezard,  even  six 
hundred  and  sixty-five  times  upon  one  wo- 
man in  the  course  of  thirteen  years.  When 
the  patient  died,  the  peritoneum  was  found 
to  he  three  lines  in  thickness.  The  omen- 
tum, mesentery,  and  even  the  liver,  gall- 
bladder, spleen,  pancreas,  kidneys,  and  blad- 
der, had  almost  disappeared,  a scirrhous  mass 
containing  pus  occupying  their  place  towards 
the  right  side.  (See  Bulletin  de  la  Socidtd- 
Medicate  d' Emulation,  No.  12,  Dec.1815.) 

Whenever  a considerable  quantity  of  fluid 
is  suddenly  let  out  of  the  abdomen  by  tap- 
ping, the  quick  removal  of  t he  pressure  of 
the  water  oft*  the  large  blood-vessels  and 
viscera,  may  produce  swooning,  convulsions, 
and  even  sudden  death-  These  consequen- 
ces led  the  ancients  to  consider  paracentesis 
as  a very  dangerous  operation,  and  when 
they  ventured  to  perform  it,  they  only 
let  out  the  w'ater  gradually , and  at  intervals 

Dr.  Mead,  after  considering  what  might 
occasion  the  bad  symptoms  resulting  from 
too  su  den  an  evacuation  of  a large  quanti- 
ty of  fluid  from  the  abdomen,  was  led  to  try 
what  effect  external  pressure  would  have  in 
preventing  such  consequences.  This  practi*- 


PARACENTESIS. 


351 


tioner  thought  that  in  this  way  be  might  keep 
up  the  same  degree  of  pressure  which  the 
fluid  made  on  the  viscera.  The  success  at- 
tending some  trials  of  this  plan,  fully  justi- 
fied the  opinion  Dr  Mead  had  conceived  ; 
for  when  the  compression  is  carefully  made, 
the  whole  of  the  water  co  tained  in  the  b- 
domen  of  a dropsical  palidnt,  may  be  safely 
discharged  as  quickly  as  the  surgeon  chooses. 
For  this  purpose,  however,  the  w hole  abdo- 
men must  be  equally  compres-ed,  the  pres- 
sure increased  in  proportion  as  the  evacua- 
tion takes  place,  and  kept  up  in  the  same 
degree  for  several  days  alterward.  In  St. 
Bartholomew’s  Hospital,  while  the  water  is 
flowing  out,  the  necessary  degree  ot  pressure 
is  usually  made  wit  a sheet,  which  is  put 
round  the  abdomen.  Two  assistants,  who 
hold  the  ends  of  the  sheet,  gradually  tighten 
it,  in  proportion  as  the  fluid  is  discharged. 
Immediately  after  the  operation,  some 
folded  flannel  sprinkled  w ith  spirit  of  wine, 
is  laid  over  the  whole  anterior  part  of  the 
belly,  and  covered  with  a broad  linen  roller, 
applied  with  due  tightness  round  the  body. 
Dr.  Monro  invented  a particular  kind  of  belt 
for  the  purpose  ; but  though  it  may  be  well 
adapted  to  the  object  in  view,  it  is,  perhaps, 
unnecessary,  as  the  above  method  seems  to 
answer  every  end. 

Tiie  instrument  used  for  tapping  the  abdo- 
men, is  called  a trocar.  (See  Trocar.) 

Of  this  instrument  there  are  -everal  varie- 
ties; but  Richter  and  many  other  experien- 
ced surgeons,  give  a decided  preference  to 
the  common  trocar.  Most  ofth-  modern  al- 
terations which  have  been  made  in  the 
construction  of  trocars,  have  only  tended, 
says  Richter,  to  render  the  employment  of 
these  instruments  more  difficult.  There  is 
no  reason  for  the  ordinary  objection,  t hat 
the  corjiiion  trocar  cannot  be  introduced 
without  considerable  force.  If  the  part  into 
which  it  is  about  to  be  passed,  be  made 
tense,  very  little  force  will  be  necessary, 
especially  if  care  be  taken  to  rotate  the  in- 
strument gently,  as  well  as  push  it  forward. 
Hence  all  the  invention-  which  have  origi- 
nated from  this  supposed  imperfection,  are 
represented  by  Richter  to  be  entirely  useless. 
He  condemns  the  trocar  with  a double-edged 
point,  as  a bad  instrument.  The  proposal  of 
Mr.  Cline  to  make  a puncture  w'ith  a lancet 
first,  and  then  !o  introduce  into  Hie  opening 
a blunt-pointed  trocar,  is  alleged  to  be  su- 
perfluous. Nay — these  innovations  are  de- 
clared to  be  worse  ihan  useless.  A cutting 
instrument  is  liable  to  injure  blood-vessels, 
and  bring  on  a weakening  degree  of  hemor- 
rhage ; and  it  is  said,  that  the  wound  thus 
made  does  not  heal  so  readily  as  that  made 
with  a common  trocar.  That  sharp-edged 
instruments  are  attended  with  the  inconve 
nienceof  being  apt  to  wound  enlarged  veins, 
and  produce  an  unpleasant  degree  of  hemor- 
rhage, is  a truth  of  w hich  I have  myself  met 
with  a convincing  example.  A female  who 
had  a strong  aversion  to  being  tapped  w ith  a 
trocar,  prevailed  upon  me  to  make  tiie  open- 
ing wish  a lancet.  The  puncture  was  made 
in  the  linea  alba,  about  three  inches  below 


the  navel.  A stream  of  dark-coloured  ve- 
nous blood  continued  to  run  from  the  wound, 
the  whole  time  the  water  was  flowing  out  of 
the  cannula,  and  did  not  cease  until  a com 
press  was  applied.  The  quantity  of  blood 
lost  could  not  be  less  than  a pint,  or  a pint 
and  a half.  In  many  rases  the  loss  of  «o 
much  blood  would  prove  fatal  to  dropsical 
patients,  and  is  what  one  must  alway  s feel 
anxious  to  avoid. 

The  most  convenient  position  for  the  ope  - 
ration, is  certainly  when  the  patient  is  sitting 
in  an  arm-chair.  However,  weakness  and 
other  circumstances  frequently  make  it  ne- 
cessary to  operate  on  the  patient  as  he  lies  in 
bed. 

Until  of  late,  the  place  in  which  surgeons 
used  to  puncture  the  abdomen,  In  cases  of 
ascites,  was  the  centre  of  a line  drawn 
from  the  navel  to  the  anterior  superior  spi 
nous  process  of  the  ilium,  and  on  the  left 
side,  which  was  preferred  in  consequence  of 
tiie  liver  not  being  theie.  The  place  for  the 
puncture  was  usually  marked  with  ink,  and 
was  supposed  to  be  always  situated  just  over 
a part  of  the  linea  semilunaris,  w here  In  e 
is  n<  fleshy  substance,  nor  any  large  blood- 
vessel, exposed  to  injury.  This  calculation, 
however,  u as  made  w ithout  considering  that, 
in  dropsy,  the  parietes  ol  the  abdomen  do 
not  yield  equaily  in  every  situation.  On  the 
contrary,  it  is  known,  that  the  front  is  always 
more  distended  than  the  lateral  parts,  and 
that  the  recti  muscles,  in  particular,  are 
sometimes  very  much  widened.  In  conse- 
quence of  these  alterations  induced  by  the 
disease,  no  dependence  can  be  put  on  any 
measurement,  made  with  the  view  ot  ascer- 
taining the  piecise  situation  of  tiie  linea 
semilunaris.  The  surgeon  who  trusts  to  his 
being  aide  to  introduce  the  trocar  exactly  in 
this  place,  from  any  calculation  of  the  above 
kind,  will  frequently  wound  a great  thickness 
of  muscle,  instead  ol  a part  where  the  abdo 
ininal  parietes  are  thinne-t.  But  a still 
stronger  objection  is  to  be  urged  against  the 
practice  of  attempting  t-o  tap  in  the  linea 
semilunaris.  Men  v\ell  acquainted  with 
anatomy,  have  frequently  been  deceived 
in  their  reckoning,  and  instead  of  hitting  the 
intended  line  with  their  trocars,  they  have 
introduced  these  instruments  through  the 
rectu-  muscle,  and  wounded  the  epigastric 
artery.  Patients  have  died  from  this  error, 
with  large  extravasations  of  blood  in  the 
cavity  of  the  peritonaeum.  n a dropsical 
person,  who  has  been  tapped,  it  is  to  be  ob- 
served'also,  that  an  effusion  td  biood  in  the 
abdomen  will  of  course  more  readily  take 
place,  in  consequence  of  the  parts  not  being 
in  the  same  close,  compact  state,  in  which 
they  are  in  the  healthy  condition. 

Let  every  prudent  practitioner,  therefore, 
henceforth  abandon  the  plan  of  tapping  in 
the  linea  semilunaris,  and  he  may  the  more 
easily  make  up  his  mind  to  do  so,  as  there 
is  another  place  where  the  operation  may 
be  done  with  the  utmost  facility  and  safety. 
The  iitiea  alba  is  iro vv  commonly  preferred 
by  the  best  surgeons  ; because,  here  no 
muscular  fibres  need  be  xvounded.  the  place 


PARACENTESIS. 


B&2 

can  be  hit  with  certainty,  and  no  large 
blood-vessel  can  be  injured.  About  the 
middle  point,  between  the  navel  and  pubes, 
is  as  good  a situation  for  making  the  punc- 
ture as  can  possibly  be  chosen.  The  sur- 
geon should  introduce  the  trocar  in  a steady, 
firm  manner,  never  in  an  incautious,  sud 
den  way,  lest  parts  contained  in  the  perito- 
naeum should  be  rashly  wounded.  For  the 
same  reason,  immediately  the  point  of  the 
trocar  has  entered  the  abdomen,  a thing 
always  known  at  once  by  the  sudden  ces- 
sation of  resistance  to  its  passing  inward,  it 
should  be  introduced  no  further,  and  its 
office  of  making  a passage  for  the  cannula 
is  already  accomplished.  The  surgeon,  con- 
sequently, is  now  to  take  hold  of  the  cannula 
with  the  thumb  and  index  finger  of  his  left 
hand,  and  gently  insinuate  it  further  into 
the  cavity  of  the  peritonaeum,  while  with 
his  right  hand  he  is  to  withdraw  the  stilette. 
The  fluid  now  gushes  out,  and  regularly  as 
it  escapes,  the  sheet  which  is  round  the  pa- 
tient’s body  is  to  be  tightened.  All  the  wa- 
ter having  been  evacuated,  a piece  of  flan- 
nel and  a roller  are  to  be  immediately  ap- 
plied, as  above  explained,  a piece  of  lint 
and  soap-plaster  having  been  previously 
applied  to  the  wound. 

It  is  not  uncommon  for  the  water  suddenly 
to  stop,  long  before  the  full  quantity  is  dis- 
charged. Sometimes  this  happens  from  a 
piece  of  intestine,  or  omentum,  obstructing 
the  cannula.  This  kind  of  stoppage  may  he 
removed  by  just  introducing  a probe  or  di- 
rector, and  holding  the  portion  of  bowel 
back.  When  the  w ater  is  very  viscid,  the 
only  thing  we  can  do  is  to  introduce  a large 
trocar,  if  doing  so  should  premise  to  facili- 
tate the  evacuation.  Also,  when  hydatids 
obstruct  the  cannula,  a larger  instrument 
might  allow  them  to  escape.  In  encysted 
dropsies,  the  practitioner,  of  course,  can 
only  let  the  fluid  out  of  those  cavities  which 
he  can  safely  puncture. 

When  a dropsy  of  the  ovary  is  very  large, 
it  also  admits  of  being  tapped  in  the  linea 
alba;  but,  in  this  particular  case,  it  is  gene- 
rally best  to  make  the  puncture  where  the 
swelling  is  most  prominent.  In  this  disease, 
the  ovary  is  either  converted  into  one  large 
cavity,  filled  with  fluid  or  else  it  contains 
several  distinct  cells.  The  contents  are 
sometimes  exceedingly  viscid.  In  the  early 
stages  of  the  case,  the  tumour  is  situated 
towards  one  side  of  the  abdomen,  and  seems 
to  ascend  out  of  the  pelvis.  This  kind  of 
progress  at  once  distinguishes  the  disease 
from  a common  ascites,  which  is  attended, 
from  the  first,  with  an  equal,  gradual,  uni- 
versal swelling  of  the  abdomen.  The  cyst 
of  the  ovary,  when  it  has  attained  a large 
size,  generally  adheres,  in  different  places, 
to  the  inner  surface  of  the  peritonaeum,  and, 
in  this  state,  the  whole  abdomeu  often 
seems  uniformly  swollen,  in  consequence  of 
the  immense  magnitude  of  the  disease.  (See 
G.  D.  Mots,  (le  Structure! , Usu,  el  M or  bis  Ora- 
riorum,  4lo  Jeiur',  178S.)  The  impairment 
of  the  health,  arising  from  the  pressure  of 
the  viscera,  and  interruption  tbmr  func- 


tions, and  the  great  difficulty  of  breathing' 
produced  by  the  pressure  on  the  diaphragm, 
make  it  necessary  to  let  out  the  fluid,  and 
paracentesis  must  be  done  in  the  way  alrea- 
dy related.  The  disease  is  often  attended 
with  an  almost  total  stoppage  of  the  secre- 
tion of  urine.  Sometimes  the  urine  is  duly 
secreted,  but  a retention  occurs,  so  that  the 
use  of  the  catheter  becomes  indispensable. 
Tapping,  however,  can  only  be  regarded  as 
a palliative  measure  ; the  water  collects 
again,  the  same  grievances  recur,  and  the 
operation  must  be  repeated.  While  an  ova- 
rial  dropsy  is  recent,  aud  even  after  it  has 
been  tapped,  some  attempts  may  be  made 
to  effect  a radical  cure.  Blistering  the  sur- 
face of  the  abdomen,  keeping  up  a discharge 
with  the  savine  cerate,  and  applying  a tight 
roller,  have  been  known  to  do  good.  In 
France,  the  celebrated  Le  Dran  laid  open 
the  cysts  of  ovarial  dropsies.  His  patients 
did  not  die  of  the  consequent  inflammation, 
and  the  dropsy,  indeed,  was  cured ; but 
there  remained  either  a sarcomatous  en- 
largement of  the  ovary,  which  continued  to 
increase  till  death,  or  else  incurable  fistula;, 
leading  into  the  cyst,  were  the  consequen- 
ces. 'J£he  large  size  of  a wound  necessary 
for  this  purpose,  the  danger  of  inducing  in- 
flammation in  so  extensive  a surface  as  the 
cyst  of  a large  ovarial  dropsy,  and  the  events 
of  Le  Dran  s cases,  are  circumstances,  on 
the  whole,  which  ought  to  keep  the  prac- 
tice from  ever  being  revived. 

A still  more  absurd  plan  has  been  attempt- 
ed, viz.  to  cure  the  disease  by  injections, 
like  hydroceles.  I formerly  saw'  twro  cases 
in  which  port  wine  and  water  were  inject- 
ed, by  the  late  Mr.  Ramsden  of  St.  Bartho- 
lomew’s Hospital;  one  patient  died  very 
soon  afterward  of  the  inflammation,  and  the 
other  perished  more  lingeringly  from  the 
same  cause.  Setons  have  been  tried  with- 
out success. 

Sometimes,  though  very  seldom,  the  ope- 
ration of  paracentesis  is  necessary  for  giving 
vent  to  collections  of  air  in  the  abdomen 
Air,  when  confined  in  this  manner,  is  gene- 
rally contained  in  the  bowels,  which  it  in- 
flates to  an  enormous  size.  Instances,  how- 
ever, are  related  of  quantities  of  air  being 
confined  between  the  peritonaeum  and  intes- 
tines : but,  in  some  of  these  cases,  it  is  said 
that  the  air  yvas  known  to  have  escaped 
through  a small  hole  in  some  part  of  the  in- 
testinal canal,  and  it  is  probable,  that  all  the 
other  examples  were  of  the  same  kind.  This 
disease  is  named  tympanites , and  may  ren- 
der making  an  opening  into  the  abdomen 
necessary.  Notwithstanding  authors  gene- 
rally recommend  a small  trocar  for  the  pur- 
pose, there  can  be  no  doubt  that  dividing 
the  skin,  and  making  a cautious  puncture 
with  a lancet  through  the  linea  alba  and 
peritonaeum,  would  be  a preferable  mode  of 
proceeding.  The  abdomen  must  also  be 
compressed  with  a sheet  while  the  air  is 
escaping,  and  afterward  with  a roller,  just 
as  if  the  case  were  an  ascites,  liven  when 
the  air  is  contained  in  the  bowels,  it  it  should 

enbrutoMs  in  qmudijv,  occasion  urgent 


FAR 


PAR 


o63 


symptoms,  anti  cannot  be  got  rid  of  in  other 
ways,  authors  recommend  paracentesis. 

PARACENTESIS  OF  THE  THORAX 

The  necessity  for  this  operation  is  indica- 
ted when  the  heart  or  lungs  are  oppressed 
by  any  kind  of  fluid  confined -in  the  cavity 
of  the  chest.  Every  body  knows  that  the 
free  and  uninterrupted  performance  of  the 
functions  of  these  organs  is  essential  to  the 
support  of  life.  When  the  action  of  these 
viscera  is  disturbed  by  the  lodgment  of  a col- 
lection of  any  kind  of  fluid  in  the  thorax,  no 
internal  medicines  can  be  much  depended 
upon  for  procuring  relief.  The  only  means 
from  which  benefit  can  be  rationally  ex- 
pected, is  letting  out  the  fluid  by  making  an 
opening  in  the  parietes  of  the  chest. 

The  nature  of  the  effused  fluid  can  make 
no  difference  in  regard  to  the  propriety  of 
discharging  it  in  this  manner;  and,  though 
some  authors  have  only  treated  of  this  ope- 
ration as  applicable  to  cases  of  hydrops  pec- 
toris and  empyema,  it  may  also  be  of  the 
greatest  service  when  air  is  confined  in  the 
chest,  (see  Emphysema ) or  blood  extravasa- 
ted  there,  (see  Woundsof  the  Thorax)  so  as 
to  make  dangerous  pressure  on  the  lungs 
and  diaphragm. 

In  this  place  I shall  content  myself  with 
describing  the  best  method  of  performing 
paracentesis  thoracis,  referring  the  reader  to 
the  articles  just  mentioned  for  information 
concerning  the  particular  symptoms  and 
circumstances  which  may  render  the  opera- 
tion proper,  and  the  rest  of  the  surgical 
treatment  peculiar  to  each  affection. 

The  safest  and  most  convenient  situation 
for  making  an  opening  into  the  chest,  is  be- 
tween the  sixth  and  seventh  true  ribs,  on 
either  side,  as  circumstances  may  ^render 
necessary.  The  surgeon  should  only  recol- 
lect, that  the  two  cavities  of  the  pleura  are 
completely  distinct  from  each  other,  and 
have  no  communication  whatsoever,  so 
that,  if  fluid  were  contained  on  the  left  side 
of  the  thorax,  making  an  opening  into  the 
right  cavity  would  not  serve  for  discharging 
the  accumulated  matter.  The  practitioner 
should  also  remember,  that,  when  there  is 
a fluid  on  both  sides  of  the  chest,  paracente- 
sis must  never  be  done  for  the  relief  of  the 
two  collections  at  the  same  time;  because 
there  is  great  reason  to  believe  that,  as  the 
lungs  on  one  side  usually  collapse,  when 
there  is  a free  communication  between  the 
air  and  inside  of  the  thorax,  they  would  do 
so  on  both  sides,  were  an  opening  made  at 
the  same  time  into  each  bag  of  the  pleura. 
It  is  hardly  necessary  to  remark,  that,  in 
this  condition,  the  patient  could  not  breathe, 
and  would  die  suffocated.  The  operation 
consists  in  making  an  incision,  about  two 
inches  long,  through  the  integuments  which 
cover  the  space  between  the  sixth  and 
seventh  true  ribs,  just  where  the  indigita- 
tions  of  the  serratus  major  anticus  muscle 
meet  those  of  the  externus  obliquus.  Here 
it  is  unnecessary  to  divide  any  muscular 
fibres,  except  those  of  the  intercostal  mus- 
Voi.  II  4.5 


cles,  and,  by  putting  the  patient  in  a proper 
posture,  the  opening  that  is  to  be  made  will 
be  depending  enough  for  any  purpose  what- 
soever. The  surgeon,  avoiding  the  lower 
edge  of  the  upper  rib,  where  the  intercostal 
artery  lies,  is  then  cautiously  to  divide  the 
layers  of  the  intercostal  muscles,  till  he 
brings  the  pleura  into  view;  when  this 
membrane  is  to  be  very  carefully  ided 
with  a lancet.  The  instrument  should  never 
be  introduced  in  the  least  deeply,  1 . e 
lungs  should  be  injured.  The  size  of  the 
opening  in  the  pleura  should  never  be  larger 
than  necessary.  The  discharge  of  blood 
and  matter  will  of  course  require  a freer 
aperture  than  that  of  air  or  water.  If  requi- 
site, a cannula  may  be  introduced  into  the 
wound  for  the  purpose  of  facilitating  the 
evacuation  of  the  fluid,  and  it  may  even  in 
some  cases  be  proper  to  let  this  instrument 
remain  in  the  part,  in  order  to  let  the  wrater 
or  pus  escape,  as  often  as  another  accumu- 
lation takes  place.  It  is  obvious,  however, 
that  a cannula  for  this  object  should  only 
be  just  long  enough  to  enter  the  cavity  of 
the  pleura,  and  should  have  a broad  rim  to  1 
keep  it  from  slipping  into  the  chest.  A piece 
of  sticking-plaster  would  easily  fix  the  can- 
nula, which  might  be  stopped  up  with  a 
cork,  or  any  other  convenient  thing,  or  left 
open,  according  as  the  circumstances  of  the 
case,  and  the  judgment  of  the  surgeon  should 
direct. 

Paracentesis  of  the  abdomen,  and  that  of 
the  thorax,  are  described  in  all  treatises  on  the 
operations  and  systems  of  surgery.  The  works 
of  Sharp,  Le  Dran,  Bertrandi,  Callisen,  Rich- 
ter, Sabatier,  Larrey , and  Boyer , are  particu- 
larly deserving  attention.  A case,  in  which 
eleven  pints  of  a fluid,  resembling  whey,  were 
discharged  from  the  chest  by  paracentesis,  and 
the  patient  recovered,  is  detailed  by  Dr.  Archer 
in  the  Trans,  of  the  King's  and  Queen's  Col- 
leges of  Physicians  in  Ireland,  Vol.  1 , art.  1. 

See  also  JY.  Friedreich,  Vorzuge  des  Bauch- 
stichesin  der  Bauchwassersucht,  12 mo.  Wurzb. 
1816,  1817. 

For  an  account  of  the  paracentesis  of  the 
bladder,  refer  to  Bladder,  Puncture  of.  Con- 
sult also  Emphysema,  Empyema,  and  Wounds 
of  the  Thorax. 

PARAPHYMO'SIS,  or  Paraphimosis. 
(from  mget,  back,  and  cpifxo to  bridle.)  This 
signifies  the  case  in  which  the  prepuce  is 
drawn  quite  behind  the  glans  penis,  and 
cannot  be  brought  forward  again.  See 
Phymosis,  with  which  it  will  be  considered. 

PAKONY'CHIA.  (from  near,  and 

ovv$j,  the  nail.)  An  abscess  at  the  end  of  the 
finger,  near  the  nail.  See  Whitlow. 

PAROTID  DUCT.  Every  one  acquaint- 
ed w ith  anatomy  is  aware,  that  behind  the 
jaw7,  on  each  side,  there  is  situated  a large 
conglomerate  gland,  being  the  principal  one 
of  such  as  are  destined  to  secrete  the  saliva, 
with  which  the  cavity  of  the  mouth,  and  the 
food  which  we  swallow,  are  continually 
moistened.  The  parotid  duct  crosses  the 
cheek,  being  situated  about  one-third  from 
the  zygofoa,  and  two-thirds  from  the  basis' 
of  the  jaw.  After  passing  over  the  ma&setev 


PAH 


PAR 


354 


muscle,  it  pierces  the  buccinator,  and  ter-, 
mrnates  in  the  mouth  by  a considerable  ori- 
fice opposite  the  space,  between  the  second 
and  third  bicuspid  grinders  of  the  upper  jaw. 
As  soon  as  it  has  passed  the  masseter,  it 
dives  deeply  into  the  fat  of  the  cheek,  and, 
as  M.  Louis  observes,  makes  an  angle  be- 
fore it  opens  into  the  mouth.  ( M6m . de 
Acad.  de  Chir.  T.  3,  p.  457  ) 

From  the  situation  of  the  parotid  duct  it 
is  liable  to  be  wounded,  and  this  has  even 
been  done  by  the  surgeon’s  lancet,  through 
ignorance.  (See  Monro’s  Works,  p.  520.) 
In  cases  of  this  kind,  the  continual  escape 
of  saliva  may  prevent  the  wound  from  heal- 
ing, and,  what  is  called  a salivary  fistula 
would  be  the  perpetual  consequence,  if  no 
steps  were  taken  to  afford  relief.  The  pa- 
rotid duct  has  sometimes  been  ruptured  by 
blows.  ( CEuvres  Chir.  de  Desault,  T.  2,  p. 
221.)  Cases  also  occur,  in  which  the  face 
becomes  considerably  swollen,  in  conse- 
quence of  the  saliva  insinuating  itself  into 
the  cellular  substance,  just  as  the  air  does 
In  emphysema.  Respecting  the  last  circum- 
stance, I shall  only  just  mention,  that  mis- 
chief of  this  kind  must  always  be  prevented 
lrom  becoming  very  extensive,  by  making 
a depending  opening  for  the  ready  escape 
of  the  fluid. 

With  regard  to  the  treatment  of  salivary 
fistulae,  if  the  division  of  the  parotid  duct  is 
recent,  the  sides  of  the  wound  should  be 
■brought  into  contact,  and  a steady  pressure 
maintained  on  that  part  of  the  cheek,  by 
means  of  suitable  compresses  and  a roller. 
In  this  manner,  a salivary  fistula  may  often 
be  prevented  altogether  : either  the  divided 
ends  of  the  duct  reunite,  and  the  spittle  re- 
sumes its  original  course  into  the  mouth  ; 
or,  what  is  more  probable,  the  wound  in  the 
face  heals  at  every  part,  with  the  exception 
of  a small  fistulous  track,  which  serves  as  a 
continuation  of  the  duct  into  the  inside  of 
the  mouth.  The  latter  kind  of  cure,  how- 
ever, can  only  take  place  when  the  wound 
extends  quite  through  the  cheek ; but  the 
chance  of  the  two  portions  of  the  duct  uni- 
ting, and  becoming  continuous’again,  should 
always  be  taken  in  recent  cases. 

When  a salivary  fistula  is  actually  form- 
ed, a seton,  introduced  from  the  external 
fistulous  orifice  into  the  mouth,  is  a method 
which  seems  to  have,  with  justice,  the  great- 
est share  of  approbation.  The  celebrated 
Monro  adopted  this  plan  with  success  ; he 
k^ept  in  the  selon  till  the  channel,  which  it 
had  formed,  had  become  fistulous,  after 
which  it  was  withdrawn,  the  external  orifice 
being  touched  with  the  argentum  nitratum, 
healed  up,  and  the  saliva  in  future  flowed 
through  the  artificial  fistulous  channel  into 
the  mouth. 

Desault  used  to  practise  the  seton  as  fol- 
lows : — He  introduced  two  fingers  of  his 
left  hand  into  the  patient’s  mouth,  and  pla- 
cing them  between  the  teeth  and  the  cheek, 
opposite  the  fistula,  thus  kept  the  integu- 
ments tense,  and  the  gums  from  being  in- 
jured. He  then  introduced  a small  hydro- 
cele trocar,  with  its  cannula,  just  before  the 


opening  of  the  posterior  part  of  the  doct, 
and  pushed  it  through  the  cheek,  in  a direc 
tion  a little  inclined  forward.  An  assistant 
now  took  hold  of  the  cannula,  while  Desault 
withdrew  the  perforator, and  passed  through 
the  tube  a bit  of  thread  into  the  cavity  of 
the  mouth.  The  cannula  was  next  taken 
out,  and  a seton,  which  was  then  fastened 
to  the  end  of  the  thread  in  the  mouth,  was 
drawn  from  writhin  outward ; but  not  so  far 
as  to  come  between  the  edges  of  the  exter- 
nal opening,  where  the  thread  alone  lodged, 
and  this  was  fastened  with  sticking-plaster 
to  the  outside  of  the  cheek.  The  outer 
wound  was  dressed  with  lint  and  compres- 
ses. Desault  used  to  change  the  seton  daily, 
introducing  regularly  rather  a larger  one, 
and  taking  especial  care  not  to  bring  it  be- 
tween the  edges  of  the  wound,  which  was 
afterward  covered  with  sticking  plaster. 
He  enjoined  the  patient  not  to  move  the 
jaw  much,  and  only  allowed  him,  for  some 
time,  liquid  food.  In  about  six  weeks  he 
used  to  omit  the  seton,  leaving  in  the  thread, 
however,  for  a little  while  longer.  This 
being  taken  way,  he  used  to  finish  the  cure 
by  touching  the  little  aperture  remaining, 
with  caustic. 

The  making  of  an  artificial  passage  is  one 
of  the  most  ancient  plans  of  curing  salivary 
fistulae.  Every  author  has  had  his  particu- 
lar method  of  doing  it,  and  numerous  va- 
riations are  to  be  met  with,  either  in  the 
instrument  employed  for  piercing  the  cheek, 
or  in  the  substance  intended  for  maintaining 
the  opening.  For  the  first  step  of  the  ope- 
ration, surgeons  sometimes  used  the  actual 
cautery,  as  Saviard  furnishes  us  an  instance 
of ; sometimes  an  awl,  as  Monro  did  ; some- 
times a common  knife,  or  lancet ; some- 
times a straight  needle,  which  drew  in  the 
thread  after  it ; but  Desault’s  trocar  gene- 
rally merits  the  preference,  because  the 
cannula,  by  remaining  in  the  wound  after 
the  perforator  is  withdrawn,  allows  the 
thread  to  be  introduced,  which  in  every 
other  way  is  either  difficult  to  accomplish, 
or  requires  the  use  of  several  instruments. 

For  the  second  step  of  the  operation,  viz. 
keeping  the  opening  distended,  cannula; 
were  employed  by  Duphenix,  wrho  used  to 
make  a suture  over  them  ; a plan  objection  - 
able, inasmuch  as  it  wras  attended  with  the 
inconvenience  of  a solid  body  left  in  the 
parts,  and  also  that  of  the  instrument  being 
apt  to  slip  into  the  mouth.  The  setoti, 
therefore,  ought  to  be  preferred,  and  there 
can  be  no  doubt  that  Desault’s  method  is 
better  than  the  one  followed  by  Monro 
(See  on  this  subject,  Monro's  Works;  CEu- 
vres Chir.  de  Desault,  par  Bichat,  T.  2,  p 
221.  Also  M&m.  de  l' Acad,  de  Chir.  T.  S. 
J.  B.  Siebold,  Diss.  sistens  Historiam  Syste- 
matis  Salivalis  physiologice  et  pathologice  con 
siderati,fol.  Jencc,  1797.) 

PAROTID  GLAND,  EXTIRPATION 
OF.  (See  Tumours.) 

PARU'LIS.  (from  r^ar,  and 

the  gum.)  An  inflammation,  boll,  or  ab 
sues?  in  the  gums- 


PENIS. 


PENIS,  AMPUTATION  OF.  No  part  of 
The  penis  should  ever  be  amputated,  on  ac- 
count of  a mortification,  because  the  dead 
portion  will  be  naturally  thrown  off,  and 
the  ulcer  heal  without  the  least  occasion 
for  putting  the  patient  to  any  pain  from  the 
employment  of  the  knife.  Some  cancerous 
and  fungous  diseases,  are  the  cases  in  which 
it  is  often  really  proper  and  necessary  to 
amputate  more  or  less  of  this  organ. 

However,  before  a surgeon  ventures  to 
do  the  operation,  he  ought  to  be  certain 
that  it  is  the  substance  of  the  penis  which 
is  incurably  diseased  ; for,  as  that  judicious 
surgeon  Callisen  remarks,  tumours,  excres- 
cences, ulcers,  and  gangrenous  mischief,  of 
the  prepuce,  sometimes  present  appearances 
which  may  lead  an  inexperienced  practi- 
tioner to  fancy  the  whole  thickness  of  the 
part  affected  with  irremediable  disorder, 
while  the  glans  is  actually  in  a sound  state. 
Hence,  whenever  the  least  doubt  exists,  it 
is  better  to  remove  first  the  prepuce  and 
skin,  in  order  that  the  true  condition  of  the 
glans  may  be  detected.  ( Callisen , Systema 
Chirurgia  Hodiemce,  pars  posterior,  p.  420, 
Hafnicc , 1800.) 

The  old  surgeons,  fearful  of  hemorrhage, 
used  sometimes  to  extirpate  a part  of  the 
penis,  by  tying  ligatures  round  it  with  suffi- 
cient tightness  to  make  it  mortify,  and 
slough  off.  Thus  Ruysch  once  performed  the 
operation.  (See  Obsv.  30)  The  plan,  how- 
ever, is  exceedingly  painful,  and  notwith- 
standing the  authority  of  Heister,  has  been 
most  properly  rejected  from  modern  surgery. 

The  amputation  may  be  done  in  the  fol- 
lowing manner  : — A circular  incision  is  to 
be  made  through  the  skin,  abcuit  a finger- 
breadth  from  the  cancerous  part.  As  Calli- 
sen observes,  it  is  hardly  ever  requisite  to 
draw'  the  skin  back  before  it  is  cut ; be- 
cause after  the  corpora  cavernosa  are  divi- 
ded, they  retract  so  considerably,  that  there 
is  always  a sufficiency  of  the  integuments. 
(Syst.  Chir.  Hodiemce,  pars  posterior,  p.  421.) 
As  soon,  therefore,  as  the  circular  incision 
through  the  skin  has  been  made,  the  cor- 
pora cavernosa  and  urethra  are  to  be  cut 
through,  by  one  stroke  of  the  knife,  on  a 
level  with  the  cut  edges  of  the  integuments. 
Sabatier  even  advises  us  to  draw  the  skin 
towards  the  glans  penis,  before  we  employ 
the  knife,  so  convinced  is  he  of  the  inutility 
of  saving  any  of  it,  and  of  the  inconveni- 
ences which  may  result  from  its  lying  over 
and  obstructing  the  orifice  of  the  urethra. 
His  mode  of  operating  is  also  particularly 
simple,  as  he  cuts  through  the  integuments 
and  penis  together  by  one  stroke  of  the 
knife,  without  making  any  preliminary  cir- 
cular division  of  the  skin.  ( Mddecine  Op6- 
ratoire , T.  3,  p.  305,  Edit.  2.) 

The  bleeding  arteries  are  now  to  be  im- 
mediately tied  : the  chief  are,  one  on  the 
dorsum  of  the  penis,  and  *one  in  each  cor- 
pus cavernosum.  When  a general  oozing 
from  the  wound  still  continues,  some  re- 
commend ( IVhile,  Hey,  §'c.)  applying  sponge 
to  its  surface  ; others  ( Latta ) finely  scraped 
agaric,  with  a small  proportion  of  pounded 


35o 

white  sugar,  or  gum  arabic.  Perhaps,  how- 
ever, finely  scraped  lint,  supported  with 
compresses,  would  be  quite  as  effectual  as 
any  styptics,  and  certainly  the  latter  appli- 
cations should  be  avoided,  if  possible,  be- 
cause stimulating,  and  productive  of  pain 
and  inflammation.  A surer  and  preferable 
method  of  stopping  the  oozing  of  blood,  and 
at  the  same  time  of  healing  the  wound, 
might  be  to  bring  the  skin  forward  over  the 
end  of  the  stump,  with  two  strips  of  sticking 
plaster,  after  introducing  a flexible  gum  ca- 
theter into  the  continuation  of  the  urethra, 
so  as  to  keep  its  orifice  unobstructed,  and 
the  urine  from  coming  into  contact  with 
the  wound.  There  can  be  little  doubt  that 
the  gum  catheter  would  be  better  than  a 
silver  one,  or  any  metallic  cannula,  com- 
monly advised  for  the  above  purposes,  be- 
cause it  lies  in  the  passage  with  less  irrita- 
tion. It  is  but  justice  to  Callisen  to  state, 
that  he  seems  to  be  one  of  the  few  good 
surgical  writers,  who  have  particularly  re- 
commended in  these  cases  the  elastic  gum 
catheter,  in  preference  to  that  made  of  sil- 
ver. (Op.  cit.  p.  421.)  In  one  case,  in 
which  Mr.  Hey  operated,  he  made  a longi- 
tudinal division  of  the  integuments,  at  the 
inferior  part  of  the  penis,  so  as  to  make  them 
cover  its  extremity  without  puckering,  or 
lying  over  the  orifice  of  the  urethra.  The 
corpora  cavernosa,  however,  do  not  readily 
granulate,  and  unite  to  the  skin  by  the  first 
intention.  (Hey,  p.  452.)  After  the  first 
dressings  are  removed,  the  part  should  be 
dressed  with  the  unguentum  spermatis  ceti, 
or  any  mild  unirritating  salve. 

In  consequence  of  the  introduction  of  a 
cannula  being  neglected,  Le  Dran  mentions 
his  having  seen  the  orifice  of  the  urethra 
become  closed  a few  hours  after  the  opera- 
tion, so  that  the  patient  could  not  make 
water.  The  orifice  of  the  passage  could 
not  be  discovered  without  great  difficulty. 
A lancet  being  introduced  at  the  point, 
against  which  the  urine  seemed  to  be  forced, 
a quantity  of  it  gushed  out,  and  as  a cannula 
was  not  at  hand,  a sound  was  introduced 
till  one  could  be  procured.  (Traitd  des 
Oper.  de  Chirurgie.) 

Pearson,  in  his  Practical  Observations  on 
Cancerous  Complaints , has  treated  of  this 
operation : he  particularly  advises  the  skin 
not  to  be  drawn  back,  because,  when  saved 
in  this  manner,  it  impedes  the  free  exit  of  the 
urine-  He  likewise  disapproves  of  introducing 
cannula),  as  creative  of  pain,  and  spasms  of 
the  urethra,  and  unnecessary,  since  the 
stream  of  urine  will  always  preserve  the 
urethra  in  a permeable  state.  (P.  103.) 

When  the  penis  is  amputated  near  the 
pubes,  the  remainder  shrinks  under  that  bone 
and  within  the  integuments  so  far,  that  it  is 
difficult  to  tie  the  arteries.  1 n order  to  obviate 
this  inconvenience,  Schreger  recommends 
the  skin  to  be  drawn  forwards,  and  fixed 
with  a band  ; then  to  make  an  incision  only 
deep  enough  to  divide  the  dorsal  arteries, 
which  are  to  be  tied,  before  the  knife  is 
used  again.  The  incision  is  then  to  be  con- 
tinued perpendicularly,  till  the  two  arteries 


35.6 


PEN 


PH  a 


of  the  eo:  pora  cavernosa  are  cut.  These  are 
now  to  be  tied.  Then  the  corpus  spongiosum 
and  its  two  arteries  are  to  be  cut  through, 
which  last  are  to  be  secured.  Lastly,  the 
rest  of  the  skin  of  the  penis  is  to  be  divided. 
In  this  way  Schreger  amputated  a diseased 
penis,  of  which  ofily  a part,  about  an  inch  in 
length,  was  sound.  . 

(Sharp,  Le  Dran,  Eertrandi , and  Sabatier's 
books  on  the  operations , may  be  consulted. 
Also,  I' Encyclopedic  Melhodique  ; Par  lie 
Chir.  Art.  Verge.  Hey' s Practical  Observa- 
tions in  Surgery,  p.  445.  Pearson  on  Can- 
cerous Complaints,  p.  103,  fyc.  Warner's 
Cases  in  Surgery,  p.  278,  Edit.  4.  E.  C. 
Biener,  De  Exlirpalione  Penis  per  Ligatu- 
ram,4to.  Lips.  1S16.  J.  H-  Thaut,  Diss.  de 
Virgce  Virilis  Statu  sano  et  morb.  ejusdem  im- 
primis ampulalione.  B.  G.  Schreger’s  Chir. 
Fersuche;  JYeue  Melhode  den  Penis  zu  Am- 
putvren , B.  l,p.  242,  8 vo.  JVurnberg,  1801.) 

PENIS,  CANCER  OF.  A wart,  or  a 
tubercle,  on  the  prepuce,  the  fraenum,or  the 
glans  penis,  is  generally  the  first  symptom, 
and  it  often  remains  in  a quiet  state  for  ma- 
ny years.  When  irritated,  however,  it  be- 
comes painful,  and  enlarges,  sometimes 
enormously  in  a very  short  time.  At  the 
same  time  ulceration,  and  a discharge  of  sa- 
nious  fetid  matter,  take  place.  The  disease 
sometimes  also  occasions  in  the  urethra  fis- 
tulous openings,  out  of  which  the  urine  es- 
capes, and  the  lymphatic  glands  in  the  groin 
may  become  affected  as  the  disease  advances. 
Mr.  Pearson  says,  that  “ cancerous  excres- 
cences have  a broad  base,  often  more  exten- 
sive than  their  superficies;  they  seem  to 
germinate  deeply  from  within,  or  rather  to 
be  a continuation  of  the  substance  of  the 
part ; and.  in  their  progressive  state,  the 
contiguous  surface  has  a morbid  appear- 
ance.” What  Mr.  P.  considers  as  a venereal 
wart,  has  a basis  smaller  than  its  surface ; 
its  roots  have  rather  a superficial  attach, 
ment,  and  the  contiguous  parts  have  a na- 
tural appearance  (p.  97.)  Such  are  this 
gentleman’s  marks  of  discrimination.  We 
might  question,  however,  whether  Mi*. 
Pearson,  notwithstanding  his  great  opportu- 
nities, ever  saw  a really  venereal  wart.  For 
many  years  past  1 have  never  seen  any  ex- 
crescences of  this  kind  in  St.  Bartholomew’s 
hospital,  which  truly  required  mercury  for 
their  cure,  or  which,  when  cured  without 
it,  were  followed  by  any  inconvenience.  If 
my  memory  does  not  fail  me,  Mr.  Aberne- 
thy  also  disbelieves  in  the  doctrine  of  vene- 
real warts. 

Foul,  spreading,  sloughy  ulcers  of  the 
penis,  should  be  discriminated  from  cancer. 
It  is  worthy  of  attention  that  almost  all  the 
cases  of  cancer  of  the  penis  recorded  by 
Mr.  Hey  were  attended  with  a congenital 
phymosis.  The  same  complication  also  ex- 
isted in  another  example,  in  which  Boyer 
performed  amputation  of  the  penis  in  la 
Charitfc,  on  account  of  a cancerous  affection 
of  the  part.  In  the  only  two  opportunities 
of  doing  this  operation,  which  M Roux  has 
had,  the  cases  were  likewise  accompanied 
with  a natural  phyrnosi's.  Hence,  this  au- 


thor considers  such  a state  of  the  prepuce 
as  particularly  conducive  to  cancer  of  the 
penis,  and  earnestly  enjoins  surgeons  to  re- 
commeud  their  patients  to  have  the  first 
inconvenience  rectified,  so  that  no  risk  of 
the  other  more  serious  affection  may  be  en- 
countered. (See  Parallele  de  la  Chirurgie 
Angloise , fyc.  p.  306,  307.)  In  two  out  of 
three  cases  which  were  reported  to  be  can- 
cerous, and  for  which  amputation  was  done 
under  my  notice,  it  did  not  appear  that  any 
degree  of  phymosis  existed.  (See  Pearson 
on  Cancerous  Complaints.  Hey's  Practical 
Observations  in  Surgery . Roux,  Voyage  fait 
en  Aagleterre  en  1814,  ou  Parallele.  de  la 
Chir.  Angloise,  tyc.  p.  306.) 

PERINEUM,  FISTULA  OF.  (See 
Fistulce  in  Perinoeo.) 

PE'RNIO.  (from  <arygva,or  <©-TS£vsi,the  heel.) 
A chilblain,  especially  on  the  heel.  (See 
Chilblain.) 

^PESSARY,  (from  ^tro-a>,  to  soften.)  The 
intention  of  pessaries  among  the  old  prac- 
titioners, was  to  keep  medicinal  substances 
applied  within  the  pudenda.  They  are  now 
never  made  use  of,  except  lor  preventing  a 
prolapsus  of  the  uterus  or  vagina,  or  for 
keeping  up  a very  uncommon  kind  of  rup- 
ture, explained  in  the  article  Hernia. 

PIIAGEDvE'NA.  (from  <t>u.yce,  to  eat.) 
An  ulcer  which  spreads,  and  as  it  were 
eats  away  the  flesh.  Hence  the  epithet, 
phagedenic,  so  common  among  surgeons. 
For  an  account  of  the  phagedoena,  gangree- 
nosa,  see  Hospital  Gangrene. 

PHARYNGOTOMY.  (from  <p*$ oy the 
pharynx,  and  rtywoo,  to  cut.)  See  (Esopha - 
gotomy. 

PHARYNGO'TOMUS.  (from  p<*gi uy f,  the 
throat,  and  to//#,  an  incision.)  An  instru- 
ment for  scarifying  the  tonsils,  and  for  open- 
ing abscesses  about  the  fauces.  It  was  in- 
vented by  Petit,  and  is  nothing  more  than  a 
sort  of  lancet  which  is  enclosed  in  a sheath. 
By  means  of  aspring  the  point  is  capable  of 
darting  out  to  a determinate  extent,  so  as  to 
make  the  necessary  wound,  without  risk  of 
injuring  other  parts. 

PHLEBO  TOMY,  (from  yyef,  a vein,  and 
n/uva,  to  cut.)  The  operation  of  opening  a 
vein,  for  the  purpose  of  taking  away  blood. 
See  Bleeding. 

PHLE'GMON.  (from  qxiyce,  to  burn.) 
Healthy  inflammation.  (See  Inflammation.) 

PHLOGO'SIS.  t(frorn  <p*cyoa>,  to  inflame.) 
An  inflammation.  A flushing. 

PHRENI'TIS.  (from  the  diaphragm, 
supposed  by  the  ancients  to  be  the  seat  of 
the  mind.)  An  inflammation  of  the  brain. 
Phrensy. 

Inflammation  of  the  brain  is  a frequent 
consequence  of  injuries  of  the  head.  The 
symptoms  are  an  increased  and  disordered 
state  of  the  sensibility  of  the  whole  nervous 
system  ; the  retina  cannot  bear  (lie  usual 
stimulus  of  light  ; the  pupils  are  contracted  ; 
the  pulse  is  frequent  and  small  ; the  eyes 
are  red  and  turgid,  arid  the  iris  sometimes 
actually  inflamed,  (E  ardrop,  Essays  on  the 
Morbid  Anal,  of  the  Eye,  Vol.  2,1  the  coun- 
tenance is  flushed,  and  the  patient  is  rest 


W-IYMOSJS 


ie.'?,  mutters  incoherently,  and  grows  wild 
and  delirious. 

Phrenitis  is  treated  on  the  antiphlogistic 
plan.  Copious  bleedings  and  other  evacua- 
tions, are  highly  proper.  Some  of  the  blood 
should  be  taken  from  the  temporal  arteries. 
The  skin  ought  to  be  kept  moist  with  anti- 
monials,  and  a counter-irritation  should  be 
excited  on  the  scalp  by  blisters. 

PHY'MA.  (from  <pva>,  to  grow.)  Tuber- 
cles comprehend  eight  genera,  and  we 
learn  from  Dr.  Bateman,  that,  under  the  ge- 
nus phyma,  the  late  Dr.  Willan  intended  to 
comprise  the  terminthus,  the  epinyctis,  the 
furunculus,  and  the  carbuncle.  (See  Bate- 
man's Synopsis  of  Cutaneous  Diseases,  p.  270, 
Edit.  3.)  According  to  Pott,  this  term  was 
formerly  applied  to  an  inflammation  near 
the  anus.  See  Anus , Abscesses  of  . 

PHYMOSIS,  or  rather  Phimosis,  (from 
Vi/uoc,  a muzzle.)  A case  in  which  the  pre- 
puce cannot  be  drawn  back,  so  as  to  unco- 
ver the  glans  penis.  It  is  of  two  kinds, 
viz.  accidental , and  natural  or  congenital. 
Both  the  accidental  phymosis,  and  para- 
phymosis,  according  to  Mr.  Hunter,  arise 
from  a thickening  of  the  cellular  membrane 
of  the  prepuce,  in  consequence  of  an  irrita- 
tion capable  of  producing  considerable  and 
diffused  inflammation.  A chancre  is  a fre 
quent  cause ; but  a mere  inflammation  and 
discharge  from  the  glans  and  prepuce,  and 
also  a gonorrhoea,  may  bring  on  these  affec- 
tions. The  inflammation  often  runs  high, 
and  is  frequently  of  the  erysipelatous  kind. 
The  cellular  membrane  being  loose,  the  tu- 
mefaction becomes  considerable,  and  the 
end  of  the  prepuce  being  a depending  part, 
the  serum  often  lodges  in  it,  and  makes  it 
oedematous.  A congenital  contraction  of 
the  aperture  of  the  prepuce  is  very  common, 
and  persons  so  affected  have  a natural  and 
constant  phymosis.  Such  a state  of  parts 
(says  Mr.  Hunter)  is  often  attended  with 
chancres,  and  it  produces  very  great  incon- 
veniences during  the  treatment.  When 
there  is  considerable  diffused  inflammation, 
a diseased  phymosis  similar  to  the  natural 
one,  unavoidably  follows;  and  whether 
diseased  or  natural,  it  may  produce  a para- 
phymosis,  simply  by  the  prepuce  being 
brought  back  upon  the  penis.  This  tight 
part,  then  acting  as  a ligature  round  the 
body  of  the  penis,  behind  the  glans,  retards 
the  circulation  beyond  the  constriction,  so 
as  to  produce  an  oedematous  inflammation 
on  the  inverted  part  of  the  prepuce. 

When  the  prepuce  is  very  long,  phymosis 
may  also  arise  from  the  swelling  of  the 
glans  penis,  produced  by  sores  on  the  latter 
part,  or  the  irritation  of  a severe  gonor- 
rhoea. ( Travers  in  Surgical  Essays,  Part  1, 
p.  132.)  My  own  observations  lead  me  to 
consider  an  irritation  and  swelling  of  the 
prepuce  itself  as  by  far  the  most  common 
causes  of  the  accidental  phymosis. 

In  some  children,  the  natural  or  congenital 
phymosis  is  so  considerable,  that  the  urine 
cannot  pass  with  ease  ; but  the  aperture  of 
the  prepuce  generally  becomes  larger  as 
they  grow  older,  and  the  bad  consequences 


which  the  phymosis  might  have  occasioned 
in  disease,  are  thus  avoided. 

In  certain  individuals,  especially  old  men, 
the  prepuce  sometimes  contracts  without 
any  visible  cause  whatever,  and  becomes  so 
narrow  as  to  hinder  the  water  from  getting 
out,  even  after  it  has  got  free  of  the  urethra, 
and  consequently,  the  whole  cavity  of  the 
prepuce  becomes  filled  with  urine,  attended 
with  great  pain. 

In  phymosis,  when  the  prepuce  swells  and 
thickens,  more  and  more  of  the  skin  of  the 
penis  is  drawn  forwards  over  the  glans,  and 
the  latter  part  becomes  at  the  same  time 
pushed  backward  by  the  ^welling  against 
its  end.  From  such  a cause  Mr.  Hunter  has 
seen  the  prepuce  projecting  more  than 
three  inches  beyond  the  glans,  with  its 
aperture  much  diminished. 

Mr.  Hunter  also  notices,  that  the  prepuce 
often  becomes,  in  some  degree,  inverted, 
by  the  inner  skin  yielding  more  than  the 
outer,  and  the  part  seems  to  have  a kind  of 
neck  where  the  outer  skin  naturally  termi- 
nates. From  the  tightness  and  distention 
of  the  parts,  the  prepuce  now  cannot  be 
drawn  more  back,  so  as  to  expose  any  sores, 
which  may  be  situated  under  it.  This  state 
is  frequently  productive  of  bad  consequen- 
ces, especially  when  there  are  chancres  be- 
hind the  glans  ; for,  the  glans  being  between 
the  orifice  of  the  prepuce  and  the  sores,  the 
matter  sometimes  cannot  get  a passage  for- 
ward, between  the  glans  and  prepuce,  and, 
consequently,  it  accumulates  behind  the  co- 
rona glandis,  so  as  to  form  a kind  of  abscess, 
which  produces  ulceration  on  the  inside  of 
the  prepuce.  This  abscess  bursts  externally, 
and  the  glans,  often  protruding  through  the 
opening,  the  whole  prepuce  becomes  thrown 
towards  the  opposite  side,  and  the  penis 
seems  to  have  two  terminations.  On  the 
other  hand,  (says  Mr.  Hunter)  if  the  pre- 
puce is  loose  and  wide,  and  is  either  accus- 
tomed to  be  kept  back  in  its  sound  state,  or 
is  pulled  back  to  admit  of  the  chancres  be- 
ing dressed,  and  is  allowed  to  remain  in 
this  situation,  till  the  above  tumefaction 
takes  place,  the  case  is  then  named  a para- 
phymosis.  Also,  when  the  prepuce  is  pulled 
forcibly  back,  after  it  is  swelled,  it  is  then 
brought  from  the  state  of  a phymosis  to 
that  of  a paraphymosis.  The  latter  case  is 
often  attended  with  worse  symptoms  than 
the  former,  especially  when  it  has  first  been 
a phymosis.  According  to  Mr.  Hunter,  the 
reason  of  this  is,  that  the  aperture  of  the 
prepuce  is  naturally  less  elastic  than  any 
other  part  of  it ; therefore,  when  the  pre- 
puce is  pulled  back  upon  the  body  of  the 
penis,  that  part  grasps  it  more  tightly  than 
any  other  portion  of  the  skin  of  Ihe  penis, 
and  more  so,  according  to  the  inflammation . 
Hence,  there  are  two  swellings  of  the  pre- 
puce, one  close  to  the  glands;  the  other 
behind  the  stricture.  The  constriction  is 
often  so  great  as  to  interrupt  the  circulation 
beyond  it.  This  increases  the  swelling,  adds 
to  the  stricture,  and  often  produces  a morti- 
fication of  the  prepuce  itself,  by  which  means 
the  whole  diseased  part,  together  with  the 


356 


PHIMOSIS. 


stricture,  is  sometimes  removed,  forming, 
as  Hunter  ably  expresses  himself,  a natural 
cure.  In  many  cases,  the  skin  and  pre- 
puce are  not  the  only  parts  affected  ; adhe- 
sions, and  even  mortification  may  also  take 
place  in  the  glans,  corpora  cavernosa,  &,c. 
(See  Hunter  on  the  Venereal,  221,  ^c.) 

An  accidental  phymosis  should  always  be 
prevented  if  possible,  and  therefore,  says 
Mr.  Hunter,  upon  the  least  signs  of  a thick- 
ening of  the  prepuce,  which  is  known  by 
its  being  retracted  with  difficulty  and  pain, 
the  patient  should  be  kept  quiet  ; if  in  bed, 
so  much  the  better,  as  in  a horizontal  posi- 
tion, the  end  of  Jhe  penis  will  not  be  so  de- 
pending. If  confinement  in  bed  cannot  be 
complied  with,  the  end  of  the  penis  should 
be  kept  up,  though  this  can  hardly  be  done 
when  the  patient  is  walking  about.  The 
object  of  this  plan  is  to  keep  the  extrava- 
ted  fluids  from  gravitating  to  the  prepuce, 
which  they  would  hinder  from  being  drawn 
back  again  even  more  than  the  inflammation 
itself. 

When  phymosis  is  recent,  and  attended 
with  swelling  of  the  glans  or  prepuce  from 
inflammation,  Mr.  Travers  recommends  in- 
jections of  tepid  water,  or  milk  and  water, 
beneath  the  foreskin  ; and  the  immersion  of 
the  penis  three  or  four  times  a day,  in  a te- 
pid bath,  keeping  the  end  of  the  penis  up- 
wards ; and  the  use  of  leeches ; which  I 
think  with  him  and  other  writers,  (see  Did. 
des  Sciences  Med.  T.  41,  p.  334,)  should  ne- 
ver be  put  exactly  on  the  swelled  prepuce 
itself.  As  the  inflammation  subsides,  injec- 
tions of  weak  goulard,  or  the  solution  of 
alum,  or  liquor  calcis  and  calomel,  may  be 
substituted.  ( Travers,  Surgical  Essays,  Part 
l,p.l36.)  Instead  of  warm  applications, 
some  practitioners  prefer  cold  : and  it  is  yet 
an  unsettled  question  which  remedies  an- 
swer best. 

When  the  inflammation  is  of  longer 
standing,  the  swelling  compresses  the  ure- 
thra, and  there  is  tendency  to  abscess,  ul- 
ceration of  the  latter  passage,  extravasation 
of  urine,  land  gangrene  of  the  skin,  Mr. 
Travers  advises  the  employment  of  emol- 
lient poultices  and  fomentations  (the  com- 
mon practice,  I believe,)  and  the  introduc- 
tion of  a small  elastic  gum-catheter  into  the 
bladder.  “ This  (says  he)  is  not  a practice 
indicated  by  the  degree  of  stricture,  which 
is  seldom  considerable  enough  to  require 
it : but,  by  the  approaching  danger  of  ex- 
travasation. It  should  not , therefore,  be  taken 
up,  unless  the  cellular  membrane  of  the  penis 
has  advanced  to  suppuration.'' 

As  when  there  are  sores,  they  cannot  be 
dressed  in  the  common  way,  injections  must 
frequently  be  thrown  under  the  prepuce,  or 
the  operation  for  phymosis  performed.  Mr. 
Hunter  advises  mercurial  injections  ; either 
crude  mercury,  rubbed  down  with  a thick 
solution  of  gum-arabic  ; or  calomel  with 
the  same,  and  a proportion  of  opium  ; or 
else  a solution  of  one  grain  of  the  oxymu- 
riate  of  mercury  in  one  ounce  of  water. 
Mr.  Hunter  also  recommends  the  applica- 
tion of  emollient  poultices,  with  laudanum 


in  them,  and  to  let  the  part,  previously  to 
the  application  being  made,  hang  over  the 
steam  of  hot  water,  with  a little  vinegar  and 
spirit  of  wine  in  it. 

When,  in  a case  of  phymosis,  chancres 
bleed,  Mr.  Hunter  recommends  the  oil  of 
turpentine  as  the  best  stimulus  for  making 
the  vessels  contract ; but,  when  the  hemor- 
rhage proceeds  from  irritation,  he  recom- 
mends sedatives.  Whatever  is  used,  he 
says,  must  be  injected  under  the  prepuce. 
Under  such  circumstances,  it  has  always 
been  a rule  with  me  to  avoid  irritating  ap- 
plications, and  on  this  account  I have  never 
used  turpentine,  particularly  as  any  trouble- 
some bleeding  from  chancres  may  always 
be  effectually  checked  by  covering  the  pe- 
nis with  linen  kept  well  wet  with  very  cold 
water.  When  the  inflammation  has  abated, 
Mr.  Hunter  advises  moving  the  prepuce  oc- 
casionally, to  prevent  its  becoming  adhe- 
rent to  the  glans.  He  says,  he  has  seen  the 
opening  of  the  prepuce  so  much  contract- 
ed, from  the  internal  ulcers  healing  and  uni- 
ting, that  there  was  hardly  any  passage  for 
the  water.  If  the  passage  in  the  prepuce, 
so  contracted,  be  in  a direct  line  with  the 
orifice  of  the  urethra,  a bougie  must  be 
used.  If  otherwise,  the  operation  of  slit- 
ting up,  or  removing  part  of  the  prepuce, 
becomes  necessary. 

When  matter  is  confined  under  the  pre- 
puce, in  the  manner  above  described,  Mr. 
Hunter  recommends  laying  the  prepuce 
open,  from  the  external  orifice  to  the  bot- 
tom, where  the  matter  lies,  as  in  a sinus  or 
fistula.  However,  Mr.  Hunter  thinks  laying 
open  the  prepuce  for  the  :nre  purpose  of 
applying  dressings  unnecessary,  as  the  sores 
may  be  washed  with  injections,  by  means 
of  a syringe. 

I happened  to  serve  my  apprenticeship  at 
St.  Bartholomew’s,  at  a time  when  the  fa- 
shion of  cutting  every  phymosis,  inflamed 
or  not,  was  far  too  common,  and  I had 
abundant  opportunities  of  witnessing  the  ir- 
reparable gangrenous  mischief  frequently 
thus  produced.  It  gives  me  pleasure,  there- 
fore, to  find  this  villanous  practice  justly 
disapproved  of  by  a modern  writer.  “ It 
is  not  adviseable,  (says  Mr.  Travers,)  to  cut 
the  inflamed  prepuce,  nor,  indeed,  any  in- 
flamed part.  I lately  saw  a phymosis  indu- 
ced by  a thickened  and  rigid  state  of  the 
membrane  of  the  prepuce,  during  the  free 
use  of  mercury,  constitutionally  and  locally, 
for  the  cure  of  two  sores,  each  of  the  size 
of  a split  pea,  situated  one  on  each  side  of 
the  anterior  fold  of  the  prepuce.  It  was 
the  opinion  of  an  eminent  surgeon,  that 
those  sores,  wdiicli  were  thoroughly  intract- 
able, would  not  heal  unless  the  prepuce 
was  freely  divided  ; and,  impressed  with 
the  same  idea,  after  poulticing  for  some 
days,  I slit  it  up.  The  sores  immediately 
healed  ; but  the  wound  as  quickly  assumed 
the  same  indolent  and  intractable  character 
which  had  belonged  to  the  sores,  and  was 
so  slow  in  healing,  that  it  seemed  to  he 
only  a transfer  of  the  disease  from  one  part 
to  another.”  (P.  139.)  f have  not  only 


PHYMOSIS 


359 


>vitnessed  the  same  fact,  in  several  cases 
under  the  late  Mr.  Ramsden,  and  in  St. 
Bartholomew’s  Hospital,  but  have  seen  mor- 
tification brought  on  by  the  still  more  rash 
practice  of  cutting  the  prepuce  either  when 
the  part  was  in  a state  of  acute  inflamma- 
tion, or  there  were  ulcers  within  it,  when 
the  constitution  was  in  a reduced  and  very 
disordered  state  from  the  injudicious  and 
immoderate  use  of  mercury. 

The  common  operation,  for  the  cure  of 
phymosis,  consists  in  slitting  open  the  pre- 
puce, nearly  its  whole  length,  in  the  direc- 
tion of  the  penis.  This  plan  is  certainly  the 
most  eligible,  when  the  matter  of  a chancre 
cannot  escape  from  under  the  prepuce  ; be- 
cause circumcision,  which  many  surgeons, 
since  Mr.  Hunter’s  time,  have  preferred, 
would  not  suffice  forgiving  vent  to  the  ac- 
cumulated pus.  In  many  cases  of  phymo- 
sis, says  Mr.  Hunter,  an  operation  is  impro- 
per; for,  while  the  inflammation  is  very 
considerable,  such  a measure  might  bring 
on  mortification.  He  acknowledges,  how- 
ever, that  there  are  cases,  in  which  a free- 
dom given  to  the  parts  would  prevent  the 
latter  event.  When  matter  is  confined  un- 
der the  prepuce,  an  opening  is  indispensa- 
ble, and,  if  the  patient  should  object  to  the 
common  operation,  an  opening  should  be 
made  with  a lancet  directly  through  the 
prepuce,  or  else  with  a caustic.  (See  Hun- 
ter on  the  Venereal  Disease, p.  232,  etseq .) 

When  the  prepuce  is  to  be  slit  open,  a di- 
rector is  first  to  be  introduced  under  it,  and 
the  division  is  then  to  be  made  with  a curved 
pointed  bistoury,  from,  within  upward. 

Many  surgeons  object  to  this  operation, 
because  the  prepuce  continues  afterward  in 
a very  deformed  state  ; and  they  perform 
circumcision,  or  amputation  of  the  prepuce, 
?n  the  following  manner.  The  prepuce  is 
first  taken  hold  of  with  a pair  of  forceps, 
•as  much  of  the  part  being  left  out,  as  is 
judged  necessary  to  be  removed.  The  re- 
moval is  then  accomplished  by  one  sweep 
of  the  knife,  which  directed  by  the  blades 
°/  the  forceps,  is  sure  of  making  the  inci- 
sion in  a straight  and  regular  manner.  A 
fine  suture  is  next  passed  through  the  edges 
of  the  inner  and  outer  portions  of  the  skin 
of  the  prepuce  so  as  to  keep  them  together. 

The  anly  necessary  dressings  are  lint,  and 
over  it  an  emollient  poultice. 

At  the  period  when  I first  entered  the 
profession,  it  was  the  custom  to  salivate 
every  patient  who  happened  to  have  a phy- 
mosis. Howrever,  now  that  the  fact  of  any 
irritation  about  the  prepuce  and  glans  penis, 
even  that  of  common  warts,  being  capable 
of  producing  the  complaint  is  well  known, 
such  absurd  practice  has  been  relinquished, 
and  the  cause  and  condition  of  the  disease 
are  always  considered  previously  to  the  de- 
termination for  any  particular  method  of 
treatment.  Nay,  even  when  phymosis  does 
arise  from  chancres,  if  there  be  a great 
deal  ot  inflammation,  the  use  of  mercury 
may  rather  do  harm  than  good,  and  the 
practitioner  should  not  be  precipitate  in  its 
administration  On  this  point.  I fully  coin- 


cide with  Mr.  Travers  : — Upon  many  oc- 
casions (says  he)  practitioners  are  too 
anxious  to  contend  with  the  scientific  cha- 
racter of  the  venereal  disease,  to  the  neglect 
of  the  inflammatory  state  of  the  affected 
parts  exhibited  duringits  height.  The  abuse 
of  administering  mercury  for  an  acute  go- 
norrhoea, and  recent  sores,  accompanied  by 
phymosis,  or  an  approach  to  that  state,  is  of 
common  occurrence,  and  it  is  far  from  being 
recognized  by  the  profession,  as  an  estab- 
lished rule  of  practice,  that  its  constitutional 
administration  is  inadmissible  during  the 
existence  of  active  inflammation,  in  cellular 
textures.”  ( Surgical  Essays,  Part  1 ,p.  131.) 

In  nine  cases  out  of  twelve,  in  which  the 
experienced  Mr.  Hey  had  occasion  to  am- 
putate the  penis  for  cancerous  disease,  the 
patients  were  also  affected  with  a natural 
phymosis.  ( Pract . Obs.  in  Surgery.)  Roux 
has  noticed  the  same  thing  in  three  similar 
examples,  and,  therefore,  as  he  conceives 
that  phymosis  may  be  conducive  to  carci- 
noma of  the  penis,  he  thinks  that  it  should 
always  be  remedied  in  time.  (Parallble  de 
la  Chir.  Angloise,  p.  306.) 

TREATMENT  OF  PARAPHYMOSIS. 

The  removal  of  the  stricture  in  this  case 
should  always  be  effected,  because  its  con- 
tinuation is  apt  to  produce  a mortification 
in  the  parts,  between  the  stricture  and  the 
glans.  It  may  be  done  in  two  ways  ; either 
by  compressing  with  the  fingers  all  the 
blood  out  of  the  swelled  glans  so  as  to  ren- 
der this  part  sufficiently  small  to  allow  the 
constricting  prepuce  to  be  brought  forward 
over  it,  with  the  aid  of  the  two  fingers  ; or 
by  dividing  the  stricture  with  a knife.  In 
the  last  edition  of  this  work,  as  Mr.  Dunn 
of  Scarborough  has  reminded  me,  the  power 
of  cold  applications,  in  promoting  the  re- 
duction of  the  glans,  should  have  been  men- 
tioned. This  method  should  always  be  put 
in  practice,  before  the  reduction  by  com- 
pression is  attempted,  as  a preliminary 
measure,  wiiich  sometimes  succeeds  of 
itself,  and  renders  unnecessary  any  painful 
handling  of  the  parts.  From  the  great 
success,  which  I have  seen  attend  the 
first  mode,  I should  not  conceive  the  second 
one  so  frequently  necessary,  as  Mr.  Hunter 
seems  to  lay  down.  This  operation  is 
always  troublesome  to  accomplish,  because 
the  swelling,  on  each  side  of  the  stricture, 
covers  or  closes  the  tight  part,  which  cannot 
be  got  at  without  difficulty.  Mr.  Hunter 
says,  the  best  way  is  to  separate  the  two 
swellings,  as  much  as  possible,  where  you 
mean  to  cut,  so  as  to  expose  the  constricted 
part ; then  take  a crooked-pointed  bistoury, 
pass  it  under  the  constriction,  and  divide 
it.  None  of  the  swollen  skin,  on  each  side, 
should  be  cut.  The  prepuce  may  now  be 
brought  forward,  unless  it  be  thought  more 
convenient,  for  the  purpose  of  dressing  the 
chancres,  to  let  it  remain  in  its  present  situ- 
ation. (See  Hunter  on  the  Venereal  Dis- 
ease, p.  238,  239.) 

The  original  disease  producing  phymosis 
and  parapbymosis,  must  always  be  attended 


/*()0 


PIL 


PIL 


to,  and  the  employment  of  mercury  must  be 
necessary  or  unncessary,  according  to  the 
nature  of  the  affection,  of  which  these  are 
only  effects. 

One  of  the  most  interesting  writers  on  Phy - 
inosis  and  Paraphymosis  is  J.  L.  Petit,  Trails 
(Its  Mai.  Chir.  T.  2 ; many  of  whose  valuable 
observations  are  contained  in  the  2 d vol.  of  the 
First  Lines  of  Surgery , 8 vo.  1820.  Consult 
also  J.  Hunter  on  the  Venereal  Disease.  Sa- 
batier, Medecine  Op&ratoire,  T.S,  8 vo.  Paris, 
1810.  Travers , in  Surgical  Essays,  Part  1, 
8 no.  Loud.  1818.  There  is  also  a valuable 
chapter  on  this  subject  in  Richter's  Anfangsgr. 
der  Wundarzn.  B.  6. 

PILES.  (See  Hemorrhoids.) 

PILULES  AMMONIARETI  CUPRI  — 
ft.  Cupri  Ammoniareti  gr.  xvj.  Micee  Panis 
3)iv.  Liquoris  Ammon,  q.  s.  M.  fiant  pilulae 
xxxii.  (Edinb.  Disp.)  This  is  said  to  be  the 
best  form  of  exhibiting  copper  internally, 
which  mineral  some  think  worthy  of  trial  in 
cases  of  gleets. 

PILULE  ARGENTI  NITRAT1S.  ft. 
Argenti  Nitratis  gr.  iij.  Aquae  Distillates  gutt. 
aliquot.  Micae  Panis  q.  s.  ut  fiant  pil.  xx. 
The  author  of  the  Pharmacopoeia  Chirurgica 
suggests  the  trial  of  these  pills  in  obstinate 
leprous,  and  other  cutaneous  affections,  and 
phagedenic,  anomalous  ulcers,  connected 
with  constitutional  causes.  Two  or  three 
may  be  given  twice  a day.  Dr.  Powell  gave 
the’argentum  nitratum  internally,  in  a case 
of  hydrophobia,  but  without  any  sensible 


effect. 

PILULE  COLOCYNTIIIDIS  CUM 
HYDR.  SUBM.  ft.  Extracti  Colocynth. 
comp.  3’»j.  Hydr.  Submur.  gr.  xii.  Saponis 
3j.  Misce.  ut  fiant  pilulae  duodecim.  Two 
of  these  pills  operate  as  a purgative,  and 
they  ace  often  prescribed  in  various  surgi- 
cal cases. 

PILULES  CONIL  ft.  Extracti  Conii  3ss. 
Pulv.  Herb.  Cicutae  q.  s.  fiant  pil.  lx.  These 
are  the  hemlock  pills  in  use  at  Guy's  Hos- 
pital. Cicuta  is  occasionally  given  in  scro- 
fulous, cancerous,  and  venereal  cases. 
The  surgeon  should  begin  with  small  doses, 
and  increase  them  gradually,  till  nausea  and 
headach  arise.  From  one  to  a greater 
number  of  these  pills  may  be  given,  in  this 
manner,  every  day. 

PILULE  CUPRI  SULPHATtS.  ft. 
Cupri  Sulphatis  gr.  xv.  Olibani  Extracti 
Cinchona;,  sing.  3'j-  Syrup,  simpl.  q.s.  fiant 
pil.  lx.  From  one  to  four  of  these  pills  may 
be  given  in  a day,  for  gleets.  ( Pliarm . 
Chirurg.) 

PILUL  E HYDRARGYRI.  Of  these,  I 
need  only  observe  here,  that  the  usual  dose 
is  ten'  grains.  (See  Mercury.) 

PILULAE  HYDRARGYRI  OXYDI  RU- 


BRI.  One  grain  of  this  preparation  in  each 
pill  is  the  dose,  which  is  commonly  taken  at 
bedtime.  (See  Mercury.) 

PILULE  HYDRARGYRI  CUM  CONIO. 
ft.  Hydrargyri  puriiicati  drach.  j.  Arabici 
gummi  pulverisati  drach.  ij.  Extracti  Conii 
drach.  j.  Herb®  Cicutae  foliorum,in  pulve- 
rem  tritorum,  q.  s.  The  quicksilver  is  to  be 
first  reduced  by  triture  with  the  gum  arabic, 


moistened  with  a little  rain  water.  The  in- 
spissated juice  of  hemlock  is  afterward  to  her 
added,  and  lastly,  the  powdered  leaves  in 
sufficient  quantity  to  make  a suitable  mas* 
for  pills.  These  with  a slight  variation  in 
the  proportion  of  the  hemlock,  are  the 
pilules  mercuriales  of  Plenck,  who  directs 
three  or  four  pills,  each  of  three  grains,  to 
be  given  every  night  and  morning. 

There  are,  no  doubt,  many  cases,  to  which 
this  formula  must  be  very  suitable  ; as  for 
instance,  the  enlarged  prostate  gland,  and 
some  forms  of  bronchocele,  &c.  For  such 
diseases.  Dr.  Saunders,  in  his Formulce  Selectee , 
directs  equal  parts  of  pil.  hydrarg.  andex- 
tractum  conii.  ( Pharm . Chir.) 

PILULE  HYDRARG.  SUBMUR.  ft. 
Hydrarg.  Submur.  gr.  xij.  Conservae  Cynos- 
bati  quod  satis  sit.  M.  fiant  pil.  xii.  These 
are  the  calomel  pills  in  common  use.  Sur- 
geons give  one,  or  two  of  them  daily,  as  al- 
teratives, in  numerous  cases.  At  Guy’s  Hos- 
pital, they  add  three  grains  of  the  pulvis 
opiatus  to  each  pill,  using  syrup,  instead  of 
the  conserve. 

PILUL/E  HYDRARG.  SUBMUR.  CUM 
CONIO.  ft.  Hydrarg.  Submur.  gr.  vj.  Ex- 
tracti Conii  3j.  M.  fiant  pil.  xii.  One  maybe 
given  thrice  a day,  in  scirrhous,  cancerous, 
scrofulous,  and  some  anomalous  diseases, 
resembling  venereal  diseases. 

PILULE:  HYDRARGYRI  SUBMUR. CUM 
ANTIMONIO  TARTARISATO.  ft.  Hy- 
drarg. Submur.  3j-  Antimon.  Tga-t.  gr.  xv. 
Opii.  Pur.  3ss.  Syrupi  simpl.  q.  s.  fiant  pil 
Jx.  One  of  these  is  given  twice  a day,  in  St. 
Thomas’s  Hospital,  in  cases  of  diseased 
joints.  As  the  author  of  the  Pharm.  Chirurg. 
adds,  they  are  also  of  use  in  herpetic 
affections,  and  obstinate  ulcers.  The  union 
of  antimony  with  quicksilver,  according  to 
Dr.  G.  Fordyce,  quickens  the  specific  opera- 
tion of  the  latter. 

pilule:  hydrarg.  submur.  com- 
posite:. ft.  Hydrarg.  Subm.  Sulph.  An- 
tim.  Prajcip.  sing.  gr.  xii.  Guaiaci  Gummi 
Resina;  gr.  xxiv.  Saponis  q.  s.  M.  fiant  pil. 
xii.  Similar  to  Plummer’s  pills:  In  porrigo, 
herpetic  affections,  and  many  anomalous 
diseases,  they  are  exceedingly  useful.  Some 
diseased  enlargements  of  the  breast,  and  tes- 
ticle, seem  also  to  be  benefited  by  them. 

PILULE!  OPII.  These  need  ^mly  be 
mentioned  among  such  as  are  of  eminent 
utility  in  surgery. 

pilule:  opii  composite:,  ft.  Opii 

Purif.  Camphor®,  sing.  3j-  Antim.  Tart.  gr. 
xv.  Syrup.  Simpl.  q.  s.  fiant.  pil.  Ix.  Used 
for  alleviating  pain,  and  keeping  up  a gentle 
perspiration  ; are  particularly  useful  in  pre- 
venting painful  erections,  in  cases  of  gonor- 
rhoea, chordee,  &c.  (See  Pharm.  Chir.) 

PILULE:  PLUMBI  ACETATIS.  ft.  Plum- 
bi  Acetatis  gr.  xii.  Opii  Purif.  gr.  vj.  Con- 
serv.  Cynosbati  q.  s.  M.  fiant  pil.  xii.  One 
may  be  given  thrice  a day.  Gleets  are, 
perhaps,  the  only  cases,  in  which  surgeons 
can  employ  these  pHls.  . 

pilule:  sode:  cum  sapone.  ft. 

Sod®  3j.  Saponis  3j.  M.  Fiant  pil.  xii. 
Four  may  be  given  thrice  a clay,  in  cases  ol 


POLYPUS. 


lbtonchoceie,  and  indurations  of  the  absor- 
bent glands  from  scrofula. 

PILULE  ZINCI  SULPHATIS.  R.  Zinci 
Sulphatis,  3 * j - Terebiuthinse  q.  s.  Fiant  pi!, 
lx.  One,  or  two,  are  occasionally  given,  in 
cases  of  gleets,  thrice  a day. 

PLAN  1'ARIS  MUSCLE.  This  long  slen- 
der muscle  of  the  leg  is  said  to  be  sometimes 
ruptured,  particularly  in  dancing  and  leap- 
ing. The  surgeon  can  do  little  more  than 
advise  rest,  and  the  same  posture  of  the  limb, 
as  in  the  rupture  of  the  tendo  Achillis. 
(See  Tendon.) 

POLYPUS,  (from  .-a row;,  many,  and 
a foot.)  A kind  of  tumour,  w hich  is  gene- 
rally narrow  where  it  originates,  and  then 
becomes  wider,  somewhat  like  a pear ; 
which  is  most  commonly  met  with  in  the 
nose,  uterus,  vagina,  andjantrum  ; and  which 
received  its  name  from  an  erroneous  idea, 
that  it  usually  had  several  roots,  or  feet,  like 
polypi,  or  zoopkites. 

Polypi  more  frequently  grow  in  the  cavity 
of  the  nose,  from  the  Schneiderean  mem- 
brane, than  any  other  situation,  and  are 
visibly  of  different  kinds  ; some  being  red, 
soft,  and  sensible  ; but  free  from  pain,  and 
exactly  like  a piece  of  healthy  flesh.  This, 
which  has  been  termed  the  fleshy  polypus , is 
the  most  common,  and  fortunately  the  most 
easy  of  cure.  Other  polypi  are  called  ma- 
lignant, being  hard,  scirrhous,  and  painful : 
some  are  said  to  be  even  capable  of  con- 
version into  carcinoma.  Richter  describes 
another  kind  of  nasal  polypus,  which  is  pale, 
very  tough,  and  secretes  a viscid  discharge  ; 
which  undergoes  an  alteration  of  its  size 
with  every  change  of  the  weather;  and 
which  is  rather  a relaxation,  or  elongation, 
of  a part  of  the  Schneiderean  membrane, 
than  a polypous  excrescence.  The  whole 
membranous  lining  of  the  nostrils  is  some- 
times relaxed,  and  thickened  in  this  manner, 
so  as  nearly  to  till  all  the  cavity  of  the  nose 
( Jinfangsgr . der  Wundarzn.  B.  1,  Knp.  21.) 

Mr.  Pott  has  taken  great  pains  to  explain, 
that  there  is  one  kind  of  polypus,  originally 
benign;  another  originally  malignant.  He 
states,  that  those  which  begin  with,  or  are 
preceded  by  considerable,  or  frequent  pain 
in  the  forehead  and  upper  part  of  the  nose, 
and,  which,  as  soon  as  they  can  be  seen,  are 
either  highly  red,  or  of  a dark  purple  colour  ; 
those,  which  from  the  time  of  their  being 
first  noticed,  have  never  been  observed  to 
be  sometimes  bigger,  sometimes  less,  but 
have  constantly  rather  increased  ; those,  in 
which  coughing,  sneezing,  or  blowing  the 
nose,  gives  pain,  or  produces  a very  disa- 
greeable sensation  in  the  nostril,  or  forehead; 
those  which,  when  within  reach,  are  painful 
to  the  touch,  or  which,  upon  being  slightly 
touched,  are  apt  to  bleed ; those  which 
seem  to  be  fixed,  and  not  moveable  by  the 
action  of  blowing  the  nose,  or  of  driving  the 
air  through  the  affected  nostril  only  (when 
the  polypus  is  only  on  one  side;) those  which 
are  incompressibly  hard,  and  which,  when 
pressed,  occasion  pain  in  the  corner  of  the 
eye,  and  forehead,  and  which,  if  they  shed 
anv  thing,  shed-  blood  ; those  which  hv 
Tor.  I f 46 


361 

adhesion  occupy  a very  considerable  space, 
and  seem  to  consist  of  a thickening,  or  of 
an  enlargement  of  all  the  membrane  cover- 
ing the  septum  narium  ; those  which  some  - 
times shed  an  ichorous,  offensive,  discolour- 
ed discharge  ; and  those,  round  whose  lower 
part,  within  the  nose,  a probe  cannot 
easily  and  freely  be  passed,  and  that  to  some 
height,  ought  not  to  be  attempted,  at  least 
by  the  forceps,  nor  indeed  by  any  other 
means  ; and  this  for  reasons  obviously  dedu- 
cible  from  the  nature  and  circumstances  of 
the  polypus.  On  the  one  hand,  the  very  large 
extent  and  quantity  of  adhesion  will  render 
extirpation  impracticable,  even  if  the  dis- 
ease could  be  comprehended  within  the  for- 
ceps, which  it  very  frequently  cannot ; and 
on  the  other,  the  malignant  nature  of  the 
distemper  may  render  all  partial  removal,  all 
unsuccessful  attacks  on  it,  and  indeed  any 
degree  of  irritation,  productive  of  the  most 
disagreeabie  consequences. 

But,  the  polypi,  which  are  of  a palish  or 
grayish  light-brown  colour,  or  iook  like  a 
membrane  just  going  to  be  sloughy  ; which 
are  seldom  or  never  painful,  nor  become  so 
upon  being  pressed  ; which  have  appeared 
to  be  at  one  time  larger,  at  another  less,  as 
the  air  has  happened  to  be  moist  or  dry  ; 
which  ascend  and  descend  freely  by  the  action 
of  respiration  through  the  nose  ; which  the 
patient  can  make  to  descend  by  stopping  the 
nostril  which  is  free,  or  even  most  free,  and 
then  driving  the  air  through  that  which  the 
polypus  possesses  ; which  when  pressed  give 
no  pain,  easily  yield  to  such  pressure,  be- 
come flat  thereby,  and  distil  a clear  lymph  ; 
and  round  whose  lower  and  visible  part  a 
probe  can  easily,  and  that  to  some  height, 
be  passed,  are  fair  and  fit  for  extraction  ; 
the  polypus,  in  these  circumstances,  fre- 
quently coming  away  entire  : or,  if  it  does 
n >t,  yet  it  is  retnoveable  without  pain,  he- 
morrhage, or  hazard  of  any  kind  ; the  se- 
cond of  which  circumstances  Mr.  Pott  can 
with  strict  truth  affirm,  he  never  yet  met  with 
when  thedisease  was  at  all  fitforthe  operation. 

Of  the  benign  kind  of  polypus,  fit  for  ex- 
traction, there  are  (says  Mr.  Pott)  two  sorts, 
whose  principal  difference  from  each  other 
consists  in  their  difierent  origin  or  attach 
ment.  That  which  is  most  freely  moveable 
within  the  nostril,  upon  forcible  respiration  ; 
which  has  been  found  to  be  most  liable  to 
chanoe  of  size,  at  different  times  and  seasons; 
which  has  increased  the  most  in  the  same 
space  of  time  ; which  seems  most  limpid, 
and  most  freely  yields  lymph  upon  pressure, 
has  its  origin  most  commonly  by  a stalk  or 
kind  of  peduncle,  which  is  very  small,  com- 
pared with  the  size  of  the  polypus.  The 
other  which,  although  plainly  moveable, 
is  much  less  so  than  the  one  just  mentioned, 
which  has  been  less  liable  to  alteration  from 
air  and  seasons  ; and  which  has  been  rather 
slow  in  arriving  at  a very  troublesome  size, 
is  most  frequently  an  elongation  of  the 
membrane  covering  one  of  the  ossa  spon- 
giosa.  These  latter  may  be  extracted  with 
no  kind  of  hazard,  and  with  very  little  pain, 
and  hemorrhage  : but  the  former  require 


'POLYPI  S. 


362 

the  least  force,  ami  mostly  come  away  en- 
tire ',  while  the  others  often  break,  come 
away  piecemeal,  and  stand  in  need  of  the 
repeated  use  of  the  forceps.  (Pott,  on  the 
Polypus  of  the  Nose.) 

Mr.  John  Beil  criticises  the  distinctions 
drawn  by  the  preceding  writer,  and  he  says, 
that  a polypus  is  never  mild,  and  never  ma- 
lignant ; time,  and  the  natural  growth  of  the 
tumour,  and  the  pressure  it  occasions  within 
the  soft  and  bony  ceils  of  the  nostrils  and 
jaws,  must  bring  every  polypus  to  one  inva- 
luable form,  in  its  last  and  fatal  stage.  Po- 
lypus, says  Mr.  John  Bell,  is  indeed  a dread- 
ful disease ; but  it  becomes  so  by  a slow 
progression,  and  advances  by  gradations 
easily  characterized.  Every  polypus  in  its 
early  sttyre,  is,  according  to  this  writer,  a 
small  moveable  tumour,  attended  with  a 
sneezing  and  watering  of  the  eyes  ; swelling 
in  moist  weather  ; descending  with  the 
breath  ; but  easily  repressed  with  the  point 
of  the  finger.  It  is  void  of  pain,  and  not  at 
all  alarming  ; it  may  also  be  easily  extracted, 
so  as  to  clear  for  a time  the  passage  for  the 
breath.  Yet  this  little  tumour,  simple  as  it 
may  appear,  is  the  germ  of  a very  fatal  and 
loathsome  disease,  and  this  easy  extraction 
often  the  very  cause  of  its  appearing  in  its 
most  malignant  form  The  more  easily  it  is 
extracted,  (says  Mr.  J.  Bell,)  the  more  easily 
does  it  return  ; and  whether  carelessly  ex- 
tracted, or  altogether  neglected,  it  soon  re- 
turns. But  when  it  does  return,  it  has  not 
really  changed  its  nature  ; it  has  not  ceased 
to  be  in  itself  mild,  it  is  then  to  be  feared, 
not  from  its  malignity,  but  from  its  pressure 
among  the  delicate  cells  and  membranes  of 
the  nose.  It  soon  fills  the  nostrils,  obstructs 
the  breathing,  and  causes  indescribable  anx- 
ieties. The  tears  are  obstructed,  and  the 
eyes  become  watery  from  the  pressure  on 
the  lachrymal  sac  ; the  hearing  is  in  like 
manner  injured,  by  the  pressure  of  the  tu- 
mour against  the  mouth  of  the  eustachian 
lube  ; the  voice  is  changed,  and  its  resonance 
and  tone  entirely  lost,  by  the  sound  no  lon- 
ger passing  through  the  cells  of  the  nose 
and  face.  The  swallowing  is  in  some  de- 
gree affected  by  the  soft  palate  being  depress- 
ed by  the  tumour.  The  pains  arising  from 
such  slow  and  irresistible  pressure  are  un- 
ceasing. From  the  same  pressure  the  bones 
become  carious,  and  the  cells  of  the  face  and 
nose  are  destroyed  by  the  slow  growth  of 
the  swelling.  It  is  not  long  before  the  tu- 
mour begins  to  project  from  the  nostril  in 
front,  and  over  t lie  arch  of  the  palate  be- 
hind. One  nostril  becomes  widened  and 
thickened  ; the  nose  is  turned  towards  the 
opposite  side  of  the  face,  and  the  whole 
countenance  seems  distorted.  The  root  of 
the  nose  swells,  and  becomes  putty,  the  fea- 
tures tumid  and  flabby,  the  face,  yellow,  and 
the  parts  round  the  eye  livid.  The  patient 
is  affected  with  headachs,  which  seem  to 
rend  the  bones  asunder,  and  with  perpetual 
stupor,  and  dozing.  The  bones  ore  now  ab 
sorbed,  and  the  membranes  ulcerate  ; a foul 
and  fetid  matter,  blackened  with  blood,  is 
discharged  from  the  nostrils,  and  excoriates 


them.  The  blood-vessels  next  give  way,  ami 
sudden  impetuous  hemorrhages  weaken  the 
patient  ; the  teeth  fall  from  the  sockets,  and 
through  the  empty  sockets  a foul  and  fetid 
matter  issues  from  the  antrum. 

Now  the  disease  verges  to  its  conclusion 
The  patient  has  terrible  nights,  and  experi- 
ences a sense  of  suffocation.  The  repeated 
loss  of  blood  renders  him  so  weak,  that  he 
cannot  quit  his  bed  for  several  days  together  ; 
and  when  he  does  get  up,  he  is  (to  use  Mr 
Bell’s  words)  pale  as  a spectre,  his  lips  co- 
lourless, and  his  face  like  wax,  yellow,  and 
transparent.  He  now  suffers  intolerable 
pain,  while  his  saliva  is  continually  dribbling 
born  bis  mouth,  and  a fetid  di-charge  from 
his  nose.  In  this  state,  he  survives  a few 
weeks  ; during  the  last  days  of  his  illness, 
lying  in  a state  of  perpetual  stupor,  and  dy- 
ing lethargic.  Mr.  J.  Bell  afterward  ob- 
serves, that  “ if  horrid  symptoms  could  es- 
tablish the  fact  of  malignity,  there  is  not  to 
be  found  in  all  nosology  a more  malignant 
disease  than  this  : but  aneurism,  though  it 
destroys  the  thigh  bone,  the  sternum,  or  cra- 
nium, is  not  accounted  malignant  ; neither 
is  polypus  malignant,  though  it  destroys 
the  cells  of  the  face,  and  penetrates  even 
through  the  ethmoid  bone  to  the  brain. 
These  consequences  result  merely  from 
pressure.”  (John  Belt's  Principles  of  Surge- 
ry, Vol.  3,  Purl  1 ,p  90 — 92.) 

in  April,  1817,  there  was  a boy  in  St.  Bar- 
tholomew’s Hospital,  only  twelve  years  old, 
who  had  just  fallen  a victim  to  the  ravages 
ot  the  largest  and  most  disfiguring  disease 
within  the  nose  which  I have  ever  had  an 
opportunity  of  beholding.  The  tumour  be- 
fore death  had  expanded  the  upper  part  of 
the  nose  to  an  enormous  size,  while  below 
the  left  nostril  was  immensely  enlarged 
The  distance  between  the  eyes  was  extraor- 
dinary, being  more  than  four  inches.  The 
left  eye  vvu3  affected  with  amaurosis,  brought 
on  by  the  pressure  of  the  swelling  ; the  right 
retained  to  the  last  the  faculty  of  seeing. 
The  tumour  nearly  covered  the  mouth,  so 
that  food  could  only  he  introduced  with  a 
spoon,  and  an  examination  of  the  slate  of 
the  palate  was  impossible.  About  a fortnight 
before  death,  the  leg  became  paralytic,  and 
during  the  last  week  of  the  boy’s  existence, 
an  incontinence  of  the  urine  and  feces  pre- 
vailed. On  examination  of  the  head  after 
death,  a good  deal  of  the  tumour  was  found 
to  be  of  a cartilaginous  consistence,  and, 
what  was  most  remarkable,  a portion  ot  it, 
which  was  as  large  as  an  orange,  extended 
within  the  cranium,  where  it  had  annihila- 
ted the  anterior  lobe  ol  the  left  hemisphere 
of  the  brain.  Yet,  notwithstanding  this  ef- 
fect, the  boy  was  not  comatose,  nor  insensi- 
ble, till  a few  hours  before  his  decease.  All 
the  surrounding  bones  had  been  more  or  less 
absorbed,  and  the  place  from  which  the  ex- 
crescence first  grew  could  not  be  determined 
The  celebrated  Professor  Richter  has  de- 
nied the  validity  of  (he  objections  urged  by 
Pott  against  attempting  to  relieve  the  pa- 
tient : neither  the  malignant  nature  ot  a po- 
lypus, it»  adhesions,  iinn)ovcublenesst  nice- 


POLYPUS. 


363 


rations,  dot  disposition  to  hemorrhage,  &,c. 
are,  according  to  Richter,  any* apology  for 
leaving  the  disease  to  itself.  (See  An- 
fangigr.  dtr  IVundarxn.  B.  I,  cap.  21.) 

Mr.  J.  Bell  refutes  the  common  notions, 
that  polypi  may  be  caused  by  picking  the 
nose,  blowing  it  too  forcibly, ‘colds,  and  local 
injuries.  He  asserts,  that  a polypus  is  not 
in  general  a local,  solitary  tumour:  he  has 
only  found  it  so  in  three  or  four  instances. 
Both  nostrils  are  usually  affected.  He  states, 
that  no  finger  can  reach  that  part  of  Ihe  nos- 
tril whei  e the  root  of  the  swelling  is  situated, 
as  it  is  deep  and  high  in  the  no-trils,  towards 
tile  throat,  and  near  the  opening  of  the  eus 
tachian  tube.  The  finger  cannot  be  intro- 
duced further  than  ihe  cartilaginous  wing  of 
the  nose  extends  and  can  hardly  touch  the 
anterior  point  of  the  lower  spongy  bone. 
The  anterior  and  posterior  chambers  of  the 
nostril  are  separated  Irom  each  other  by  a 
narrow  slit,  which  (he  finger  can  never  pass, 
and  which  is  divided,  in  consequence  of  the 
projection  ot  the  lower  spongy  bone,  into 
two  openings,  one  above,  the  other  below. 
Through  these  the  heads  of  the  polypus  pro- 
ject. These  tangible  parls  of  the  tumour, 
however,  are  very  distant  from  its  root,  which 
is  in  the  highest  and  narrowest  part  of  the 
nostril.  (See  p.  103,  lu4.)  Mr.  J.  Bell  also 
says,  that  three  or  four  polypi  are  often 
crowded  together  in  one  nostril,  while  more 
are  formed,  or  forming,  in  the  other. 

He  dwells  upon  the  difficulty  and  imprac- 
ticableness  of  tying  the  root  of  a polypus; 
and  explains,  in  all  attempts  to  extirpate 
such  tumours,  the  surgeon’s  aim  should  be 
to  reach  a point  nearly  under  the  socket  of 
the  eye,  in  the  deepest  and  highest  part  of 
the  nostrils,  and  that  instruments  can  only 
do  good  w hen  introduced  beyond  the  narrow 
cleft,  formed  by  the  projection  of  the  spongy 
bone.  (P.  108.) 

Though  Mr.  John  Bell  is  probably  right  in 
his  opinion,  that  polypi  do  not  proceed  from 
the  several  circumstances  which  have  been 
above  noticed,  yet  they  are,  in  most  instan- 
ces, diseases  of  an  entirely  local  nature. 
Certainly,  in  general,  it  is  very  difficult  to 
describe  what  is  the  cause  of  a nasal  polypus. 
Frequently  the  patient  is,  in  other  respects, 
perfectly  well ; and  after  the  removal  of  the 
tumour,  no  new  one  makes  its  appearance. 
In  this  circumstance,  it  must  originate  from 
a local  cause,  though  it  is  generally  difficult 
to  define  what  the  nature  of  this  is.  Some- 
times several  catarrhal  symptoms  precede 
the  polypus,  and,  perhaps,  constitute  its 
cause.  It  is  possible,  they  may  only  bean 
effect  of  the  same  cause  which  gives  bir  h 
to  the  tumour  ; but,  no  doubt,  they  are  some- 
times the  effect  of  the  polypus  itself.  Some- 
times, perhaps,  a faulty  slate  of  (he  constitu- 
tion really  contributes  to  the  disease  ; for  se- 
veral polypi  frequently  grow  in  both  nostrils, 
and  even  in  o:her  situations  at  the  same 
time  ; are  reproduced  immediately  after 
their  removal  ; and  the  patient  often  has  an 
unhealthy  appearance.  Notwithstanding  it 
has  been  asserted,  that  a solution  of  the  mu 
riate  ot  ammonia,  frequently  injected  into 


the  nose,  sometimes  disperses  polypi,  the  ef- 
ficacy of  tile  remedy  remains  unestablished 
by  experience  ; as,  indeed,  the  very  nature 
of  the  disease  might  lead  one  to  anticipate. 
An  operation  affords  the  only  rational  chance 
of  a cure. 

There  are  four  modes  of  extirpating  a na- 
sal polypus  : viz.  extracting  it  with  forceps  ; 
tying  it  with  a ligature  ; cutting  it  out  ; and 
destroying  it  with  caustic. 

Extraction  is  i he  most  common  and  pro- 
per meihod.  It  is  performed  with  the  ordi- 
nary polypus  forceps,  the  blades  of  which 
have  holes  in  them,  and  are  internally  ra- 
ther rough,  in  order  that  they  may  take  hold 
of  the  tumour  more  firmly,  and  not  easily 
slip  off  it.  The  front  edge  of  each  blade 
must  not  be  too  thin  and  sharp,  lest,  with  its 
fellow,  it  should  pinch  off  a portion  of  the 
polypus.  The  blades  must  necessarily  have 
a certain  breadth  ; for  when  they  are  too 
small,  they  cannot  properly  take  hold  of  and 
twist  the  tumour.  When  the  handles  are 
rather  long,  the  instrument  may  be  more 
firmly  closed,  and  more  conveniently  twisted. 

However,  the  forceps  is  not  applicable  to 
all  cases.  The  anterior  part  of  the  polypus, 
lying  in  the  nostril,  distending,  and  totally 
obstructing  it,  is  sometimes  quite  hard,  and 
when  theforeeps  is  introduced,  it  presses  the 
blades  in  such  a manner,  from  each  other, 
as  it  lies  between  them,  that  the  instrument 
cannot  be  introduced  sufficiently  far  to  take 
hold  of  the  tumour  at  a proper  depth.  If 
introduced  fo  a proper  distance,  it  cannot 
be  closed.  In  such  a case,  says  Richter,  one 
might,  perhaps,  advantageously  make  use  of 
a pair  of  forceps,  the  pieces  of  which  may 
be  separately  introduced,  and  then  fastened 
together  again  at  Ihe  joint,  and  the  blades  of 
which  diverge  from  each  other  behind  the 
joint,  and  touch  again  at  their  extremities 
The  anterior  indurated  portion  of  the  poly- 
pus lies  in  the  interspace,  and  does  not  pre- 
vent the  closure  of  the  instrument. 

It  is  generally  deemed  of  importance  to 
take  hold  of  the  polypus  with  the  forceps 
close  to  its  root ; and,  indeed,  when  this  rule 
is  observed,  the  whole  of  the  polypus,  to- 
gether with  its  root,  is  commonly  extracted, 
and  there  is  less  reason  to  apprehend  he- 
morrhage, which  is  naturally  more  profuse 
when  the  polypus  is  broken  at  the  thick,  mid- 
dle portion  of  its  body.  It  is  also  a rule  fre- 
quently easy  of  observance,  especially  when 
the  polypus  is  not  too  large.  But  in  many 
instances  the  tumour  is  so  large,  and  the  nos- 
tril so  completely  occupied  by  it,  that  it  is 
impracticable  to  get  hold  of  its  root.  In  tins 
circumstance  it  is  often  altogether  impossi- 
ble to  discover  even  where  the  root  lies. 
Here  we  must  be  content  to  take  hold  of 
the  polypus  as  high  as  possible.  The  conse- 
quences are  of  two  kinds.  The  tumour 
sometimes  gives  way  at  its  root,  though  it  be 
only  taken  hold  of  at  its  anterior  part ; and, 
in  other  cases,  breaks  where  it  is  grasped,  a 
portion  being  left  behind,  and  a profuse  he- 
morrhage ensuing.  This  is,  however,  void 
of  danger,  if  the  surgeon  does  not  waste 
time  in  endeavouring  to  suppress  the  effu- 


POLYPUS 


364 

sion  of  blood  ; but  immediately  introduces 
the  forceps  again,  grasps  the  remnant  piece, 
and  extracts  it.  The  most  infallible  method 
of  diminishing  the  bleeding,  is  to  extract 
what  remains  behind  at  its  root.  In  this  way, 
a large  polypus  is  frequently  extracted,  piece- 
meal, without  any  particular  loss  of  blood. 

After  the  polypus  has  been  propelled  as 
far  forward,  into  the  nostrils,  as  it  can  be  by 
blowing  strongly  through  the  nose,  its  ante- 
rior part  is  to  be  taken  hold  of  by  a small 
pair  of  common  forceps,  held  in  the  left 
hand  ; and  is  to  be  drawn  gradually  and 
slowly  out,  to  make  room  for  the  introduc- 
tion of  fhe  polypus-forceps  into  the  nostril. 
The  more  slowly  we  proceed  in  this  ma- 
noeuvre, the  more  the  polypus  is  elongated, 
the  narrower  it  becomes,  the  greater  is  the 
space  in  the  nostril,  for  the  introduction  of 
the  polypus-forceps,  and  the  higher  can  this 
instrument  grasp  the  tumour.  Atier  it  has 
taken  hold  of  the  polypus  as  high  as  possi- 
ble, it  is  to  be  twisted  slowly  round,  and,  at 
the  same  time,  pulled  outward,  til!  the  tu- 
mour breaks.  It  is  a very  important  maxim, 
rather  to  twist  the  instrument  than  to  pull  it, 
and  thus  rather  to  writhe  the  polypus  off  than 
to  drag  it  out.  The  longer  and  more  slowly 
the  polypus-forceps  is  twisted,  the  more  the 
part  where  the  excrescence  separates  is 
bruised,  the  less  is  the  danger  of  hemor- 
rhage, and  the  more  certainly  does  the  tu- 
mour break  at  its  thinnest  part,  or  root. 
When  the  extraction  is  done  with  violence 
and  celerity,  only  a piece  is  usually  brought 
away,  and  we  run  hazard  of  occasioning  a 
copious  bleeding. 

As  soon  as  the  polypus  has  given  way,  the 
surgeon  is  to  examine  whether  any  part  re- 
mains behind.  When  the  polypus  is  very 
narrow  at  the  place  where  it  has  bf-en  broken, 
and  the  patient  can  breathe  through  the  nose 
freely,  there  is  reason  to  presume  that  the 
polypus  has  given  way  at  its  root,  and  that 
none  continues  behind.  The  finger,  if  it 
can  be  introduced,  procures  the  most  certain 
information  ; or  the  probe,  when  this,  for 
want  of  room,  cannot  be  employed.  The 
ancients  proposed  several  means  for  the  ex- 
tirpation of  the  remaining  piece  of  polypus  ; 
but  they  are,  for  the  most  part,  objectiona- 
ble. It  is  best  to  introduce  the  forceps  again, 
under  the  guidance  of  the  finger,  or  probe, 
and  thus  pinch,  and  twist  off,  the  part  con- 
tinuing behind. 

Hemorrhage  invariably  succeeds  the  ope- 
ration ; and  by  many  writers  has  been  re- 
presented as  exceedingly  perilous  and  alarm 
ing.  But  it  is  not  constantly  so,  and  in  some 
cases  is  quite  insignificant.  Frequently, 
however,  it  is  really  serious ; and  as  the  sur- 
geon can  never  know  beforehand  to  what 
extent  it  will  happen,  he  is  always  to  furnish 
himself,  before  the  operation,  with  the  most 
effectual  means  for  its  suppression.  The 
danger  of  hemorrhage  may  always  be  less- 
ened, as  was  before  mentioned,  by  slowly 
twisting  the  polypus  at  its  root,  in  preference 
to  pulling  it  directly  out.  When  only  a por- 
tion of  the  tumour  has  been  extracted,  the 
surest  mode  of  slopping  the  effusion  of  blood 


is  to  extract  the  remaining  part  without  Ge 
lay.  When  the  polypus  has  given  way  at  ite 
root,  if  there  should  be  profuse  bleeding, 
we  may  first  try  ice-cold  water  and  strong 
brandy,  which  may  either  be  sucked  or  in- 
jected into  th§  nose.  This  single  remedy 
proves  effectual  in  numerous  instances.  If 
the  hemorrhage  should  still  prevail,  it  may 
always  be  checked  with  certainty,  how  co- 
pious soever  it  may  be,  in  the  following  man- 
ner. Roll  a considerable  piece  of  lint,  as 
fast  as  possible,  round  the  extremity  of  a 
probe ; wet  it  completely  through  with  a 
strong  solution  of  the  sulphate  of  zinc  ; in- 
troduce it  into  the  nostril,  and  press  it  as 
strongly  as  possible  against  the  part  whence 
the  blood  issues.  When  the  nostril  is  very 
much  dilated,  the  fingers  may  be  used  for 
this  purpose  with  more  advantage  than  the 
probe.  The  point  from  which  the  blood  is 
effused,  may  easily  be  ascertained,  by  press- 
ing the  finger  on  various  points.  As  soon  as 
the  blood  ceases  to  flow,  we  may  conclude 
that  the  finger  is  on  the  situation  of  the  he- 
morrhage. This  method  is  so  efficacious, 
that  there  is  seldom  occasion  for  any  other. 
When  the  bleeding  point  lies  deeply  in  the 
nostril,  it  might  be  difficult  to  reach  it  with 
the  finger.  At  all  events,  we  may  then  em- 
ploy a plan  which  has  been  strongly  praised 
in  urgent  cases. 

A piece  of  catgut  may  be  introduced  into 
the  nostril,  and  by  means  of  a pair  of  for 
ceps,  be  brought  out  of  the  mouth.  A roll 
of  lint  is  then  to  be  attached  to  it,  and  drawn 
through  the  mouth  into  the  nose  ; thus  the 
posterior  aperture  of  the  nostril  may  be 
stopped  up.  Then  the  nostril  in  front  is  to 
be  filled  with  a sufficient  quantity  of  lint, 
moistened  in  the  solution  of  zincum  vitrio- 
latum. 

The  objections  to  extracting  some  polypi, 
says  Richter,  have  been  much  exaggerated. 
When  the  polypus  is  so  large,  that  its  root 
cannot  be  got  at,  its  anterior  part  is  to  be 
taken  bold  of,  and  the  tumour  extracted 
piecemeal.  It  has  already  been  noticed, 
that  this  practice  is  free  from  danger.  Ex- 
perience does  not  prove,  that  the  polypus, 
which  often  bleeds  profusely,  is  apt  to 
occasion  a violent  hemorrhage  in  the  opera- 
tion ; and  even  if  it  should  do  so,  powerful 
measures  may  be  adopted  for  the  stoppage 
of  the  bleeding.  The  malignity  and  ulcera- 
tions attending  a polypus,  are  no  objections 
to  the  operation  ; but  are  rather  motives  for 
its  being  promptly  performed,  as  delay  must 
occasion  more  manifest  and  urgent  danger. 
If  the  polypus  should  be  here  and  there 
adherent  to  the  membrane  investing  the 
nostrils,  it  is  proper  to  separate  it  before  the 
operation.  This  object  cannot  be  accom- 
plished by  straight  inflexible  instruments 
such  as  have  been  invented  by  various 
surgeons.  It  may  be  very  conveniently 
done,  according  to  Richter,  with  thin,  long, 
flat  pieces  of  tortoise-shell,  introduced  as 
deeply  as  possible  into  the  nostril,  on 
every  side  of  the  polypus.  As  it  can  seldom 
be  known  with  certainty,  a priori,  that  ad- 
hesions are  not  present?  it  is  proper  whene- 


I'OLYl'Ufe 


3(i5 


ver  the  tumour  is  large,  to  introduce  these 
instruments  before  the  operation. 

Sometimes,  the  greatest  part  of  the  polypus 
extends  backward,  hanging  down  behind 
the  palatum  molle,  towards  the  pharynx.  If 
there  should  be  but  little  of  the  polypus 
visible  in  the  nostril,  its  extraction  must  be 
performed  backward,  in  ihe  throat.  This  is 
usually  done  with  a pair  of  curved  polypus 
forceps,  which  is  to  be  introduced  through 
the  mouth,  in  order  to  seize  and  tear  off  the 
tumour  as  high  as  possible  above  the  soft 
palate.  Care  must  be  taken  not  to  irritate 
the  root  of  the  tongue,  or  else  a vomiting  is 
produced,  which  disturbs  the  operation. 
When  the  polypus  cannot  be  properly  taken 
hold  of,  we  may,  according  to  the  advice  of 
some  surgeons,  divide  the  soft  palate.  But 
this  is  very  rarely  necessary.  As,  by  this 
mode,  the  polypus  is  not  twisted,  but  pulled 
away,  the  hemorrhage  is,  in  general,  rather 
copious.  If  a fragment  of  the  tumour  should 
remain  behind,  it  may  commonly  be  extract- 
ed through  the  nose. 

Some  recommend,  for  the  extraction  of 
polypi  in  the  throat,  a ring,  consisting  of 
two  semicircular  portions,  with  a kind  of 
groove  externally,  which  are  capable  of 
being  opened  and  shut,  by  being  fixed  on 
the  ends  of  an  instrument  constructed  like 
forceps.  A ligature  is  to  be  placed  round 
the  ring,  and  its  end  is  to  be  brought  to  the 
handle  of  the  instrument,  and  held  with  it 
in  the  hand.  The  instrument  is  to  be  intro- 
duced into  the  mouth,  under  the  polypus, 
and  expanded  as  much  as  the  size  ot  the 
tumour  requires.  Its  ring  is  then  to  be 
carried  upward,  over  the  polypus,  so  as  to 
embrace  it ; and  afterward  is  to  be  shut., 
whereby  the  noose,  after  being  carried  up- 
ward, is  disengaged  from  the  ring.  The 
noose  is  to  be  pushed  as  high  as  possible 
over  the  tumour,  by  means  of  forceps,  and 
the  extremity  of  the  packthread  is  then  to 
be  drawn,  so  as  to  apply  the  noose  tightly 
round  the  polypus.  When  this  is  done,  the 
ring  of  the  instrument  is  to  be  turned  round 
firmly  closed,  and  placed  in  front  of  the 
polypus,  on  the  noose,  in  such  a way,  that 
the  packthread  is  to  lie  between  two  little 
pegs,  made  for  the  purpose,  at  the  ends  of 
the  ring.  On  drawing  the  packthread  firmly, 
and  pressing  the  instrument  at  the  same 
time  downward  so  as  to  make  it  act  like  a 
lever,  the  polypus  in  general  easily  breaks. 
Another  peg  projects  in  the  direction  of  the 
ring,  so  as  to  prevent  the  ligature  from  in- 
sinuating itself  within  the  circle.  (See 
Theden’s  Bemerk.  Part  2.  and  Platt  6.  fig.  1. 
in  Richter's  Jlnfangsgr.) 

The  employment  of  this  instrument, 
however,  is  attended,  says  Richter,  with 
many  difficulties,  and  little  advantage.  Po- 
lypi in  the  throat  are  most  conveniently 
extracted  by  the  ordinary  straight  polypus 
forceps,  with  which  they  may  be  seized, 
and  gradually  drawn  out  through  the  mouth. 
The  tumour  generally  allows  itself  to  be 
drawn  out  without  trouble,  and  the  inclina- 
tion to  vomit,  which  at  this  moment  occurs, 
also  contributes  to  propel  it  outward.  When 


it  is  so  stretched,  that  it  cannot  be  drawn 
out  further,  without  considerable  force,  a 
spatula  is  to  be  introduced  into  the  mouth, 
and  to  be  carried  as  high  as  possible  behind 
the  polypus,  in  order  to  press  it  downward, 
toward  the  root  of  the  tongue.  When  the 
tumour  is  at  the  same  time  forcibly  pulled 
outward  by  the  forceps,  it  usually  gives  way. 

When  the  polypus  is  situated  partly  in  the 
throat  and  partly  in  the  nostril,  though  it 
admits  of  being  extracted,  in  the  same  way, 
through  the  mouth,  yet  its  anterior  part  often 
continues  attached,  and  must  afterward  be 
saparately  removed  through  the  nostril.  It 
is  also  frequently  adviseable  to  twist  off  the 
anterior  portion  of  the  polypus  first,  by 
which  the  mass  in  the  throat  is  often  ren- 
dered so  loose,  that  it  can  be  easily  extract- 
ed. Whenever  it  is  conjectured,  that  the 
polypus  will  come  away  in  two  pieces,  it  is 
always  preferable  first  to  extract  the  part  in 
the  nostril,  and  afterw  ard  that  in  the  throat 
because  tiie  separation  of  the  last  is  con- 
stantly productive  of  more  bleeding,  than 
the  removal  of  the  first.  Sometimes,  the 
following  plan  succeeds  in  detaching  the 
whole  polypus  at  once.  Both  the  part  iri 
the  nostril,  and  that  in  the  throat,  are  to  be 
firmly  take  hold  of  w ith  the  for;  ms,  and 
drawn  at  first  gentlv  and  then  more  f cibly,, 
backward  and  forward.  By  such  repeated 
movements,  the  root  is  not  unfrequently 
broken,  and  the  whole  polypus  brought 
away  from  the  mouth. 

Frequently  the  polypus  grow  s again.  Po- 
licy requires  that  the  patient  should  be 
apprized  of  this  beforehand.  Some  of  the 
root  remaining  behind,  may  often  be  a cause 
of  the  relapse.  Hence  the  surgeon  should 
examine  carefully,  after  the  operation,  the 
part  at  wnich  the  root  of  the  polypus  was 
situated,  and  separate,  and  twist  off,  most 
diligently,  with  the  forceps,  any  fragments 
that  may  still  continue  attached.  I he  re- 
currence of  the  disease,  however,  may 'arise 
from  other  causes.  The  tumour  is  occasional- 
ly reproduced,  after  it  has  been  extracted 
in  the  most  complete  manner;  and  doubt 
less,  this  circumstance  is  sometimes  ow  ing 
to  the  continued  agency  of  constitutional 
causes,  which  so  often  remain  undiscovered 
and  unremoved  Sometimes,  also,  the  re- 
currence of  the  disease  is  owing  to  a local 
morbid  affection  oi  the  Schneiderian  mem- 
brane, or  of  the  bones  situated  beneath  the 
root  of  the  poly [ius.  Richter,  in  this  case, 
approves  ot  the  cautery  ; but  few  English 
surgeons  will  coincide  w ith  him.  The  po- 
lypus, sometimes  observed  subsequently  to 
tin  operation,  is  fr<  quently  not,  in  fact,  a 
a new'  substance,  but  only  a part  of  the 
original  tumour,  not  previously  noticed  by 
the  surgeon.  Sometimes  it  occurs,  thai  a 
smaller  and  larger  polypus  are  found  in  the 
nose  at  the  same  time  The  larger  one  is 
extracted,  while  the  other  remains  undisco- 
vered ; and  when  it  has  increased  in  magni- 
tude, it  is  apt  to  be  mistaken  for  a repro- 
duction of  the  one  previously  extirpated. 
(See  Richter's  Anfangsgr.  drr  Wuvdarsn , B 
1.  Kap.  21 A 


POLYPUS. 


Ligature.  As  the  extraction  of  the  poly- 
pus is  invariably  attended  wiih  hemorrhage, 
which  is  sometimes  profuse,  another  more 
modern  method  of  cure  has  been  proposed 
as  more  convenient  and  secure.  This  con- 
sists in  tying  the  root  of  the  tumour  with  a 
ligature,  by  which  the  polypus  is  thrown 
into  the  state  of  inflammation,  suppuration, 
and  sphacelus  ; and  at  length  becomes  de- 
tached. Many  instruments  have  been  in- 
vented for  applying  the  ligature ; but 
Levret’s  double  cannula  seems  to  be  the  best. 
Through  this,  a silver  wire  is  to  be  introdu- 
ced, so  as  to  form  a noose  at  the  upper  end 
of  the  instrument,  proportioned  in  size  to 
the  anterior  part  of  the  tumour,  situated  in 
the  nostril.  t he  two  ends  of  the  wire  are 
t>  hang  out  of  the  two  lower  apertures  of 
the  dou!  e ^nnula  ; and  one  of  them  is  to 
be  iastened  to  a small  ring  on  its  own  sid8 
of  the  instrument.  The  other  is  to  remain 
loose.  Ti.e  wire  must  be  made  of  the 
purest  silver,  and  ought  to  be  as  flexible  as 
possible,  tnat  it  may  not  readily  break  It 
must  also  not  be  too  thin  lest  it  should  cut 
through  the  root  of  the  polypus.  The  can- 
nula is  to  be  somewhat  less  than  five  inches 
long  By  the  assistance  of  this  cannula,  the 
noose  is  to  be  introduced  into  the  nose,  and 
put  round  the  polypus.  But  as  the  cannula, 
which  is  usually  constructed  of  silver,  is 
straight  and  inflexible,  while  the  inner 
surface  of  the  nostril  is  preternaturally 
arched,  especially  when  much  distended  by 
the  polypus,  it  is  easy  to  discern  that  its 
introduction  must  be  attended  with  consi- 
derable difficulty,  in  fact,  it  can  seldom  be 
introduced  as  deeply  as  the  root  of  (he 
polypus.  There  are  two  ways  of  avoiding 
this  obstacle.  The  cannula  may  either  be 
passed  under  the  polypus,  over  the  ossa 
palati,  which  present  a tolerably  straight 
surface,  or  it  must  be  curved  a little.  Per- 
haps, a tortoise-shell  cannula,  says  Richter, 
might  be  convenient. 

The  noose  is  to  be  applied  in  the  follow- 
ing manner.  rlbe  polypus  is  to  be  taken 
hold  of  with  the  forceps,  and  drawn  a little 
out  of  the  nose.  The  noose  is  then  to  be 
carried  over  the  forceps  and  polypus,  into 
the  nostril.  In  order  to  carry  it  as  high  as 
possible,  it  is  necessary  not  to  push  the  can- 
nula st'-aight  forwards  into  the  nose,  but  to 
move  it  from  one  side  of  the  polypus  to  the 
other.  The  more  deeply  the  instrument 
has  entered  the  nose,  the  more  of  the 
loose  end  of  the  wire  must  be  drawn  out  of 
the  lower  aperture  of  the  cannula,  so  as  to 
contract  the  noose,  which  otherwise  might 
stop  in  the  nostril,  and  not  be  carried  suffi- 
ciently high.  The  elasticity  of  the  silver 
wire  tends  to  assist  in  raising  it  over  the 
p ! vpus,  and  hence,  it  is  more  easy  of  appli- 
c lion  than  a more  flaccid  kind  of  a ligature. 
When  there  is  cause  to  conclude,  that  the 
polypus  is  complicated  with  adhesions,  they 
must  be  previously  broken,  in  the  way 
already  mentioned. 

As  soon  as  the  noose  has  been  introduced 
as  deeply  as  possible,  the  loose  extremity  of 


the  wire  is  to  be  drawn  out.  of  the  lower 
aperture  of  the  cannula,  and  rolled  round 
the  ring  on  that  side  of  the  instrument. 
Thus  the  root  of  the  polypus  suffers  con 
striction.  The  wire  must  not  be  pulled 
too  forcibly,  nor  yet  too  feebly.  In  the 
first  circumstance,  it  readily  cuts  through 
the  root  of  the  polypus:  in  the  second, 
great  tumefaction  of  the  excrescence,  and 
many  inconveniences  arise,  which  a tenser 
state  of  the  wire  prevents.  As  the  noose 
gradually  makes  a furrow  where  it  surrounds 
the  polypus,  it  grows  slack  after  a short 
time,  and  no  longer  constricts  the  tumour. 
One  end  of  the  wire,  therefore,  is  to  be  daily 
unfastened,  and  drawn  more  tightly.  The 
more  tense  it  is  kept,  the  sooner  the  separa- 
tion of  the  polypus  is  brought  about.  Hence, 
when  it  is  particularly  indicated  to  produce 
a speedy  attachment  of  the  polypus,  the 
wire  should  be  tightened,  at  least,  once  a 
day. 

In  this  mannner  the  cannula  is  to  remain 
in  the  nose  until  the  noose  is  detached,  to- 
gether with  the  poiypus.  There  is  another 
method  of  tying  the  tumour,  without  leav- 
ing the  cannula  in  the  nose.  After  the 
noose  has  been  introduced  as  far  as  possible 
into  the  nostril,  the  two  ends  of  the  wire 
are  to  be  twisted  round  the  two  rings,  and 
the  cannula  is  to  be  turned  round  a couple 
of  times.  The  wire  is  then  to  be  unfastened 
from  the  rings,  and  the  cannula  withdrawn. 
In  this  way  the  noose  is  made  to  embrace 
the  poi  pus,  round  which  it  remains  fastly 
applied.  Whenever  it  is  wished  to  produce 
a greater  constriction,  the  cannula  may  be 
again  introduced  into  the  nose,  the  ends  of 
the  wire  fastened  to  the  rings,  and  the  in- 
strument turned  round  again  ; after  which 
it  is  to  be  taken  away,  as  before.  As  the 
cannula,  when  it  continues  long  in  the  nose, 
may  occasion  pain,  and  other  inconveni- 
ences, the  last  method  seems  preferable  to 
the  former.  However,  introducing  and 
withdrawing  the  cannula  every  day,  as 
Richter  adds,  may,  perhaps,  be  equally  trou- 
blesome and  painful.  The  cannula  for  this 
purpose  being  necessarily  straight,  is  by  no 
means  handy.  One  might,  at  all  events, 
make  use  of  a single  cannula,  the  upper 
opening  of  which  is  divided  by  a bridge ; 
this  could  be  much  more  conveniently  twist- 
ed than  a double  one. 

Although  the  ligature  has  been  very  much 
praised  by  some  of  the  moderns,  it  is  at- 
tended with  so  many  difficulties,  that  in  the 
majority  of  cases,  the  forceps  is  infinitely 
preferable.  Hemorrhage  is  the  only  incon- 
venience, for  which  extraction  is  abandon- 
ed for  the  employment  of  the  ligature.  But 
this,  as  was  before  stated,  is  much  less  dan 
gerous  than  is  represented.  The  inconve- 
niences of  the  ligature  are  far  more  serious, 
and  numerous.  The  cure  bv  the  ligature  is  al- 
ways accomplished  with  much  less  expedi- 
tion than  by  extraction.  When  the  polypus  is 
of  such  a size  as  to  occupy  the  whole  of  the 
nostril,  it  is  generally  impracticable  to  in- 
troduce the  noose  to  a sufficient  depth 


POLYPI  S. 


•The  figure  oi  the  polypus  renders  it  almost 
impossible  to  tie  its  root ; for  commonly  the 
tumour  expands  very  much  before  and 
behind,  and  the  wire  must  be  brought  over 
the  posterior  part  of  the  polypus,  ere  it  can 
be  applied  to  its  root.  In  general,  also,  the 
noose  only  includes  the  front  part  of  the 
polypus,  while  the  root,  and  back  portion 
remain  untied,  and  consequently  do  not 
become  detached. — It  is,  indeed,  asserted, 
that  the  ligature,  when  only  applied  to  the 
front  part  of  the  polypus,  is  capable  of  bring- 
ing about  inflammation,  suppuration,  and 
a detachment  of  the  whole  of  the  tumour. 
This  may  sometimes  be  the  case;  but  ana- 
logous instances  prove,  that  it  is  undoubted- 
ly not  constantly  so.  The  ligature  seldom 
accomplishes  an  entire  destruction  of  the 
disease,  and  there  is  usually  reason  to  appre- 
hend its  recurrence.  If  the  polypus  be  very 
large,  and  the  w hole  nostril  occupied,  it  is 
frequently  utterly  impossible  to  introduce 
the  wire ; and  when  this  is  done,  the  front 
of  the  tumour  alone  can  be  tied. 

The  polypus  nasi  is  commonly  highly  sen- 
sible, and  consequently,  tying  it  proves  very 
painful.  As  soon  as  the  noose  is  drawn 
tight,  not  only  the  polypus  inflames,  but  the 
whole  extent  of  the  Schneiderian  mem- 
brane. The  pain  and  inflammation  often 
extend  even  to  parts  at  some  distance,  such 
as  the  throat,  eyes,  he.  occasioning  acute 
fever,  which  requires  the  strict  observance 
of  low  dietvthe  exhibition  of  cooling  physic, 
and  the  evacuation  of  blood  Hence,  it  is 
adviseable  in  many  cases,  to  prepare  pa- 
tients for  this  treatment,  by  diet  and  medi- 
cines. 

When  the  polypus  is  tied,  it  swells  very 
much,  and  all  the  complaints  which  it  pre- 
viously caused  are  exasperated.  But,  in 
particular,  the  part  situated  in  the  throat, 
sometimes  obstructs  deglutition  and  respi- 
ration, in  such  a degree,  that  prompt  re- 
lief becomes  necessary  ; and  one  of  the 
best  plans  for  affording  it,  is  to  make  a few 
punctures  in  the  tumour.  These  excite  a 
bleeding,  that  very  speedily  lessens  the 
swelling,  but  is  sometimes  difficult  to  check. 
Hemorrhage  from  a part  of  the  polypus 
that  is  tied,  is  most  effectually  stopped  by 
twisting  the  wire  so  tight,  that  it  closes  the 
arteries  distributed  to  it. 

The  wire  sometimes  breaks  off'  close  to 
the  lower  aperture  of  the  cannula,  in  con- 
sequence of  being  twisted  so  much  and 
thus  the  progress  of  the  cure  is  interrupted. 
A new  wire  may  be  introduced  ; but  it  is 
difficult  to  apply  it  exactly  in  the  situation 
of  the  other.  A fresh  place  is  commonly 
tied,  which  is  almost  the  same  thing  as  com- 
mencing the  cure  anew.  It  is  better  to 
prevent  this  interruption  of  the  treatment 
by  employing  very  flexible  w ire,  made  of 
the  purest  silver  ; and  by  not  twisting  and 
untwisting  regularly  the  same  extremity  of 
it,  but  sometimes  one  and  sometimes  the 
other.  A strong  piece  of  catgut  might  be 
a very  good  substitute  for  silver  wire. 

Immediately  the  polypus  is  tied,  it  swells, 
inflames,  and  becomes  painful;  in.  a few 


days,  it  becomes  shrunk,  free  from  pain, 
and  sphacelated.  The  fetid  discharge  now 
occasions  considerable  inconvenience  to 
the  patient,  and  ought  to  be  washed  awrny 
by  repeated  injections.  Towards  the 'ter- 
mination of  the  case,  the  surgeon  ought  to 
take  hold  of  the  polypus  with  the  forceps, 
to  try  whether  any  of  it  is  loose.  When 
the  polypus  is  extracted,  one  may  inject  a 
solution  of  alum,  tor  a day  or  two  after- 
ward, in  order  to  diminish  the  effect  of  the 
irritating  discharge  on  the  Schneiderian 
membrane,  and  the  suppuration  in  the  situa- 
tion of  the  ligature,  as  it  is  sometimes  pro- 
fuse, and  of  long  duration. 

Though  one  might  also  tie  polypous 
tumours  in  the  throat;  and,  indeed,  the 
introduction  of  the  cannula  through  the 
mouth,  and  the  application  of  the  noose, 
would  be  attended  with  no  great  difficulty; 
and,  though  the  treatment  might  be  rendered 
more  tolerable  to  the  patient,  by  withdraw- 
ing the  cannula  afier  tw  isting  the  wire  ; yet, 
the  swelling  of  the  tied  portion  of  the  tumour 
would,  probably,  create  immense  inconve- 
nience. In  this  case,  therefore,  extraction 
usually  merits  the  preference,  and  the  liga- 
ture is  only  fit  to  be  practised  in  the  throat, 
when  tin*  polypus  is  very  small,  or  there  is 
some  especial  cause  forbidding  extraction. 
When  deglutition  and  respiration  are  impe- 
ded by  the  swelling  of  the  tied  portion  of 
the  polypus  in  the  throat,  the  swollen  part 
must  be  scarified  by  means  of  the  pharyngo  • 
tomus.  so  as  to  excite  a bleeding,  ai.d 
thereby  produce  a diminution  of  the  swell- 
ing. The  noose  is  to  be  frequently  and 
strongly  tightened,  in  order  to  accelerate 
the  detachment  of  the  polypus,  and  shorten 
the  inconveniences.  When  the  excrescence 
has  not  only  descended  towards  the  pha- 
rynx, but  also  into  the  nostril,  its  front  por- 
tion is  to  be  tied  first.  The  result  of  this 
may  be,  such  an  inflammation  and  suppura- 
tion of  the  whole  polypus,  that,  after  the 
separation  of  its  anterior  portion  the  pos- 
terior one  may  also  become  detached,  or 
at  least,  easy  of  removal. 

Caustics.  The  cautery,  formerly  recom- 
mended for  the  cure  of  the  polypus  nasi,  is 
now  almost  entirely  rejected,  and  indeed, 
in  the  manner  it  wras  customary  to  use  it, 
little  good  could  be  done.  It  was  applied 
to  the  anterior  surface  of  the  tumour  in  the 
nostril,  and  its  employment  was  repeated 
every  time  the  slough  separated.  Its  opera- 
tion could  naturally  be  but  of  small  extent, 
as  it  only  came  into  contact  with  a trivial 
portion  of  the  polypus.  Its  irritation  aug- 
mented the  determination  of  blood  to  the 
excrescence,  and  accelerated  its  growth  ; 
w hile  as  much  ot  the  the  tumour  was  repro- 
duced. ere  the  slough  separated,  as  was  thus 
destroyed;  and  the  design  of  completely 
extirpating  the  disease,  in  this  way  seldom 
or  never  proved  successful.  However,  says 
Richter,  there  is  one  particular  example, 
where  the  cautery  is  the  only  means  from 
which  relief  can  be  derived  ; and,  used  in 
a certain  way,  it  always  speedily  produces 
the  desired  effect . 


POLYPUs 


Tliere  are  some  nasal  polypi,  much  dis- 
posed to  profuse  bleeding.  Touching  them 
in  the  gentlest  manner,  and  every  trivial  con- 
cussion of  the  body,  give  rise  to  hemorrhage. 
The  patient  is  exceedingly  debilitated  by  re- 
peated loss  of  blood  ; his  countenance  is 
pallid;  his  feet  swollen;  he  is  affected  with 
hectic  fever;  and  faints  whenever  there  is  any 
considerable  bleeding.  Doubtless,  exirac- 
tion,in  this  case,  is  a very  precarious  method, 
as  the  patient  is  so  circumstanced,  that  any 
copious  effusion  ot  blood  must  be  highly 
perilous.  Sometimes  the  polypus  is,  at  the 
same  time,  so  large,  and  the  nostril  so  com- 
pletely occupied  and  distended,  that  it  is 
impossible  to  apply  a ligature.  Such  is  the 
ease,  to  which  alone  the  cautery  promises 
assistance,  (Richter.) 

In  employing  the  cautery,  (says  the  latter 
author,)  the  object  is  not  to  effect,  by  its 
direct  agency,  a gradual  destruction  of  the 
polypus  ; but  to  excite  such  an  inflammation, 
and  suppuration,  of  the  whole  of  it,  as  shall 
lead  to  this  event.  To  fulfil  this  purpose,  a 
common  trocar,  three  inches  long,  may  Jae 
used.  The  cannula  ought  to  be  two  inches 
shorter  than  the  trocar,  whereby  the  latter 
may  protrude  from  it  so  far ; and  it  should 
be  constructed  with  a handle.  The  cannula 
should  be  made  wider  than  i’t  is  in  common, 
so  as  to  allow  the  trocar  to  be  introduced, 
and  withdrawn  with  facility.  It  is  to  be 
wrapt  round  with  apiece  of  wet  linen,  and 
applied  to  the  polypus.  The  red-hot  trocar 
is  then  to  be  pushed  into  the  tumour,  as  far 
as  the  cannula  will  allow  it,  which  is,  of 
course,  two  inches. 

When  the  patient  entertains  a dread  of 
the  actual  cautery,  Richter  sanctions  the 
introduction  of  a tent  of  the  emplastrum 
cantharidum,  ora  tent  smeared  with  butter 
of  antimony,  into  the  puncture  of  the  un- 
heated trocar,  and  as  soon  as  suppuration 
has  taken  place!,  emollient  and  detergent 
lotions  are  to  be  injected.  ( Richter's  An- 
faitgsgr.)  In  England,  the  actual  and 
potential  cauteries  are  never  used  for  the 
destruction  of  nasal  polypi. 

Excision.  In  the  treatment  of  the  poly- 
pus, the  use  of  cutting  instruments  has  al- 
ways been  reprobated,  because  they  usually 
occasion  a profuse  hemorrhage,  and  c.tn 
hardly  ever  be  passed,  without  mischief,  to 
a sufficient  dentil  into  the  nose  to  divide  the 
root  of  the  tumour.  Yet.  there  are  instan- 
ces in  which  their  use  might  be  productive 
of  advantage.  The  anterior  part  of  the  po- 
lypus, situated  in  the  nostril,  is  sometimes 
so  thick  and  hard  that  it  is  utterly  imprac- 
ticable to  introduce  the  forceps  for  the 
performance  of  extraction,  or  the  cannula 
for  the  application  of  the  ligature.  In  such 
a case,  it  might  be  a judicious  step  to  cut  off 
the  front  of  the  polypus  with  a sharp  in- 
strument, of  a suitable. shape,  in  order  to 
make  room  for  the  use  of  the  ligature,  or 
forceps.  The  polypus  is  sometimes  of  a 
ligamentous  structure,  and  neither  admits  of 
being  tied  hor  extracted.  There  is  no  means 
of  removing  such  a polypus  except  the  knife, 
by  which  it  b to  be.  cut  away  piecemeal. 


Mr.  Whately,  after  tailing  in  several  at- 
tempts to  extract  and  tie  a considerable  po- 
lypus of  (he  nose,  succeeded  in  cutting  it 
out.  He  used  a narrow,  straight  bistoury, 
with  a probe  point,  having  a sheath  fixed 
upon* its  edge,  by  a screw  put  into  a hole  in 
the  handle.  An  eye  was  made  at  its  point, 
to  receive  one  end  of  a thread  intended  to 
be  passed  round  the  polypus,  for  the  pur- 
pose of  directing  the  knife  to  the  extremity 
of  the  tumour.  There  was  also  a contri- 
vance by  which  the  knife  could  be  unsheath- 
ed at  its  extremity,  the  length  of  three-quar- 
ters of  an  inch.  This  was  done  by  means 
of  a screw,  which  might  be  fixed  in  another 
hole,  by  drawing  back  the  sheath.  By  ex- 
posing such  a length  of  edge  only,  the  in- 
terior parts  of  the  nose  were  defended  from 
the  danger  of  being  wounded.”  Whoever 
wishes  a particular  account  of  the  manner 
of  using  the  instrument,  must  consult  Mr. 
Whately’s  Cases  of  two  extraordinary  Po- 
lypi, §'C.  1805. 

In  the  polypus  which  arises  from  a relax- 
ation of  the  Schneiderian  membrane,  ex- 
ternal astringent  applications  may  be  first 
tried ; such  as  ice-cold  w^ater,  solutions  of 
acetite  of  lead,  alum,  muriate  of  ammonia. 
&c.  These  remedies  (says  Richter)  common  - 
ly lessen  it,  and  frequently,  when  it  is  not 
very  large,  accomplish  its  entire  removal 
If  this  should  not  happen,  there  is  no  reason 
against  putting  a ligature  round  it.  Here, 
also,  w^e  may  venture  to  employ  a cutting 
instrument,  if  it  be  in  our  power  to  do  so  ; 
which,  as  far  as  my  experience  goes,  will 
very  rarely  be  the  case.  But  the  practice 
of  extraction  is  here  prohibited. 

When  the  Schneiderian  membrane  is  pre- 
ternaturally  swollen  all  over  the  nostril, 
which  is  quite  obstructed,  the  pervious  state 
of  the  cavity  is  to  be  restored  by  the  intro- 
duction of  catgut  or  bougies.  A thin  piece 
is  at  first  passed  into  the  nose,  and  afterw  ard 
a larger  and  larger  one  gradually,  until  the 
passage  for  the  air  is  perfectly  re-established. 
But  usually,  this  relief  is  only  of  short  dura- 
tion, as  the  nostril  very  soon  closes  again 
Hence,  such  patients  are  advised  to  make 
constant  use  of  flexible  tubes  passed  into  the 
nose  ; or,  when  this  is  too  troublesome,  to 
fill  the  nose  regularly  at  bedtime  w ith  cat- 
gut, and  take  it  out  again  in  the  morning. 
(See  Richter's  Anfangsgr.  B.  1.) 

POLYPI  OF  THE  UTERUS. 

Polypi  of  the  uterus  are  of  three  kiuds, 
in  respect  to  situation : they  grow  either 
from  the  fundus,  the  inside  of  the  cervix, 
or  the  lower  edge  of  the  os  uteri.  The  first 
case  is  the  most  frequent ; the  last  the  most 
uncommon.  Polypi  of  the  uterus  are  always 
shaped  like  a pear,  and  have  a thin  pedicle. 
They  are  almost  invariably  of  that  species, 
which  is  denominated  fleshy,  hardly  ever 
being  scirrhous,  cancerous,  or  ulcerated. 

A polypus  of  the  first  kind,  grow  ing  from 
the  fundus  uteri,  is  very  difficult  to  detect 
in  its  incipient  state.  While  small,  it  pro- 
duces not  the  smallest  perceptible  change  in 


fOLYPLfc. 


•U){J 


the  organs  ol  generation.  As  it  enlarges,  it 
distends  the  uterus,  and  often  excites  a sus- 
picion of  pregnancy,  which,  however,  a 
more  attentive  examination  soon  dispels. 
The  swelling  of  the  abdomen  does  not  take 
place  in  the  degree  and  space  of  time,  which 
it  does  in  pregnancy  ; the  menstrual  dis- 
charge continues  to  flow ; the  breasts  do  not 
become  full  ; and,  in  the  progress  of  the 
case,  no  motion  is  to  be  felt.  While  the 
polypus  lies  in  the  uterus,  its  growth  is  slow. 
At  this  early  period  it  frequently  occasions 
profuse  bleeding.  Women,  afflicted  with 
the  disease,  are  seldom  pregnant,  and  when 
they  are  so,  parturition  commonly  happens 
prematurely.  However,  they  sometimes 
bold  out  to  the  end  of  the  regular  time,  and 
experience  an  easy  and  safe  delivery. 

As  the  polypus  increases,  it  expands  the 
os  uteri,  and  at  length  protrudes  into  the 
vagina.  This  takes  place  either  suddenly, 
from  an  accidental  concussion  of  the  body  ; 
or  slowly  and  gradually.  In  the  latter  cir- 
cumstance, pains  similar  to  those  of  labour 
occur,  and  cause  the  tumour  to  be  expelled 
into  the  vagina.  As  soon  as  it  has  arrived 
in  this  situation,  and  is  no  longer  confined 
and  compressed  by  the  uterus,  it  begins  to 
grow  more  rapidly,  and  gives  rise  to  far 
more  troublesome  complaints  ; for  it  presses 
the  bladder  and  rectum,  and  thus,  more  or 
less,  disturbs  the  evacuation  of  the  urine  and 
feces.  But  in  particular,  it  causes  repeated 
and  profuse  hemorrhages,  which  weaken 
the  patient  exceedingly,  and  often  bring  her 
to  the  brink  of  the  grave.  The  root  of  the 
polypus  is  situated  in  the  os  uteri,  and  is 
there  so  compressed,  that  the  blood  in  the 
tumour  is  prevented  from  returning  through 
the  veins  ; consequently,  all  the  vessels  be- 
come turgid,  and  the  above  effusions  of 
blood  are  the  result.  Though  they  generally 
cease  spontaneously,  the  least  circumstances 
cause  their  recurrence  ; such  as  slight  con- 
cussions of  the  body  in  riding,  walking,  &,c. 
In  the  mean  while,  a quantity  of  mucous 
and  aqueq,i>s  fluid  is  voided,  by  which  the 
patient’s  strength  is  more  reduced.  The 
polypus,  the  source  of  this  blood  and  mu- 
cus, is  frequently  misunderstood,  and  the 
patient  is  in  a perilous  state.  So  necessary 
is  it  in  cases  of  preternatural  discharge  , 
from  the  uterus,  always  to  examine  with  the 
finger,  per  vaginam. 

At  length,  after  the  polypus  has  been 
some  time  in  the  vagina,  it  begins  to  pro- 
trude externally.  This  happens  gradually 
or  suddenly,  from  some  effort  or  concussion 
of  the  body.  Hence  additional  grievances 
are  again  excited.  As  the  polypus  cannot 
descend  so  low  without  dragging  the  fundus 
of  the  uterus  downward  Avith  it,  and  occa- 
sioning a prolapsus  of  this  organ,  the  pa- 
tient, in  walking  or  standing,  commonly 
experiences  a very  painful  sense  of  dragging 
or  stretching,  in  the  pelvis.  As  the  bladder 
and  ureters  are  also  forced  into  a deranged 

Eosition,  the  evacuation  of  urine  is,  more  or 
;ss,  disturbed,  or  rendered  difficult.  Lastly, 
the  dribbling  of  the  urine  over  the  polypus, 
and  the  friction  which  the  part  accidentally 
Vox.  II.  47 


suffers,  frequently  cause  it  to  inflame,  and 
become  painful,  and  ulcerated. 

A polypus,  situated  in  the  vagina,  or  pro 
truding  from  it  externally,  may  easily  be 
mistaken  for  a prolapsus  uteri  ; an  error 
Avhich,  though  not  difficult  to  avoid  when  a 
careful  examination  is  made,  may  have  very 
perilous  consequences.  The  polypus  is  softer 
and  less  sensible  than  the  uterus  in  the  state 
of  a prelapsus.  The  imperfect  prolapsus 
uteri,  in  which  this  viscus  is  not  turned  in- 
side out,  is  betrayed  by  the  os  tincae,  at  the 
lower  part  of  which  it  is  plainly  perceptible 
In  this  situation,  the  polypus  may  occasion- 
ally have  a depression  resembling  the  mouth 
of  the  w omb,  but  easy  of  discrimination 
from  it.  A probe  can  be  passed  deeply  into 
the  os  uteri  ; but,  not  so  into  this  other 
opening.  The  polypus  resembles  an  in- 
verted pear,  that  is,  it  is  thickest  beloAV,  and 
becomes  gradually  thinner  upward.  The 
above  species  of  the  prolapsus  uteri  is  thin- 
nest below7,  and  gradually  increases  in  width 
upward.  The  fallen  uterus  may  easily  be 
pressed  back,  and  when  it  is  so,  the  patient 
experiences  relief.  The  polypus  does  not 
admit  of  being  pressed  back,  and,  during  an 
attempt  to  do  this,  the  patient  is  put  to 
much  inconvenience.  A probe  may  be  in- 
troduced by  the  side  of  the  polypus  deeply 
to  the  fundus  uteri.  When  passed  by  the 
side  of  the  fallen  uterus,  it  is,  very  soon 
stopped  at  the  upper  part  of  the  vagina, 
which  has  sunk  down  with  the  cervix  of 
this  organ. 

A polypus,  protruding  externally  from  the 
vagina,  may  be  much  more  easily  distin- 
guished from  a perfect  prolapsus  uteri,  with 
out  inversion.  The  os  uteri  at  once'charac- 
terizes  the  uterus,  as  it  can  here  not  only  be 
felt,  but  seen.  A probe  may  be  passed 
deeply  into  the  vagina,  along  the  side  of  the 
polypus  ; but,  not  so  by  the  side  of  the  ute- 
rus, for  reasons  easy  of  comprehension.  The 
figure  of  the  tumour,  and  the  state  of  the 
patient,  on  an  effort  being  made  to  reduce 
the  protruded  part,  also  betray  its  real  na- 
ture. 

The  inversio  uteri  is  usually  the  conse- 
quence of  a difficult  labour,  arid  hence  is 
easily  discriminated  from  a polypus,  by  its 
occasional  cause.  While  the  inverted  ute- 
rus lies  in  the  vagina,  its  shape  is  broad 
above  and  narrow1  below  ; whereas  the  po- 
lypus is  thin  above  and  broad  below.  Hence 
in  cases  of  very  large  polypi  in  the  vagina, 
the  os  uteri  is  but  little  dilated  ; uffiile  it  is 
extremely  distended  by  the  incemplete  de- 
scent of  the  inverted  uterus  itself.  Here, 
likewise,  the  reduction  of  the  part  is  at 
tended  with  relief ; while  every  effort  to 
push  back  a polypus  causes  an  aggravation 
of  all  the  complaints. 

When  the  inverted  uterus  hangs  out  of 
the  vagina,  its  figure,  like  that  of  the  poly- 
pus, is  thin  upward,  and  broad  downward  ; 
and,  like  the  latter  tumour,  has  no  aperture 
at  its  lowest  part  Here  an  erroneous  opi- 
nion is  very  liable  to  be  formed.  An  atten- 
tive observer,  however,  will  easily  avoid  it. 
The  inverted  uterus  includes  a circular  fold 


370 


POLYPUS. 


at  its  upper  part,  next  to  the  orifice  of  the 
vagina.  This  fold  is  nothing  less  than  the 
os  uteri  itself,  through  which  the  body  of 
this  viscus  has  descended.  There  is  nothing 
of  this  kind  to  be  felt  in  cases  of  polvpi.  By 
the  side  of  a polypus  the  finger  or  probe 
may  be  passed  deeply  into  the  vagina ; but 
not  so  by  the  side  of  the  uterus.  The  root 
of  the  polypus  is  firm  and  hard  to  the  touch  , 
the  upper  thin  [tart  of  the  uterus,  which  is 
hollow,  has  a soft  flabby  feel.  Useful  light 
is  also  generally  thrown  on  the  case,  by  the 
above-mentioned  occasional  cause  of  the 
prolapsus  uteri  with  inversion.  However, 
in  particular  cases,  the  diagnosis  is  much 
more  difficult,  and  the  observations  of 
a modern  writer  fully  prove  that  it  is  al- 
ways difficult,  and  perhaps  sometimes  im- 
possible to  distinguish  a partial  and  chronic 
inversion  of  the  uterus  from  a polypus. 
(IV.Newnham, Essay  on  the  Symptoms-,  Causes , 
and  Treatment  oj  Inversio  Uteri , with  the  His- 
tory  of  the  successful  Extirpation  of  that  Or- 
gan during  the  Chronic  Stage  of  the  Disease , 
p 82,  iyc.  8 vo.  Lond.  1818  ; also  First  Lines 
of  the  Practice  of  Surgery,  Vol.  2,  p 317.) 

In  the  two  last  descriptions  of  uterine 
polypi,  situated  either  on  the  inside  of  the 
cervix,  or  at  the  margin  of  the  os  uteri,  the 
disease  is,  as  it  were,  from  its  commence- 
ment in  the  vagina,  and  the  tumour,  when 
large,  produces  all  the  complaints  attendii  g 
polypi  of  the  first  kind,  except  frequent 
profuse  bleedings.  These  seldom  occur, 
and  when  they  do,  are  slight,  because  the 
root  of  the  polypus  suffers  no  constriction 
in  the  os  uteri.  As  the  tumour  descends  out 
of  the  vagina,  it  occasions  a prolapsus  uteri 
without  inversion,  in  addition  to  the  other 
inconveniences. 

Experienceproves  that  uterine  polypi, when 
once  extirpated,  have  not  that  propensity  to 
be  Reproduced,  which  those  of  the  nose 
have.  Here,  for  obvious  reasons,  extrac- 
tion is  not  the  right  practice  Sometimes, 
however,  uterine  polypi  are  met  with  which 
have  such  a thin  and  soft  pedicle,  that,  al 
though  they  ought  not  to  be  pulled  out,  they 
admit  of  being  twisted  off  with  facility  and 
safety.  Also,  numerous  complaints  of  a 
serious  nature  are  occasionally  the  result  of 
tying  a polypus  of  the  uterus.  In  this  cir- 
cumstance, after  the  ligature  has  been  ap- 
plied some  days,  an  attempt  may  be  made 
to  shorten  such  complaints,  by  twisting  off 
the  tumour  altogether.  This  object  is  most 
conveniently  performed  with  a pair  of  forceps 
made  somethinglike  Smeilie’s  midwifery  for- 
ceps. As  the  part  of  the  polypus  in  the  li- 
gature is  constricted,  thin,  and  already  part- 
ly detached,  the  tumour,  with  a little  cau- 
tion, may  frequently  be  easily  twisted  off, 
■without  any  material  bleeding. 

The  ligature  is  the  must  proper  means  of 
extirpating  uterine  polypi,  and  is  here  much 
more  easy  of  application,  than  in  the  nose. 
Large  as  the  polypus  may  be,  there  is  always 
abundance  of  room  for  the  introduction  of 
ihe  necessary  instruments.  The  polypus  of 
the  uterus  has  commonly  a thinner  pedicle 
than  that  of  the  nose  ; hence  its  cure  by  the 


ligature  is  more  expeditious ; and  on  account 
of  the  greater  room  and  more  yielding  na 
ture  of  the  parts,  the  swelling  of  the  tumour, 
after  the  ligature  is  applied,  produces  less 
inconvenience  than  in  the  same  mode  of 
treatment  of  nasal  polypi.  The  inconve- 
niences which  do  arise  are  easy  of  remo- 
val ; for  instance,  the  retention  of  urine 
may  be  relieved  by  the  catheter;  costive- 
ness by  clysters,  lie.  Uterine  are  also  less 
sensible  than  nasal  polypi ; and  hence, 'less 
pain  and  fever  follow  the  application  of  a 
ligature  to  them.  The  fetid  matter,  formed 
as  soon  as  the  polypus  sphacelates,  has  a 
free  vent  out,  and  may  easily  be  washed 
away  by  injections. 

That  the  polypus  cannot  be  tied  while  it 
lies  in  the  uterus,  is  easily  comprehensible. 
But  immediately  it  has  descended  into  the 
vagina,  the  operation  may  be  undertaken, 
and  may  be  performed  with  the  same  kind 
of  double  cannula,  as  was  employed  in  the 
nose.  However,  here  it  is  extremely  re- 
quisite that  the  cannula  should  be  rather 
longer  than  that  already  described,  and 
somewhat  curved.  But,  as  the  silver  wire 
sometimes  breaks,  two  other  very  conveni- 
ent instruments  have  been  invented. 

The  first  is  Levret  s instrument.  It  con- 
sists of  two  silver  cannula;,  which  are  cur- 
ved in  such  a manner,  and  so  united  by  a 
joint,  that  they  are  shaped  like  a pair  of  for  - 
ceps. After  introducing  a ligature  through 
the  two  tubes,  so  that  its  ends  hang  out  of 
their  lower  apertures,  the  instrument  is  to 
be  shut,  and  passed  upwards  into  the  vagi- 
na, over  the  polypus,  on  whichever  side 
seems  most  convenient.  Then  it  is  to  be 
opened,  and  the  polypus  is  to  be  pushed 
through  the  two  branches  of  the  instrument, 
which  is  to  be  brought  over  the  opposite 
side  of  the  tumour.  In  doing  this,  the  li- 
gature becomes  applied  round  the  root  of 
the  polypus,  and  forms  a noose.  The  ex- 
tremities of  the  ligature  are  next  drawn  as 
tightly  as  possible  out  of  the  lower  openings 
of  the  cannulas,  and  tied  first  in  a surgical 
knot,  and  then  in  a slip-knot.  The  instru- 
ment is  then  shut,  and  the  ligature  con- 
stricts the  root  of  the  polypus.  Afterward 
it  is  to  be  tightened  daily,  until  the  tumour 
separates. 

It  is  plain  that  this  instrument  has  some 
defects,  which,  however,  are  easily  amend- 
ed. It  is  very  inconvenient  that  the  surgeon 
should  be  obliged  to  have  several  such  in- 
struments of  various  sizes  and  curvatures, 
so  as  to  be  able  to  select  that  which  seems 
most  calculated  for  the  magnitude  and  shape 
of  the  polypus.  And,  as  the  size  and  figure 
of  the  polypus  cannot  always  be  ascertain- 
ed beforehand,  it  is  often  indispensable  to 
try  several  instru  nents,  ere  the  most  suita- 
ble one  is  found  out,  and  such  fruitless  at- 
tempts must  be  distressing  and  painful  to  the 
patient.  The  worst  is,  that  though  the  upper 
ends  of  the  instrument  were  to  touch,  when 
the  lower  are  tied  together,  yet  there  would 
always  be  a space  between  the  two  aper- 
tures, where  no  ligature  would  be  applied 
to  the  root  of  the  polypus,  and  where,  con* 


POLYPUS 


371 


sequently,  its  separation  would  not  easily 
be  accomplished.  The  tubes  may  also  bend 
w ith  the  force  used  in  applying  them,  and 
the  pain  caused  by  the  expansion  of  the  in- 
strument would  then  be  very  considerably 
increased. 

All  these  defects  are  done  away  in  the 
instrument  described  by  Nissen,  de  polypis 
uteri,  (See  Richter's  Chir.  Bibl.  9.  B.  S.  613  ) 
It  consists  of  two  silver  tubes,  twelve  inches 
in  length,  and  as  thick  as  an  ordinary  wri 
ting  pen.  Both  are  curved  about  as  much 
as  the  os  sacrum  ; but,  as  they  are  made  of 
pure  silver,  the  curvature  may  easily  be  in- 
creased or  diminished,  according  to  circum- 
stances. Through  each  of  the  cannulae  a 
strong  ligature  is  10  be  passed,  so  that  its 
ends  hang  out  of  the  lower  apertures,  while 
its  middle  portion  forms  a noose  between 
the  upper  apertures  of  the  cannulae.  . 

The  tubes  are  to  be  kept  together  until 
they  have  been  introduced  into  the  vagina, 
as  far  as  the  root  of  the  polypus.  One  is 
then  to  be  held  fast,  while  the  other  is  to 
be  carried  round  the  tumour,  to  the  opposite 
side  of  the  cannulae  that  remains  stationary. 
Thus  the  ligature  becomes  applied  round 
the  root  of  th#  polypus.  After  introducing 
the  finger  into  the  vagina,  to  ascertain  that 
the  ligature  lies  in  its  proper  situation,  its 
ends  are  to  be  drawn  through  a small  dou- 
ble cannula,  which  is  only  one  third  of  an 
inch  long,  but  so  wide  that  it  can  be  pushed 
over  both  the  tubes  a certain  way  w ith  the 
finger,  and  the  upper  end  of  the  long  can- 
nulee  with  the  aid  of  a sort  of  long  probe, 
with  a forked  extremity.  Then  a third 
double  cannula,  through  wffiicb  the  ends  of 
the  ligatures  have  likewise  been  passed,  and 
the  width  of  which  is  sufficient  is  to  be 
pushed  over  the  lower  ends  of  the  long  can- 
nulae so  as  to  unite  them.  The  ligatures  are 
next  to  be  drawn  tight  in  the  ordinary  way, 
and  fastened  to  the  rings.  The  manage- 
ment of  this  instrument  is  so  easy  as  to  need 
no  further  explanation. 

Besides  the  above  instruments,  many 
others  have  been  devised  and  recommended 
for  tying  polypi  of  the  uterus.  In  particular, 
one  invented  by  Desault,  claims  the  atten- 
tion of  such  surgeons  as  wish  to  be  informed 
of  others. 

Acute  symptoms  frequently  follow  the  ap- 
plication of  the  ligature,  and  are  either  of 
an  inflammatory  or  spasmodic  kind.  The 
former  require  antiphlogistic  treatment. 
Sometimes  fever  arises,  and  the  polypus 
becomes  exceedingly  painful  ; in  this  case, 
venesection  is  necessary.  Spasmodic  symp- 
toms require  the  exhibition  of  opium.  When 
this  is  ineffectual,  and  the  symptoms  are 
severe,  it  may  be  proper  to  slacken  the  liga- 
ture a little.  As  the  polypus  at  first  always 
swells,  it  produces  great  prp«sure  on  the 
adjacent  parts.  For  this  reason,  it  is  gene- 
rally necessary,  for  the  first  few  days,  to 
draw  off' the  urine  with  the  catheter,  and  to 
open  the  bowels  with  clysters.  Sometimes 
hemorrhage  takes  place.  This  may  gene- 
rally be  suppressed  with  astringents  ; but 
when  they  prove  ineffectual;  tying  the  liga- 


ture more  tightly  answers  the  purpose.  The 
rest  of  the  treatment  resembles  that  of  nasal 
polypi. 

When  the  polypus  is  large,  it  is  often  ne- 
cessary in  the  end  to  use  forceps  for  its  ex- 
traction. The  inflammation,  <y-  ulceration, 
liable  to  be  occasioned  in  the  vagina  during 
the  treatment,  requires  injections  and  anti- 
phlogistic remedies.  As  the  ligature  is  ge- 
nerally applied  mund  the  pedicle,  close  to 
the  os  uteri,  and  seldom  to  the  very  root  of 
the  polypus,  usually  situated  at  the  fundus 
uteri,  a portion  of  the  root  almost  always 
remains  behind,  alter  the  tumour  has  se- 
parated ; but,  in  all  probability,  it  after- 
ward diminishes  and  fall  off”,  and  however 
this  may  he,  it  is  an  undoubted  fact,  that  a po- 
lypus uteri  is  seldom  reproduced.  (Richter.) 

This  author  observes,  that  cutting  instru- 
ments are,  in  general,  improper  for  polypi 
of  the  uterus,  as  their  employment  would 
injure  the  vagina,  and  for  (he  most  part, 
occasion  a dangerous  hemorrhage.  Howe- 
ver, there  is  one  case  where  the  knife  is  in- 
dispensable. The  polypus  has  occasionally 
a ligamentous  pedicle,  and  consequently  can 
neither  be  lied  nor  extracted.  This  circum- 
stance is  usually  undiscovered  till  after  a 
ligature  ha?  been  applied,  which  here  com- 
monly produces  extraordinary  pain,  and 
though  it  be  applied  ever  so  long  and  forci- 
bly , occasions  no  detachment  of  the  poly- 
pus. In  this  instance,  the  surgeon  may 
either  cut  off  the  polypus  closely  to  its 
root  in  'he  vagina;  or  he  may  first  draw  it 
gradually  downward  out  of  this  situation, 
and  then  remove  it  : perhaps  the  first  object 
might  he  performed  with  a sharp  hook, 
somewhat  curved  at  its  side,  and  similar  to 
w’hat  is  used  for  tearing  the  foetus  piecemeal 
in  the  uterus  ; or  with  what  seems  better*  a 
pair  of  long  curved,  blunt-pointed  scissors. 
The  last  object  may  be  accomplished  With 
an  instrument  resembling  Smellie’s  midw  ife 
ry  forceps,  which  is  to  be  introduced  into 
the  vagina  in  the  ordinary  w'ay.  The 
polypus  is  then  to  be  taken  hold  of,  and  gra- 
dually drawn  so  far  out  of  the  vagina,  that 
its  pedicle  may  be  divided  with  a knife. 
This  is,  indeed,  not  done  without  pain,  and 
a forcible  inversion  of  the  uterus;  but  it 
may  be  executed  without  dangerous  conse- 
quences. When  a polypus,  whose  root  is 
attached  to  the  fundus  uteri,  lies  in  the  vagi- 
na, the  uterus  is  always,  in  some  degree,  in- 
verted beforehand  ; and  this  state  is,  there- 
fore, only  increased  by  the  foregoing  plan, 
which,  does  not  create  danger  wffien  done 
slowly  and  cautiously.  It  is  a plan  which 
has  been  successfully  practised.  (See  Her- 
biniaux , Par  allele  des  differens  Instrumens 
pour  la  Ligature  des  Polypes.) 

Wben  a p-dypus  tbat  has  its  pedicle  at- 
tached to  the  fundus  uteri,  suddenly  falls 
downward,  it  occasions  a sudden  inversion 
of  this  viscus.  In  order  to  relieve,  a-  speedily 
as  possible,  the  great  pain  and  danger  of 
this  case,  the  surgeon  must  tie  the  root  of 
the  polypus  as  soon  and  as  firmly  as  he  can. 
and  pass  the  ligature,  by  means  of  a needle, 
through  the  pedicle,  before  the  place  where 


an 


POL 


PGR 


it  is  tied,  allowing  the  ends  afterward  to 
hang  down  for  some  length.  Then  th«k 
polypus  is  to  be  amputated  belew  the  liga- 
ture, and  the  uterus  immediately  reduced. 
This  is  another  example,  where  a cutting 
instrument  %may  be  usfed  with  advantage. 
The  ordinary  method  of  tying  such  tumours, 
so  situated,  accomplishes  only  a slow  de- 
tachment of  them,  and  does  not  afford  relief 
with  sufficient  expedition. 

Fleshy  excrescences  > Iso  occasionally  form 
in  the  vagina,  some  of  which  have  a broad 
basis,  and  others  a thin  pedicle.  The  last 
merit  the  appellation  of  polypi-  Their  ex- 
istence is  easily  ascertained  by  the  touch. 
By  making  pres  u re  on  the  bladder  and  rec- 
tum,  they  occasion  several  impediments  to 
the  evacuation  of  the  urine  and  fttces.  They 
may  be  conveniently  tied,  by  means  of  the 
double  cannula.  Should  the  polypus  be 
situated  at  the  lower  part  of  the  vagina,  the 
cannulae  would  not  be  required.  The  liga- 
ture might  be  applied  with  the  hand,  and  the 
tumour  cut  off  below  the  constricted,  part. 

There  is  still  another  kind  ot  tumour  in 
♦lie  vagina,  to  be  classed  in  the  rank  of  po- 
lypi. It  resembles,  in  many  points,  the  po- 
lypus of  the  mucous  membrane  of  the  nostril, 
consisting  altogether  of  the  membranous 
lining  of  the  vagina  which,  at  the  part 
affected,  becomes  relaxed,  thickened,  and 
elongated;  hence  the  (uraour  might  be  . ore 
properly  termed  aprolapsus  of  the  membranous 
lining  of  the  vagina,  than  a pulypus.  When 
it  resists  the  efficacy  of  astringent  and  corro- 
borant injections,  if  may  be  tied,  or  what  is 
better,  cut  off. 

A polypus  in  the  oesophagus  renders  de- 
glutition difficult  ; and  when  of  large  size, 
puts  an  entire  stop  to  it.  When  an  inclina- 
tion to  vomit  is  excited  by  irritating  the 
throat  with  the  finger,  or  a feather,  the  poly- 
pus, if  situated  tow  ards  the  upper  part  of  the 
tube,  ascends  in'o  the  mouth,  so  as  to  become 
visible.  But  as  it  impedes  respiration  dunng 
its  residence  in  the  inmitfa,  the  patient  is 
soon  necessitated,  as  it  were,  to  swallow  it 
again.  When  the  polypus  is  situated  far 
dowm  the  oesophagus,  of  course  it  cannot  be 
brought  into  the  mouth,  and  is  very  difficult 
to  detect.  The  difficulty  of  swallowing,  its 
only  symptom,  may  result  from  other  causes. 
In  this  case  it  is  also  incurable  ; for  it  is 
impossible  to  take  hold  of  it  with  instru- 
ments. An  operation  can  only  be  practi- 
sed, when  the  polypus  is  situated  in  the 
upper  part  of  the  oesophagus.  The  tumour 
cannot  be  extracted  ; and  the  tying  of  it  is 
difficult. 

Polypi  in  the  rectum  may  bp  tied  with  the 
aid  of  the  cannuiae.  Excre  c‘*nces  in  the 
meatus  auditorius  externus,  resembling  po- 
lypi, have  been  successfully  extirpated  by 
extraction,  or  rather  by  twisting  them  off. 

For  many  of  the  foregoing  remarks,  I am 
indebted  to  Richter,  who  has  very  ably 
treated  of  polypi  in  his  Ansfangsg.  der  Wun - 
darzn.  B.  1,  Kap.  21.  See  also  J.  B.  de 
Lamsweerde,  Historia  JValuralis  Malorum 
Uteri,  12 mo.  Lugd.  1700.  P.  G Schachev, 
Programma  de  Polypi*,  Lips.  1721.  G.  F. 


Balt  schmid,  De  Mola  scirrhosa  in  ulero 
inverse  extirpata,  Jenee , 1754.  C.  Schunck , 
De  polypo  post  febrern  Epidemicum  ex  utero 
egresso.  Witiemb.  1739.  A.  Levret,  Obs. 
sur  la  Cure  radicate  de  plusieurs  Polypes  de 
la  Matrice , de  la  Gorge,  et  du  Nez.  Svo.  Paris , 
1749.  M.  G.  Hcrbiniaux,  Traill  sur  divers 
Accouchemens  laborieux , et  sur  les  polypes  de 
la  Matrice,  fyc.  2 Tom.  8 vo.  Bruzelles, 
1782 — 1794.  E.  Grainger,  Medical  and  Sur- 
gical tie  m arks,  including  a descript  ion  of  a 
simple  and  effectual  method  of  removing 
polypi  from  the  uterus,  tyc.  Svo.  Lond  1815. 
Denman’s  Plates  of  a Polypus  with  an  In- 
version of  tht  Uterus,  and  of  a Polypus  of  the 
Ulerus.  fol  lSol.  F.  A.  Waller,  Annotationes 
Academii  ce  4 to  Btrol  1786  W.  JYewnham , 
An  Essay  an  the  Symptoms,  fyc.  of  Inversio 
Uteri , with  a History  of  the  successful  Extir- 
pation of  that  Organ,  Svo.  Lond.  1818.  Pott's 
Remarks  on  the  Polypus  of  the  Nose.  Whate- 
ly's  Two  Cases  of  extraordinary  Polypi,  Svo. 
Lond.  1805.  John  Bell's  Principles  of  Sur- 
gery, Vol.  3,  Part  1.  Encyclopedic  M6tho- 
dique,  Art.  Polype.  J.  G.  Haase,  De  Narium 
Morbis  Comment.  Lips.  1794 — 1797.  Lassus, 
Pathologic  Chir.  T.  I,  p.  528 — 538,  fyc.  Edit. 
1809.  Callisens  Systema  CHrurgice  Hodier- 
nce.  Vol.  2,  p.  169.  fyc.  J.  L.  Deschamps, 
Traite  des  Maladies  dts  Fosses  JYnsales,  et  de 
leur  Sinus , Svo.  Paris,  18o4.  JVauche,  des 
Mai.  de  V Uterus,  Svo.  Paris,  1816. 
Schmeider,  Schediasma  de  Polypo  (Esophagi 
vermiformi  rarissimo,  fyc.  Delitii,  1717.  See 
Halleri  Disp.  Morb.  7,  595. 

PORRIGO.  TINEA  CAPITIS,  (called 
also  Ringworm  of  the  Scalp,  Scald-head , 
is,  according  to  Dr.  Bateman’s  excellent 
account  of  the  subject,  a contagious  disease, 
principally  characterized  by  an  eruption  cf 
of  the  pustules  denominated  fan  and  achorcs 
The  achor  is  defined  to  be  a small  acumina- 
ted pustule,  containing  a straw-coloured 
matter,  which  has  the  appearance  and  nearly 
the  consistence  of  honey,  and  is  succeeded 
by  a thin  brown  or  yellowish  scab.  The 
favus  is  larger,  flatter,  and  not  acuminated, 
and  contains  a more  viscid  matter  ; its  base, 
which  is  often  irregular,  is  slightly  inflamed  : 
and  it  is  succeeded  by  a yellow',  semi- 
transparent, and  sometimes  cellular  scab, 
like  a honey-comb  ; whence  it  has  obtained 
its  name.  (See  Bateman's  Synopsis  of 
Cutaneous  Diseases,  p.  xxiv.  and  159,  Edit. 
3.) 

This  intelligent  physician  has  noticed  sis 
species  of  Porrigo,  of  which  my  limits  will 
allow  me  to  give  only  a very  abridged  de- 
scription. 

1.  The  Porrigo  larvalis,  or  crusta  lactea  of 
authors,  begins  with  an  eruption  of  numerous 
minute  whitish  achores,  upon  a red  surface. 
These  pustules  soon  break,  and  discharge  a 
viscid  fluid,  which  concretes  into  thin  yel- 
lowish or  greenish  scabs.  The  disease  in- 
creases in  extent,  and  the  scabs  become 
thicker  and  larger,  until  the  forehead  and 
cheeks,  even  the  whole  face,  excepting  the 
eyelids  and  nose,  become  enveloped,  as  it 
w ere,  in  a mask,  whence  the  epithet  larvalis. 
Small  patches  of  the  disease  sometimes 


FORRTGO. 


appear  about  the  uecfc  and  breast,  and  on 
the  extremities ; and  the  ears  and  scalp  are 
usually  affected  in  the  progress  of  the  case. 
The  infant  suffers  more  or  less  from  the 
itching  and  irritation  When  the  discharge 
is  copious  and  acrid,  Dr.  Bateman  recom- 
mends the  part  to  be  washed  two  or  three 
times  a day  with  tepid  milk  and  water,  and 
the  application  of  the  unguentum  zinci 
alone,  or  mixed  with  the  saturnine  cerate.  The 
latter,  he  says,  will  be  useful  for  the  relief 
of  the  excoriation  left  after  the  cessation  of 
the  discharge.  Small  doses  of  the  submu- 
riate oi  mercury,  cither  alone,  or  in  combi- 
nation with  a testaceous  powder,  wili  «lso 
expedite  the  cure.  If  ibe  bowels  are  very 
irritable,  the  bydrargyrus  cum  creta,  or  the 
cinereous  oxide,  may  be  exhibited  instead 
of  the  calomel.  When  the  health  is  good, 
soda,  precipitated  sulphur,  and  the  tesiacca, 
will  lessen  the  local  inflammation  and  dis- 
charge. 

When  the  irritation  is  removed,  and  the 
crusis  are  dry  and  falling  off,  the  unguentum 
bydrarg.  nitrat.  much  diluted,  may  be  used, 
and  the  decoction  of  bark,  or  the  vinum  ferri 
prescribed. 

2.  Porrigo  furfurans  begins  with  an  erup- 
tion of  small  achores : The  excoriation  is 
slight,  and  the  discharge,  which  is  not 
abundant,  soon  concretes  and  falls  off  in 
innumerable  thin  laminated  scabs.  At  irre- 
gular periods  fresh  pustules  arise,  and  follow 
the  course  of  the  preceding.  The  com- 
plaint is  confined  to  the  scalp,  which  is 
affected  with  itching  and  soreness ; and  the 
hair,  which  partly  (alls  off,  becomes  tbin,  less 
strong,  and  sometimes  of  a lighter  colour 
than  natural.  This  species  of  porrigo  occurs 
principally  in  adults,  and  it  is  sometimes 
attended  with  swelling  of  the  glands  in  the 
neck.  Dr.  Bateman  observes,  that  the 
treatment  requires  the  hair  to  be  closely  cut 
off  the  scalp.  The  branny  scabs  are  then  to 
be  gently  washed  .away  with  some  mild 
soap  and  water  twice  a day ; and  an  oil  silk 
cap  should  be  worn.  In  the  beginning,  w'ben 
the  surface  is  moist,  tender,  and  inflamed, 
the  zinc  ointment,  or  one  made  w ith  3>j*  of 
the  cocculus  indicus  and  2j.  of  lard.  After- 
ward, when  the  scalp  is 'dry  and  free  from 
irritatioo,  it  may  be  washed  with  common 
soft  soap  and  water:  or  with  a mixture  of 
equal  parts  of  soft  soap  and  unguentum 
sulphuris.  Then  the  unguentum  hydrargyri 
nit  rati,  the  ung.  bydrarg.  nitrico  oxydi,  the 
tar  and  sulphur  ointments,  or  the  ung.  acidi 
nitrosi  of  the  Edinb.  Pharm.  may  be  employ- 
ed. These  last  stimulant  applications, 
however,  must  be  left  off,  if  the  inflammation 
and  discharge  return. 

3.  Porrigo  lupinosa  is  characterized,  ac- 
cording to  Dr.  Bateman,  by  dry,  circular, 
yellowish  white  scabs,  set  deeply  in  the 
skin,  with  elevated  edges,  and  a central 
depression,  and  somewhat  resembling,  on  the 
whole,  the  seeds  of  lupines.  These  scabs 
are  formed  upon  the  separate  cluster.'  of 
achores,  and  attain  on  the  scalp  the  size  of 
a sixpence  ; but  when  on  the  extremities. 


they  are  not  more  than  two  lines  in  diame- 
ter. 

In  the  treatment  ol  the  porrigo  lupinosa 
the  scabs  arc  first  to  be  gently  washed  oft' 
with  some  soap  and  water,  and  the  scalp  is 
to  be  shaved,  if  it  be  the  part  affected.  When 
the  scabs  are  difficult  of  removal,  the  liquor 
potassaj,  or  a weak  lotion  of  muriatic  acid 
may  be  u-ed  for  loosening  them.  Then  the 
ointment  of  cocculus  indicus  is  to  be  applied 
to  the  red  cuticle,  and  afterward  any  of 
the  more  stimulant  ointments  above  enu- 
merated 

4.  Porrigo  Scutulata,  or  ringworm  of  the 
Scalp,  as  Dr  Bateman  has  observed,  makes 
its  appearance  in  separate  patches,  of  an 
irregular  circular  shape,  upon  the  scalp, 
forehead,  and  neck.  It  commences  with 
clustersof  small, light-yellow  pustules,  which 
soon  break,  and  form  thin  scabs,  which,  it 
neglected,  become  thick  and  hard.  If  the 
scabs  are  removed,  however,  the  surface  un- 
derneath is  left  red  and  shining,  but  studded 
with  slightly  elevated  points  or  pustules. 
When  the  disorder  is  neglected,  the  patches 
become  confluent,  and  the  whole  head 
affected  Where  the  disease  is  siti^ed,  the 
hair  becomes  lighter  in  its  colour,  it  falls  oft', 
and  its  roots  are  destroyed.  The  porrigo 
scutulata  generally  occurs  in  children  three 
or  four  years  old  and  upwards,  and  fre- 
quently proves  exceedingly  obstinate.  Ac- 
cording to  Dr.  Bateman,  it  seems  to  origi- 
nate spontaneously  in  children  of  feeble  and 
flabby  habit,  and  who  are  ill  fed,  uncleanly, 
and  not  sufficiently  exercised  ; but  he  thinks 
that  it  is  chiefly  propagated  by  contagion, 
i.  e.  by  the  actual  conveyance  of  the  matter 
from  the  diseased  to  the  healthy,  as  may 
happen  in  the  frequent  contact  of  the  heads 
of  children,  the  use  of  the  same  towels, 
combs,  caps,  and  hats. 

While  the  patches  are  inflamed  and  irrita 
ble,  it  is  necessary  to  limit  the  local  appli- 
cations to  washing  the  parts  with  warm  wa- 
ter. Even  shaving  the  scalp,  which  must 
be  repeated  at  intervals  of  eight  or  ten  days, 
produces  a temporary  irritation.  Nothing 
but  a light  linen  cap  is  now  to  be  worn,  and 
it  must  be  often  changed. 

The  disease  afterward  forms  dry  scabs, 
and  becomes  for  a time  less  irritable  ; but 
a fresh  eruption  of  achores  soon  follow's, 
and  the  inflammation  and  redness  return. 

In  the  inflamed  states.  Dr.  Bateman  recom- 
mends the  use  of  ointments,  made  either 
with  the  cocculus  indicus,  submuriate  of 
mercury,  oxide  of  zinc,  superacetate  of  lead, 
opium,  or  tobacco  ; or  else  the  infusion  of 
poppy-heads,  or  tobacco.  Where  there  is 
an  acrimonious  discharge,  Dr  Bateman  pre- 
scribes the  zinc,  or  saturnine  ointments,  the 
ung.  hydrarg.  prascip.  calomel  ointment,  or 
a lotion  of  lime-water  and  calomel. 

In  the  less  irritable  stages,  the  ung.  hv 
drarg.  praecip.  the  ung.  hydrarg.  nitrico- 
oxydi,  and  especially  the  ung.  hydrarg. 
nitrat.  are  often  effectual  remedies.  So  arc 
the  ointments  of  sulphur,  tar,  hellebore,  and 
turpentine,  and  lotions  of  the  sulphates  of 
zinc  and  copper,  the  oxymuriate  of  mercury 


374 


POR 


PRE 


1 have  often  seen  a solution  of  3j  of  the 
sulphuret  of  potassa  in  a pint  of  lime-water, 
succeed  when  most  other  applications  had 
failed.  In  the  very  dry  and  inert  state  of 
the  patches,  Dr.  Bateman  has  seen  the  dis- 
ease removed  by  a lotion,  containing  from 
three  to  six  grains  of  the  nitrate  of  silver  in 
an  ounce  of  distilled  water.  The  applica- 
tion of  the  diluted  mineral  acids,  or  of  a 
blister,  has  also  been  known  to  put  a perma- 
nent stoppage  to  the  morbid  action. 

In  general,  no  local  application  agrees 
well,  if  long  continued,  and  it  is  necessary 
to  have  several,  which  must  be  alternately 
employed. 

The  cure  may  often  be  expedited  by  cin- 
chona, chalybeate,  and  alterative  medi- 
cines; and  attention  must  be  paid  to  the 
patient’s  diet,  exercise,  &,c. 

5.  Porrigo  decalvans  consists  in  bald 
patches,  surrounded  by  hair  which  is  as 
thick  as  usual  It  is  not  known  whether 
any  eruption  of  minute  achores  actually 
precedes  the  detachment  of  the  hair. 

Dr.  Bateman  remarks,  that  if  the  scalp  is 
regular^T  shaved,  and  some  stimulating 
linimeAf  be  applied  to  it,  this  obstinate 
affection  may  at  length  be  overcome,  and 
the  hair  will  regain  its  usual  strength  and 
colour.  Two  drams  of  oil  of  mace,  in  three 
or  four  ounces  of  alcohol,  are  said  to  make 
an  excellent  liniment. 

6.  Porrigo  favosa  consists  of  an  irruption 
of  the  large,  soft,  straw-coloured  flattened 
pustules,  denominated  favi,  which  may 
occur  on  any  part  of  the  body  ; but  most 
commonly  spread  from  the  scalp,  especially 
behind  the  ears,  to  the  face,  or  from  the  lips 
and  chin  to  the  scalp.  They  are  attended 
with  considerable  itching,  and  are  most  fre- 
quently seen  in  children  from  six  months  to 
four  years  of  age,  though  adults  are  also  often 
affected.  The  pustules  pour  out  a viscid 
matter,  which  concretes  into  greenish  or 
yellowish  semi-transparent  scabs.  When 
the  hair  and  moist  scabs  are  matted  together, 
pediculi  are  often  generated  in  great  num- 
bers, and  aggravate  the  itching  and  irrita- 
tion. If  the  disease  be  allowed  to  increase, 
the  scabs  are  thickened  into  irregular  masses, 
not  unlike  honey  comb  ; and  considerable 
ulcerations  sometimes  form, especially  when 
the  heel  and  toes,  or  other  parts  of  the  lower 
extremities,  are  affected.  The  ulcerating 
blotches  are  generally  soon  followed  by  irri- 
tation and  swelling  of  the  lymphatic  glands, 
which  sometimes  slowly  suppurate,  lhe 
contact  of  the  discharge  inoculates  the  dis- 
ease ; thus,  in  young  children,  the  breast  is 
inoculated  by  the  chin  ; and  the  arm  and 
breast  of  the  nurse  may  be  infected  in  the 
same  way ; though  adults  do  not  take  the 
complaint  so  quickly  as  children. 

The  porrigo  favosa  requires  the  same 
alteratives,  internally,  as  the  porrigo  larva- 
lis.  The  diet  should  consist  of  milk,  pud- 
dings, and  a little  plain  animal  food.  When 
the  habit  is  bad,  and  the  glands  swelled, 
bark,  chalybeates,  and  a solution  of  the  mu- 
riate of  barytes,  are  proper. 

As  local  applications,  Dr  Kateman  pre- 


fers the  unguentum  zinci,  or  the  ung.  by- 
drarg.  praecip.  mixed  with  this  or  the  satur- 
nine ointment,  especially  when  the  discharge 
is  copious.  He  also  speaks  favourably  of 
the  ung.  hydrarg.  nitrat.  the  strength  of 
which  is  to  be  diminished  by  an  addition  of 
simple  cerate,  according  to  the  degree  of 
irritation  present. 

For  the  preceding  particulars  I am  indebt- 
ed to  Dr.  Bateman’s  valuable  Synopsis  of 
Cutaneous  Diseases,  where  the  reader,  de- 
sirous of  additional  information  respecting 
porrigo,  will  be  amply  gratified. 

POTASS*  ARSENICATA.  Kali  Arstni- 
catum.  Arsenias  Kali.  Oxydi  albi  arseni- 
ci,  potassa?  nitratis  sing  Crucibulo  am- 
plo  igne  candenti  injice  nitrum,  et  liquefacto 
adde  gradatim  arsenicum  in  frustulis  donee 
vapores  nitrosi  oriri  eessaverint.  Solve  ma- 
teriam  in  aqua?  distillatae  ft>iv.  et  post  ido- 
neara  evaporationem  sepoue  ut  fiant  crys- 
talli.  These  crystals  may  be  given  in  the  dose 
of  one-tenth  of  a grain,  thrice  a day. 
( Pharm . Saadi  Barthol.  1799.)  Justamond 
strongly  recommended  the  internal  exhibi- 
tion of  arsenic  in  cases  of  cancer.  (See 
Cancer.) 

POTASSiE  CARBONAS.  Two  drams  of 
this  medicine  have  been  given,  as  a lithon- 
triptic,  at  St.  Bartholomew’s  Hospital,  in  a 
pint  of  distilled  water,  twice  a day. 

POTASSA  FUSA.  Caustic  Potash.  This 
is  one  of  the  most  useful  caustics  for  de- 
stroying fungi,  making  issues  in  cases  of 
diseased  vertebrae,  white  swellings,  &.C.; 
and  it  is  recommended  be  used  in  a par- 
ticular manner,  by  Mr.  Whately,  for  the  cure 
of  strictures  in  the  urethra.  When  surgeons 
prefer  opening  buboes,  or  any  other  ab- 
scesses, with  caustic,  the  caustic  potassa  is 
very  commonly  employed.  When  surgeons 
used  to  cure  hydroceles,  by  destroying  a 
part  of  the  scrotum  and  tunica  vaginalis  with 
caustic,  the  potassa  fusa,  either  alone  or 
mixed  with  quicklime,  was  made  use  of. 
(See  Vertebra,  Urethra , Strictures  of,  fyc.) 

POTASSiE  SULPHURETUM.  Sulphu- 
ret of  Potash,  Liver  of  Sulphur.  Two  drams, 
dissolved  in  a pint  of  lime  or  distilled  water, 
make  an  excellent  lotion  for  the  cure  ot 
porrigo.  Many  other  cutaneous  affections 
yield  also  to  the  same  remedy.  When  arse- 
nic has  been  swallowed  as  a poison,  twenty 
grains  of  the  sulphate  of  zinc  may  be  given  as 
an  emetic  of  the  quickest  operation  ; and, 
after  keeping  up  the  vomiting  by  drinking 
warm  water,  and,  what  is  better,  sweet  oil, 
some  authors  recommend  making  the  pa- 
tient drink  as  much  as  possible  of  a solution 
of  the  sulphuret  of  potash. 

PREGNA1NCY  is  set  down  by  some  wri- 
ters as  preventive  of  the  union  of  broken 
bones  ; but  many  exceptions  to  the  remark 
present  themselves  in  practice  ; for  I have 
attended  myself  a female,  six  months  gone 
with  child,  who  broke  both  bones  of  her 
leg,  yet  they  grew  together  again  in  the 
usual  time.  (See  Fractures.)  Pregnant  wo- 
men also  frequently  bear  operations  much 
better  than  might  be  expected.  Thus  M. 
JNicod  bus  recently  published  a successful 


PROSTATE  GLAAD. 


amputation  of  the  left  leg  during  pregnancy, 
in  a case  where  the  right  tendo  Achillis  was 
also  ruptured.  Both  the  wound,  and  the 
broken  tendon,  united  very  well.  (See 
Annuaire  Med.  Chir.  des  Hdpitaux  de  Paris, 
p.  509  4 to.  Paris,  1819.) 

PROBANG  A long  slender  bit  of  whale- 
bone, with  a bit  of  sponge  at  its  extremity, 
intended  for  the  examination  of  the  oesopha- 
gus, or  the  removal  of  obstructions  in  it. 

PROCIDENTIA.  Prolapsus.  A falling 
down  of  any  part.  (See  Anus,  Prolapsus 
of.  Uterus,  Prolapsus  of,  fyc.) 

^PROSTATE  GLAjND,  DISEASES  OF. 
It  is  an  observation,  made  by  Mr.  Hunter, 
that  the  use  of  this  gland  is  not  sufficiently 
known  to  enable  us  to  judge  of  the  bad  con- 
sequences of  its  diseased  state,  abstracted 
from  swelling.  Its  situation  (says  he)  is 
such,  that  the  bad  effects  of  its  being  swelled 
must  be  evident,  as  it  may  be  said  to  make 
a part  of  the  canal  of  the  urethra,  and  there- 
fore, when  it  is  so  diseased  that  its  shape  and 
size  are  altered,  it  must  obstruct  the  passage 
of  the  urine.  (On  the  Venereal  Disease , p. 
169.)  A swelling  of  the  prostate  gland, 
however,  may  be  of  very  different  kinds : 
thus  it  may  depend  either  upon  common 
inflammation  of  the  part,  abscesses,  calculi 
formed  within  its  substance,  a varicose  en- 
largement of  its  vessels,  or  a scirrhous  chro- 
nic induration,  (.->ee  (Euvres  Chir.  de  De- 
sault par  Bichat,  T.  3,  p.  220.) 

Modern  anatomists  describe  the  prostate 
gland  as  not  being  itself  a very  sensible  part, 
and  hence  it  is  more  subject  to  chronic  than 
acute  disease,  to  which,  however,  it  is  also 
liable.  We  have  the  authority  of  Desault, 
Hunter,  and  Dr.  Baillie,  for  setting  it  down 
as  subject  to  scrofula.  The  latter  physician, 
after  stating  that  he  has  seen  a common 
abscess  situated  in  it,  adds,  that  it  is  also 
subject  to  scrofulous  disease,  as,  on  cutting 
into  it,  he  has  met  with  the  same  white 
curdy  matter  which  is  formed  in  a scrofu- 
lous absorbent  gland  ; he  has  likewise  forced 
out  of  its  duct  scrofulous  pus.  (Morbid 
Anatomy,  fyc.) 

Mr.  Lloyd  states,  that  he  has  also  met 
with  fleshy  enlargements  of  the  gland,  in 
the  substance  of  which  several  small  ab- 
scesses were  formed,  containing  “ a com- 
plete scrofulous  matter. ' He  has  also  known 
enormous  enlargements  of  this  gland  hap- 
pen in  young  men  who  were  labouring,  at 
the  same  time,  under  other  scrofulous  dis- 
ease. Other  instances  of  supposed  scrofu- 
lous svvellings  of  the  same  part  in  young 
patients  are  likewise  cited  by  this  author, 
one  of  w hich  is  particularly  remarkable,  as 
in  it  the  gland  was  found  after  death  to  be 
of  the  size  of  a child’s  head,  though  its  na- 
tural consistence  was  not  much  changed. 
(On  the  Nature  and  Treatment  of  Scrofula, 
p.  107.)  Other  chronic,  or  as  they  are  more 
often  called,  scirrhous  enlargements  of  the 
prostate  gland,  rarely  occur  in  subjects  un- 
der the  age  of  fifty.  To  these  cases  I shall 
presently  return. 

Like  every  other  part  of  the  body,  the 
prostate  gland  is  .sometimes,  but  not  often. 


the  seat  of  common  phlegmonous  inflamma- 
tion Mr.  Wilson  has  known  two  or  three 
instances  of  this  kind  take  place  soon  after 
puberty ; one  case  was  from  a fall ; the 
others  arose  without  any  assignable  cause, 
(On  the  Male  Urinary  and  Genital  Organs, 
p.  327.)  There  is  also  a phlegmonous  swell- 
ing of  the  prostate  gland,  sometimes  an 
effect  of  strictures,  as  will  be  presently  no- 
ticed. \s  Desault  observes,  the  retention 
of  urine,  arising  from  such  a cause,  comes 
on  very  suddenly  and  rapidly  increases. 
The  patient  at  first  complains  of  a sense  of 
heat  and  weight  about  the  perinaeum  ; and, 
soon  afterward,  of  a continual  throbbing 
pain  about  the  neck  of  the  bladder.  The 
pain  is  severely  increased  when  the  patient 
goes  to  stool ; and  there  is  tenesmus,  and 
frequent  inclination  to  make  wrater.  How- 
ever, according  to  Mr.  Wilson,  the  desire  to 
evacuate  the  urine  is  here  less  constant  than 
in  cases  where  the  inner  membrane  of  the 
bladder  is  inflamed.  (Vol.  cit.p.  327.)  The 
patient  feels  also  as  if  a large  mass  of  excre- 
ment filled  the  extremity  of  the  rectum,  and 
were  ready  to  come  out.  If  a finger  oe  in- 
troduced within  the  rectum,  the  swelling  of 
the  gland  is  plainly  distinguishable;  and, 
according  to  J.  L.  Hetit,  the  projection  of 
the  prostate  gland  in  the  bowel  makes  a 
corresponding  hollow  groove  along  the 
concave  side  of  the  excrement,  as  may  be 
noticed,  when  what  is  voided  is  hard.  How- 
ever,  Bichat  conceiv  es,  that  such  an  appear- 
ance must  generally  be  obliterated  as  the 
excrement  is  passing  through  the  sphincter. 
When  the  patient  attempts  to  make  water,  it 
is  a long  while  befor,  the  first  drops  come 
out,  and  asstraining  has  the  effect  of  pro- 
pelling the  swelled  prostate  more  against 
the  neck  of  the  bladder,  it  only  increases 
the  difficulty,  and  no  urine  will  come  out 
until  such  efforts  are  discontinued.  The 
more  violent  the  inflammation  is,  the  smaller 
is  the  stream  of  urine,  and  the  more  acute 
the  pain  felt  during  its  expulsion.  Accord- 
ing to  Desault,  it  is  likewise  particularly  re- 
markable in  such  cases,  that  if  an  attempt, 
be  made  to  introduce  a catheter,  the  instru- 
ment passes  without  the  least  resistance  as 
far  as  <he  prostate  gland,  where  it  stops,  and 
causes  great  pain.  The  pulse  is  hard  and 
frequent ; and  the  patient  is  exceedingly 
thirsty  and  feverish.  Desault  considered 
the  retention  ot  urine  in  cases  of  this  kind, 
and,  indeed,  in  all  enlargements  of  the 
prostate  gland,  or  other  obstruction  of  the 
urethra,  as  generally  more  dangerous  than 
other  retentions,  merely  depending  upon 
weakness  of  the  bladder,  where  there  is 
little  risk  of  this  organ  giving  way.  When 
the  urethra  is  free  from  obstruction,  the 
urine,  after  distending  the  bladder  in  a cer- 
tain degree,  generally  oozes  through  that 
canal  and  the  patient  may  live  in  this  con- 
dition for  years  without  any  alarming  symp- 
toms. But  the  case  is  different  when  the 
retention  of  urine  depends  upon  any  stop- 
page or  stricture  in  the  urethra.  The  urine 
does  not  then  partially  escape,  but  stagnates 
in  bladder;  the  distention  increases; 


376 


PROSTATE  GLAND. 


and  if  speedy  relief  be  not  afforded,  a peril- 
ous extravasation  follows.  The  datiger, 
however,  of  such  a retention  of  urine  de- 
pends very  much  upon  the  extent  and  seve- 
rity of  the  inflammation.  However,  this 
statement  will  not  apply  to  the  chronic 
scirrhous  enlargement  of  the  prostate,  be- 
cause, as  w . 1 1 be  presently  explained,  in  this 
affection  some  of  the  urine  begins  to  drib- 
ble away  alter  the  bladder  has  become  dis- 
tended in  a certain  degree. 

In  cases  of  phlegmonous  inflammation  of 
the  prostate  gland,  antiphlogistic  treatment 
is  indicated  ; especially  venesection,  leeches 
to  the  perinaeum  and  near  the  anus,  the 
warm  bath,  emollient  clysters,  poultices, 
and  fomentations,  a. id  a low  regimen.  JHowr- 
r.ver,  as  Desault  admits,  the  efficacy  of  these 
means  is  often  too  slow',  and  the  symp- 
toms too  urgent,  to  allow  the  surgeon  to 
wait  for  the  urine  to  flow  of  itself.  Fre- 
quently, also,  the  distention  has  so  weaken- 
ed the  bladder,  that  this  organ  cannot  expel 
its  contents;  in  which  event  the  catheter 
must  be  used,  though  the  diminished  dia- 
meter and  altered  course  of  the  prostatic 
portion  of  the  urethra  sometimes  renders  its 
introduction  difficult,  and  always  very  pain- 
ful. The  practical  observations  respecting 
the  best  kind  of  catheters,  and  the  mode  of 
introducing  them  in  cases  of  swelled  pros- 
tate gland,  wrill  be  more  conveniently  intro- 
duced when  the  chronic  enlargement  of  this 
part  is  considered.  (See  also  Catheter  and 
Urine,  Retention  of.)  In  every  instance  of 
retention  of  urine  from  acute  inflammation 
about  the  neck  of  the  bladder,  whether  the 
case  he  an  abscess  forming  near  the  anus, 
or  a phlegmonous  inflammation  of  the  pros- 
tate gland,  or  other  adjacent  part,  it  has 
always  appeared  to  me  ihat  antiphlogistic 
and  anodyne  remedies  should  first  be  fairly 
tried,  and  the  catheter,  which  always  in- 
creases the  pain  and  irritation,  only  used 
where  such  means  do  not  afford  relief  w ith 
sufficient  expedition. 

When  a catheter  has  been  introduced, 
ought  it  to  be  left  in  the  bladder,  or  with- 
drawn, after  the  discharge  of  the  urine  ? 
Its  presence  no  doub^wili  increase  the  irri- 
tation about  the  neck  of  the  bladder;  but 
on  the  other  hand,  if  it  be  taken  out,  the 
surgeon  may  noi  be  able  to  introduce  it 
again.  No  general  precept,  says  Desault, 
can  be  laid^dow  n on  this  point.  The  course 
which  the  practitioner  will  pursue,  must 
depend  upon  the  difficulty  he  has  experien- 
ced in  getting  the  instrument  into  the  blad- 
der, anil  upon  the  confidence  w hich  he  may 
have  in  his  own  skill,  and  which  must  be 
founded  upon  constant  success  in  analogous 
instances. 

According  to  Desault,  when  an  abscess 
follows  inflammation  of  the  prostate,  the 
body  of  the  gland  itself  does  not  suppurate, 
but  only  the  surrounding  parts,  and  the  cel- 
lular substance,  which  connects  its  lobes 
together.  This,  at  least,  was  what  was  ob- 
served in  examining  several  dead  subjects, 
who  were  publicly  opened  in  the  amphi- 
theatre of  the  Hotel-Dien. 


When  the  symptoms  of  inflammation  have 
lasted  a week,  and  all  this  time  have  con- 
tinued to  increase  ; W'hen,  after  this  period, 
they  have  abated  a little,  and  then  become 
violent  again  ; and  when  the  febrile  symp- 
toms grow  worse  in  the  evening,  and  have 
been  preceded  by  shiverings  ; there  is  rea- 
son to  suspect  the  formation  of  matter.  It 
cannot  be  known,  whether  the  pus  is  col- 
lected in  one  particular  place,  or  diffused. 
When  the  matter  is  external  to  the  gland, 
the  case  is  less  serious  than  when  it  occu- 
pies the  cellular  substance  connecting  the 
lobes.  According  to  Desault,  the  latter 
form  of  the  disease  seldom  gets  wrell.  There 
are  no  peculiar  symptoms  which  denote  it; 
the  matter  does  not  readily  make  its  way 
outward  ; and  the  state  of  things  is  not  clear 
enough  to  admit  of  an  incision  being  made. 
Besides,  Desault  doubted  whether  an  inci- 
sion could  be  of  much  use,  since  it  would 
probably  only  discharge  the  manner  in  its 
vicinity. 

I hings  are  different  when  the  pus  is  col- 
lected in  one  place,  and  is  more  superficial 
If  situated  betw'een  the  gland  and  neck  of 
the  bladder,  Desault  says,  it  will  often 
spontaneously  burst  into  this  viscus,  or  it 
may  be  let  out  with  the  point  of  the  cathe- 
ter. It  will  then  either  be  discharged  through 
the  instrument,  or  come  away  with  the 
urine.  However,  according  to  Mr.  Wilson, 
abscesses  of  the  prostate  gland  generally 
burst  into  the  urethra  behind  the  caput  gal- 
linaginis,  but  sometimes  before  it ; and  he 
has  seen  more  than  one  instance,  in  which 
they  have  burst  in  the  perinaeum.  (On  the 
Male  Urinary  and  Genital  Organs,  p.  329.) 
Should  the  abscess  lie  near  the  rectum  and 
perinaeum,  and  admit  of  being  distinctly 
felt,  Desault  conceived,  that  a free  opening 
would  expedite  the  cure. 

In  all  these  cases,  the  use  of  the  catheter 
is  requisite,  in  order  to  let  out  the  urine, 
and  as  the  instrument  must  be  left  in  the 
passage  some  time,  Desault  preferred  one 
made  of  elastic  gum.  As  Mr.  Wilson  has 
remarked,  soothing  means  should  also  be 
employed  ; internal  narcotic  medicines, 
anodyne  clysters,  the  mixtura  amygdala- 
rum,  &,c. 

Morgagni  has  taken  notice  of  the  reten- 
tions of  urine,  arising  from  the  presence  of 
calculi  in  ihe  prostate  gland.  The  nature 
of  these  concretions  will  be  described  in 
the  article  Urinary  Calculi  Calculi  also 
sometimes  form  in  or  about  the  prostate 
gland,  when,  after  lithotomy,  the  outer  part 
of  the  wound  heals  sooner  than  the  bottom. 
A kind  of  urinary  fistula  then  ensues  ; and 
as  the  extraneous  substance  is  constantly 
exposed  to  the  contact  of  fresh  urine,  it  may 
increase  to  a very  large  size.  The  diagnosis 
of  prostatic  calculi  is  seldom  very  clear. 
A retention  of  urine,  and  an  impediment 
to  the  emission  of  the  semen,  are  said  to  be 
the  only  symptoms,  and  these  are  common 
to  several  other  affections  of  the  prostate 
gland  and  urethra.  When  the  finger  is  in- 
troduced into  the  rectum,  the  gland  inay 
indeed  be  felt,  to  be  enlarged  ; but  the  hr- 


ROSTAPTE  GLAND 


Jure  and  cause  of  such  enlargement  cannot 
*n  general  be  distinguished.  In  one  instance, 
however,  lately  recorded  by  Dr.  Marcet,the 
calculi  could  be  plainly  felt  through  the 
coats  of  the  rectum,  and  a proposal  was 
made  to  extract  them  by  an  incision  in  that 
situation  ; but  the  patient  did  not  accede  to 
so  judicious  a measure.  (Med.  and  Chym. 
Hist,  of  Calculous  Disorders , 8 vo.  1817.) 
When  a calculus  projects  from  the  prostate 
gland  into  the  urethra,  the  end  of  a sound 
will  strike  against  it ; but  then  it  can  rarely 
be  known  whether  the  extraneous  substance 
may  not  be  a calculus  that  has  passed  out 
of  the  bladder  into  the  urethra,  or  lies  close 
to  the  neck  of  this  viscus. 

Whether  the  case  be  of  one  description  or 
the  other,  however,  the  treatment  should  be 
the  same  ; viz.  the  calculus  should  be  ex- 
tracted by  an  incision,  resembling  that  prac- 
tised in  the  lateral  operation. 

A considerable  varicose  affection  of  the 
vessels  of  the  prostate  gland,  which  is  also 
itself  generally  somewhat  enlarged,  is  an- 
other disease,  treated  of  by  writers  as  one 
cause  of  a retention  of  urine.  In  this  case 
the  water  should  be  drawn  off  with  an  elas- 
tic gum-catheter,  which  should  be  kept  in 
the  urethra  ; and  a large  instrument  is  to  be 
preferred  to  a smaller  one.  For  an  account 
of  the  symptoms  of  this  case,  I must  refer  to 
Les  (Euvres  Chir.  de  Desault,  T.  3,  p.  234. 
The  practice  of  this  author  was  gradually  to 
dilate  the  portion  of  the  urethra  which 
passes  through  the  prostate,  with  bougies, 
or  elastic  catheters,  which  were  worn  a 
long  while,  and  cleaned  and  changed  at 
proper  intervals.  I am  not  aware,  that  these 
cases  are  recognized  in  the  practice  of  sur- 
gery in  England. 

The  most  frequent  disease  of  the  pros- 
tate gland,  and,  of  course,  that  which  is 
most  "interesting  to  the  practical  surgeon,  is 
a slow  hardening  and  enlargement  of  it, 
sometimes  denominated  scirrhvs , whereby 
its  natural  size,  which  is  that  of  a common 
chesnut,  is  sometimes  gradually  changed  to 
that  of  a man’s  fist.  (J  L.  Petit.)  Accord- 
ing to  the  observations  of  Mr.  Hunter,  De- 
sault, and  Sir  Everard  Home,  this  chronic 
swelling  of  the  prostate  gland  is  most  com- 
mon in  the  decline  of  life  ; one  circum- 
stance in  which  it  differs  from  scrofulous 
diseases  of  the  same  part,  which  are  well 
known  to  happen  chiefly  in  youngish  persons. 

It  is  observed  by  Mr.  Hunter,  that  when  the 
prostate  gland  swells,  “ it  does  not  lessen 
the  surface  of  the  urethra  at  the  part,  like  a 
stricture  ; on  the  contrary,  it  rather  in- 
creases it ; but  the  sides  of  the  canal  are 
compressed  together , producing  an  obstruction 
to  the  passage  of  the  urine,  which  irritates  the 
bladder , and  brings  on  all  the  symptoms  in 
that  viscus,  usually  arising  from  a stricture , 
or  stone.  From  the  situation  of  the  gland, 
which  is  principally  on  the  two  sides  of  the 
canal,  and  but  little,  if  at  all,  on  the  fore- 
part, as  also  very  little  on  the  posterior  side, 
it  can  only  swell  laterally, whereby  it  presses 
the  two  sides  of  the  canal  together,  and,  at 
Von.  II. 


377 

the  same  time,  stretches  it  from  the  anterior 
edge,  or  side,  to  the  posterior,  so  that  the 
canal,  instead  of  being  round,  is  flattened 
into  a narrow  groove,  sometimes  the  gland 
swells  more  on  one  side  than  the  other , which 
makes  an  obliquity  in  the  canal  passing 
through  it. 

u Besides  this  effect  of  the  lateral  parts 
swelling,  a small,  portion  of  it  which  lies  be- 
hind the  very  beginning  of  the  urethra,  swells 
forwards,  like  a point,  as  it  were,  into  the 
bladder,  acting  like  a valve  to  the  mouth  of 
the  urethra,  which  can  be  seen  even  when 
the  swelling  is  not  considei'able,  by  looking 
upon  the  mouth  of  the  urethra  from  the  ca- 
vity of  the  bladder  in  a dead  body.  It  Some- 
times increases  so  much  as  to  form  a tumour , 
projecting  into  the  bladder  some  inches.  This 
projection  turns,  or  bends  the  urethra  for- 
wards, becoming  an  obstruction  to  the  passage 
of  a catheter,  bougie,  or  any  such  instrument  • 
and  it  often  raises  the  sound  over  a small  stone 
in  the  bladder , so  as  to  prevent  its  being  felt.” 
(Hunter  on  the  Vencrbal  Disease,  p.  169.)  The 
valvular  production  just  behind  the  begin- 
ning of  the  urethra,  here  described,  particu- 
larly merits  attention,  because  it  is  repre- 
sented by  Sir  Everard  Home  as  arising  from 
the  enlargement  of  what  he  considers  a new- 
ly discovered  part  in  anatomy,  viz.  a third, 
or  middle  lobe  of  the  prostate  gland.  (See 
Phil.  Trans.  1806.)  In  the  dissections, 
which  Sir  Everard  mentions,  as  having  led 
to  this  discovery,  “the  urinary  bladder  was 
distended  with  water,  and  the  surfaces  of 
the  prostate  gland,  vesicula?  seminales,  and 
vasa  deferentia,  were  fairly  exposed.  This 
being  done,  the  vasa  deferentia  and  vesi- 
culae  seminales  were  carefully  dissected  off 
from  the  bladder,  without  removing  any 
other  part.  These  were  turned  down  upon 
the  body  of  the  prostate  gland.  An  accurate 
dissection  was  then  made  of  the  circumfer- 
ence of  the  two  posterior  portions  of  the 
prostate  gland,  and  the  space  between  them 
was  particularly  examined.  In  doing  this, 
a small  rounded  substance  was  discovered, 
so  inuch  detached  that  it  seemed  a distinct 
gland,  and  so  nearly  resembling  Cow  per  s 
glands  in  size  and  shape,  as  they  appeared 
in  the  same  subject,  in  which  they  were 
unusually  large,  that  it  appeared  to  be  a 
gland  of  that  kind.  It  could  not,  how  ever, 
be  satisfactorily  separated  from  the  prostate 
gland,  nor  could  any  distinct  duct  be  found 
leading  into  the  bladder. 

“ A similar  .examination  was  made  of  this 
part  in  five  different  subjects.  The  appear- 
ance was  not  exactly  the  same  in  any  two 
of  them.  In  one,  there  ivas  no  apparent  glan- 
dular substance,  but  a mass  of  condensed  cel- 
lular membrane  : this,  however,  on  being 
cut  into,  differed  from  the  surrounding  fat. 

In  another  there  was  a lobe,  blended  late- 
rally with  the  sides  of  the  prostate  gland. 
These  facts  (says  Sir  Edward  Home)  are 
mentioned  in  proof  of  its  not  being  always 
of  the  same  sizexor  having  exactly  the  same 
appearance.” 

This  is  found  also  to  be  the  case  with 


PROSTATE  GLAND. 


378 


Cowper’s  glands  : they  are  sometimes  large 
and  distinct  ; in  other  subjects,  they  are 
scarcely  to  be  detected  ; and,  in  others 
again,  are  .in  all  the  intermediate  states. 
The  most  distinct  and  natural  appearance 
of  this  part  was  in  a healthy  subject, 
twenty-five  years,  of  age,  of  which  the 
following  is  an  account.  On  turning  off  the 
vasa  deferentia  and  vesiculai  semlnales, 
exactly  in  the  middle  of  the  sulcus,  between 
the'  two  lateral  portions  of  the  prostate 
gland,  there  was  a rounded  prominent  body, 
the  base  of  which  adhered  to  the  coats  of 
the  bladder.  It  was  imbedded,  not  only 
between  the  vasa  deferentia  and  the  bladder, 
but  also,  in  some  measure,  between  the 
lateral  portions  of  the  prostate  gland  and 
the  bladder,  since  they  were  in  part  spread 
over  it,  so  as  to  prevent  its  circumference 
from  being  seen,  and  they  adhered  so  closely 
as  to  require  dissection  to  remove  them  ; 
nor  could  this  be  done,  beyond  a certain 
extent,  after  which  the  same  substance  was 
continued  from  one  to  the  other.  This 
proved  it  to  oe  a lobe  of  the  pfostate  gland ; 
its  middle  had  a rounded  form,  united  to 
the  gland  at  the  base  next  the  bladder,  but 
rendered  a separate  lobe  by  two  fissures  on 
its  opposite  surface.  Its  ducts  passed 
directly  through  the  coats  of  the  bladder, 
on  which  it  lay,  and  opened  immediately 
behind  the  verumontanum.  By  means  of 
this  lobe,  a circular  aperture  is  formed  in 
the- prostate  gland,  which  gives  passage  to 
the  vasa  deferentia.  “ Previous  to  this 
investigation  (says  Sir  Everard)  it  was  not 
known  to  me,  that  any  distinct  portion  of 
the  prostate  gland  was  situated  between  the 
vasa  deferentia  and  the  bladder/’  (On 
Diseases  of  the  Proslate  Gland, p.  9, 8vo.  Land. 
1811.)  Notwithstanding  this  explanation, 
to  the  correctness  of  which  most  English 
anatomists  have  acceded,  it  is  worthy  of  no- 
tice, that  Langenbeck,  the  present  distin- 
guished Professor  of  Anatoipy  and  Surgery 
at  Gottingen,  in  a review  of  Sir  Everard’s 
account,  declares,  that  he  has  never,  in  the 
natural  state  of  the  parts,  found  the  middle 
lobe,  as  it  is  called,  which  he  considers  as  a 
partial  induration,  rising  up  in  the  shape  of 
a lobe.  (JVeuc  Bibl.  B.  1,  p.  360,  12mo. 
Hanover,  1818.)  This  dissent  would  seem 
extraordinary,  if  it  were  not  possible  to 
suppose,  that  it  may  proceed,  not  from  all 
the  subjects  at  Gottingen  differing  from 
Londoners  in  being  destitute  of,  what  Sir 
Everard  Home  has  named,  the  middle  lobe 
of  the  prostate  gland,  but  from  Langenbeck’s 
not  having  traced  in  the  healthy  slate  of 
the  gland,  any  portion  which  he  thought 
deserving  of  that  name.  But  though 
differences  of  opinion  may  be  entertained 
about  the  name,  none  l presume  can  remain 
about  the  thing  itself,  which  appears  to 
have  been  long  ago  mentioned,  though  not 
perfectly  described,  by  Morgagni.  (Adversa- 
ria Anal.  4,  Animad.  15.)  The  paper  by  Mr. 
C.  Bell,  illustrating  how  i’arour  predecessors 
bad  a knowledge  of  this  portion  of  the 
gland,  seems  to  me  one  of  his  best  produc- 
tions: and  it  is  therefore  with  pleasure  that 


I refer  to  it.  (See  An  Account  of  the  MuscUn 
of  the  Ureters  in  Med.  Chir.  Trans.  Vol.  3, 
p.  171,  4*.)  However,  as  this  author 
impartially  acknowledges,  it  is  not  because 
a fact  was  anciently  known,  or  perhaps 
only  cursorily  noticed,  that  there  may  not 
be  great  merit  in  reviving  the  recollection, 
or  perfecting  the  description  of  it ; and  as 
far  as  I can  learn,  none  of  the  anatomical 
teachers  in  this  city,  previously  to  Sir 
Everard’s  paper,  particularly  adverted,  in 
the  healthy  original  state  of  the  prostate 
gland,  to  the  structure,  which-he  has  pointed 
out,  by  whatever  name  it  be  distinguished. 

According  to  Sir  Everard  Home,  this  lobe, 
in  the  earlier  periods  of  life,  when  the  body 
of  the  gland  is  in  a sound  state,  is  small  ; 
nor  does  it  appear  to  become  enlarged,  even 
when  the  body  and  the  lateral  lobes  have 
been  considerably  increased  in  size  ; but, 
in  subjects  of  advanced  age,  this  part,  as 
well  as  the  cest  of  the  gland,  is  usually  found 
somewhat  enlarged,  even  in  cases  where  no 
disease  has  been  suspected  during  life.  (P. 
17.)  When  the  middle  lobe  begins  to 
enlarge,  it  presses  inwards  towards  the 
cavity  of  the  bladder,  putting  the  internal 
membrane  upon  the  stretch,  and  communi- 
cating to  it  by  immediate  contact  the  in- 
flammation, which  occasioned  its  -own 
enlargement.  Hence,  pain  in  making  water, 
particularly  after  the  last  drops  are  voided, 
and  a desire  and  strairiingto  discharge  more, 
after  the  bladder  is  empty. 

As  this  organ  cannot  now  retain  much 
urine,  the  desire  to  make  watfr  becomes 
frequent,  and  there  is  commonly  more  or 
less  constitutional  disturbance,  or  sympto- 
matic fever.  According  to  Sir  Everard 
Home,  in  prop  uon  as  the  middle  lobe 
increases  in  size:;  it  projects  into  the  cavity 
of  the  bladder  in  the  form  of  a nipple  ; but 
after  a further  augmentation,  it  loses  the 
nipple-like  appearance,  becomes  broader, 
and  forms  a transverse  fold  by  pushing  for- 
ward, and  stretching,  the  membrane,  con- 
necting it  to  the  lateral  lobes,  “ As  the  tu- 
mour, arid  the  transverse  fold,  are  situated  im- 
mediately behind  the  orifice  of  the  urethra,  they 
are  pushe.il forwards  before  the  urine  in  every 
attempt  that  is  made  to  void  it,  acting  like  a 
valve,  and  closing  up  the  opening,  till  the  cavi- 
ty °f  the  bladder  is  very  much  distended,  when 
the  anterior  pari  of  the  bladder  being  pushed 
forward,  and  the  tumour  being  drawn  back, 
in  consequence  of  the  membrane  of  the  poste- 
rior part  of  the  bladder  being  pul  on  the  stretch, 
the  valve  is  opened,  so  that  a certain  quantity 
of  water  is  allowed  to  escape,  but  the  blad- 
der is  not  completely  emptied.  (P.  19.) 
Sir  Everard  Home  afterward  explains,  that, 
as  the  tumour  enlarges,  the  quantity  voided 
at  each  time  becomes  smaller,  and  that 
which  is  retained  is  increased,  until  at 
length,  the  disease  becomes  so  much  aggra- 
vated, that  there  is  a complete  retention  of 
urine.  The  body  of  the  gland,  and  the  late- 
ral lobes,  though  less  disturbed  tlffm  the 
middle  lobe  by  the  patient’s  repeated  ef- 
forts to  void  the  urine,  become  more  or  less 
enlarged  ; but  it  is  remarked,  that  they  do 


PROSTATE  GLAND 


not  preserve  either  their  natural,  or  any 
regular,  proportion,  to  the  middle  lobe,  nor 
do  they  always  swell  equally  together,  the 
left  in  some  instances  becoming  much  larger 
than  the  right.  (P.  22.)  When  Sir  Everard 
Home  published  his  first  vol.  on  diseases  of 
the  prostate  gland,  he  had  seen  only  the  left 
lobe  form  the  greatest  projection  within  the 
bladder  ; but,  in  his  second  vol.  published 
in  1818,  there  is  an  engraving,  representing 
the  right  lobe  thus  altered  ; and  he  mentions 
two  instances,  in  which  a similar  enlarge- 
ment of  the  same  lobe  had  taken  place. 
Mr.  Wilson  has  also  more  than  once  met 
with  this  greater  swelling  of  the  right  lobe. 
( On  the  Male  Urhiary  and  Genital  Organs , 
p.  336.)  The  recollection  of  these  facts  will 
often  enable  the  practitioner  to  incline  the 
beak  of  a catheter  in  the  direction  by  which 
it  may  be  conducted  into  the  bladder,  and 
thus,  as  Sir  Everard  Home  has  remarked, 
the  surgeon,  after  trying  gently  on  the  left 
side,  and  not  succeeding,  is  not  to  perse- 
vere in  that  direction,  but  try  whether  the 
passage  will  offer  less  resistance  on  the  op- 
posite side. 

The  diseased  state  of  the  body  of  the 
prostate  gland,  and  of  the  lateral  lobes,  here 
alluded  to  by  Sir  Everard  Horne,  he  says, 
is  very  different  from  that,  which  is  met 
with  in  the  earlier  periods  of  life,  in  conse- 
quence of  strictures  of  the  urethra,  and 
which  subsides  when  the  obstruction  in  that 
canal  is  removed.  This  enlargement  of  the 
prostate  gland  from  strictures,  he  observes, 
may  not  be  unaptly  compared  to  the  swell- 
ing of  the  testicle  in  gonorrhoea,  a case  of 
accidental  inflammation  in  a healthy  tes- 
ticle ; while  the  other  disease  of  the  pros- 
tate is  analogous  to  the  more  permanent 
disease  of  the  latter  organ.  This  author 
adverts,  however,  to  a few  instances,  in 
which  the  enlargement  of  the  body  of  the 
prostate  gland  from  strictures,  in  persons 
50  years  of  age,  did  not  subside  immediate- 
ly the  latter  affection  was  cured,  a common 
bougie  stopping  at  the  neck  of  the  bladder, 
although  a catheter, ' which  had  a regular 
curve,  readily  passed.  According  to  Sir 
Everard  Home,  as  in  such  cases,  the  patients 
were  able  to  empty  their  bladders,  it  is  evi- 
dent, that  there  .could  be  no  enlargement 
of  the  middle  lobe.  In  cases  like  these,  no 
symptom  of  importance  is  produced,  and, 
whether  the  swelling  of  the  prostate  readily 
subsides,  or  not,  is  of  no  consequence  ; 
though,  if  the  stricture  do  not  return,  it  will 
always  ultimately  diminish.  (On  Diseases 
of  the  Prostate  Gland , Vol.  1,  p.  24.)  In 
patients  under  50  years  of  age,  Sir  Everard 
Home  has  rarely  found  the  middle  lobe  so 
swelled  as  to  produce  retention  of  the  urine, 
or  an  inability  to  empty  the  bladder,  not- 
withstanding the  rest  of  the  gland  might  be 
much  enlarged.  (P.  23.)  When  the  middle, 
and  one  of  the  lateral  lobes,  project  consi- 
derably into  the  bladder  together,  their  sur- 
face is  sometimes  excoriated,  and  has  an 
ulcerated  appearance.  Under  such  circum- 
stances, the  pain,  after  voiding  the  last 
drops  of  urine,  is  said  to  be  very  severe, 


and  attended  with  spasmodic  affections  of 
the  neck  of  the  bladder,  of  the  most  dis- 
tressing kind. 

According  to  Sir  Everard  Home,  another 
effect  of  a similar  enlargement  of  the  pros- 
tate gland  is  to  render  its  secretion  extreme  •' 
ly  viscid  and  very  abundant.  A question, 
might  arise  about  the  real  source  of  this 
ropy  mucus,  and  some  might  infer,  that  it 
was  secreted  by  the  bladder  ; but  that  it 
comes  entirely  from^the  inflamed  prostate 
gland  is  proved,  says  this  gentleman,  by  its 
having  been  found  in  one  instance  with  one 
extremity  floating  in  the  bladder  in  the  dead 
body,  while  the  other  extremity  appeared 
divided  into  small  filaments,  terminating  in 
the  orifices  of  the  excretory  ducts  of  the 
gland  at  the  verumontanum.  The  quantity 
of  secretion  rs  observed  to  depend  more 
upon  the  degree  of  irritation,  than  the  actual 
enlargement  of  the  gland,  and,  as  this  in- 
creased secretion  happens  in  cases  of  swell- 
ing of  this  part  from  strictures,  where  the 
body  and  lateral  lobes  are  alone  affected,  it* 
is  inferred,  that  the  disease  of  the  middle 
lobe  only  contributes  to  this  effect  by  keep- 
ing up  a straining,  and  disturbance  of  every 
part  of  (he  gland.  (P.  32.)  The  internal 
membrane  of  the  bladder  inflames,  and  be- 
comes extremely  irritable,  so  that,  even 
when  the  quantity  of  urine  is  small,  there  is 
a great  deal  of  straining.  When  the  size 
and  form  of  the  tumour  are  such  as  to  allow' 
the  greater  part  of  the  urine  to  pass,  though 
with  great  effort,  Sir  Everard  states,  that 
the  symptoms  may  continue  nearly  the  same 
for  months  ; liable,  however,  to  occasional 
aggravations  from  slight  causes,  and  becom- 
ing more  or  less  relieved,  when  these  are 
removed/*  Nay,  he  observes,  that  the  symp- 
toms may  even  lessen,  although  the  disease 
is  not  at  all  diminished  ; a circumstance, 
which  is  ascribed  to  the  muscular  coats 
of  the  bladder  having  acquired  greater 
strength,  and  the  internal  membrane  having 
lost,  from  habit,  the  sensibility,  which  it 
possessed  in  the  earlier  stage.  (P.  34.)  He 
further  explains,  that,  in  this  disease,  when 
the  inside  of  the  bladder  is  inflamed,  fila- 
mentous portions  of  coagulating  lymph  arc 
thrown  off  from  it,  which,  when  the  in- 
flammation increases,  subside  in  the  urine 
evacuated,  looking  not  unlike  white  hair- 
powder  ; and,  when  the  irritation  is  very 
violent,  perfectly  formed  pus  is  met  with 
in  the  urine.  (P.  35-)  After  the  inflam- 
mation subsides,  the  bladder  becomes 
again  capable  of  retaining  a larger  quan- 
tity of  urine,  though  its  power  of  com- 
pletely emptying  itself  is  still  further  dimi- 
nished. 

According  to  Mr.  Wilson,  the  symptoms, 
which  generally  attend  an  enlarged  prostate 
gland,  are  similar  to  those  of  an  irritable 
bladder  : — constant,  heavy,  dull  pain  in  the 
gland,  and  sometimes  sharp  lancinating 
pains,  darting  fronvit  to  the  urethra,  and 
occasionally  to  the  bladder  and  ureters. 
Frequent  calls  to  void  the  urine,  which  is 
passed  with  difficulty,  only  a small  quantity 
being  discharged  at  a time,  as  more  or  less 


PROSTATE  GLANDS. 


350 


always  remains  behind  in  the  bladder.  A 
complete  retention  of  urine  may  be  produ- 
ced, so  that  not  one  drop  will  pass,  although 
much  straining  is  used.  Great  difficulty  in 
. expelling  the  feces,  and  after  each  evacua- 
tion, a feeling  is  still  experienced,  as  if  the 
gut  were  not  yet  emptied.  During  the  ef- 
forts to  expel  the  urine  and  feces,  a quantity 
of  the  mucous  secretion  of  the  prostate 
gland  is  not  unfrequently  forced  out.  Most 
of  these  symptoms,  a»  Mr.  Wilson  observes, 
are  similar  to  those  produced  by  stone,  and, 
therefore,  when  they  occur,  the  gland 
should  be  examined  by  the  rectum,  and,  if 
it  be  not  found  diseased,  a sound  should  be 
introduced  nto  the  bladder.  (On  the  Male 
Urinary  and  Genital  Organs,  p.  339.)  The 
particular  differences, bet  ween  the  symptoms 
of  stone,  and  those  arising  from  disease  of 
the  prostate  gland,  are  explained  in  the  ar- 
ticle Lithotomy. 

Mr.  Hunter  first  pointed  out  a fact,  which 
. the  practical  surgeon  should  never  forget, 
viz.  that  the  swelling  of  what  is  now  called 
the  middle  lobe  of  the  prostate  gland,  often 
raises  the  sound  o\?er  u small  stone  in  the 
bladder,  and  prevents  it  from  being  felt.  (On 
the  Venereal  Disease,  p.  170.)  Hunter  also 
first  noticed  another  circumstance  well  de- 
serving recollection,  viz.  that  an  enlarge- 
ment of  the  same  part  may  account  for  the 
disappearance  of  all  the  symptoms  of  stone 
in  patients  who  have  already  suffered  greatly 
from  them,  as  the  swelling  prevents  the  cal- 
culi from  falling  down  upon,  and  irritating 
the  neck  of  the  bladder.  These  truths  are 
exemplified  by  cases  which  are  highly  inte- 
resting. It  appears  also  probable,  from  the 
observations  of  Sir  Everard  Home,  that  an 
enlargement  of  the  middle  lobe  conduces  to 
tiie  formation  and  lodgment  of  calculi  in  the 
bladder,  partly  by  preventing  the  evacua- 
tion of  small  ones  through  the  urethra,  and 
partly  by  hindering  the  bladder  from  com- 
pletely discharging  its  contents.  (Vol.  1,  p. 
40.)  Lastly,  it  is  explained,  that  in  disease 
of  the  prostate  gland,  patients  secrete  less 
urine  than  natural,  and  that  death  is  some- 
times produced  by  the  retention  of  urine 
suppressing  such  secretion  altogether.  In 
cases  of  enlargement  of  the  middle  lobe, 
one  symptom,  on  which  Sir  Everard  Home 
lays  great  stress,  is  hemorrhage  produced  by 
riding  on  horseback.  (Vol.  2,  p.  27.)  In- 
flammation and  even  ulceration  of  the  mem- 
brane covering  the  middle  lobe,  he  says,  are 
more  frequent  than  he  was  at  first  aware  of, 
and  are  produced  by  the  rough  introduction 
of  instruments.  Hence,  the  burning  heat  at 
the  neck  of  the  bladder,  the  great  pain  and  dis- 
tress attending  the  passage  and  the  continu- 
ance of  an  instrument,  the  occasional  neces- 
sity of  taking  it  out,  and  the  duration  of  the 
pain  for  sometime  afterward.  (Vol.cit.p. 
29.) 

According  to  Mr.  Wilson,  in  a case  of 
what  is  named  scirrhous  prostate  gland,  the 
enlargement  at  first  takes  place  slowly,  at- 
tended with  pain,  and  no  particular  altera- 
tion of  the  structure  is  apparent  in  the  gland, 
\vhen  examined  in  this  stage  after  death,  nor 


is  any  change  discoverable  when  the  part  is 
felt  from  the  rectum  in  the  living  patient. 
As  the  disease  proceeds,  the  structure  of  the 
whole  gland  changes,  and  the  part  enlarges, 
sometimes  regularly  so  as  to  preserve  its 
shape,  to  the  size  of  a moderate  orange  ; 
sometimes  very  irregularly,  projecting  in  a 
lobulated  manner.  When  the  gland  in  this 
sta'e  is  cut  inio,  its  substance  feels  firm,  the 
cut  surface  is  of  a whitish  brown  colour,  and 
the  membranous  septa,  extending  through  it 
in  various  directions,  are  often  very  strongly 
marked.  In  general,  before  the  urethra  and 
bladder  are  opened,  the  gland  appears  most 
enlarged  laterally.  It  also  swells  backwards 
towards  the  rectum,  producing  that  appear- 
ance of  the  excrement  particularly  noticed 
by  J.  L.  Petit,  and  already  mentioned  in 
speaking  of  common  inflammation  of  the 
gland.  Mr.  Wilson  further  states,  that  its  an- 
terior part  is  generally  least  enlarged,  be- 
cause its  connexion  with  the  pubes  prevents 
it  from  passing  far  forward  However,  this 
gentleman  has  seen  some  instances,  in  whieh 
the  enlargement  above,  or  in  front  of  the 
urethra,  was  considerable.  The  extent  of 
the  lateral  and  posterior  swelling  may  be 
readily  felt  with  the  finger,  introduced  with- 
in the  rectum.  That  these  very  irregular 
windings  in  the  prostatic  portion  of  the  ure- 
thra are  frequently  occasioned  by  the  dis- 
ease, is  also  confirmed  by  Mr.  Wilson’s  ex- 
perience, and  numerous  preparations  in  the 
Museum  of  the  College  of  Surgeons.  “ In 
the  progress  of  the  enlargement,  the  two 
sides  do  not  always  swell  equally  ; one  of- 
ten enlarges  most,  and  often  swells  more  in 
one  particular  part  than  another.  This  pro- 
duces a lateral  bend,  or  obliquity  in  the 
passage,  which  will  of  course  increase  the 
difficulty  of  passing  the  urine,  and  of  intrp- 
ducing  the  catheter.  I have  seen  from  the 
irregularity  of  the  lateral  swelling,  the 
passage  through  the  gland  bend  in  suc- 
cession to  both  sides  ” (J.  Wilson  on  the 

Male  Urinary  and  Genital  Organs , p.  332, 
335.) 

As  every  considerable  enlargement  of  the 
prostate  gland  is  attended  with  great  difficul 
ty  of  voiding  the  urine,  the  muscular  coat 
of  the  bladder  always  becomes  more  or  less 
thickened,  in  consequence  of  the  efforts 
which  it  is  obliged  make. 

In  relation  to  the  third,  or  middle  lobe,  it 
is  to  be  observed,  that  from  some  dissections 
made  by  Mr.  Shaw,  it  would  appear,  that  in 
many  cases  the  enlarged  portion  of  the  pros- 
tate, projecting  into  the  bladder,  is  not  the 
third  lobe,  but  a part  of  the  gland  situated 
more  forwards.  (See  Bell's  Surgical  Obs. 
Vol.l,p.223,fyc.) 

According  to  Sir  Everard  Home,  a stric- 
ture may  be  distinguished  from  an  enlarge 
ment  of  the  prostate  gland,  by  the  following 
circumstances  : the  distance  of  the  obstruc- 
tion from  the  external  orifice  is  to  be  deter- 
mined by  passing  a soft  bougie,  which  is  to 
be  left  in  the  canal  for  a minute,  so  as  to  re- 
ceive an  impression  from  the  obstruction. 
If  the  bougie  does  not  pass  further  than  se 
ven  inches,  and  the  end  is  marked  by  an  ori- 


PROSTATE  GLAND. 


38 1 


lice  of  a circular  form,  (it  is  immaterial  as  to 
the  size  of  the  orifice,)  the  disease  is  cer- 
tainly a stricture  ; but  if  it  passes  further 
on,  and  the  end  is  blunted,  a disease  in 
the  prostate  gland  is  to  be  suspected.  This 
in  general  may  be  ascertained  by  the  possi- 
bility of  passing  into  the  bladder  a flexible 
gum-catheter  with  a stilet,  very  much  curved, 
which  in  most  cases  of  enlargement  of  the 
gland  may  he  accomplished. 

On  the  subject  of  the  causes  of  a scirrhous 
enlargement  of  the  prostate  gland,  it  ap- 
pears to  me,  that  little  certain  is  known,  ex- 
cepting that  it  is  a disease  seldom  met  with 
under  the  age  of  fifty.  Desault  suspected, 
that  it  was  sometimes  venereal,  and  common 
in  individuals  who  had  repeatedly  had  go- 
norrhoeu.  ( Traiti  des  Mai.  Chir.  T.  3,  p. 
238.)  I believe  neither  of  these  sentiments 
is  entertained  by  the  best  surgeons  of  the 
present  day.  According  to  Sir  Everard 
Home,  it  is  a rare  occurrence  for  a man  to 
arrive  at  80  years  of  age,  without  suffering 
more  or  less  under  disease  of  this  part. 
**  The  more  common  causes  (says  he)  of  in- 
flammation of  the  prostate  gland,  are  full 
living  of  every  kind,  inebriety,  indulgence 
to  excess  with  women,  a confined  state  of 
the  bowels,  and  exposure  to  the  effects  of 
cold  ; indeed,  whatever  increases  the  circu- 
lation of  the  bloo!-'  in  these  parts  (the  geni- 
tals I suppose)  beyond  the  healthy  standard, 
tnay  become  a cause  of  inflammation  in  this 
gland,  the  blood-vessels  of  which  lose  their 
tone  in  the  latter  periods  of  life.”  ( On  Dis- 
eases of  the  Prostate  Gland,  Vol.  1,  p.  18, 
19.)  If  we  are  to  credit  another  statement, 
the  disease  occurs  most  frequently  either  in 
persons  who  have  not  used  the  genital  or- 
gans so  much  as  nature  intended,  or  in  others 
who  have  led  a life  of  excess.  ( Wilson  on 
the  Urinary  and  Genital  Organs,  p.  332.)  It 
seems  to  me  better  to  confess,  that  the  etio- 
logy of  this  complaint  is  unknown.  Nor  are 
we  rendered  much  wiser  by  conjectures 
about  the  effects  of  horse  exercise,  or  those 
of  a retarded  venous  circulation  in  old  sub- 
jects, in  creating  a tendency  to  the  disease. 

1 have  known  several  persons  afflicted,  who 
had  led  very  sedentary  lives. 

I am  afraid,  that  the  observation  formerly 
made  by  Mr.  Hunter  still  continues  true, 
which  is,  that  a certain  cure  for  the  scirrhous 
enlargement  of  the  prostate  gland  is  not  yet 
discovered.  But  though  such  is  the  fact, 
surgery  is  undoubtedly  capable  of  affording 
a great  deal  of  relief,  so  as  to  lengthen  the 
patient’s  days,  and  render  them  much  more 
comfortable.  This  is  accomplished  princi- 
pally by  anodyne  medicines,  and  drawing  off 
the  patient’s  water,  when  he  cannot  void  it 
himself  either  at  all,  or  but  imperfectly,  and 
with  considerable  straining  and  suffering. 
As  a temporary  relief  from  pain,  and  also  as 
a means  of  removing  spasm,  opiate  clysters' 
should  be  administered  once  or  twice  a day. 
(Hunter,  p.  174.)  Scrofulous  enlargements 
ot  the  prostate  gland,  occurring  in  younger 
subject!1,  are  probably  more  under  the  con- 
trol of  judicious  treatment.  Thus,  Mr.  Hun- 
ter informs  us,  that  in  several  cases  he  had 


seen  hemlock  of  service.  “ It  was  given 
upon  a supposition  of  a scrofulous  habit.  On 
the  same  principle,  (he  adds,)  I have  re- 
commended sea-bathing  ; and  have  seen 
considerable  advantages  from  it,  and  in  two 
cases,  a cure  of  some  standing.”  In  one 
case,  burnt  sponge  had  reduced  the  swelling  ; 
and  in  another  the  same  effect  was  produced,, 
and  the  irritability  of  the  bladder  lessened, 
by  means  of  a seton  in  the  perinasum.  Af- 
ter the  healing  of  the  seton,  however,  the 
symptoms  returned,  and  on  a trial  of  the 
plan  again, the  former  good  effects  were  not 
experienced  from  it.  Some  time  ago,  I at- 
tended a gentleman  under  Mr.  Lawrence, 
who  was  trying  the  effect  of  an  issue  in  the 
same  situation  ; but  I am  not  at  present  ac- 
quainted with  the  result.  In  these  cases,  the 
pilulaj  hydrargyri  cum  conio  (see  Pilulce) 
have  been  very  commonly  prescribed,  as  an 
eligible  alterative.  Sir  Everard  Home  men- 
tions an  instance,  in  which  suppositories  of 
opium  and  hemlock,  passed  up  the  funda- 
ment,  and  allowed  to  dissolve  there,  gave 
more  relief  than  any  other  plan,  not  only 
lessening  the  irritation,  but  producing  a di- 
minution of  the  projection  of  the  gland. 

In  the  first  stage  of  the  enlargement  of  the 
middle  lobe,  when  there  is  no  absolute  ob- 
struction to  the  passage  of  the  urine,  Sir 
Everard  recommends  bleeding  from  the 
loins,  opiate  clysters,  and  the  pulv.  ipecac, 
comp.  (On  Diseases  of  the  Prostate  Gland, 
Vol.  1 ,p.  70.)  The  tepid  bath,  the  use  of 
which  he  formerly  advised,  he  now  con- 
demns as  a practice  “ as  little  applicable  to 
this  disease,  as  putting  the  head  in  warm  wa- 
ter would  be  to  remove  the  symptoms  of 
apoplexy  ; if  any  applications  are  to  be  made 
to  the  parts,  they  should  be  such  as  produce 
cold.”  (Vol.  2,  p.  83.)  In  this  stage,  he 
observes,  that  catheters  and  bougies  should 
on  no  account  be  introduced,  more  especial- 
ly those  of  the  metallic  kind,  since  they  pro- 
duce a degree  of  disturbance  which  the  parts 
are  not  in  a state  to  bear,  and  if  unskilfully 
employed,  they  will  increase  the  swelling, 
and  bring  on  a complete  retention  of  urine. 
Sir  Everard  is  an  advocate  for  keeping  the 
bowels  open,  for  which  purpose  he  prefers 
the  infusion  and  tincture  of  senna,  with  the 
tartrate  of  potash.  (Vol.  2,  p.  84.)  If,  in 
defiance  of  these  means,  the  patient  becomes 
unable  to  make  any  water,  or,  although  able 
to  pass  a few'  ounces,  is  every  hour  obliged 
to  make  the  attempt,  and  after  much  strain- 
ing, discharges  only  the  same  quantity,  Sir 
Everard  directs  a flexible  gum-catheter, 
without  a stilet,  to  be  passed  into  the  blad- 
der, in  the  gentlest  manner  possible.  This 
instrument  is  to  be  kept  introduced  with  the 
catheter  bracelet,  or  retainer,  made  and  sold 
by  Mr.  Weiss  of  the  Strand,  and  the  water 
drawn  off  at  regular  intervals,  not  only  till 
the  first  symptoms  go  off,  but  till  the  bladder 
retain  the  urine  for  the  usual  length  of  time, 
and  what  is  voided  has  the  appearance  of 
heathly  urine.  If,  when  the  catheter  is  with- 
drawn, the  patient  should  not  be  able  to 
empty  his  bladder,  it  must  be  re-introduced, 
and  after  six  or  seven  days,  taken  out  again 


PRO 


PSD 


382 

When  the  disease  is  somewhat  more  ad- 
vanced, and  the  patient  cannot  keep  himself 
quiet,  the  above  practice  of  course  cannot  be 
adopted,  and  it  becomes  necessary  to  pass 
the  catheter  three  or  four  times  a day.  But 
even  under  such  circumstances,  when  irri- 
tation is  brought  on  by  accidental  circum- 
stances, SirEverard  recommends  keeping  the 
instrument  in  the  bladder  until  the  attack 
has  subsided.  (Vol.  2,p.  92,  96.)  This  gen- 
tleman finds  that,  for  cases  of  diseased  pros- 
tate gland,  common  flexible  gum-catheters, 
originally  made  straight, are  disadvantageous, 
as  it  is  a long  while  before  they  can  be  made 
to  keep  a permanent  curved  form.  “ When 
(says  he)  the  curvature  of  the  catheter  is  no 
part  of  its  original  formation,  although  it  may 
have  been  produced  by  being  long  kept  in  a 
curved  state,  yet,  wjien  allowed  to  remain  in 
the  bladder,  it  gradually  returns  to  its  straight 
form  by  being  moistened,  and  when  it  has 
acquired  it,  the  point  is  no  longer  kept  di- 
rected upwards  in  the  cavity  of  the  bladder, 
but  is  constantly  pressing  against  the  pos- 
terior coats,  pushing  itself  out  of  the  urethra, 
and  the  irritation  it  gives  the  muscular  coat 
of  the  bladder,  will  often  be  the  means  of 
its  being  expelled  by  a spasm  with  consider- 
able violence.”  (On  Diseases  of  the  Pros- 
tate Gland , Vol.  2,  Chap.  5.)  Sir  Everard 
further  informs  us,  that  Mr.  Weiss,  No.  33, 
in  the  Strand,  has  at  length  succeeded  in 
making  flexible  gum-catheters,  originally 
curved,  so  that  they  always  retain  their  shape. 
Their  polish  is  great,  and  they  can  be  had 
of  any  size : they  are  also  made  particular- 
ly strong,  a quality  necessary  to  secure  them 
from  being  broken  in  vioient  attacks  of 
spasm.  Sir  Everard  stales,  that  he  has 
kept  them  fifteen  days  in  the  bladder, 
without  their  being  spoiled  by  the  urine,  or 
mucus  ; whereas,  common  French  and  Eng- 
lish catheters  become  in  a shorter  period  so 
rough  as  to  be  unfit  for  further  use.  Metal 
catheters,  he  asserts,  should  never  be  em- 
ployed but  in  cases  of  necessity,  where  the 
patient  cannot  be  relieved  by  milder  means. 
(Vol  2,  p.  87.)  To  such  instruments,  he 
ascribes  the  frequently  noticed  ulceration  of 
the  middle  lobe,  the  abrasion  of  its  surface, 
the  wounds  throygh  its  substance,  the  gene- 
ral inflammation  of  the  whole  internal  mem- 
brane of  the  bladder,  and  quick  destruction 
of  the  patient’s  life.  The  gum  catheter, 
however,  is  to  be  as  large  as  the  urethra  will 
easily  admit,  in  order  that  it  may  more  rea- 
dily disengage  itself  at  the  turns  into  the 
bladder.  (Vol.  1,  p.  75.)  * 

According  to  Desault,  a large  catheter 
generally  answers  better  than  a small  one, 
and  it  may  either  be  of  silver,  or  elastic  gum. 
The  latter,  though  the  best  for  the  purpose 
of  being  kept  in  the  passage,  he  says,  has 
not  always  sufficient  firmness  to  get  through 
the  obstruction  in  the  canal,  not  even  with 
the  aid  of  a stilet.  In  this  respect,  a silver 
catheter  is  sometimes  preferable.  But 
whatever  may  be  the  kind  of  catheter  em- 
ployed, it  generally  passes  as  far  as  the 
prostate  with  perfect  facility,  where  it  is 
stopped,  rot,  only  by  the  narrowness,  but 


also  by  the  new  curvature  of  the  passage. 
For  the  prostate  cannot  be  enlarged,  with- 
out pushing  forward  and  upwards,  or  to  one 
side,  that  portion  of  the  urethra  behind 
which  it,  is  situated.  This  circumstance 
ought  never  to  be  forgotten,  in  regulating 
the  length  and  direction  of  the  beak  of  the 
catheter,  which  should  also  be  longer,  have 
a more  considerable  curvature,  and  be  more 
elevated,  at  the  time  of  its  introduction, 
than  in  other  cases  of  obstruction  in  the 
urethra. 

In  swellings  of  the  prostate  gland,  Mr. 
Hey  has  particularly  pointed  out  one  ad- 
vantage, which  belongs  to  elastic  catheters, 
viz.  that  their  curvature  may  be  increased 
while  they  are  in  the  urethra.  This  gentle- 
man was  introducing  an  elastic  gum-cathe- 
ter in  a patient,  whose  prostate  gland  was 
much  enlarged,  and  finding  some  obstruction 
near  the  neck  of  the  bladder,  he  withdrew 
the  stilet,  in  doing  which  he  accidentally 
repressed  the  tube,  Which  then  yveht  into 
the  bladder.  In  fact,  lie  found  that  the  act 
of  withdrawing  the  stilet  increases  the  cur- 
vature, and  lifts  up  the  point  of  the  catheter. 
(Pract.  Obs.  in  Surgery , p.  399,  Edit.  2.) 
For  further  remarks  connected  with  this 
subject,  see  the  articles  Cathether,  and  Urine , 
Retention  of.  Sir  Everard  Home  states  with 
confidence,  that  if  the  symptoms  of  the  fore- 
going disease"  be  prevented  in  their  early 
stage  from  increasing  by  the  treatment  which 
he  has  recommended,  the  disease  will  get 
well.  (See  J.  Hunter's  Treatise  on  the  Vene- 
real Disease,  p.  169,  &c.  2 d Ed.  4 to.  Lond. 
1788.  Baillie's  Morbid  Anatomy.  P.  J.  De- 
sault, (Euvres  Chir.  T.  3,  p.  220,  fyc.  8 vo. 
Paris,  1803.  Sir  Everard  Horne,  On  the 
Treatment  of  Diseases  of  the  Prostate  Gland , 
2 Vols.  8vo.  Lond.  1811—1818.  Also,  On 
Strictures,  3 Vols.  8 vo.  3 d Edit.  1S05 — 1821. 
C.  Bell,  On  the  Muscles  of  the  Ureters  in 
Med.  Chir.  Trans.  Vol.  3.  J.  Shaw,  On  the 
Structure  of  the  Prostate  Gland,  in  C.  Bell's 
Surgical  Obs.  Vol.  1,8 vo.  1816*.  E.A.  Lloyd 
on  Scrofula,  p.  107,  <^c.  8 vo.  Lond.  1821. 
./.  How  skip , Pract.  Obs.  on  Diseases  of  the 
Urinary  Organs,  fyc.  8 vo.  Lond.  1816.  J. 
Wilson,  On  the  Male  Urinary  and  Genital 
Organs,  8 vo.  Lond.  1821.) 

PSEUDOSYPHILIS.  (from  false, 

and  Syphilis,  the  venereal  disease.)  Disease 
resembling  the  venereal,  but  not  really  of 
this  nature.  The  spurious  venereal  disease. 
(See  Venereal  Disease.) 

PSOAS  ABSCESS.  (See  Lumbar  Ab- 
scess.) 

PSORIASIS.  Scaly  tetter.  A disease  of 
the  order  Squamae,  in  Dr.  Bateman’s  Sy- 
nopsis. It  is  attended  with  more  or  less 
roughness  and  scaliness  of  the  cuticle,  with 
a subjacent  redness.  The  skin  is  often  di- 
vided by  deep  fissures ; and  the  complaint 
is  generally  attended  with  constitutional 
disorder,  and  liable  to  cease  and  return  at 
certain  seasons.  For  a particular  account  ot 
its  varieties  and  treatment,  see  the  above 
work. 

PSOROPHTHALMY.  (from  4*ga,  the 
itbh,  and  o<pB»hyia.,  an  inflammation  of  the 


pye.)  An  inflammation  of.  the  eyelids,  at- 
tended with  ulcerations,  which  itch  very 
much.  Beer  actually  understands  by  the 
expression,  such  a disease,  from  the  sudden 
repression  of  the  itch,  or  the  infection  of 
th*>se  parts  with  psoric  matter.  ( Lelire  von 
den  Augenkr.  B.  1 ,p.  566.)  Weller  not  only 
adopts  the  same  notion,  but  makes  an  ad- 
dition to  it,  by  extending  the  tern^flriso  to 
cases,  in  which  the  eyelids  are  affected  with 
psoriasis,  porrigo,  and  impetigines.  (Ma- 
nual of  the  Diseases  of  the  Eye,  Vol.  2,  p. 
264.)  By  psoropktkalmy,  the  late  Mr.  Ware 
meant  a case,  in  which  the  inflammation  of 
the  eyelids  is  attended  with  an  ulceration  of 
their  edges,  upon  which  a glutinous  matter 
lodges,  in  crusts,  and  becomes  hard,  so  that, 
in  sleep,  when  they  have  been  long  in  con- 
tact, they  become  so  adherent,  that  they 
cannot  be  separated  without  pain.  He  has 
remarked,  that  “ the  ulceration  in  the  pso- 
rophthalmy  is  usually  confined  to  the  edges 
of  the  eyelids ; but  sometimes  it  is  seen  to 
'extend  over  their  whole  external  surface, 
and  even  to  excoriate  the  greater  part  of 
the  cheek.  In  cases  of  the  latter  kind,  the 
inflammation  which  accompanies,  has  often 
much  the  appearance  of  an  erysipelas,  and 
will  receive  most  relief  from  the  cooling  ap- 
plications. The  use  of  the  citrine  ointment, 
which  will  hereafter  be  recommended,  must 
in  such  instances,  be  deferred  until  the 
irritability  of  the  skin  is  in  a good  degree 
abated. 

il  This  disorder  is  also  sometimes  attend- 
ed with  ^ contraction  of  the  skin  of  the 
lower  eyelid  ; in  consequence  of  which  that 
lid  is  drawn  down,  and. the  inner  part  turn- 
ed outward,  so  as  to  form  a red,  fleshy,  and 
most  disagreeable  appearance,  called  ectro- 
pium.  Whenever  this  happens,  it  proves  the 
complaint  to  be  of  the  most  obstinate  na- 
ture ; though  it  is  generally,  removed  by  the 
cure  of  the  psorophthalmy,  whichristhe  oc- 
casion of  it.”  ( Remarks  on  Ophthalmy,  fyc. 
p.  112.)  Mr.  Ware  recommended,  for  the 
cure  of  this  disease,  the  unguentum  hydrar- 
gyri  nitrati.  This  is  to  be  melted  into  an 
oil,  and  rubbed  with  the  end  of  the  fore-fin- 
ger, or  the  point  of  a small  pencil-brush, 
into  the  edges  of  the  affected  eyelids,  once 
every  night,  on  going  to  bed.  A plaster  of 
ceratum  album  is  then  put  over  the  eyelids 
to  keep  them  from  adhering  together.  If 
they  should  still  adhere  in  the  morning,  they 
are  to  be  cleaned  with  milk  and  butter,  well 
mixed  together.  In  a few  cases,  it  is  neces- 
sary to  touch  the  ulcers,  formed  on  the 
edge  ot  the  eyelid,  after  the  small-pox,  with 
the  argentum  nitraturn.  When  the  globe  of 
the  eye  is  inflamed,  the  vinous  tincture  of 
opium  is  applied,  as  directed  in  the  article 
Ophthalmy.  In  scrofulous  subjects,  altera- 
tive medicines  ; an  issue,  or  perpetual  blis- 
ter; and  attention  to  diet,  &c.  are  proper. 
(See  Ware  on  Ophthalmy , <^c.) 

In  the  treatment  of  psorophthalmy,  Beer 
lays  considerable  stress  upon  the  necessity 
ot  cleanliness.  The  itehy  places  he  directs 
to  be  frequently  washed  with  a tepid  infu- 
cton  of  scordiuiri,  and  afterward  well  dried. 


When  the  uneasiness  and  tension  of  the 
skin  are  thus  quite  removed,  Beer  adds  to 
the  preceding  infusion  some  of  the  sulphu- 
ret  of  potash,  the  proportion  being  at  first 
small,  and  gradually  increased.  This  plan 
is  to  be  followed,  until  the  ulcerations  dry 
and  the  scabs  fall  off  of  themselves,  leaving 
the  subjacent  skin  yet  red  and  sensible,  and 
sometimes  moist ; in  this  state,  a small  bit  of 
the  annexed  salve  may  be  smeared  with  a. 
camel-hair  pencil  along  the  edges  of  the 
eyelids,  and  upon  the  affected  points  of  the. 
skin  : R.  Butyri  recentis  insulsi,  ^ss.  Cu- 
pri  Sulphatis,  gr.  x.  Camphoree,  gr.  iv.  Tu 
tise  ptt.  gr.  vj.  Misce.  If  the  disease  prove 
obstinate,  Beer  recommends  Hufeland’s 
salve,  wbich  consists  of  equal  parts  of  fresh, 
butter,  yellow  wax,  and  the  pulv.  hydrarg. 
nitneo-oxydi  rubr. ; and,  in  still  more  inve- 
terate cases,  Janin’s  eye  salve,  which,  he 
says,  must  rarely  be  used  oftener,  than 
every  other  day.  In  the  psorophthalmy, 
conjectured  by  Beer  to  depend  upon  the 
sudden  cure  of  the  itch,  he-states,  that  in- 
ternal medicines  are  necessary,  as  antimo- 
nials,  joined  with  sulphur  and  camphor. 
He  also  praises  sulphur  baths,  and  irrita- 
ting the  part  of  the  skin  where  the  itch 
has  receded,  by  th$  application  of  antimo- 
nial  ointment ; or /if  such  part  should  be 
very  far  from  the  eyes,  he  advises  such 
ointment  to  be  rubbed  on  the  skin  behind 
the  ears.  Attention  to  diet  is  particularly 
enjoined,  and  eating  pork,  lard,  and  sub- 
stances difficult  of  digestion,  is  prohibited, 
(B.  1.  p.  569,  fyc.) 

(tlim.  of  <vr<rigo^,  a wing.) 
As  Scarpa  remarks,  surgeons  usually  apply 
the  term  “ pterygium'’  to  that  preternatural, 
reddish,  ash-coloured,  triangular  little  mem  - 
brane, which  most  frequently  grows  from 
the  internal  angle  of  the  eye,  near  the  ca- 
run cula  lachrymalis,  and  gradually  extend* 
over  the  cornea,  so  as  to  cause  considerable 
impediment  to  vision. 

The  disease,  however,  presents  itself  some 
times  in  the  form  of  a semitransparent  thin 
grayish  membrane,  not  furnished  with  many 
visible  vessels ; and  sometimes  as  a thick, 
red,  fibrous  mass,  very  like  muscle,  being 
very  prominent  even  on  the  cornea,  where 
it  seems  to  terminate  in  a substance  like 
tendon,  and  it  is  observed  to  be  pervaded 
by  numerous  blood-vessels.  The  first  is  the 
pterygium  tenue  of  Beer  ; the  second  the 
pterygium  crassum  ( Lehre  von  den  Augenkr. 
B.  2,  p.  636.)  or,  the  membranous  and  fleshy 
pterygia  of  other  writers. 

Though  the  pterygium  most  commonly 
proceeds  from  the  internal  angle,  (also  Beer , 
B.  2,  p 637.)  it  is  observed  to  arise  some- 
times from  the  external  one,  and,  in  some 
instances,  from  the  superior  or  inferior  he- 
misphere of,  the  eyeball.  • But,  whatever  be 
*ts  origin,  its  figure  is  invariably  that  of  a tri- 
angle, with  its  base  on  the  white  of  the  eye, 
and  its  apex  more  or  less  advanced  over  the 
cornea,  towards  its  centre,  and  that  of  the 
pupil.  Indeed,  there  are  a few  cases  in 
which  two  or  three  pterygia  of  different 
sizes  occur  on  the  same  eye,  and  are  arran- 


TTERtGim 


384 

round  its  circumference  at  interspaces 
of  various  breadths.  Tbeir  points  are  di- 
rected towards  the  centre  of  the  cornea, 
and  if  they  should  unfortunately  conjoin 
there,  the  whole  of  that  transparent  mem- 
brane becomes  covered  with  an  opaque  veil, 
and  a total  loss  of  sight  is  the  consequence. 
It  seems  to  Scarpa,  that  the  term  “ p annus” 
was  applied  by  t lie  ancients  to  exactly  this 
sort  of  complication.  However,  the  occur- 
rence of  more  than-  one  pterygium  on  the 
same  eye  is  uncommon,  as  may  be  interred 
from  the  experienced  Beer  having  met  with 
but  two  cases  of  a double  pterygium,  and 
with  only  one  instance  of  three  pterygia  on 
the  eye.  (B.  2,  p.  638.) 

According  to  Scarpa,  (whose  observations 
apply  chiefly  to  the  membranous  form  ot  the 
disease)  chronic  varicous  ophthalmy,  with 
relaxation,  and  thickening  of  the  conjuncti- 
va ; opacity  of  the  cornea  ; and  the  ptery- 
gium ; only  differ  in  the  degree  of  the  dis- 
ease In  reality,  all  the  three  complaints 
consist  of  a more  or  less  extensive  varicous 
state  of  the  vessels  of  the  conjunctiva,  com- 
bined with  a.  degree  of  preternatural  relaxa- 
tion, and  thickening  of  that  membrane. 

In  chronic  varicous  ophthalmy,  the  e*tra- 
ordinary  amplitude,  and  knottiness  of  the 
vessels;  the  flacciditv,  and  thickening  of 
the  conjunctiva  ; are  limited  to  the  white 
of  the  eye.  In  opacity  of  the  cornea, 
certain  veins  even  dilate,  andbecome  knotty 
for  some  way  over  that  delicate  layer  of 
the  coniunctiva,  which  is  continued  over 
the  surface  of  the  cornea.  In  the  pterygium, 
an  extraordinary  swelling  of  this  subtile 
membranous  expansion  is  added  to  the  v at  1- 
cous  slate  of  its  veins.  Hence,  the  ptery- 
srium  seems  at  first  like  a new  membrane 
*ormed  on  the  cornea,  while  it  is  really 
nothing  more  than  the  delicate  continuation 
of  the  conjunctiva  just  mentioned,  deprived 
of  its  transparency,  and  degenerated,  in 
consequence  of  chronic  ophthalmy,  into  a 
thick,  opaque  membrane,  on  which  theie  is 
a plexus  of  varicous  blood-vessels.  Con- 
sequently, in  the  case  of  pterygium,  there  is 
no  new  production  of  the  eye,  but  only  an 
alteration. of  one  of  the  thin  transparent 
membranes,  which  naturally  cover  it.  The 
following  circumstance,  as  will  be  more 
fully  explained  presently,  illustrates,  says 
V Scarpa,  the  veracity  of  the  preceding  state- 
ment. The  incipient  pterygium  may  be 
cured  in  the  name  mariner  as  opacity  of  the 
cornea,  viz.  by  merely  cutting  off  that  por- 
tion of  it,  which  is  situated  at  the  Jul*ct,OIJ 
of  the  cornea  with  the  sclerotica,  without 
detaching  the  whole  of  it  from  the  surface 
of  the  former  membrane ; just  as  is  practi- 
sed in  the  opacity  of  the  cornea,  m order  to 
destroy  the  communication  of  the  varicous 
veins  of  the  conjunctiva,  with  their  trunks, 
the  ramifications  of  which  produce,  and 
maintain  the  disease. 

Scarpa  observes,  that  the  pterygium  would 
be  as  common  a complaint  as  the  varicous 
chronic  ophthalmy,  so  often  occupying  the 
white  of  the  eye,  if  the  delicate  continua- 
tion of  the  conjunctiva  over  the  surface  ot 


the  cornea  were  not  naturally  ot  a denser* 
and  more  compact  texture  than  the  rest  of 
the  membrane,  from  which  it  is  produced, 
and  if  its  vessels  were  not  very  minute  and 
delicate,  and  not  so  dilatable  as  those  of  the 
other  part  of  the  conjunctiva.  This  is  the 
reasp n why  the  pterygium  is  comparatively 
a rare  case,  in  respect  to  the  great  fre- 
quency^!' varicous,  chronic  ophthalmies. 
But  shmnd  the  vessels  of  the  transparent  lay- 
ers of  the  conjunctiva  once  yield  to  the  im- 
pulse of  the  fluid  propelled  into  them  ; 
should  they  once  become  varicose,  the  cel- 
lular texture,  in  which  they  are  enveloped, 
never  fails  to  swell  gradually,  and  thus 
the  delicate,  diaphanous  membrane  in  ques- 
tion changes  into  a pulpy,  reddish  tunic, 
precisely  similar  to  the  pterygium. 

That  the  pterygium  is  truly  nothing  else 
but  the  natural,  delicate,  transparent  ex- 
pansion of  the  conjunctiva,  on  the  cornea, 
converted,  for  a certain  extent,  into  a pulpy 
flaccid  varicous  membrane,  may  be  inferred 
(continues  Scarpa)  from  the  tolds,  which 
the  pterygium  and  conjunctiva  form  at  the 
same  time,  when  the  morbid  eye  is  turned 
towards  the  origin  of  the  disease.  The 
same  inference  is  equally  deductible  from 
the  tension  occasioned  in  both  these  paits, 
whenever  the  eye  is  moved  in  the  opposite 
direction.  We  become  still  more  convin- 
ced of  the  fact  on  observing,  that  in  the 
first  position  of  the  eye,  both  the  pterygium 
and  the  corresponding  portion  of  the  con- 
iunctiva (which  is  equally  relaxed,  varicous, 
and  reddish,)  may  be  easily  taken  hold  ot 
with  a small  pair  of  forceps,  and  raised 
together  in  the  form  of  a fold. 

The  pterygium  is  observed  by  Mr.  Travers 
to  be  most  prevalent  in  warm  climates. 
(Synopsis  fyc.  p.  101.)  It  is  also  said  to  be 
most  frequent  in  old  people,  though  Mr. 
Wardrop,  and  Dr.  Monteath  have  seen  it 
in  very  young  infants.-W/er’s  Manual 
of  the  Diseases  of  the  Eye,  Vol.  l,p.  -18.) 

The  constancy  of  the  triangular  figure  o 
the  pterygium,  with  its  basis  on  the  white  ot 
the  eye,  and  its  apex  on  the  cornea,  is  one 
of  its  principal  diagnostic  characters,  by 
which  the  true  disease  may  be  discriminated 
from  every  other  soft,  fungous,  reddish  ex- 
crescence, obscuring  the  cornea,  kor,  on 
this  membrane,  excrescences  sometimes 
form,  which,  from  having  the  colour  and 
consistence  of  a soft  membrane,  bear  a very 
great  resemblance  to  the  pterygium,  though 
they  are  really  widely  different,  and^  strictly 
speaking,  consist  of  the  texture  of  the  cornea 
itself,  degenerated  into  a soft,  fungous  sub- 
stance. Such  pellicles,  however,  not  only 
almost  always  create  a greater  prominence 
on  the  cornea,  than  what  accompanies  the 
pterygium,  but  they  are  constantly  of  an 
irregular  tuberous  form,  and  never  represent 
a triangle,  with  the  apex  pointing  towards 
the  centre  of  the  cornea,  like  the  genuine 

Pt  Another  distinguishing  ehwactep  of  ptery- 
<r*,uin,  ns  Scarpa  has  observed,  is  the  taulity, 
with  which  the  whole  of  ltmay  be  taken  hold 
of  with  a pair  of  forceps,  and  raised  into  - 


PTERYGIUM. 


3 


fold  on  the  cornea.  Every  other  kind  of 
excrescence,  attached  to  this  membrane, 
continues  firmly  adherent  to  it,  and  cannot 
be  folded,  and  raised  from  the  surface  of 
the  cornea,  in  any  manner  whatever.  This 
particularity  is  of  the  highest  importance 
in  the  treatment  of  the  disease  ; for  the 
genuiue  pterygium  may  be  cured  by  simple 
means,  while  fungous  excrescences  of  the 
cornea,  can  only  be  radically  removed, 
and  perfectly  cicatrized  with  the  utmost 
difficulty.  Plenck  very  properly  observes, 
on  this  head  : Pterygia,  qua  jfilamemis  solum- 
modb  adherent,  facile  abscinduntur,  difficilime 
qiue  ubique  aecreta  sunt  cornece , ac  in  plicam 
elevari  non  possunt. 

Scarpa’s  belief  in  the  reality  of  a malig- 
nant or  cancerous  pterygium  must  appear  a 
doctrine  requiring  confirmation,  when  it 
is  considered,  that  Mr.  Travers  makes  no 
mention  of  the  disease  assuming  this  charac- 
ter, and  Beer  distinctly  states,  that,  in  a 
practice  of  thirty-two  years,  he  has  cured 
376  pterygia,  of  various  sizes  and  thickness, 
without  one  bad  symptom,  or  consequence. 
And,  hence,  he  justly  concludes,  that  the 
disease  is  strictly  local.  ( B . 2,  p.  641.) 
This  statement,  however,  is  qualified  with 
the  condition,  that  the  knife  only  be  em- 
ployed when  requisite,  and  that  no  consi- 
derable portion  of  the  disease  be  left  unre- 
moved. 

The  true  benign  pterygium,  says  Scarpa, 
which  has  a triangular  figure,  is  ash  colour- 
ed, or  pale  red,  is  free  from  pain,  and  admits 
of  being  raised  in  the  form  of  a fold  on  the 
surfeu^e  of  the  cornea,  may  be  cured  by  cut- 
ting me  opaque  triangular  little  membrane 
accurately  from  the  surface  of  the  cornea, 
which  is  in  part  covered  by  it.  But,  as  it 
appears,  from  what  has  been  said,  that  the 
pterygium  is  nothing,  but  a portion  of  the 
delicate,  transparent  layer  of  the  conjunc- 
tiva, converted  by  chronic  varicous  oplithal- 
rny  into  a thick,  opaque  tunic,  it  follows, 
that  the  pterygium  cannot  be  removed  in 
any  way,  without  the  spot,  which  it  occu- 
pies on  the  cornea,  being  bereft  of  its 
natural  external  covering.  Also,  as  this 
denudation  of  the  cornea  renders  a cicatrix 
unavoidable  at  the  place,  it  equally  follows, 
that  the  knife  cannot  be  employed  in  the 
cure  of  the  disease,  without  the  cornea 
being  rendered  more  or  less  opaque  at  the 
part,  where  the  pterygium  was  before 
situated. 

Scarpa’s  experience  enables  him  to  state, 
however,  that  the  superficial,  indelible 
speck,  remaining  on  the  cornea,  after  the 
recision  of  the  pterygium,  is  always  less  ex- 
tensive, than  the  space  previously  occupied 
by  the  disease. 

It  is  customary  (says  Scarpa)  to  remove 
the  pterygium  by  making  the  incision  on 
the  cornea,  and  extending  it  over  the  white 
ol  the  eye,  as  far  as  the  base  of  the  disease 
reaches  on  the  conjunctiva;  so  lhat  when 
the  pterygium  grows  from  the  internal 
angle  of  the  eye,  most  surgeons  continue 
the  section  as  far  as  the  caruncula  This 
practice  is  disadvantageous,  first,  because  it 

Voi.  V 49 


denudes  too  much  of  the  white  of  the  eye  , 
secondly,  because,  in  consequence  of  the 
large  portion  of  the  conjunctiva  removed 
at  the  base  of  the  pterygium,  and  in  conse- 
quence of  the  direction  of  the  wound,  the 
cicatrix  in  the  white  of  the  eye  forms  an 
elevated  frgenum,  which,  like  a little  cord, 
keeps  the  eyeball  approximated  to  the  ca 
ruucula  lachrymalis,  and  destroys  the  free- 
dom of  its  motions,  particularly  towards 
the  external  angle. 

In  the  treatment  of  pterygia  with  bases 
extending  far  in  the  white  of  the  eye,  Scarpa 
prefers  detaching  them  at  their  apex,  as  far 
as  the  junction  of  the  cornea  with  the  scle- 
rotica, and  then  to  separate  them  at  their 
base  by  a semicircular  incision,  comprehend- 
ing one  line  in  breadth  of  the  substance 
of  the  conjunctiva,  and  made  in  a direction 
concentrical  with  the  edge  of  the  cornea. 
Scarpa  has  observed,  that  in  this  mode  of 
operating,  the  subsequent  cure  takes  place 
sooner,  than  when  the  common  method  is 
adopted  ; the  cicatrix  occasions  no  sort  of 
fraenum,  and  the  conjunctiva,  circularly 
stretched  by  the  cicatrix,  lies  smoothly  over 
the  white  of  the  eye,  and  loses  that  relax- 
ation, and  varicous  slate,  which  are  the 
groundwork  of  the  pterygium.  Such  atten- 
tion, however,  is  not  requisite,  when  the 
pterygium  is  small,  and  its  base  does  not 
extend  far  in  the  white  of  the  eye. 

The  operator,  after  desiring  the  patient 
to  move  his  eyeball  towards  the  part  cor- 
responding to  the  base  of  the  pterygium,  is 
to  take  hold  of  the  membrane  with  a pair 
of  forceps  held  in  his  left  hand,  and  pinch 
it  into  a fold,  at  about  one  line  from  its  apex. 
The  duplicature  is  now'  to  be  raised,  and 
drawn  out  gently  until  a sensation  of  some- 
thing giving  w ay  is  felt,  which  indicates  the 
detachment  of  the  pterygium  from  the 
delicate  cellular  texture  by  which  it  is  con- 
nected with  the  subjacent  cornea.  Next, 
by  means  of  a pair  of  scissors,  the  surgeon 
must  dissect  this  fold,  as  closely  as  possible, 
from  the  cornea,  proceeding  from  the  apex 
towards  the  base  of  the  pterygium.  The 
section  being  completed  to  where  the  cor 
nea  and  sclerotica  meet,  the  fold  is  to  be 
again  elevated  still  more,  and,  with  one 
stroke  of  the  scissors,  the  pterygium,  and 
the  relaxed  portion  of  the  conjunctiva, 
forming  its  base,  are  to  be  detached,  as 
concentrically,  and  closely  to  the  cornea, 
as  possible.  This  second  incision  will  have 
a semilunar  shape,  the  horns  of  which  ought 
to  extend  two  lines  beyond  the  relaxed  part 
of  the  conjunctiva  in  following  the  curvature 
of  the  eyeball. 

When  the  operation  is  finished,  the  sur- 
geon must  promote  the  hemorrhage,  by- 
washing  the  part  with  wrarm  water,  and 
then  cover  the  eye,  that  has  been  operated 
on,  with  a pledget  of  dry  lint,  or  lint  moist- 
ened in  the  liquor  plumbi  acet.  dilutus,  kept 
on  with,a  bandage,  that  does  not  make  too 
much  pressure. 

If  no  particular  symptoms  arise,  such  as 
pain,  tension  of  the  eye,  considerable  tume- 
faction of  the  eyelids,  it  is  sufficient  to  wash 


PTE 


PTO 


38(5 


the  eye,  and  inside  of  the  eyelids,  three  or 
four  times  a day  villi  a warm  lotion  of 
mallows,  and  carefully  keep  these  parts 
from  being  exposed  to  the  air,  without 
compressing  them.  If  the  symptoms  just 
mentioned  should  occur,  antiphlogistic  treat- 
ment must  be  adopted. 

On  the  fifth  or  sixth  day,  at  latest,  after 
the  operation,  all  the  surface,  from  which 
the  pterygium  was  cut.  appears  yellowish, 
and  covered  with  a fluid  like  mucus.  The 
edges  of  the  wound,  and  the  adjoining  part 
of  the  conjunctiva,  assume  a reddish  colour. 
Afterward,  the  surface  of  the  wound  con- 
tracts more  and  more  daily,  and  at  length, 
completely  closes. 

During  the  whole  treament,  subsequent 
to  the  operation,  there  is  no  occasion  to 
employ  any  other  topical  applications,  but 
the  warm  lotion  of  mallows,  three  or  four 
times  a day.  Numerous  cases  have  convin- 
ced Scarpa  that  astringent  collyria,  and 
the  boasted  powders  of  the  florentine  iris 
and  alum,  cause  great  irritation  to  the 
eye  operated  on,  and  give  rise  to  tume- 
faction, and  a fungous  state  of  the  con- 
junctiva, which  are  impediments  to  the 
cure.  What  is  still  more  incommodious, 

is,  that  such  means  produce  fungous  ex- 
crescences on  the  middle '-of  the  wound 
itself,  which  admit  of  being  repressed  and 
cicatrized  with  difficulty.  Scarpa  has  seen 
all  these  inconveniences  arise  from  one 
single  unnecessary  application  of  the  argen- 
tum nitratum.  On  the  other  hand,  when  a 
lucre  lotion  of  mallows  is  the  only  remedy 
employed  in  the  treatment,  the  cure  pro- 
ceeds regularly  ; the  yellowish  surface  of  the 
incision  diminishes  daily,  arid  in  three,  or, 
at  most,  four  weeks,  the  wound  is  quietly 
healed.  The  zinc  coliyrium,  containing  a 
few  drops  of  camphorated  spirit  of  u ine,  can 
only  be  prudently  instilled,  Ihree  or  four 
times  a day  into  the  eye,  for  the  purpose  of 
obviating  the  relaxation  of  the  conjunctiva 
and  its  vessels,  after  the  wound  is  perfectly 
cicatrized. 

The  incipient  pterygium  (adds  tbisauthor) 
is  not  a dense,  opaque  membrane,  but  a 
pellicle  as  fine  as  a cobweb,  interwoven  in 
different  places  with  varicous  blood-vessels, 
the  iris  continuing  tolerably  visible  behind 

it.  In  this  early  state  of  the  pterygium,  it 
is  unnecessary  to  deprive  the  cornea  of  its 
natural  covering  ; it  is  quite  enough  to  cut 
off  a portion  of  it,  in  order  to  intercept  all 
communication  between  the  dilated  venous 
ramifications  of  the  pterygium,  and  the  va- 
riccms  truiiksin  the  white  of  the  eye. 

Therecision,  says  Scarpa,  is  accomplished 
by  cutting  out  with  a pair  of  forceps  and 
scissors  a semilunar  piece  of  the  conjunc- 
tiva, at  the  point  where  the  cornea  and 
sclerotica  conjoin,  anti  exactly  at  the  base 
of  the  incipient  pterygium,  just  as  is  prac- 
tised for  opacity  of  the  cornea.  The  recent 
pterygium  is  observed  to  disappear  gradu- 
ally after  the  operation,  or  to  change  into  a 
slight  dimness  of  the  cornea,  extending  over 
a part  of  the  space  previously  occupied  by 
the  disease.  This  opacity  is  commonly 


much  more  trivial  than  what  follows  a cica  - 
trix. Acrel,  in  his  Surgical  Obsecrations, 
mentions  having  successfully  treated  an 
incipient  pterygium  in  this  manner.  Scarpa, 
has  also  tried  the  plan  several  times  with 
success.  Such  treatment  must  be  better 
than  merely  making  two  or  three  deep  cuts, 
or  scarifications,  in  the  membrane  near  the 
edge  of  the  cornea,  as  advised  by  Beer. 
( B . 2,  p.  641.)  And  in  proof  of  the  uncer- 
tainty of  the  latter  method,  vve  find  Beer 
himself  speaking  of  the  necessity  of  using 
stimulating  applications,  like  powdered  su- 
gar, alum,  the  vinous  tincture  of  opium,  &c. 
if  the  operation  is  not  of  itself  sufficient. 
In  the  pterygium  crassum,  Beer  recommends 
the  knife,  as  the  best  means  of  cure  ; buf 
he  differs  essentially  from  Scarpa,  not  mere- 
ly in  preferring  a knife  to  the  scissors,  but 
in  beginning  the  operation  by  making  a 
deep  cut  through  the  base  of  tbe  pterygium 
in  the  white  of  the  eye,  from  which  point 
he  continues  the  dissection  of  the  ptery- 
gium, till  this  is  all  removed  as  far  as  its 
apex  on  the  cornea,  when  he  uses  either 
the  knife,  or  scissors,  -as  most  convenient 
(£.  1.  p.  643.) 

Beer  mentions  that  it  sometimes  happens, 
especially  in  cases  of  thin  pterygia,  that  the 
disease  stops  at  the  edge  of  the  cornea,  and 
spreads  no  further,  as  long  as  the  patient 
lives.  ( B . 2,  p.  641.)  Under  such  circum 
stances,  of  course  the  complaint  will  give 
no  trouble,  and  may  be  left  to  itself,  as  par- 
ticularly advised  by  Mr.  Travers.  ( Synop - 
sis,  4C • p • 274.)  When,  however,  it  en- 
croaches upon  the  sight,  this  gentleman 
says,  that  “ it  should  be  raised  by  dissection, 
as  close  as  possible  to  the  margin  of  the 
cornea,  and  the  relaxed  portion  of  the  mem 
brane  removed  by  an  incision,  midway  be- 
tween ilit  base  of  the  pterygium,  and  the  cor- 
nea, and  concentric  to  that  membrane.*' 
For  further  information,  consult ./.  War  dr  op. 
Essays  on  the  Morbid  Anatomy  of  the  Human 
Eye,  Vul.  1,  p.  22,  tiro.  Edinb.  1808 
Scarpa  sulle  Malailie  degli  Occhi.  cap.  11. 
Jlichter's  Anfangsgr.  dec  Wundarzneyhunst , 
B.  3,  p.  141,  fyc.  Gottingen,  1795.  Sabatier , 
De  la  M&decine  Operaloire,  T.  2,  p.  190, 
Edit.  2.  Beer's  Lehre  von  den  Augenkr.  B 
2,  p.  636,  fyc.  Svo.  Wien.  1817.  B.  Travers , 
Synopsis  of  the  Diseases  of  the  Eye,  8 ro.  Loud. 
1820.  Weller's  Manual,  Vol.  1,  8ru.  Glas- 
gow, 1821. 

PTOSIS,  (from  tmnrra),  to  fall  down.)- 
Blcuharoptasis.  Lapsus  Palp  three  Superions,. 
An  inability  of  raising  the  upper  eyelid. 
According  to  Beer,  ptosis  always  arises  from 
a considerable  relaxation  and  extension  of 
t lie  common  integuments  of  the  upper  eye- 
lid, which  hang  down  in  a kind  of  fold  over 
the/fissure  of  theclosed  palpebrse,  and  when 
the  levator  muscle  has  been  more  or  less 
weakened  by  the  same  causes,  which 
have  produced  t his  state  of  the  skin,  the 
weight  of  the  redundant  integuments  pre- 
vents the  eyelid  from  being  properly  open- 
ed. lienee,  when  the  patient  tries  to  raise 
the  eyelid,  the  efforts  of  the  levator  muscle 
may  be  seen  ; but,  the  object  cannot  be  per  - 


FfO 


reetly  accomplished.  With  the  exception  of 
the  inability  of  raising  the  upper  eyelid,  the 
patient  has  not  the  slightest  ailment ; the  eye 
is  not  at  all  red,  though,  when  opened,  it 
does  not  bear  the  light  well,  on  account  of 
not  being  accustomed  to  the  stimulus ; no 
stiliicidum  lachrymarurn  is  observable  ; and 
the  edge  of  the  eyelid,  with  all  the  eyelashes 
quite  dry,  is  seen  directly  trie  part  is  eleva- 
ted with  the  thumb*  When  the  relaxed  fold 
of  the  skin  is  taken  hold  of  between  the 
til  mib  and  forefinger,  without  pulling  or 
stretching  it,  but  o;.ly  just  so  as  to  take  oft" 
the  weight  opposed  to  the  levator  muscle, 
by  the  redundance  of  skin,  the  patient  is 
immediately  able  to  raise  the  eyelid  without 
any  difficulty  ; but,  as  soon  as  the  surgeon 
relinquishes  his  hold  of  the  skin,  the  part 
falls  down  again.  The  relaxed  fold  of  skin 
is  sometimes  situated  rather  over  the  outer 
commissure,  than  the  middle  of  the  eyelid, 
in  which  case,  the  latter  part  can  be  opened 
towards  the  nasal  commissure,  and  the  eye- 
ball becomes  habitually  rotated  towards  the 
nose  for  the  purpose  of  vision,  whereby 
strabismus,  and  if  the  disorder  be  not  soon 
rectified,  an  obliquity  of  sight,  are  occasioned. 
Beer  adds,  that  some  eyelids  are  formed 
with  a predisposition  to  such  an  elongation 
of  their  integuments. 

According  to  the  same  writer,  a prolapsus 
of  the  upper  eyelid  may  be  the  consequence 
of  any  inflammation  of  the  part,  accom- 
panied with  considerable  oedema,  or  ecchy- 
mosis,  as  happens  from  severe  wounds  of 
the  forehead,  eyebrow,  or  the  eyelid  itself, 
particularly  when  no  attempt  is  made  to 
unite  the  parts  by  the  first  intention.  The 
infirmity  may  also  be  the  consequence  of 
ophthalmy,  that  has  been  either  long  neglect- 
ed, or  badly  treated  with  relaxing  poultices, 
and  it  is  said,  that  scrofulous  patients  have  a 
disposition  to  the  complaint.  (Beer,  B.2.p. 
109—111.) 

The  case,  as  described  by  this  author, 
may  be  cured  by  the  excision  of  a long  slip 
of  skin  from  the  eyelid,  just  broad  enough 
for  the  removal  of  the  redundant  quantity. 
For  taking  hold  of  the  portion  of  integu- 
ments, Beer  employs  forceps,  the  extre- 
mities of  which  are  broad,  with  a somewhat 
concave  edge.  As  much  of  the  superfluous 
skin  is  to  be  taken  hoid  of,  and  raised,  as 
will  enable  the  patient  to  open  the  eyelid, 
which  circumstance  is  the  criterion  of  the 
quantity  selected  for  removal  being  enough. 
The  excision  may  then  be  performed  with 
scissors,  as  Beer  directs,  or  with  a knife,  as 
others  may  prefer;  and  the  wound  is  to  be 
dosed  with  a suture.  The  slip  of  skin 
chosen  for  removal,  should  not  be  too  near 
the  edge  of  the  eyelid,  for  then  the  skin 
of  the  lower  edge  of  the  wound,  would 
foe  too  narrow  for  the  application  of  the 
the  suture.  {Beer,  B.  2 ,p.  1 (5.)  Some  wri- 
ters refer  particular  cases  of  ptosis  altogether 
to  paralysis  of  the  levator  muscle  ; and  other 
instances  to  spasm  of  the  orbicular  muscle. 
When  the  disease  depends  entirely  on  para- 
lysis, the  eye  and  surrounding  parts,  may  be 
frequently  bathed  with  cold  spring  water, 


TCB  387 

and  the  eyelid  and  eyebrow  rubbed  with  the 
camphor  liniment,  to  which  a little  of  the. 
tinctura  lytUe  is  added.  The  shower  bath, 
bark,  and  other  tonics  are  also  indicated. 
The  cure  of  spasmodic  ptosis,  which  is 
rather  a symptom  ot  other  diseases,  Tike 
hysteria,  chorea,  worms,  ike.  than  a distinct 
affection,  c insists  in  the  removal  of  Ifie 
original  complaint,  tlowever,  generally 
speaking,  antispasniodic  medicines;  blisters 
on  the  temple,  or  behind  the  ear;  an  issue 
between  the  mastoid  process  and  angle  of 
the  jaw,  as  recommended  by  Adam  Schmidt, 
on  account  of  some  nervous  ramifications  of 
the  third  branch  of  the  fifth  pair,  which  give 
twigs  to  the  eyelids,  lying  irt  that  situation  ; 
and  fomenting  and  bathing  the  eye,  eyelids, 
and  face,  with  a decoction  of  poppy  heads 
and  cicuta ; are  means,  which  merit  the 
consideration  of  the  practitioner.  (See  Rich- 
ter's Anfangsgr.  der  Wundurzn.  B.  4,  p.  488, 
Svo.  od  Edit.  GoU.  1802.  Weller's  Manual , 
TransL  by  Monteath,  FoL  1,  p.  97,  fyc.  8 tic*. 
Glasgow,  1821.  6’.  J Beer,  Lehr e von  den 

Augtnkr.  B.  2 ,p.  109,  <yc.  Svo.  Wien.  181 7.) 
PUNCTURED  WOUNDS.  See  Wounds. 

PUPIL.  When  the  opening  in  the  centre 
of  the  iris  is  preternaturally  large,  and  this 
organ  more  or  less  deprived  of  its  power  of 
motion,  the  disease  is  technically  named 
mydriasis,  which  is  jpither  symptomatic , or 
idiopathic.  The  first  lorm  of  the  complaint, 
as  Weller  observes,  is  exemplified  in  cases 
of  hydrocephalus,  hydrophthalmia,  pressure 
on  the  brain  from  various  causes,  worms, 
amaurosis,  ike  T he  second  often  presents 
itself  as  a paralytic  affection  of  the  iris;  a 
state,  frequently  induced  by  the  application 
of  certain  narcotics,  like  belladonna  and 
hyosciamus.  Congenital  cases  of  mydriasis 
are  also  met  with,  as  well  as  instances 
brought  on  by  a loug  residence  in  darkness. 

A dilatation  of  the  pupil  may  likewise  be 
the  consequence  of  an  adhesion  of  the  uvea 
to  the  anterior  capsule  of  the  lens.  When 
the  retina  continues  sensible,  the  inconve- 
niences, produced  by  mydriasis,  are  intole- 
rance of  light,  complete  blindness  in  the  day- 
time, and  in  the  end  amaurotic  mischief, 
occasioned  by  the  irritation  of  the  immo- 
derate quantity  of  the  rays  of  light,  admitted 
within  the  eye.  The  kind  of  prognosis, 
and  the  mode  of  treatment,  must  often 
depend  entirely  upon  the  primary  affection, 
of  which  many  cases  of  mydriasis  are  only 
symptomatic.  Of  course,  the  original  dis- 
order must  always  be  cured,  if  possible. 
When  mydriasis  appears  to  arise  from  para- 
lysis of  the  iris,  blisters  may  be  applied  over 
the  eyebrows,  and  the  same  remedies  tried, 
which  are  usually  employed  in  other  locaL 
paralytic  disorders.  Tire  entrance  of  too 
much  light  into  the  eye  may  be  moderated 
with  shades,  and  tubulated  spectacles. 

The  case,  which  is  the  reverse  of  the  pre- 
ceding, is  a preternaturally  contracted,  more 
or  less  immoveable  state  of  the  pupil,  termed 
myosis.  According  to  Weller,  it  is  sometime^ 
congenital.  It  is  often  met  with  as  a symp- 
tom of  other  disorders,  especially  ophthalmy, 
inflammation  of  the  dura  mater,  phreuilrs,- 


PUPIL. 


;sh 


concussion  of  the  brain,  &ic."  Persons,  whose 
business  is  to  be  looking  at  small  shining  ob- 
jects, as  watchmakers,  often  acquire  a mvo- 
sis  from  habit,  and  they  cannot  be  cured  of 
it,  unless  they  avoid  the  causes  which 
brought  it  on,  keep  themselves  in  a darkish 
room,  and  use  a green  shade,  or  tubulated 
spectacles.  (See  Wellefs  Manual :tyc.  Tran  si. 
byMonieath , Vol.(2,p.  54.)  It  is  noticed  by 
Beer, that  rnyosis,  when  a sequel  of  ophthal- 
my,  is  less  obvious  than  most  other  conse- 
quences of  ocular  inflammation  ; for  though 
the  iris  is  motionless,  and  the  pupil  consider- 
ably diminished,  this  opening  is  perfectly 
clear  and  black,  and  not  drawn  out  of  its 
usual  position,  nor  its  pupillary  edge  in  the 
slightest  degree  angular,  i he  patient,  though 
he  is  continually  complaining  of  weakness 
of  sight,  is  able  to  distinguish  (with  some 
trouble  indeed)  even  the  smallest  objects  in 
the  daytime,  and  in  very  light  situations, 
but,  his  sight  is  evidently  worse  in  the  even- 
ing, and  in  darkish  places  in  the  daytime ; 
for,  when  both  his  eyes  are  affected,  he  is  in 
the  dusk  nearly  blind,  and  can  scarcely  find 
his  way.  Beer  remarks,  that  almost  every 
considerable  internal  ophthalmy,  or  iritis, 
however  favourably  the  disorder  may  be. 
cured,  and  the  eyesight  restored,  always 
leaves  after  it  more  or  less  contraction  of 
the  pupil,  which  affection,  though  not  the 
least  portion  of  coagulating  lymph  can  be 
perceived  iri  the  posterior  chamber,  is  com- 
bined with  a partial,  or  complete  immobility 
of  the  iris.  Beer  assures  us,  that  every  ex- 
pedient, which  he  has  y7et  tried  for  the  per- 
manent removal  of  this  complaint  has  failed, 
the  dilatation  of  the  pupil,  thus  produced, 
being  but  temporary.  And,  with  respect  to 
the  most  powerful  narcotics,  he  states,  that 
in  two  cases,  they  were  worse  than  useless, 
as  they  caused  a still  greater  contraction  of 
the  pupil,  which,  however,  after  a few  hours, 
resumed  its  former  diameter.  Hence,  this 
experienced  oculist  is  disposed  to  set  down 
the  rnyosis,  following  internal  ophthalmy, 
as  an  incurable  complaint.  (See  Lehre  van 
den  Angenkr.  B.  2,  p.  261,  fyc.) 

The  next  case,  demanding  some  notice  in 
this  work,  is  a closure  of  the  pupil  ( atresia 
pupillce.)  According  to  Beer’s  observations, 
there  is  only  one  exception,  in  which  in  the 
adult  patient  a closure  of  the  pupil  is  not 
the  consequence  of  ophthalmy,  and  the  case, 
here  signified,  is  termed  a collapse,  of  the 
pupil , or  synizesis  pupillce, , the  causes  of 
which  are  said  to  be,  either  a very  consider- 
able loss  of  the  vitreous  humour  from  a 
wound  of  the  eye,orelseadissolved,or  rather 
disorganized  state  of  the  same  humour, 
known  among  the  oculists  under  the  name 
of  synchysis  (See  Beefs  Lehre , fyc.  B.  2,  p. 
390.)  Every  internal  ophthalmy,  extending 
to  the  retina  and  choroides,  when  in  its 
highest  degree,  is  apt  to  produce  a complete 
closure  of  the  pupil.  However,  in  such  cases, 
as  Beer  remarks,  the  obliteration  of  this 
opening  is  not  the  only  cause  of  blindness, 
for,  long  before  this  state  of  the  iris  happens, 
the  sight  is  destroyed  by  considerable,  and 
frequently  irremediable,  injury  of  the  retina, 


and  neighbouring  textures,  in  which  the  in- 
flammation  is  directly  situated.  An  incom 
plete  closure  of  the  pupil,  he  says,  is  still 
more  disposed  to  take  place  at  the  period, 
when  the  iritis  passes  from  its  first  into 
its  second  stage,  and  syphilitic  iritis  is  said 
to  be  particularly  apt  to  leave  after  it  this 
disagreeable  consequence.  (Fol.  cit. p.  191.) 
In  cases  of  the  latter  description,  vision  is 
not  always  quite  prevented,  but  only  more 
or  less  diminished,  the  coagulating  lymph, 
effused  in  the  posterior  chamber  having 
formed  only  a delicate,  semi-transparent  web. 
However,  if  in  (he  second  stage  of  the  in- 
flammation, such  lymph  should  be  converted 
into  a dense  membrane,  with  opacity  of 
the  lens  and  its  capsule,  the  eye  then  only 
retains  more  or  less  perfectly  the  faculty  of 
just  distinguishing  the  light.  But,  when  in 
such  a case,  the  patient  is  completely  insen- 
sible of  the  difference  between  light  and 
darkness,  the  blindness,  as  in  the  examples 
mentioned  above,  is  not  owing  to  the  clo- 
sure of  the  pupil,  or  to  the  cataract,  but  to 
other  morbid  changes,  resulting  from  the 
same  inflammation,  which  caused  the  defect 
in  the  pupil  itself,  and  capable  of  being  as- 
certained by  certain  appearances  in  the  eye. 
Passing  over  obstructions  of  the  pupil  by  the 
unabsorbed  matter  of  hypopium,  and  by  the 
continuance  of  effused  blood  in  the  chambers 
of  the  eye,  I come  to  the  case,  next  noticed 
by  Beer,  in  which  a closure  of  the  pupil 
arises  from  a partial  adhesion  of  the  iris  to 
the  cornea,  ( synechia  anterior ,)  and  will 
inevitably  happen,  when  a considerable  por- 
tion of  the  iris,  or  a great  part,  or  the  whole, 
of  its  pupillary  edge  protrudes  through  an 
opening  in  the  cornea,  and  becomes  ad- 
herent to  it.  However,  as  Beer  observes, 
sometimes,  in  these  cases,  the  pupil  becomes 
completely  obstructed,  though  the  protrusion 
of  the  iris  is  inconsiderable,  and  its  pupillary 
edge  not  engaged  in  the  cicatrix  ; a circum- 
stance exemplified,  when  the  cicatrix  over 
the  adherent  part  of  the  iris  expands  very 
much,  and  has  an  extensive  leucomatous 
surface,  so  that,  though  the  pupil  may  be  of 
considerable  size,  it  is  concealed,  and  vision 
impeded.  And,  even  w'hen  there  is  no  ad- 
hesion of  the  iris  to  the  cornea,  no  synechia 
anterior,  as  it  is  termed,  and  no  distortion  of 
the  pupil,  a large  dense  cicatrix  of  the  cor- 
nea may  obstruct  vision  by  lying  exactly  over 
that  aperture.  Lastly,  usBeerhasexplained, 
the  greater  part  of  the  cornea  may  be  in  an 
opaque,  spoiled  condition, sothat  the  healthy 
iris  can  be  discerned  only  here  and  there  be- 
hind its  circumference,  no  vestige  of  the 
pupil  itself  being  distinguishable  ; and  such 
concealment  of  the  pupil,  may  be  either 
combined,  or  not,  with  a partial  adhesion  of 
the  iris  to  the  cornea,  in  such  cases,  the 
patient  can  frequently  perceive  the  light 
very  well.  (B.  2 ,p.  194,  95.) 

From  what  has  been  stated,  it  is  manifest, 
says  Beer,  that  in  many  cases  of  atresia  iri- 
dis,  the  prognosis  must  be  highly  unfavour- 
able, and  that  no  attempt  to  form  an  arti- 
ficial pupil  should  ever  be  made  when  the 
patient’s  blindness  proceeds  from  other 


eauses,  besides  the  imperforate  state  of  the 
iris.  Such  an  operation,  Beer  observes,  can 
only  be  proper  when  the  blindness  is  en- 
tirely owing  to  the  closed  or  concealed 
state  of  the  pupil ; when  the  different  de- 
grees of  light  can  be  plainly  distinguished  ; 
when  the  case  is  uncomplicated  with  any 
disease  of  other  important  textures  of  the 
eye,  capable  of  rendering  the  manual  pro- 
ceedings difficult  or  impracticable ; when 
the  eye  has  been  for  a long  time  perfectly 
free  from  inflammation  ; when  the  patient 
fi  healthy,  without  any  tendency  to  scro- 
fula, syphilis,  or  gout  ; and  both  his  eyes 
are  completely  blind.  (B  2 p.  196.)  Some 
questions  may  be  entertained  respecting  this 
absolute  prohibition  of  the  operation  in  un- 
healthy subjects,  because  the  line  between 
the  degree  of  health,  requisite  for  the  suc- 
cess of  the  operation,  is  difficult.to  specify, 
and  gout,  syphilis,  and  scrofula,  are  often 
vague  expressions.  Yet,  no  doubt  can  exist, 
I think,  about  the  propriety  of  Beer’s  ad- 
vice never  to  attempt  the  formation  of  an 
artificial  pupil,  when  the  patient  enjoys  vi- 
sion with  one  of  his  eyes;  for,  when  the 
new  opening  is  made,  as  it  is  not  in  the  axis 
of  vision,  the  sight  is  confused  in  the  other 
eye,  unless  the  imperfect  mae  be  kept  closed, 
and  the  operation  can  n^er  be  done  with- 
out exposing  the  patient  to  the  risk  of  more 
or  less  inflammation  in  the  eye,  which  is  at 
present  so  useful  to  him.  Whatever  may  be 
the  differences  of  opinion  about  operating 
in  cases  of  single  cataract,  I believe  that  all 
surgeons  will  unanimously  join  Beer  in  the 
foregoing  advice  respecting  the  imprudence 
of  attempting  to  make  an  artificial  pupil, 
when  the  patient  can  see  with  one  eye. 

Beer  represents  the  event  of  the  opera- 
tion as  being  very  uncertain,  when  the  pa- 
tient cannot  plainly  discern  the  various  de- 
grees of  light;  when  the  cornea  is  affected 
with  leucoma,  or  scarred  and  spoiled  nearly 
to  its  very  circumference  ; when  there  is 
only  a partial  staphyloma  of  it ; or  the  con- 
stitution is  unhealthy  or  impaired  by  the 
effects  of  former  attacks  of  scrofula,  syphi- 
lis, or  gout.  Lastly,  Beer  *ets  down  the 
operation  as  certainly  useless,  or  even  as 
likely  to  cause  an  entire  destruction  of  the 
eye,  when  the  patient  is  quite  insensible  of 
light;  when  the  iris  and  neighbouring  tex- 
tures, such  as  the  corpus  ciiiare,  corona  ci- 
liaris,  the  membrane  of  the  vitreous  hu- 
mour, this  humour  itself,  and  the  blood- 
vessels of  the  organ,  are  in  a morbid  state, 
or  the  whole  eyeball  manifestly  in  a preter- 
natural condition.  However,  an  opacity  of 
the  lens  and  its  capsule,  even  when  the 
latter  is  completely  adherent  to  the  uvea 
forms  no  prohibition  to  the  formation  of  an 
artificial  pupil,  though  it  is  a circumstance 
that  has  great  weight  in  the  selection  of  the 
method  of  operating.  (Beer,  B.  2,  p.  197.) 

The  following  information,  from  the  same 
source,  is  highly  important  to  the  practi- 
tioner : the  morbid  state  of  the  iris  and 
other  adjacent  textures  of  the  eyeball,  con- 
tradicting the  operation,  may  be  known  by 
the  annexed  circumstances.  Together  with 


the  smaller  circle  of  the  iris,  the  larger  one 
is  strikingly  changed,  in  respect  to  its  co- 
lour, its  consistence,  and  its  layers.  Its  ra- 
diated fibres  are  collected  into  dark  blue  or 
blackish  fasciculi,  between  which  there  is 
an  appearance  of  empty  interspaces,  pro- 
duced by  the  indentations  of  the  iris,  and 
actually  semi-transparent,  in  consequence  of 
the  tapetum  of  the  uvea  having  always  been 
in  these  casts  more  or  less  annihilated  by  the 
previous  inflammation.  Around  the  cornea, 
the  scleroticaseems  bluish,  or  rather  of  a smut- 
ty grayish  blue  colour ; and  sometimes  certain 
points  of  this  membrane  are  protuberant.  The 
morbid  states  of  the  whole  eyeball,  which  may 
complicate  the  atresia  iridis,  and  render  the 
operation  not  only  useless,  but  hazardous  to 
the  preservation  of  tire  eye,  are  its  dropsical 
enlargement,  (see  Hydrophthalmia ,)  its  atro- 
phy ; its  preternatural  firmness,  from  a ge- 
neral varicose  affection  of  its  blood-vessels  ; 
and  its  morbid  softness  from  a disorganiza- 
tion of  the  vitreous  humour.  (Beer,  Vol. 
cit.  p.  198.) 

Before  proceeding  further  into  the  sub- 
ject, 1 think  it  will  simplify  it  very  much  to 
state,  that  numerous  as  the  plans  of  opera- 
ting for  artificial  pupils  are,  if  we  except 
the  occasional  plan  of  making  a kind  of 
artificial  prolapsus  of  the  iris,  in  order  to 
change  the  position  or  shape  of  the  imper- 
fectly closed  pupil,  they  may  all  be  classed 
into  three  principal  methods.  1.  The  sim- 
ple transverse,  perpendicular,  or  otherwise 
directed  incision  in  the  iris,  now  termed 
corotomia  2.  I he  excision  of  a piece  of 
the  iris,  technically  named  corectomia.  3, 
The  separation  of  a part  of  its  circumfe- 
rence from  the  ciliary  ligament,  called  in 
the  language  of  oculists  corodialysis.  The 
excision  of  a portion  of  sclerotica,  close  to 
the  cornea,  with  the  view  of  forming  an 
inlet  for  the  rays  of  light  to  the  retina,  as 
proposed  by  Autenrieth,  when  the  cornea 
is  entirely  opaque,  may  be  considered  a 
hopeless  proceeding.  With  respect  also  to 
the  three  other  methods,  it  is  now  well  un- 
derstood by  all  impartial  surgeons,  that  the 
choice  of  them  must  depend  upon  the  par- 
ticular circumstances  of  the  case,  and  that 
here  it  is  as  absurd  to  think  of  employing 
in  ail  instances  only  one  plan  of  operating 
as  to  have  the  idea  of  extending  the  same 
principle  to  all  the  forms  and  varieties  of 
cataract. 

Where  the  thing  is  possible,  it  is  consi- 
dered by  Beer  most  advantageous  to  make 
the  artificial  pupil  rather  towards  the  inner 
canthus  ; though  others  express  a preference 
to  the  centre  of  the  iris.  But,  as  Beer  very 
truly  remarks,  since  the  new  opening  must 
be  where  the  cornea  is  transparent,  the  ope- 
rator is  frequently  obliged  to  form  it  either 
below,  or  towards  the  temple,  or  quite 
above  ; for  there  is  often  only  just  room 
enough  left  at  one  point  for  conducting  the 
necessary  manoeuvres,  with  any  degree  of 
precision. 

Cheselden  first  devised  and  executed  a 
section  of  the  iris,  for  the  purpose  of  form- 
ing an  artificial  pupil.  He  .introduced  a 


P'to'PlL. 


390 


couching  needle,  having  a sharp  edge  only 
on  one  side,  through  the  sclerot  ca,  at  the 
distance  of  a line  and  a half  from  the  cor- 
nea, into  the  anterior  of  the  eye.  After 
perforating  the  iris  towards  the  external  an- 
gle, and  then  pushing  the  point  of  the  nee- 
dle through  the  anterior  chamber  of  the 
aqueous  humour,  as  far  as  that  side  of  tile 
iris  which  is  nearest  the  nose,  ho  turned  the 
edge  of  the  instrument  backward,  and  with- 
drew it,  so  as  to  make  a transverse  division 
of  that  membrane.  This  operation  seems 
to  have  been  attended  with  the  greatest 
success.  However,  Janin  (Mem.  sur  i'CEil) 
assures  us,  that  having  performed  it  on  two 
subjects  with  the  utmost  care  possible,  he 
did  not  find  the  smallest  benefit  follow  it; 
for,  in  these  two  patients,  as  soon  as  the 
symptoms,  produced  by  the  operation,  sub- 
sided, the  transverse  section  made  in  the 
iris  by  the  edge  of  the  needle,  reunited,  and 
Sharp  had  experienced  the  same  thing  ear- 
lier than  Janin.  (On  Operations,  chap.  29.) 

An  accident  occurred  to  Janin,  in  the  act 
of  extracting  a cataract  ; viz.  he  included 
the  iris  together  with  the  cornea,  in  Daviei’s 
scissors,  and  cut  it  perpendicularly,  and  the 
division  remained  permanent.  This  led  him 
to  propose  a perpendicular  incision  as  the 
best  expedient  for  making  an  artificial  pupil. 
His  plan  consisted  in  opening  the  cornea,  as 
Is  practised  for  the  extraction  of  the  cata- 
ract, and  in  dividing  the  iris  perpendicularly 
with  scissors,  near  that  part  of  the  pupil 
which  is  next  to  the  nose  ; for,  he  affirms, 
that  he  has  seen  strabismus  result  from 
making  the  section  towards  the  external 
side,  on  account  of  the  two  great  divarica- 
tion of  the  optical  axes. 

Although  the  practice  of  making  an  inci- 
sion in  the  iris  or  corotomia,  is  severely 
disapproved  of  by  Beer,  who  states  that  it 
admits  of  being  practised  only  in  very  few 
cases,  and  is  rendered  quite  unnecessary  by 
what  he  considers  the  two  other  better  plans, 
(B.  2.  P.  i99.)  the  operation  is  still  consi 
dered  by  some  men  of  experience,  as  having 
recommendations,  and  they  have  therefore 
endeavoured  to  improve  it.  However,  it 
will  only  be  in  my  power  to  notice  in  this 
work  a few  of  its  modifications. 

In  1812,  Sir  VV.  Adams  recommended  the 
revival  of  Cheselden’s  method  of  forming 
an  artificial  pupil,  with  the  difference  of 
using  for  the  purpose  a particular  sort  of 
knife.  "With  a cataract  needle  (says  this 
oculist)  I could  not  cut  through  the  iris  by 
a gentle  force  ;.  and  if  l ventured  to  apply  a 
greater  force,  the  iris  separated  from  its  at- 
tachment to  the  ciliary  ligament,  which  ren- 
dered all  further  attempts  to  effect  a central 
aperture  useless  The  sarcw  accident  appears 
to  have  happened  to  Mr.  Sharp  in  his  trials 
of  this  operation.  In  the  hopes  of  procuring 
an  appropriate  instrument,  1 twice  went  to 
London,  at  the  interval  of  a lew  months : 
but  though  I described  to  different  instrument- 
makers  the  purposes  for  which  it  was  in- 
tended, still  I could  only  procure  the  needle, 
which  cuts  on  one  edge,  and  the  spear- 
pointed  knife,  of  different  sizes,  described  by 


Chese'den.  At  length  it  occurred  fco  me  that 
the  curved  edge  of  the  common  dissecting 
scaipel  \va3  well  adapted  to  cut  with  facility, 
I therefore,  when  in  London  a third  time, 
got  a small  knife  made,  two-thirds  of  an  inch 
in  length,  and  nearly  a line  in  width,  with  a 
straight  back,  sharp  point,  and  a curved 
edge,  which  cuts  back  towards  the  handle 
for  about  three  lines.”  (Adams's  Pract.  Ob*, 
on  Edropium,  fyc.  p.  30.)  According  to  this 
gentleman,  in  all  cases  where  there  is  no 
crystalline  lens,  and  the  cornea  is  free  from 
opacity,  the  division  of  the  iris  should  bo 
made  in  the  centre,  and  should  extend  across 
at  least  two-thirds  of  its  transverse  diameter. 
In  a later  work,  however,  this  author  states, 
that  experience  has  convinced  him,  that 
so  extensive  a division  of  the  iris  is  unneces- 
sary for  the  prevention  of  the  reunion  of  this 
membrane*  and  that  a cut  through  one-third 
of  its  diameter  is  sufficient.  The  eye  being 
gently  fixed,  either  with  the  finger  of  the 
assistant,  who  supports  the  upper  eyelid,  or 
with  a concave  sort  of  speculum,  placed 
under  the  upper  eyelid,  the  artificial  pupil 
knife  is  to  be  introduced  through  the  coats 
of  the  eye.  about  a line  behind  the  iris,  with 
its  cutting  edge  turned  backwards.  The  point 
is  next  to  be  hi^ugbt  forward  through  the 
iris,  somewhat  than  a line  from  its 

temporal  ciliary  attachment,  and  cautiously 
carried  through  the  anterior  chamber,  until 
it  has  nearly  reached  the  inner  edge  of  that 
membrane,  (or  as  is  expressed  in  a later 
description,)  “ until  it  has  traversed  more 
than  two-thirds  of  the  width  of  the  iris,” 
when  it  should  be  almost  withdraw  n out  of 
the  eye,  gentle  pressure  being  made  with 
the  curved  part  of  the  cutting  edge  of  the 
instrument  against  the  iris,  in  the  line  of  its 
transverse  diameter.  If  in  the  first  attempt, 
the  iris  should  not  be  sufficiently  cut,  the 
point  of  the  knife  is  to  be  again  carried  for- 
ward, and  similarly  withdrawn,  until  the 
incision  is  of  a proper  length.  After  ihe 
operation,  the  eye  is  to  be  covered  with  a 
plaster  of  simple  ointment,  and  the  patient 
put  into  bed,  with  his  head  raised.  (P.  3(5, 
37.)  When  the  closure  of  the  pupil  is  at- 
tended with  a cataract,  the  primary  steps  of 
the  operation  are  the  same  ; but  Sir  William 
Adams  takes  care  also  to  cut  the  cataract 
into  pieces,  some  of  which  he  brings  forward 
into  the  anterior  chamber,  while  others  he 
leaves  in  the  opening  of  the  iris,  where  they 
at  first  serve  as  a plug,  hindering  union  by 
the  first  intention,  (P.  38.)  and  are  after- 
ward absorbed.  For  an  account  of  this 
gentleman’s  particular  methods  in  all  the  va- 
rious complications  of  these  cases  the  reader 
mu  i consult  bis  publications,  where  many 
successful  examples  of  the  operation  are  re- 
corded. 

That  Cheselden’s  method  ought  not  to  be 
entirely  rejected,  there  can  now  he  no  doubt 
Like  all  other  modes  of  forming  an  artificial 
pupil,  it  certainly  does  not  merit  exclusive 
preference.  Besides  the  authority  ot  Sir  W. 
Adams,  we  have  the  testimony  ot  Mr.  Ware, 
to  prove  that  Cheselden’s  operation  fre- 
quently .succeeds.  This  gentleman  informs 


PUPIL 


us,  that  when  the  pupil  has  become  closed, 
after  an  unsuccessful  operation  of  extracting 
the  cataract,  he  has  in  several  instance's 
made  a new  pupil,  agreeably  to  Cheselden’s 
mode  of  performing  the  operation,  with  the 
most  perfect  and  striking  success.  “The 
fibres  of  the  iris  retracted  as  soon  as  they 
were  divided,  and  left  the  pupil  very  nearly 
of  its  natural  size.  Its  shape  was  not  quite 
round  ; but  the  sight  was  immediately  re- 
stored, and  to  so  great  a degree,  as  to  enable 
the  patient,  by  the  help  of  suitable  convex 
glasses,  to  see  distinctly  both  near  and  distant 
objects,  neither  pain  nor  inflatnmqtion  being 
consequent  to  the  operation.” 

Where  there  is  a prolapsus  of  the  iris, 
through  a breach  of  the  cornea,  involving 
more  or  less  of  t lie  pupillary  margin,  Mr. 
Travers  considers  Cheseldens  method  the 
most  applicable;  “viz.  the  transverse  divi- 
sion of  the  stretched  fibres  of  the  ins,  and 
which,  if  the  section  be  made  in  front  of 
the  membrane,  i.  e.  from  before  backwards, 
admits  of  no  improvement.  The  edges  of *the 
section  instantly  recede  and  form  an  excel- 
lent pupil.”  However,  he  afterward  adds, 
“ that  a partial  adhesion  of  the  pupillary 
margin  may  be  combined  with  a healthy 
lens  In  this  case,  the  removal  of  the  free 
border  of  the  pupil,  drawn  by  means  of  for  - 
ceps, through  an  incision  in  the  cornea,  will 
Vre  preferable,  on  account  of  reserving  (lie 
transparency  of  the  lens.”  (Synoj>sis  of  the 
Diseases  of  ike  Eye , p.  343.) 

In  a modern  work,  Professor  Maunoir  of 
Geneva,  has  published  a very  successful 
case,  in  which  an  artificial  pupil  was  former^ 
and  a caseous  cataract  extracted.  u I ope- 
rated, (says  M.  Maunoir)  on  the  right  eye  in 
the  following  manner.  The  patient  being 
seated  on  a chair,  and  having  the  head  in- 
clined upon  a cushion,  I placed  myself  be- 
hind him,  and  with  the  fore-iingei  of  the  left 
hand,  confining  the  upper  eyelid, 'whilst  an 
assistant  depressed  i be  lower.  I made  with  the 
right  hand  a semicircular  incision  in  t lie  lower 
and  external  part  of  the  cornea  This  incision 
occupied  a full  third  of  the  circumference  of 
the  membrane.  On  reopening  th<?  eye,  the  iris 
was  seen  projecting  a little  from  the  wound 
in  the  cornea.  I replaced  it  with  the  blunt 
point  ol  my  scissors.  Introducing  the  two 
blades  closed  into  the  anterior  chamber,  and 
then  opening  them,  I caused  the  pointed 
blade  to  penetrate  the  iris,  leaving  the  blunt 
blade  between  that  membrane  and  the  cor- 
nea ; then  closing  the  scissors,  a perpendicu- 
lar incisiou  of  the  iris  resulted,  describing  a 
little  more  than  half  the  chord  of  an  arc  of 
two-fifths  of  the  circumference  of  the  iris, 
traced  on  the  side  of  the  temple.  The  first  in  - 
eision  not  having  occasioned  ihe  formation 
of  a pupil  of  the  necessary  size,  I introduced 
the  scissors  into  the  iris  a second  lime  a 
little  obliquely ; and  immediately  the  pupil 
appeared  of  a satisfactory  form  and  size,  but 
exhibiting  the  crystalline  entirely  opaque. 
The  second  stroke  of  the  scissors  had  divided 
the  capsula  : I therefore  introduced  a small 
curette,  in  order  to  endeavour  to  destroy 
v/hat.  adhered  of  the  crystalline  to  the  shrunk 


and  contracted  circumference  of  the  old 
pupil.  This  attempt  did  not  succeed.  Lastly, 
! effected  the  passage  of  a portion  of  the 
opaque  lens,  by  means  of  a slight  pressure 
with  a large  scoop,  exercised  on  the  lower 
part  of  the  globe  of  the  eye.  The  crystal- 
line, which  was  of  a cheesy  consistence, 
came  out  with  the  greatest  ease,  and  though 
it  was  not  entirely  removed,  yet  a sufficient 
quantity  was  discharged  to  leave  the  artifi- 
cial pupil  of  a most  perfect  black.  This 
new  pupil  was  on  the  side  of  the  temple  ; 
and  at  the  exterior  and  lower  part  of  the 
n o.”  (See  Med.  Chir.  Trans.  Vol.  7.  p.  305, 
et  seq .)  hi  this  communication  are  also  two 
other  cases,  in  which  Professor  Maunoir 
operated  with  success,  though  complicated 
with  cataracts,  and  adhesions  of  the  lens  to 
the  iris.  In  some  remarks  annexed  by  Pro- 
fessor Scarpa  to  the  preceding  account,  the 
latter  expresses  his  opinion,  that  it  is  not  ne 
cessary  to  be  scrupulous,  whether  the  crys- 
talline be  partly  or  entirely  opaque,  whene- 
ver the  capsule  is  opaque,  and  adheres  to  the 
iris,  behind  the  edge  of  she  interior  and  en- 
closed pupil.  “ I i thi-  case  only  one  reme- 
dy can  be  pointed  out,  namely,  the  removal 
of  the  opaque  adherent  capsule,  and  conse- 
quently of  the  crystalline,  \hether  it  he 
transparent  or  opaque.  In  the  second  place, 
(says  Scarpa)  1 think  there  is  no  reason  to 
doubt,  that  in  similar  cases,  it  is  adviseabio 
to  make  an  incision  upon  the  iris,  propor- 
tioned to  the  size  of  the  body  to  he  extract  - 
ed. rather  than  to  make  i!  -mall,  which 
obliges  the  operator  to  divide  the  crystalline 
and  the  capsule,  with  the  intention  of  ex- 
tracting a part,  and  of  abandoning  the  rest 
to  the  powers  of  absorption.  Thirdly:  I 
would  establish  as  a fundamental  principle, 
in  sL-ilar  cases,  that  after  the  complete  ex 
traction  of  the  crystalline,  with  its  opaque 
capsule,  by  means  of  the  leas!  possible  in- 
troduction of  i«e  instruments,  the  artificial 
pupil  ougin  not  to  be  too  near  the  incision 
in  the  cornea,  and  consequently  not  loo 
near  the  cicatrix  occasioned  by  it.”  ( P 
317.)  Scarpa  then  recommends  a particular 
method  of  operating,  in  ease3  where  there 
are  cataracts:  after  caving  made,  in  the  man- 
ner of  Wenzel,  a transverse  incision  in  the  iris, 
at  d in  the  cornea,  he  would  introduce  Mau- 
noir’s  scissors,  blunted  at  both  points,  into 
the  anterior  chamber  of  the  aqueous  humour, 
and  make  an  incision  in  the  iris,  diverging 
from  the  cut  made  with  the  knife.  The  aper- 
ture thus  made,  Scarpa  thinks  would  be 
large  enough  to  allow  easy  egress  to  the 
opaque  lens. 

Among  other  late'opinions  professed  by 
this  distinguished  surgeon,  we  find  the  fol  - 
lowing ; that  no  instrument  is  so  proper  as 
the  scissors  for  making  an  incision  in  the 
iris  , that  when  the  case  is  not  complicated 
by  cataract,  a very  soiail  wound  in  ihe  cor- 
nea is  sufficient  ; that  the  formation  of  a 
triangular  edge  in  the  iris,  by  means  of  a 
double  incision  with  the  scissors,  is  the  most 
easy  and  least  ‘painful  of  all  uie  methods 
hitherto  proposed  for  obtaining  a permanent 
artificial  pupil  *,  and  lastly,  that  spots  of  the 


JPUTIL. 


392 


cornea  present  no  obstacle,  because  it  is 
possible  to  produce  the  artificial  pupil  op- 
posite the  transparent  part  of  that  mem- 
brane. (Med.  Cflir.  Trans.  Vol.  7,  p.  320,321.) 

As  1 have  already  noticed,  the  contraction 
of  the  natural  pupil  is  sometimes  occasioned 
by  the  iris  being  stretched  towards  some 
point  of  the  cornea,  to  which  it  is  adherent. 
This  state,  as  Scarpa  observes,  is  most  fre- 
quently accompanied  with  partial  opacity  of 
the  cornea,  around  the  adhesion,  or  prolap- 
sus of  the  iris,  as  well  as  with  opacity  of  the 
tens  and  its  capsule.  At  other  times, 
however,  these  internal  parts  preserve 
their  natural  transparency,  notwithstand- 
ing the  deviation  of  the  natural  pupil.  In 
the  latter  case  the  pupil,  though  removed 
from  its  situation,  is  not  in  reality  obliterated, 
but  merely  very  much  contracted,  and  inca- 
pable of  admitting  the  quantity  of  light  ne- 
cessary for  vision,  especially  if  the  opposite 
part  of  the  cornea  be  slightly  opaque.  In 
such  an  example,  Scarpa  recommends 
making  a small  incision  in  the  cornea  at  the 
most  commodious  part,  when  with  Maunoir’s 
scissors  closed,  and  constructed  with  little 
buttons  at  the  ends  of  both  the  blades,  an 
endeavour  is  to  be  made  to  break  the  adhe- 
sion existing  between  the  iris  and  the  cornea. 
If  this  can  be  effected,  the  natural  pupil  ge- 
nerally recovers  its  former  situation  and 
size  ; but  if  the  adhesion  be  very  firm,  Scar- 
pa introduces  one  of  the  blades  v\  ithin  the 
contracted  pupil,  behind  the  posterior  surlace 
of  the  iris,  until  the  other  blade  has  reached 
the  confines  of  the  cornea  with  the  sclerotica. 
The  iris  is  then  to  be  divided  in  the  form  of  the 
letter  V,  without  at  all  injuring  the  capsule 
or  lens,  both  of  which  are  transparent.  (On 
the  Principal  Diseases  of  the  Eyes,  p.  384, 
Ed.  2-  Transl.  by  Briggs.)  When,  after  ex- 
traction of  the  cataract,  the  pupil  has  been 
dragged  down  in  t his  manner  by  adhesion 
to  the  lower  third  of  the  cornea,  the  upper 
two-thirds  of  which  are  transparent,  Dr. 
Monteath,  of  Glasgow,  has  succeeded  five 
times  in  forming  an  artificial  pupil, and  resto- 
ring vision  by  making  a small  opening  in  the 
upper  and  outer  part  oft  be  edge  of  the  cornea, 
capable  of  admitting  Maunoir’s  eye-scissors, 
with  which  the  overstretched  fibres  of  the 
iris  are  to  be  cut  across  by  one  simple  inci- 
sion, three  lines  in  length.  The  cut  edges 
instantly  recede,  and  leave  an  oval  pupil  of 
sufficient  size-  (See  Weller's  Manual.  Vol. 
2,  p.  70.)  In  the  cases  above  specified  by 
Scarpa,  Sir  Wm.  Adams,  instead  of  per- 
forming corotomia,  endeavours  to  separate 
the  iris  from  the  cornea,  and  then  to  alter 
the  position  of  the  pupil  by  drawing  it  to- 
wards that  part  of  the  cornea  which  has 
remained  transparent.  For  this  purpose  he 
punctures  the.  cornea  about  ne  line  in  front 
of  the  iris,  separates  the  adhesion,  and  then 
makes  the  disengaged  portion  of  the  iris  pro- 
trude through  the  puncture,  -and  leaves  it 
there,  even  using  the  forceps,  if  necessary, 
for  drawing  it  out  as  far  as  is  deemed  neces- 
sary for  its  being  securely  fixed.  This  method 
is  disapproved  of  by  Scarpa,  because  a se- 
cond prolapsus  of  the  iris  in  the  same  eye 
appears  to  him  a very  serious  disease,  and 


rather  calculated  to  increase  the  opacity  of 
the  cornea,  and  augment  the  contraction 
of  the  pupil,  than  afford  relief. 

According  to  Beer,  the  excision  of  a por 
tion  of  the  iris,  corectornia  is  particularly  in- 
dicated in  all  cases  in  which  there  is  a sound 
transparent  lens,  as  iti  many  examples  of 
synechia  anterior,  concealment  of  the 
natural  pupil  by  a central  opacity  of  the 
cornea,  Hie.  Beer  admits,  however,  as  an 
exception,  the  instances  in  which  the  trans- 
parent portion  of  the  cornea  is  so  small,  that 
no  opening  can  be  made  in  it  with  the  knife, 
large  enough  to  permit  the  iris  to  be  taken 
hold  of  w ith  a small  hook  or  forceps,  and  a 
piece  ol  it  cut  out  above  the  ciliary  pro- 
cesses. (B.  2,  p.  -200.)  The  reason  here 
given,  does  not  appear  to  myself  very  strong, 
because  it  may  be  asked,  why  not  acquire 
more  room  by  cutting  a portion  of  the 
opaque  part  of  the  cornea?  Weller  assigns 
a better  reason  against  corectornia,  viz. 
when  he  refers  to  the  risk  of  a sufficient  piece 
of  the  cornea  not  being  left  transparent, 
opposite  the  new  pupil,  after  the  cicatrization 
of  that  membrane.  (Vol.  2,  p.  65.)  Beer 
further  states,  that  corectornia  may  be  per- 
formed, in  cases  of  atresia  iridis  consequent 
to  the  operation  of  extracting  the  cataract, 
when  the  surgeon  is  certain  that  no  coagu 
lating  lymph,  effused  during  the  previous  in- 
flammation, in  the  posterior  chamber,  reaches 
above  the  lesser  circle  of  the  uvea,  or  is  con- 
joined with  opacity  of  the  remaining  capsule 
of  the  lens.  The  first  state  may  be  learned 
from  the  singular  colour  and  form  of  the 
greater  ring  of  t lie  iris ; the  second,  from  the 
very  indistinct  manner  in  which  the  patient 
is  sensible  of  the  different  degrees  of  light. 
(Betr.  B.  2,  p.  200.) 

The  excision  of  a piece  of  the  iris,  says 
Beer,  requires  the  preliminary  formation  of 
a flap  in  the  cornea,  one  line  in  length,  w ith 
the  cataract  knife,  and  as  close  as  possible 
to  the  sclerotica,  so  that  no  subsequent 
opaque  cicatrix  may  interfere  with  the  suc- 
cess of  the  operation.  The  second  part  of 
the  business,  viz.  the  excision  of  a piece  of 
the  iris,  must  be  done  in  three  ways,  accord- 
ing to  circumstances.  1st.  The  iris  may  be 
nowhere  prefernaturally  adherent  to  the  cor 
nea,in  which  case,  afteran  opening  has  been 
made  irt  the  latter  membrane,  the  iris  is  pro- 
pelled out  between  the  edges  of  the  wound 
by  the  aqueous  humour,  yet  left  in  the  pos- 
terior chamber,  which  opportunity  the  sur- 
geon must  immediately  avail  himself  of  for 
taking  hold  of  the  projecting  piece  of  the  iris 
w ith  a very  tine  hook,  and  cutting  it  off  with 
David’s  scissors.  The  remainder  of  the  iris 
is  instantly  retracted  behind  the  cornea,  and 
a well-formed  pupil  is  immediately  seen 
2.  Only  the  part  of  the  edge  of  the  pupil  may 
remain  not  adherent  to  and  drawn  towards 
the  cornea,  w here  it  is  intended  to  form  the 
artificial  pupil  ; a state  best  ascertained  by  a 
lateral  inspection  of  the  eye.  In  this  case, 
after  opening  the  cornea,  Beer  says,  the  ope- 
rator is  directly  to  introduce  a small  hook 
between  the  iris  and  cornea,  so  as  not  to  in- 
jure either  of  these  parts  W'ith  its  point,  and 
he  is  then,  with  the  instrument  directed 


Hmi, 


tfyS 


obliquely,  to  get  hold  of  the  pupillary  edge 
of  the  iris,  and  while  the  iris  is  drawn  out 
between  the  edges  of  the  incision,  the  pro- 
jecting piece  is  to  be  cut  off  with  Daviel’s 
scissors.  Thus  the  natural  pupil  is  to  be  ex- 
tended behind  the  transparent  part  of  the 
cornea,  towards  the  edge  of  this  membrane. 
3.  The  pupillary  edge  of  the  iris  may  be  ad- 
herent to  the  cornea  exactly  in  the  situation 
where  the  artificial  pupil  is  to  be  formed  : 
in  this  case,  Beer  directs  the  iris  to  be  taken 
hold  of  at  its  greater  circle  with  the  hook, 
or,  (if  this  should  tear  its  way  out)  with  a pair 
of  fine-pointed  forceps  with  teeth,  drawn  out 
between  the  edges  of  the  wound,  and  the 
point  of  the  cone,  thus  produced,  cut  off 
somewhat  within  the  edges  of  the  wound,  as 
drawing  the  iris  further  out  might  tear  it,  and 
have  a prejudicial  effect.  In  all  these  cases, 
says  Beer,  the  undiseased  lens  and  its  cap- 
sule will  not  be  injured,  if  the  patient  keep 
tolerably  steady,  and  the  operator  have  al- 
ready acquired  dexterity  in  the  extraction  of 
the  cataract.  The  operation  being  finished, 
the  subsequent  treatment  is  like  that  gene- 
rally adopted  after  the  extraction  of  the  ca- 
taract. (See  Cataract .)  When  corectomia 
is  to  be  performed  for  a closure  of  the  pupil, 
consequent  to  extraction  of  the  cataract, 
Beer  particularly  recommends  the  forceps 
to  he  used,  though  he  adds,  that  such  opera- 
tion is  applicable  only  when  the  remaining 
capsule  has  not  been  spoiled  by  the  trauma- 
tic inflammation,  and  the  quantity  of  lymph 
in  the  posterior  chamber  is  not  so  great  as 
to  reach  above  the  lesser  circle  of  the  uvea. 

The  only  other  species  *of  corectomia, 
which  I deem  it  necessary  to  notice  in  this 
Dictionary,  is  what  was  proposed  in  the 
year  1811,  by  the  late  Mr.  Gibson  of  Man- 
chester. It  is  described  as  follows : “ The 
first  step  of  the  operation  is  to  secure  the 
eyelids,  as  in  the  operation  for  extracting  a 
cataract.  A puncture  is  then  to  be  made  in 
the  cornea,  with  a broad  cornea  knife,  with- 
in a line  of  the  sclerotica,  to  the  extent  of 
about  three  lines.  All  pressure  is  now  to 
be  removed  from  the  eyeball,  and  the  cornea 
knife  gently  withdrawn.  The  consequence 
of  this  is,  that  a portion  of  the  aqueous  hu- 
mour escapes,  and  the  iris  falls  into  contact 
with  the  opening  in  the  cornea,  and  closes 
it  like  a valve.  A slight  pressure  must  now 
be  made  upon  the  superior  and  nasal  part 
of  the  eyeball,  with  the  fore  and  middle 
finger  of  the  left-hand,  till  at  length,  by  an 
occasional  and  gentle  increase  of  the  pres- 
sure, or  by  varying  its  direction,  the  iris  gra- 
dually protrudes,  so  as  to  present  a bag  of 
the  size  of  a large  pin’s  head.  This  protru- 
ded portion  must  be  cut  off  with  a pair  of 
fine  curved  scissors,  and  all  pressure  at  the 
same  time  removed  : the  iris  will  then  re- 
cede within  the  eye,  and  the  portion  which 
has  been  removed  will  leave  an  artificial 
pupil  more  or  less  circular.”  ( Gibson's 
Practical  Observ.  on  the  Formation  of  an 
■Artificial  Pupil,  fyc.  London , 1811.)  Such 
was  this  surgeon’s  mode  of  operating,  when 
the  closure  of  the  pupil  was  attended  with 
central  opacitv  of  the  cornea,  uncombined 
V * 50 


with  adhesions.  The  effect  ot  a slight  ad  - 
hesion of  the  inner  border  of  the  iris  to  the 
cornea,  will  he  to  prevent  the  protrusion  of 
the  first  of  these  membranes  through  the 
puncture  in  the  cornea,  which  protrusion  so 
much  facilitates  the  operation.  In  this  case, 
a portion  which  does  not  adhere,  must  be 
drawn  out  with  a small  hook,  and  then  re- 
moved. Sometimes  the  adhesion  may  be 
separated  at  the  time  of  making  the  punc- 
ture, and  then  the  iris  will  protrude.  When 
the  whole,  or  greater  part  of  the  inner  bor- 
der of  the  iris  is  involved  in  adhesions  to 
the  cornea,  these  must  be  separated  with  the 
cornea  knife  after  making  the  puncture,  and 
the  iris  may  then  either  be  drawn  out  with 
the  hook,  or  a portion  of  it  be  removed  by- 
means  of  very  minute  scissors.  In  every 
case,  however,  the  removal  of  a portion  is 
essential  to  success. 

When  a cataract  is  known  to  exist,  which 
it  cannot  often  be,  Mr.  Gibson  recommends 
it  to  be  depressed,  or  broken  to  pieces  with 
a needle,  before  making  the  artificial  pupil; 
and,  when  the  whole  cornea  is  transparent, 
he  advises  forming  a flap  in  the  centre  of  the 
iris  with  the  cornea  knife,  and  then  cutting 
such  flap  off  witii  the  iris  scissors.  ( Gibson , 
Op.  cit.) 

Coredialysis , or  the  mode  of  formiug  an 
artificial  pupil  by  detaching  a portion  of  the 
iris  from  the  ciliary  ligament,  is  said  to  have 
been  devised  by  Ad.  Schmidt  and  Scarpa 
about  the  same  time,  and  has  been  variously 
modified  by  Resinger,  Langenbeck,  Himly, 
Graefe,  and  others.  ( Weller  on  Diseases  of 
the  Eye , Vol.  2,  p.  65.)  According  to  Beer, 
this  plan  of  operating  is  indicated,  first  only 
when  the  coagulating  lymph,  effused  in  the 
posterior  chamber  after  the  extraction  of 
the  cataract  or  reclination,  (see  this  word) 
reaches  from  above  the  lesser  circle  of  the 
uvea  towards  the  ciliary  processes;  a cir- 
cumstance which  may  be  known  by  the 
considerable  change  of  colour  in  the  greater 
circle  of  the  iris,  and  by  the1  indistinct  man- 
ner in  w'hich  the  patient  perceives  the  light. 
Secondly,  wben  the  uvea  is  every  where 
adherent  to  a secondary  capsular  cataract, 
or  capsulo-lenticular  cataract,  or  the  closure 
of  the  pupil  has  been  occasioned  by  a puru- 
lent or  bloody  cataract.  Whenever  the 
attempt  is  made  in  these  last  cases,  how  ever, 
the  patient  should  be  capable,  as  he  some- 
times is,  of  plainly  discerning  the  light. 
Lastly,  coredialysis  is  sanctioned  by  Beer 
when  the  cornea  is  every  where  incurably 
opaque,  excepting  so  small  a part  of  if,  that 
it  could  not  be  w ell  opened  for  the  excision 
of  a portion  of  the  iris.  (B  2 , p.  203.) 

The  feeble  union  of  the  iris  writh  the  cili- 
ary ligament,  and,  consequently,  the  greater 
facility  of  detaching  its  edge  from  that  liga- 
ment with  wdiich  it  is  connected  than  of 
lacerating  its  body,  induced  Scarpa  to  try  a 
new  method  of  forming  an  artificial  pupil, 
when  the  natural  one  has  become  too  much 
contracted,  or  quite  obliterated,  after  the 
extraction  or  depression  of  the  cataract. 
I-Iis  method  of  operating  consists  in  detach 
ing,  by  means  of  a couching  needle,  a cev- 


lain  extent  of  the  circumference  of  the  iris 
from  the  ciliary  ligament,  without  making  a 
section  of  the  cornea.  The  attempt  met 
with  success. 

The  patient  being  seated  and  supported, 
ns  if  he  were  about  to  have  the  operation 
for  the  cataract  performed,  a straight  slender 
couching  needle  is  to  be  introduced  through 
the  sclerotica,  at  the  external  angle  of  the 
eye,  about  two  lines  from  the  union  of  this 
membrane  with  the  cornea  ; and  its  point  is 
to  be  pushed ^.s  far  as  the  upper  and  inner 
edge  of  the  iris;  in  other  words,  as  far  as 
that  side  of  the  iris  which  is  nearest  the 
nose.  The  needle  advances  nearly  to  the 
ciliary  ligament,  and  the  surgeon  perforates 
the  internal  edge  of  the  iris,  at  its  upper  part, 
so  that  the  point  of  the  instrument  scarcely 
appears  in  the  anterior  chamber,  because 
that  part  of  it  being  very  narrow,  the  point 
of  the  instrument,  however  little  it  advance 
beyond  the  iris,  would  enter  the  substance 
of  the*  cornea.  The  moment  the  needle 
appears  in  the  anterior  chamber,  the  instru- 
ment nlftist  be  pressed  on  the  iris  from  above 
downward,  and  from  the  internal  towards 
the  external  angle,  so  as  to  bring  it  in  a pa- 
rallel line  to  the  anterior  surface  of  the  iris, 
for  the  purpose  of  detaching  a portion  of 
the  edge  of  this  membrane  from  the  ciliary 
ligament.  This  separation  being  effected, 
the  operator  must  depress  the  point  of  the 
needle,  in  order  to  apply  it  to  the  inferior 
angle  of  the  slit  that  he  has  begun  to  make. 
Then  the  aperture  may  be  enlarged  at  plea- 
sure by  pushing  the  iris  towards  the  temple, 
and  withdrawing  the  needle  from  before 
backward,  parallel  to  the  anterior  surface  of 
the  iris  and  the  greatest  axis  of  the  eye.  If, 
when  this  detachment  has  been  accom- 
plished, no  opaque  body  appear  at  the  bot- 
tom of  the  eye,  the  needle  is  to  be  with- 
drawn altogether.  If  any  portion  of  opaque 
capsule,  left  behind  after  the  depression  or 
extraction  of  the  cataract,  should  afterward 
advance,  and  present  itself  in  the  vicinity  of 
the  new  pupil,  the  little  opaque  membrane 
must  be  reduced  to  fragments,  and  pushed 
through  the  artificial  opening  into  the  ante- 
rior chamber,  where,  Scarpa  says,  they  will 
in  time  be  dissolved  and  absorbed. 

This  separation  of  the  iris  from  the  ciliary 
ligament  invariably  occasions  an  extravasa- 
tion of  blood,  which  always  renders  the 
aqueous  humour  more  or  less  turbid  ; but 
the  turbidness  is  afterward  absorbed,  and  the 
eye  recovers  its  original  transparency. 

The  patient,  says  Scarpa,  complains,  du- 
ring the  operation,  of  a vast  deal  more  suf- 
fering than  at  the  time  when  he  undergoes 
the  extraction  or  depression  of  a cataract. 
It  cannot  be  otherwise;  for,  in  detaching  a 
part  of  the  edge  of  the  iris  from  the  ciliary 
ligament,  some  filaments  of  the  ciliary 
nerves,  which  proceed  to  be  distributed  to 
the  iris,  must  at  least  be  dragged  or  lacera- 
ted. However,  on  the  whole,  the  symptoms 
consequent  to  this  operation,  have  neither 
been  obstinate  nor  fatal  in  the  two  cases 
which  Scarpa  has  seen.  From  some  expe- 
Fmcf  ts  math?  on  the  dead  subject.  Scarpa 


thinks  the  curved  needle,  which  he  use?, 
for  the  depression  of  the  cataract,  would 
also  be  . better  than  the  straight  one,  for 
making  an  artificial  pupil.  ( Scarpa  mile 

Malattie  degli  Occhi , Capo  16.) 

The  celebrated  Ad.  Schmidt  performed 
coredialysis  with  a lancet-pointed  curved 
needle,  which  was  introduced  through  the 
sclerotica  into  the  posterior  chamber,  with 
its  concavity  towards  the  uvea.  Its  point 
is  to  pass  as  far  as  the  portion  of  the  ciliary 
ligament,  where  it  is  designed  to  make  the 
artificial  pupil.  The  iris  is  then  to  be  pier 
ced  from  behind  forwards,  about  the  fourth 
part  of  a line  from  the  ciliary  ligament,  from 
which  it  is  to  be  separated,  the  surgeon 
taking  care  at  the  moment  to  catch  well 
hold  of  the  iris  with  the  point  of  the  instru- 
ment, which  is  then  to  be  withdrawn  a little 
from  the  eye.  If  the  new  pupil  should  not 
be  now  large  enough,  the  iris  is  to  be  again 
hooked  with  the  needle,  near  the  ciliary 
ligament,  and  the  opening  enlarged  at  its 
upper  or  lower  angle,  as  may  appear  most 
advantageous.  This  plan  is  said  to  be  ad- 
viseable  when  the  whole  cornea  is  opaque 
excepting  a small  spot. 

When,  however,  the  diseased  state  of  the 
cornea  does  not  forbid  it,  Beer  and  Schmidt 
very  properly  recommend  the  needle  to  be 
introduced  into  the  anterior  chamber,  and 
the  iris  thus  separated  from  the  ciliary  liga- 
ment ; a plan  which,  as  Weller  observes, 
has  proved  more  successful  than  the  prece- 
ding method.  In  both  modes,  the  lens  will 
be  pushed  away  from  the  new  pupil  by  the 
movement  of  the  needle,  so  that  whether  it 
be  opaque  already,  or  become  so  afterward, 
vision  will  not  be  obstructed  by  it.  (See 
Beer's  Lehre,  fyc.  B.  2,  p.  204 — 206,  and 
Weller's  Manual , Transl.  by  Dr.  Monleathj 
Vol.  2,  p.  66,  ^c.) 

With  the  view  of  removing  all  risk  of  the 
new  opening  becoming  closed  again,  Rei- 
singer  forms  an  artificial  pupil,  by  making  a 
small  incision  in  the  cornea,  and  introducing 
a minute  double  hook,  which  opens  and 
shuts  like  a pair  of  forceps.  After  passing 
the  hook  closed  into  the  anterior  chamber, 
as  far  as  the  greater  circle  of  the  iris,  he 
turns  the  points,  of  both  the  small  hooks 
towards  this  membrane,  then  opens  the  in- 
strument a little,  and  hooks  hold  of  the  iris, 
which  is  to  he  separated  from  the  ciliary 
ligament,  when  the  instrument  is  to  be  shut 
again,  and  the  part  of  the  iris  taken  hold  of 
drawn  a little  through  the  opening  of  the 
cornea,  where  it  adheres,  and  cannot  re- 
cede again  towards  the  ciliary  ligament 
(See  Darstellung  eiries  neuen  Vtrfahrens  die 
Mastdarmjislel  zu  unterbind^n,  und  einer 
leichten  und  sichern  meihodc  fennstliehe  Pu - 
pillen  zu  bilden.  12wo.  Jiugsburg,  1816.) 
Under  certain  circumstances,  however,  as 
there  may  be  difficulty  in  drawing  the  iris 
through  the  cornea,  or  apprehensions  may 
be  entertained  of  the  opacity  of  the  cornea 
being  increased  by  the  protrusion  and  ad- 
hesion of  the  iris  (the  great  consideration 
unquestionably  against  this  m thod,)  Reisin- 
ger  approves  of  obviating  the.  chance  of  the 


PUPIL 


395 


new  opening  being  closed  again,  by  remo 
ving  a part  of  the  iris,  after  its  detachment 
from  the  ciliary  ligament ; a combination  of 
coredialysis  wit’ll  coredomia,  in  the  technical 
language  of  modern  ophthalmology.  Were 
I a patient,  and  coredialysis  were  deemed 
most  applicable  to  the  circumstances  of  my 
case,  l should  dispense  with  any  excision  of 
the  iris,  preferring  the  chance  of  tne  new 
opening  being  permanent,  to  the  dangers  of 
too  complicated  and  protracted  an  opera- 
tion. 

Langenbeck  is  the  inventor  of  an  instru- 
ment for  the  formation  of  an  artificial  pupil : 
it  is  a silver  tube,  to  one  end  of  which  is 
attached  a very  small  gold  one,  containing  a 
minute  hook,  capable  of  being  moved  back- 
wards or  forwards,  to  the  extent  of  only  two 
lines,  by  means  of  a spring  in  the  silver 
tube.  The  following  is  the  account  of  Lan- 
genbeck’s  method,  as  extracted  by  Mr  Gu- 
thrie from  his  writings.  “ A very  small 
opening  is  to  be  made  in  the  cornea,  in  or- 
der that  the  iris,  when  brought  out,  may  not 
recede.  The  hook  enclosed  in  the  golden 
tube,  (to  prevent  its  bending  from  ilstenuity) 
is  to  be  directed  to  the  spot  where  the  iris  is 
to  be  laid  hold  of.  The  hook  is  then  to  be 
pushed  out  by  the  spring  to  the  extent  of 
one  line,  which  will  be  sufficient  to  enable 
it  to  penetrate  the  iris  As  soon  as  the  hook 

is  affixed,  it  is  to  be  allowed  to  recede  to  its 
usual  place  in  the  golden  lube,  draw  ing  with 
it  the  iris,  which  will  be  caught  between  it 
and  the  end  of  the  tube,  something  in  the 
manner  of  a pair  of  forceps.  As  soon  as  the 
hook  begins  to  recede,  a small  black  spot 
will  be  seen  at  the  edge  of  the  iris  from  its 
incipient  separation,  and  care  should  be 
taken  to  insert  the  hook  at,  or  even  under 
the  edge  of  the  sclerotica,  and  as  near  as 
possible  to  the  ciliary  processes.  The  hook 
must  recede  gradually,  the  finger  being  kept 
steadily  on,  and  moved  slowly  with  the 
knob  regulating  the  spring  in  the  silver  tube. 

As  the  chance  of  tearing  off  a part  of  the 
Iri3  is  proportionate  to  the  distance  it  has 
to  be  drawn  out.  the  opening  is  to  be  made, 
as  near  as  possible,  to  the  spot  where  the 
separation  is  to  be  effected,  taking  care  that 
the  pupil  shall  be  large  enough,  so  that  the 
prolapsed  iris  and  subsequent  opacity  of  the 
cornea  cannot  obstruct  the  entrance  of  the 
rays  of  light.  The  great  advantage  of  this 
instrument,  in  Langenbeck’s  opinion,  is, 
that  the  separation  is  effected,  by  means  of 
the  spring,  more  gently  and  gradually  than 
by  the  finger  alone,  so  that  if  a commence- 
ment of  the  separation  be  effected,  the  com- 
pletion of  it  is  certain,  without  any  risk  of 
tearing  the  iris.  As  soon  as  the  hook  has 
receded  to  the  golden  tube,  carrying  with 
it  the  iris,  the  whole  instrument  is  to  be 
gently  withdrawn,  moving  it  slowly  up  and 
down,  in  order  to  loosen  the  upper  and 
lower  attachment  of  the  iris  ; for  this  mem- 
brane may  be  torn,  if  there  has  been  much 
previous  inflammation,  or  if  direct  force  be 
employed  in  withdrawing  it.  The  instru- 
ment always  keeps  its  hold  as  firmly  as  the 
• b**st  forceps,  and  with  much  more  advan- 


tage, for  it  occupies  less  space,  and  enables 
the  operator  to  make  the  incision  in  the 
cornea  small,  on  which  the  correct  strangu- 
lation of  the  iris  depends.  In  all  his  opera- 
tions, the  capsule  of  the  lens  has  never  been 
injured  by  this  instrument,  which  he  consi- 
ders another  advantage,  and,  he  conceives, 
that  it  may  be  used  through  the  sclerotica, 
without  rendering  the  lens  opaque,  as  by 
the  methods  of  Scarpa  and  Schmidt.”  (The 
latter  author,  however,  as  I have  explained 
in  this  article,  did  not  operate  through  the 
sclerotica,  when  the  lens  was  transparent.) 
When  the  cornea  is  transparent  only  at  its 
outer  edge,  Langenbeck  sometimes  performs 
excision  ; but,  when  this  membrane  is 
opaque  opposite  the  natural  pupil,  he  opens 
the  cornea  near  the  edge  of  the  sclerotica, 
and,  if  the  iris  will  not  protrude,  he  takes 
hold  of  its  pupillary  edge  with  the  hook,  and 
draws  it  between  the  lips  of  the  wound, 
where  he  leaves  it  strangulated.  (See  G. 
F.  Guthrie  on  Artificial  Pupil,  p.  63.  fyc . Svo. 
Lond.  1819;  also  Langenbeck' s Neue  Bibl.  1 
B.  p.  3,454,  and  676,  8ro.  Hanover , 1817— 
19,  and  2 3.  p.  13  ayidt  106,  where  he  an- 
swers some  objections  made  to  his  instru- 
ment by  Schiagintweit.)  Doubtless,  one 
cause  of  the  failure  of  many  operations  for 
artificial  pupil  is  one  to  which  Mr.  Guthrie 
has  adverted,  viz.  the  omission  to  keep 
down  the  subsequent  inflammation  of  the 
iris  and  adjacent  textures  by  the  timely  em- 
ployment of  the  lancet  and  other  antiphlo- 
gistic measures.  On  this  subject,  however, 
I need  not  here  dwell,  as  the  proper  treat- 
ment is  already  described  in  that  part  of  the 
article  Ophthalmy  w4iich  refers  to  idiopathic 
iritis. 

As  it  is  impossible  for  me  to  allot  further 
room  at  present  to  the  consideration  of  alt 
the  numerous  modes  of  forming  artificial 
pupils,  I shall  conclude  with  a list -of  works,, 
in  which  further  information  may  be  found. 
Cheselden  in  Phil.  Trans,  for  1735,  p.  451, 
fyc.  Sharp's  Operations,  Chap.  29.  Janin 
Mem.sur  VCEil.  Richter  von  der  Ferschlos- 
senen  Pupille  in  Anfangsgr.  der  Wundarsri . 
B.  3.  Gutt.  1795.  Scarpa , sulle  Malattie  degli 
Occhi,  cap.  16;  or  the  English  Transl.  by  Mr, 
Briggs,  Ed.  2.  Gibson's  Practical  Observa- 
tions on  the  Formation  of  an  Artificial  Pupil, 
fyc.  8 vo  Lond.  1811  ; a work  of  considerable 
merit.  Wenzel  on  the  Cataract.  Sir  W.  Adams, 
Practical  Observations  on  Edropium,  and  on 
the  modes  of  forming  an  Artificial  Pupil,  fyc. 
8 vo.  Lond.  1812  ; also  on  Artificial  Pupil,  8 vo, 
Lond.  1819.  Roux,  Parallele  de  la  Chirurgie 
Angloise.  fyc.  p.  283,  fyc.  8vo.  Paris,  1815. 
Maunoir  and  Scarpa  in  Med.  Chir.  Trans. 
Vol.  7,  p.  301,  fyc.  G.  J.  Beer  Ansi c fit  der 
Staphyloma  tosen.  Metaniorphosen  des  Auges , 
und  der  kunsllichen  Pupillenbildung,  Wien, 
1815;  and  Lehr e von  den-  Augenkr.  B.  2, 
Wien,  1817.  P.  Assalini , Ricerche  sidle 
Pupille  Artificial! ; in  Milano,  1811.  This 
author  practises  the  detachment  of  the  iris 
from  the  ciliary  ligament  with  a particular 
kind  of  forceps.  He  must  have  an  early 
claim  to  the  invention,  as  he  began  the  method 
in  1786.  Jules  Cloquet,  Mem.  svr  la  Mem- 


RANULA 


396 


brane  Pupiilaire.  Paris,  1818.  Maunoir  snr 
V Organization  de  l'  Iris,  8 vo.  Paris,  1812. 
Benedict , De  Pupilloc  Ariificialis  Conforma- 
tione.  Lips.  1810.  R,  Muter,  Practical  Obser- 
vations on  Various  JVovel  Modes  of  Operating 
on  Cataract , and  of  forming  an  Artificial 
Pup'l,8ro.  IVisbeach  1811.  G.  F.  D.  Evans, 
Practical  Observations  on  Cataract  and  losed 
Pupil,  fyc.  8 vo.  Loud.  1815.  Ch.  Jnngktn , 
Das  Coreoncion,  tin  B ilrag  zur  Kuntslichen 
Pupiltenbildung.  l2mo  Berlin , 1817.  G. 
W agner,  Commenlalio  de  Corumorplwsi,  sistens 
brtvem  method.  ad  Pupillce  artific.  conforma- 
tionem,  novique  ad  TridodialyAn  ins'rumenti 
descriptionem,  cum  tab.  cen.  8 vo.  Brunswig. 
1818.  Schmidt  and  Himly  Ophthal.  Bibl.  B. 
! *2  and  3.  Flajani  Collezione  di  <)sservazioni, 
T.  4,  8vo.  Roma,  1801 . Ryan,  in  Dublin  Hos- 
pital Reports . 1818.  Ouadri  Annotazioni  Pra- 
iicht  suite  Malattie  degli  Occhi,  4to.  In  JVea- 
poli,  1818.  Langenbeck  JYeue  Bibl.  fur  die 
Chir.  B 1 el  2,  12mo.  Gott.  1817—1819. 


Reisinger  Darstellung,  einer  leichten , tyc. 

Methode  Kunslliche  Pupillen  zu  bildtn  12 mo. 
Augsb.  1816.  Schlagintweil,  Ueber  den  gegen- 
wuriigtn  Zu  stand  der  Kuntslichen , pupillen - 
bildung  in  Deutschland,  8vo.  Munich,  1818. 
Donegana,  Ration  ament  o sutlu  Pupilie  Arti- 
ficiali ; Milano,  1809:  this  work  suggests  the 
method  of  opening  the  sclerotica,  under  cer- 
tain circumstances,  for  the  purpose  of  dividing 
the  iris  from  behind  forwards.  G.  F.  Guthrie 
on  the  Operations Jor  the  Formation  of  an  Ar- 
tificial Pupil,  8 vo  Load  1819  ; a work,  con- 
taining a de  scrip  i on  of  nearly  every  method 
hitherto  suggested,  accom  panied  with  remarks. 
B.  Travers , Synopsis  of  the  Diseases  of  the 
Eye,  p.  334,  &,  c.  8vo.  Loud.  !820.  C.  H. 
Weller,  A Manu  al  of  the  Diseases  of  the  Hu- 
man Eye  ; transl.  by  Dr.  Montealh , Vol . 2, 
p.  55,  &pc.  8 vo.  Glasgow,  1821. 

PUS.  (from  <zm)ov,  matter.)  The  fluid, 
formed  by  the  process  of  suppuration. 
(See  Suppuration.) 


R. 


ACH1TIS.  (from  the  spine  of 

the  back,  because  the  disease  was  once 
supposed  to  depend  on  disease  of  the  spinal 
marrow.)  The  rickets.  See  this  word. 

RANULA.  (dim.  of  rana,  a frog.)  A 
whimsical  name  applied  to  a tumour  under 
the  tongue,  arising  from  an  accumulation  of 
saliva  and  mucus,  in  the  ducts  of  the  sub- 
lingual gland.  The  term  has  either  been 
derived  from  an  imaginary  resemblance  of 
the  swelling  to  a frog,  or  from  the  disease 
making  the  patient,  as  it  were,  croak  when 
lie  attempts  to  articulate.  Such  writers  as 
have  treated  of  this  disease,  before  it  was 
known  that  the  parts  affected  by  it  were 
destined  for  the  secretion  of  the  saliva  could 
have  no  accurate  notions  of  its  true  nature. 
Celsus  is  supposed  to  have  alluded  to  the 
ranula,  in  the  fifth  section  of  his  seventh 
book,  where,  after  treating  of  the  diseases 
of  the  tongue,  he  continues  with  the  follow- 
ing passage:  sub  lingud  quoque  interdum  ali- 
fjuid  abcedit , quod  fere  consistit  in  tunica,  dolo- 
resque  magnos  movet.  The  latter  circum- 
stance, however,  renders  it  probable,  that 
some  other  affection  was  signified,  as  a ranula 
is  rather  attended  with  a sense  of  restraint, 
than  of  pain.  Fabricius  ab  Aquapendente 
considered  ranula  as  an  encysted  tumour  of 
the  meliceris  kind.  Dionis  is  of  a similar 
opinion.  Munick,  better  acquainted  with 
the  modern  discoveries  of  anatomy,  does 
wot  mistake  the  nature  of  the  present  dis- 
ease ; and  he  expressly  says,  that  the  affec- 
tion originates  from  a thick  saliva,  which, 
not  b6ing  able  to  pass  out  of  the  salivary 
ducts,  accumulates  under  the  tongue,  so  as 
to  cause  a swelling  in  that  situation.  Far 
from  adopting  the  opinion  of  Munick,  Heis- 
ter  fell  back  to  that  of  Fabricius,  and 
borrows  every  thing  from  this  author. — 
Lastly,  De  La  Faye,  in  his  notes  on  Dionis, 
has  taken  up  Munick’s  sentiments ; he  says, 


that  “ there  are  two  sorts  of  ranulae  ; some 
which  are  round,  and  situated  beneath  the 
tongue,  seem  only  to  be  produced  by  a 
dilatation  of  the  excretory  duct  of  the 
sublingual  gland  ; the  others  are  longer 
than  they  are  round  ; are  situated  at  the 
side  of  the  tongue,  and  are  formed  by  a di- 
latation of  the  excretory  duct  of  the  inferior 
maxillary  gland.  The  fluid,  which  fills  such 
tumours,  is  the  saliva,  which  gradually  ac- 
cumulates in  them,  in  consequence  of  its 
viscidity  and  the  atony  of  the  duct. 

Ranula  is  said  to  be  frequently  met  with 
in  persons  who  move  their  tongue  a great 
deal,  and  in  those  who  sing.  The  fluid  in 
the  tumour  is  precisely  like  white  of  egg; 
but  it  is  thicker  after  having  remained  a long 
while  in  the  swelling,  and  it  is  occasionally 
of  a calcareous,  and  even  stony  nature. 
Ranula  does  not  proceed  from  an  inspissa- 
tion  of  the  saliva,  as  De  la  Faye  supposed, 
but  from  an  obliteration  of  the  duct,  or  ori- 
fices of  this  tube.  The  collection  often 
produces  a tumour  of  very  large  size  ; but 
the  swelling  generally  bursts  when  it  has  at- 
tained the  dimensions  of  a walnut,  and  then 
leaves  an  ulcer,  which  cannot  be  healed 
while  the  real  cause  of  the  disorder  remains 
unknown. 

Mr.  B.  Bell  mentions  his  having  seen  an 
ulcer  of  this  kind  treated  with  the  utmost 
care  for  several  months  ; various  detergent 
and  corrosive  applications  had  been  employ- 
ed ; and  even  a mercurial  course  ; but  all 
in  vain.  At  length,  the  true  cause  of  the 
disease  having  been  ascertained,  a cure  was 
accomplished  in  a few  days,  by  removing  a 
piece  of  calcareous  matter,  which,  by  ob- 
structing the  ducts,  had  first  caused  a swell- 
ing, and  then  ulceration. 

The  opening,  when  made  with  a lancet, 
and  not  of  sufficient  size,  frequently  closes 
up  again.  In  wthis  case  the  swelling  reap- 


RANUX. \ 


3W 


pears  some  time  afterward.  The  ancients 
made  the  same  remark ; and  hence  Pare 
preferred  the  actual  cautery  to  the  lancet. 
Dionis  also  mentions  having  seen  ranulae, 
which  recurred  in  consequence  of  a mere 
opening  having  been  made  with  a lancet, 
and  he  recommends,  for  the  prevention  of 
this  inconvenience,  the  application  of  a 
mixture  of  honey  of  roses,  and  vitriolic 
acid  to  the  inside  of  the  cyst,  so  as  to  destroy 
it.  As  Louis  remarks,  all  authors  seem  to 
regret  that  the  situation  of  the  tumour  should 
prevent  the  sac  from  being  totally  dissected 
out.  The  success,  which  Fabricius  ab 
Aquapendente  experienced,  when  he  merely 
opened  the  tumour  its  whole  length,  did 
not  free  him  from  this  prejudice  ; and  Heis- 
ter  says,  he  should  prefer  extirpation,  if  the 
nature  of  the  adjacent  parts,  liable  to  be 
wounded,  were  not  a formidable  objection. 
But  if  this  pretended  cyst,  this  pouch,  is 
nothing  else  than  the  gland  itself,  or  its  duct, 
dilated  by  the  retention  of  the  saliva,  it 
should  not  be  irritated.  Whenever  a suffi- 
cient opening  is  made,  no  relapse  takes 
place.  Munick  particularly  advises  such 
an  incision,  and  Rossius  mentions  the  small- 
ness of  the  opening,  among  the  defects  in 
the  treatment,  and  its  being  a cause  of  the 
disease  returning.  However,  he  also  re- 
commends destroying  the  sac  ; but  specifies 
for  the  purpose  only  astringent  drying  ap- 
plications, which  act  in  a less  powerful 
manner. 

In  a ranula  of  moderate  size,  there  is 
nothing  like  a cyst  absolutely  requiring  ex- 
tirpation. it  is  generally  enough  to  lay  the 
cavity  open,  and  cut  off  the  edges  of  the 
incision,  when  they  will  not  otherwise  unite. 
M.  Louis  always  observed  that  the  radical 
cure  depended  on  a fistulous  aperture, 
through  which  the  saliva  continued  to  flow  ; 
and  that,  when  this  opening  was  situated 
behind  the  lower  incisor  teeth,  a very  an- 
noying ejaculation  of  the  saliva  took  place, 
in  certain  motions  of  the  tongue.  The  cure 
cannot  be  complete  unless  this  inconve- 
nience be  obviated.  For  this  purpose,  such 
an  opening  for  the  saliva  must  be  made,  as 
Will  not  close. 

The  ranula,  when  of  long  standing,  is 
sometimes  so  large  as  absolutely  to  hinder 
a person  from  articulating.  Le  Clerc  has 
recorded  a case,  in  which  the  root  of  the 
swelling  extended  under  the  tongue  ; the 
tumour  filled  the  whole  mouth  ; the  promi- 
nence which  it  formed  outwardly  was  as 
large  as  a duck’s  egg  ; and  the  disease,  in  its 
progress,  had  made  the  teeth  of  both  jaws 
project  outward.  At  some  parts  of  its  sur- 
face, a fluctuation  was  perceptible  ; other 
places  were  exceedingly  hard.  The  patient, 
who  could  scarcely  breathe,  demanded  as- 
sistance ; and  a puncture  was  made  in  the 
softest  part  of  the  outside  of  the  swelling. 
A thick  yellowish  fluid  issued  out  of  the 
ranula.  The  opening  was  enlarged  with  a 
knife,  and  about  a pint  of  gritty  inodorous 
matter  was  extracted.  There  was  no  he- 
morrhage from  the  cut;  and  no  sooner  had 
the  contents  of  the  swelling  been  let  out. 


th^n  the  patient  began  to  urticulate,  which 
he  had  not  been  able  to  do  for  a long  while. 
The  sides  of  the  tumour  being  so  pfodigious- 
ly  distended,  Le  Clerc  thought  proper  to 
destroy  the  inside  of  the  cavity  with  a tent 
dipped  in  a mercurial  solution.  The  cure 
was  completed  in  a month,  and  the  tongue 
gradually  regained  its  original  size,  a part 
of  which  it  had  lost. 

But,  as  M.  Louis  observes,  fortunate  as 
the  termination  of  this  case  was,  it  must  not 
be  indiscriminately  set  down,  that  destroy- 
ing the  cyst,  or  even  opening  the  tumour,  is 
always  requisite.  A more  simple  method 
will  sometimes  succeed.  In  a particular 
case,  which  this  gentleman  has  related,  a 
sinuosity,  which  divided  the  swelling  into  a 
right  and  left  portion,  made  him  suspect 
that  it  consisted  of  two  sacs,  in  contact  with 
each  other.  On  each  side,  in  front,  and  ill 
the  same  line,  there  was  a point,  which  was 
the  orifice  of  the  salivary  duct,  somewhat 
dilated,  and  blocked  up  with  a viscid  matter.  > 
Having  very  easily  passed  a small  probe 
into  the  orifices,  a matter  similar  to  white 
of  egg,  made  its  escape.  A small  leaden 
probe  was  passed  into  each  opening,  and 
two  days  afterward,  the  sacs  were  emptied 
again,  and  two  pieces  of  lead,  somewhat 
larger,  introduced.  The  man  was  advised 
to  take  out  the  pieces  of  lead  every  morning, 
empty  the  swelling,  and  then  replace  them. 
In  a fortnight,  the  openings  having  been 
kept  continually  dilated,  had  no  tendency 
to  close  ; the  saliva  did  not  accumulate,  and 
the  ranulae  never  appeared  again. 

In  certain  cases,  the  above  means  are  quite 
inadequate,  and  the  tumour  must  be  totally 
extirpated.  Boinet  has  related  to  the  French 
academy,  a case  in  which  the  swelling  not 
only  filled  the  whole  mouth,  but  one  half  of 
the  tumour  projected  out,  and  a cure  could 
only  be  accomplished  in  the  latter  manner. 
The  two  upper  incisor  teeth  on  the  left  side, 
were  lodged  in  a depression  observable 
there;  and  the  canine  tooth,  of  the  same 
side,  forced  outward  by  the  mass  of  the 
disease,  had  pierced  the  lip  near  its  commis- 
sure. A fluid  resembling  mucus,  flowed 
from  a narrow  aperture  at  the  lower  part  of 
the  swelling.  The  tongue  could  not  be 
seen,  so  much  was  it  pushed  backward,  and 
for  some  time,  the  patient  had  only  subsisted 
on  liquid  food,  which  he  was  first  obliged  to 
convey  to  the  back  t>f  the  throat  with  some 
mechanical  contrivance.  The  tour  incisor 
teeth,  two  canine,  and  first  grinders  of  the 
lower  jaw,  had  been  pushed  out  of  their 
sockets,  by  the  pressure  of  the  swelling. 
The  patient’s  aspect  was  alarming,  and  he 
was  threatened  with  suffocation.  Extirpa- 
tion was  deemed  necessary,  and  it  was  per- 
formed with  all  the  caution  which  the  situa- 
tion of  the  tumour  demanded.  The  large 
cavity  thus  occasioned  was  filled  with  lint. 
The  lower  jaw  being  diseased,  Boinet  scra- 
ped some  of  its  surface  oft',  and  covered  the 
places  with  lint,  either  dry  or  dipped  in  spirit 
of  wine.  Some  exfoliations  followed,  and  the 
fungous  granulations  which  grew  were  re 
pressed  with  proper  applications.  In  three 


RECTUM. 


months,  the  parts  were  healed  in  so  regular 
a manner,  that  the  motion  of  the  tongue  was 
not  in  the  least  obstructed,  and  no  change 
continued,  except  the  alieration  of  the  voice, 
occasioned  by  the  loss  ol  teeth.  This  case 
is  very  interesting  and  proves  how  much 
may  be  hoped  for  in  difficult  cases,  from 
prudent  and  judicious  measures.  (S»e  E ncy- 
clop6die  M6tkodique,Art.  Grenouillette.  M6m 
de  V Acad,  de  Chirurgie , T.  3,  Sabatier.  Me- 
decine  Ophatoire , T.  2,  p.  19,  fyc.  Ed.  2. 
Callisen , Systems  Chirurgicc  Hodiernce , Vol. 
2,  p.  108,  ty-c.  II af nice,  1800.  Lassus,  Pa- 
thologic Chir.  T.  1,  p.  402,  fyc.  8 vo  Paris , 
1809.  Richter,  Anfangsgr.  der  Wundarzn. 
B.  4,  Kap.  1,  Gottingen,  1800.  J J.  Stahl , 
et  J.  F.  E.  de  Schoenerben  de  Ranula,  sub  lin- 
gud,  speciali  cum  casu , Erford.  1 i 34.) 

RECLI NATION.  A term  much  employ- 
ed abroad,  to  denote  the  operation  of  turn- 
ing a cataract,  so  as  to  change  the  position 
of  its  anterior  and  posterior  surfaces.  (See 
Cataract.) 

RECTUM.  Many  cases  in  which  this 
bowel  is  more  or  less  concerned,  are  treated 
of  elsewhere  in  this  Dictionary,  and  therefore 
it  will  only  be  necessary  for  me  here  to  re- 
fer to  them,  and  then  notice  some  diseases 
of  the  part,  which  are  not  considered  in 
other  articles.  For  an  account  of  piles,  he- 
morrhoidal excrescence,  and  other  tumours 
of  Ihe  rectum,  see  Hemorrhoids;  and  for 
that  of  prolapsus  ani,  fistuia  in  ano,  and  im- 
perforate anus,  see  Anus.  Under  the  head  of 
divine  Concretions.  I have  noticed  the  dan- 
gerous obstruction  of  this  bowel  by  masses 
of  indurated  matter.  In  the  article  Lylhoto- 
my,  the  mode  oi  cutting  through  the  rectum 
into  the  bladder,  for  the  purpose  of  extract- 
ing a calculus  irorn  the  latter  organ,  is  ex- 
plained ; and  if  the  reader  refer  to  Bladder, 
fie  will  there  find  a description  of  the  method 
of  tapping  it  from  the  rectum. 

Scirrhus,  or  stricture  of  the  rectum,  some- 
times called  the  scirrho-coniracted  rectum, 
and  sometimes  cancer,  especially  when  the 
case  is  inveterate  and  in  a state  of  ulcera- 
tion, is  a disease  which  has  received  much 
elucidation  from  the  writings  of  Desault,  Sir 
Everard  Home,  Dr.  Sherwin,  and  Mr.  Cope- 
land. In  the  various  descriptions  given  of 
the  complaint  by  these  and  other  writers, 
one  great  point  of  difference  is  remarkable, 
viz.  that  some  of  them  represent  the  case  as 
always  of  an  incurable  pature,  while  others 
consider  it  as  admitting  of  relief,  at  least 
when  it  has  not  made  considerable  progress, 
and  the  parts  are  free  from  ulceration.  Ac- 
cording to  Desault,  scirrhus  of  the  rectum  is 
not  uncommon  at  an  advanced  period  of 
life,  and  the  disease  is  said  to  afflict  women 
more  frequently  than  men,  as  from  a table 
kept  at  the  Hotel  Dieu,  it  appeared  that  ten 
cases  out  of  eleven  occurred  in  females,  if 
it  were  not  for  the  fact,  that  Desault  some- 
times effected  a cure  of  the  disease  in  its 
early  stage,  I should  venture  to  conclude, 
that  his  observations  apply  entirely  to  the 
true  scirrhus,  or  cancer  of  the  rectum,  which 
1 believe  rarely  or  never  occurs  in  young 
patients,  but  as  Desault  states,  is  not  very 


unfrequent  in  elderly  persons.  My  friend, 
Mr.  Copeland,  in  his  practical  remarks,  does 
notvconfine  himself  to  really  scirrhus  and 
cancerous  affections,  but  comprehends  stric 
tures  of  the  rectum  from  a variety  of  causes; 
and  this  accounts  for  his  statement,  that  the 
disease  “ attacks  people  of  almost  all  ages  ; 
but  is  most  common  about  the  middle  age.” 
However,  he  agrees  with  D**sauU,  that  wo  - 
men are  more  frequently  affected  th  .n  men. 
He  admits  that  it  is  sometimes  cancerous, 
though  not  so  often  as  is  generally  imagined, 
the  mere  induration  not  being  an  unequivocal, 
proof  of  it.  When  the  disease  is  really  can- 
cer, it  is  usually  attended  with  more  severe 
pain,  darting  through  the  pelvis  to  the  blad- 
der and  the  groin.  The  countenance  is  of  a 
sallow  leaden  cast.  (Copeland  on  the  prin- 
cipal Diseases  of  the  Rectum  and  Anus,  p.  15 
—17. 

Sometimes  the  disease  extends  over  a 
considerable  length  of  the  gut,  but  is  gene- 
rally more  circumscribed.  The  coats  of  the 
bowel  become  much  thicker  and  harder  than 
natural.  The  muscular  is  subdivided  by 
membranous  septa,  and  the  internal  coat  is 
sometimes  formed  into  hard,  irregular  folds. 
The  surface  of  the  inner  membrane  is  occa- 
sionally ulcerated,  so  as  to  form  a cancerous 
disease.  Every  vestige  of  the  natural  struc- 
ture is  sometimes  lost,  and  the  gut  is  changed 
into  a gristly  substance.  The  cavity  of  the 
bowel  is  always  rendered  narrow  at  the  scir- 
rhous part,  and  is  sometimes  almost  oblitera- 
ted. When  Ihe  passage  through  the  gut  is 
very  much  obstructed,  the  bowel  is  always  a 
good  deal  enlarged  just  above  the  stoppage 
or  stricture,  from  the  accumulation  of  the 
feces  there.  As  the  disease  advances,  adhe- 
sions form  between  the  rectum  and  adjacent 
parts,  and  ulcerations  produce  communica- 
tions between  them. 

As  the  disease  at  first  is  not  very  painful, 
it  is  usually  not  much  noticed  till  somewhat 
advanced.  The  patient  is  habitually  cos- 
tive, and  usually  voids  his  stools  with  a little 
difficulty.  In  time,  a good  deal  of  pain  is 
felt  in  the  part  affecied,  especially  at  stool, 
after  which  some  relief  is  experienced.  “ As 
the  gut  continues  to  decrease  in  diameter 
(says  Mr.  Copeland,)  the  efforts  to  expel  the 
feces  become  more  violent,  and  the  conse- 
quent progress  of  the  .disease  more  rapid. 
The  stools,  which  have  been  long  evacuated 
with  difficulty,  become  contracted  in  size, 
appearing  like  earth- worms  in  their  form,  or 
small  pellets;”  and  if  the  finger  be  intro- 
duced into  the  rectum,  “ the  gut  will  be 
found  either  obstructed  with  small  tubercles, 
or  intersected  with  membranous  filaments ; 
or  else  the  introduction  of  the  finger  will  be 
opposed  by  a hard  ring  of  a cartilaginous 
feel,  composed  of  the  diseased  inner  mem- 
brane of  the  intestines.”  These  states,  as 
Mr.  Copeland  observes,  are  very  different 
from  the  regular  tumour  on  t;,c  anterior 
part  of  the  rectum,  occasioned  by  an  en- 
largement of  the  prostate  gland  ; a case  apt 
to  be  suspected.  u As  the  disease  advan- 
ces (says  the  same  author,)  the  feces  become 
more  fluid,  and  there  is  a thin  saneous  div 


KECTUM 


399 


charge  from  the  anus,  accompanied  with 
tenesmus.”  According  to  Desault,  pus  and 
blood  may  sometimes  be  noticed  with  the 
excrement,  particularly  when  the  disease 
has  advanced  to  the  ulcerated  state.  The 
patient  at  length  becomes  sallow,  frequent 
eructations  of  air  from  the  bowels,  as  Mr. 
Copeland  observes,  torment  the  patient,  and 
render  his  life  miserable  ; the  constitution 
suffers,  and  dissolution  follows.  Severe 
tenesmus  attends  the  whole  course  of  the 
disease.  (CEuvres  Chir.  par  Bichat , T 2.) 

Sometimes  a small  fistulous  orifice  at  the 
verge  of  the  anus  communicates  with  the 
inferior  portion  of  the  diseased  part.  Such 
a fistula,  in  a case  recorded  by  Sir  Everard 
Home,  was  half  an  inch  in  length.  ( Obs . 
on  Cancer , p.  133.) 

Desault  has  often  seen  the  disease  form 
a communication  between  the  rectum  and 
vagina,  and  the  feces  passed  through  the 
latter  part.  In  the  latter  stage  of  the  afflic- 
tion, the  rectum,  bladder,  vagina,  uterus, 
and  adjacent  parts,  are  all  involved  in  one 
common  ulceration. 

When  the  disease  has  attained  the  ulcera- 
ted state,  it  is  probably  always  incurable. 
Palliatives  can  only  now  be  resorted  to, 
such  as  anodyne  and  emollient  glysters,  the 
warm  bath,  foe.  with  the  exhibition  of  me- 
dicines like  opium,  cicuta,  uva  ursi,  foe. 
Claudinus  applied  his  remedies  to  the  inside 
of  the  bowrel,  by  means  of  tents,  and  did  not 
employ  the  latter  as  a mode  of  curing  the 
disease  when  less  advanced.  Valsalva  in- 
troduced a cannula,  pierced  with  numerous 
holes,  and  then  made  his  patient  get  into  a 
bath,  so  as  to  let,  the  fluid  enter  the  intestine. 
Numerous  practitioners,  among  whom  is 
Morgagni,  made  mercurials  the  base  of  their 
treatment,  from  a supposition  that  the  com- 
plaint was  of  venereal  origin.  J believe  the 
latter  opinion  is  at  present  entirely  abandon- 
ed by  all  the  most  judicious  surgeons  in 
England,  and  this,  whether  mercury  ever 
prove  useful  or  not. 

When  the  disease  is  not  .attended  with 
ulceration,  the  contraction  and  thicken- 
ing of  the  gut  may  be  diminished  by  in- 
troducing bougies,  keeping  them  for  a 
certain  time,  every  day,  so  introduced, 
and  increasing  their  size  gradually.  The 
pressure  of  these  instruments  seems  to 
lessen  the  disease,  and  stop  its  progress  ; a 
proof  that  its  nature  differs  from  that  of  a 
common  malignant  scirrhus.  Desault  used 
to  employ  long  tents  made  of  lint,  smeared 
with  cerate,  and  passed  into  the  bowel  by 
means  of  a probe  with  a forked  end.  Their 
size  was  gradually  increased,  so  as  to  keep 
up  the  compression,  to  which,  it  was  con- 
ceived, all  the  good  was  owing.  Their 
length  was  also  augmented  by  degrees.  At 
first,  fresh  ones  were  introduced  twice  a 
day.  When  any  hardnesses  were  situated 
on  the  outside  of  the  anus,  Desault  cured 
them  on  the  same  principle,  viz.  by  making 
pressure  on  them  with  compresses  and  a 
bandage.  In  this  manner  he  effected  the 
cure  of  a seirrho-cpntracted  rectum.  The 
patient  was  taught  to  pass  occasionally  the 


tents,  without  assistance,  in  order  to  pre- 
vent a relapse. 

Instead  of  tents,  modern  surgeons  employ 
bougies  for  the  dilatation  of  strictures  in  the 
rectum.  When  from  habitual  costiveness, 
the  altered  figure  of  the  stools,  and  other 
circumstances,  there  is  reason  to  suspect 
organic  obstruction  to  the  passage  of  the 
fee ed,  and  this  suspicion  is  confirmed  by  an 
examination  of  the  rectum  with  the  finger, 
a the  first  object  of  the  surgeon  (says  Mr. 
Copeiand)  should  be  an  enlargement  of  the 
obstructed  part,  by  the  introduction  of  a 
bougie.  This  should  be  of  such  a size  as  to 
pass,  when  well  lubricated  with  oil,  without 
much  difficulty  or  pain.  Sometimes,  when 
the  disease  has  been  of  long  continuance,  it 
will  be  necessary  to  begin  even  with  a large- 
sized urethra  bougie,  or  one  of  the  same 
size  as  those  which  are  made  for  a stricture 
of  the  oesophagus,  and  of  a length  that  is 
likely  to  pass  beyond  the  end  of  the  stric- 
ture, that  is,  about  six,  or  seven,  or  eight 
inches.  But  I think  it  of  consequence  to 
use  a bougie,  at  first,  which  is  rather  too 
small  than  too  large.”  (P.  29.)  When  it 
has  remained  for  half  an  hour,  or  more,  it  is 
to  be  removed,  and  passed  again  the  next 
day,  the  same  sized  bougie  being  continued 
for  several  days.  In  the  introduction  of  the 
bougie,  Mr.  Copeland  cautions  the  practi- 
tioner not  to  mistake  the  projection  of  the 
sacrum  for  a stricture  of  the  gut ; a mistake 
which,  he  says,  has  often  been  made,  and, 
as  I believe,  too  often  wilfully,  and  from 
motives  of  imposition.  Mr.  Copeland  fur- 
ther advises  the  bowels  to  be  ke*pt  constantly 
lax,  by  the  use  of  castor  oil,  or  electuary  of 
senna,  during  the  whole  of  the  treatment. 
(P.  30.)  Whatever  be  the  nature  of  the 
stricture,  whether  it  be  that  kind  in  which 
the  rectum  is  obstructed  by  tubercles,  by 
membranous  filaments  intersecting  its  canal, 
(which  two  species,  Mr.  Copeland  says,  are 
the  most  easily  relieved)  or  whether  it  be 
the  indurated  stricture,  from  a thickening  of 
the  coats  of  the  intestine,  this  local  treat- 
ment is  equally  necessary.  The  pian  is  to 
be  persisted  in  until  a full-sized  bougie  will 
readily  pass,  and  even  after  all  symptoms 
have  disappeared  it  is  recommended  to  in- 
troduce the  bou  ie,  and  withdraw  it  again 
once  every  two  or  three  days,  for  some 
time,  in  order  to  prevent  a relapse.  The  in- 
durated annular  stricture,  which  long  resists 
the  bougie,  Mr.  Copeland  sometimes  divides 
with  a probe-pointed  curved  bistoury  on  the 
side  which  is  contiguous  to  the  os  sacrum  ; 
and  he  has  frequently  seen  the  late  Mr.  Ford 
perform  the  same  operation.  (P.  34.)  When 
the  disease  is  either  combined  with  venereal 
symptoms,  or  there  is  any  reason  for  sus- 
pecting it  to  be  itself  “ the  solitary  symp- 
tom” of  lues.  Mr.  Copeland  joins  Desauk 
in  recommending  a trial  of  the  effect  of 
mercury,  in  conjunction  with  bougies.  (P. 
44.)  The  formation  of  abscesses,  he  re- 
marks, is  very  frequent  in  the  advanced 
stages  of  the  disease,  and  he  has  often  seen 
the  common  operation  for  fistuladone  under 
such  circumstances  tvithout  success.  (P.3 5 • 


HICKEXS. 


'IWU 


When  uny  stoppage  of  urine  occurs  in 
the  advanced  stage  of  the  disease,  Mr.  Cope- 
land advises  surgeons  not  to  use  the  catheter 
hastily.  ( P . 39.)  And,  in  the  event  of  great 
pain  and  irritation  in  the  rectum,  he  has 
seen  the  greatest  benefit  derived  from  the 
local  application  of  opium  either  in  a glys- 
ter,  or  by  the  introduction  of  one  or  two 
grains  of  the  medicine  within  the  anus.  He 
also  speaks  favourably  of  the  effects  of  the 
warm  bath,  and  fomentations,  in  giving 
temporary  relief ; and  he  has  also  exhibited 
in  these  cases  the  pil  extracti  conii  cum 
hydrarg.  submur.  with  considerable  advan- 
tage. 

A fatal  case  of  mortification  of  the  rec- 
tum is  detailed  by  Larrey.  ( Parisian  Chi- 
rurgical  Journal,  Vol.  2,  p.  398,  <^c.  See  J. 
L.  Petit , CEuvres  Posthum.  T.  2.  Dr.  Sher- 
win  on  the  schirrho-conlraded  rectum,  in  Mem. 
of  the  London  Medical  Society , Vol.  2.  Sir 
Everard  Home , Obs.  on  Cancer , p.  129,  fyc. 
S vo.  Lond.  1805.  L.  F.  J.  Duchadoz , De 
Prodostenia , seu  de  Morbosis  Intestini  Recti 
Angustiis,  Monsp.  1771.  C.  G.  Siebold,  De 
Morbis  Intestini  Recti  Baillie's  Morbid  Anato- 
my, p.  1116.  CEuvres  Chir.  de  Desault  par 
Bichat , T.  2,  p.  422.  Observations  on  the 
principal  Diseases  of  the  Rectum , fyc.  by  T. 
Copeland , 1814.  W.  White,  Observations 
on  the  Contracted  Intestinum  Rectum,  8 vo. 
Bath,  1812.) 

RESOLUTION.  (from  resolvo.)  The 
subsidence  of  inflammation  without  any 
abscess,  ulceration,  mortification,  &c.  Also 
the  dispersion  of  swellings,  indurations,  &c. 

RETENTION  OF  URINE.  See  Urine, 
Retention  of. 

RETROVERSIO  UTERI,  a turning  back- 
ward of  the  womb.  See  Uterus , Retrover- 
sion of. 

RICKETS.  (Rachitis.)  Is  mostly  met  with 
in  young  children  ; seldom  in  adults.  Mo- 
rand,  however,  (Acad,  des  Sciences,  1753.) 
mentions  an  instance,  in  which  an  adult 
became  affected.  The  disease  it  is  said, 
may  even  take  place  in  the  foetus  in  utero  ; 
but  the  most  common  period  of  its  com- 
mencement is  in  children,  between  the  ages 
of  seven  or  eight  months,  and  two  years. 
Hence,  as  Mr.  Wilson  observes,  its  origin 
has  frequently  been  imputed  to  the  effects 
of  dentition.  He  adds,  that  he  has  often 
known  it  to  make  its  appearance  after  this 
time,  and  that  it  not  unfrequently  attacks 
the  spine  a little  while  before  puberty, 
and  may  do  so  even  later.  (On  the  Struc- 
ture and  Physiology  of  the  Skeleton,  fyc.  p. 
162.)  Pine!  has  given  a description  of  the 
skeleton  of  a rickety  foetus.  (Fourcroy’s 
Journal.)  The  disease  seems  to  consist  of 
a want  of  due  firmness  in  the  bone9,  in  con- 
sequence of  a deficiency  in  the  phosphate 
of  lime  in  their  structure.  The  causes  of 
the  affection  are  involved  in  great  obscurity. 
Authors  have  referred  them  to  scrofula, 
scurvy,  lues  venerea,  difficult  dentition,  &c. ; 
nnd  Richerand  still  firmly  believes,  that 
rachitis  is  only  one  of  the  effects  of  scrofula 
in  its  worst  forms.  (JVosographie  Chir.  T. 
3.  v ■ 148,  Edit..  4.)  But  these  are  merely 


conjectures,  which  will  not  bear  a rigorous 
investigation.  Professor  Boyer,  in  particu- 
lar, has  well  exposed  their  invalidity.  Traitd 
des  Mai.  Chir.  T.  3,  p.  611.) 

Rickety  subjects  are  often  at  the  same 
time  scrofulous ; and  this  is,  probably,  the 
only  reason  for  scrofula  being  accounted  a 
cause  of  the  other  affection.  The  particu- 
lar appearances  of  rickety  children  we 
need  not  detail,  as  every  one  is  familiarly 
acquainted  with  them  : such  children  are 
usually  of  a bad,  weak  constitution,  and 
their  limbs  and  bones  become  bent  in  direc- 
tions determined  by  the  action  of  the  mus- 
cles, and  the  weight  and  pressure  which 
they  have  to  sustain.  When  the  affection 
is  very  general,  the  spine  becomes  shorter, 
and  is  curved  in  various  directions ; the 
breast  becomes  deformed  not  only  in  con- 
sequence of  the  curvature  of  the  spine,  but 
by  the  depression  of  the  ribs,  and  projection 
of  the  sternum.  The  bones  of  the  pelvis 
fall  inwards,  and  the  os  pubis  generally  ap- 
proaches the  sacrum.  The  latter  circum- 
stance is  one  of  the  causes  of  difficult 
parturition.  The  clavicles  become  more 
bent  and  prominent  forward  ; the  os  humeri 
is  distorted  outward  ; the  lower  ends  of 
the  radius  and  ulna  are  twisted  in  the  same 
direction  ; the  thighs  are  curved  forwards 
or  outwards  ; the  knees  fall  inwards ; the 
spine  and  front  surface  of  the  tibia  become 
convex ; and  the  feet  are  thrown  out- 
wards. 

According  to  the  observations  of  Mr. 
Stanley,  when  the  tibia  and  fibula  become 
curved,  they  sometimes  “ acquire  increased 
breadth  in  the  direction  of  the  curve,  losing 
a proportionate  degree  of  thickness  in  the 
opposite  direction.  Hence  the  bones  be- 
come, as  it  were,  newly  modelled,  passing 
from  the  cylindrical  into  the  flattened  form. 
This  would  seem  to  be  designed  for  the  pur- 
pose of  enabling  them  to  support  more 
efficiently  the  weight  of  the  body,  since  by 
this  alteration  they  acquire  increased  breadth 
and  power  of  resistance  in  that  direction, 
where  the  greatest  strength  is  required.  I 
have  never  noticed  (says  Mr.  Stanley)  any 
expansion  in  the  articular  ends  of  rickety 
bones,  as  is  mentioned  by  some  authors, 
I should  therefore  feel  inclined  to  believe, 
that  there  has  existed  only  the  appearance 
of  such  a phenomenon,  the  ends  of  the 
bones  having  appeared  swollen,  in  conse- 
quence of  the  emaciation  of  the  surround- 
ing soft  parts.  (See  Med.  Chir.  Trans.  Vol. 
7,  p.  402— 405.) 

When  the  thoracic  viscera  are  considera- 
bly oppressed  by  the  alteration  in  the  figure 
of  the  chest,  produced  by  rickets,  the  dis- 
ease may  bring  on  fatal  consequences. 

Boyer  has  thus  described  the  appearances 
of  rickety  bones : They  are  lighter  than 
natural,  and  of  a red,  or  brown  colour. 
They  are  penetrated  by  many  enlarged 
blood-vessels,  being  porous,  and,  as  it  were, 
spongy,  soft,  and  compressible.  They  are 
moistened  by  a kind  of  sanies,  which  may 
be  pressed  out  of  their  texture,  as  out  ©f  ai 
sponge,  or  rather  a macerated  hide  after  it 


has  been  tanned.  The  walls  of  the  medullary 
cylinder  of  the  great  bones  of  the  extremi- 
ties are  very  thin,  while  the  bones  of  the  skull 
are  considerably  increased  in  thickness,  and 
become  spongy  and  reticular.  All  the  af- 
fected bones,  especially  the  long  ones,  ac- 
quire a remarkable  suppleness ; but  if  they 
are  bent  beyond  a certain  point  they  break, 
&c.  Instead  of  being  filled  with  medulla, 
the  medullary  cavity  of  the  long  bones  con- 
tains only  a reddish  serum,  totally  devoid  of 
the  fat  oily  nature  of  the  other  secretion  in 
the  natural  state.  \See  Boyer , Trait6  des 
Maladies  Chir.  T.  3,  p.  619.)  The  consis- 
tence of  several  rickety  bones,  examined  by 
Mr.  Stanley,  was  nearly  that  of  common 
cartilage.  They  presented  throughout  an 
areolated  texture,  and  the  cells  were  in  some 
parts  large,  and  contained  a brownish  gela- 
tinous substance.  This  gentleman  did  not 
find  the  periosteum  thickened,  as  Bichat  has 
described  it.  ( Analomie  Generate , T.  3.) 
The  investigations  of  Mr.  Stanley  have  also 
discovered,  that,  in  the  process  by  which 
rickety  bones  acquire  strength  and  solidity, 
there  is  always  an  undeviating  regularity  in 
the  situation,  extent,  and  direction  of  the 
deposited  earthy  matter.  “ Thus  it  is  obvi- 
ous (says  this  gentleman)  that,  in  the  curved 
bone,  the  part  where  there  is  the  greatest 
need  of  strength,  to  prevent  its  further 
yielding,  is  in  the  middle  of  its  concavity, 
or  in  other  words,  in  the  line  of  its  interior 
curve;  and  it  is  just  in  this  situation,  that 
strength  and  compactness  will  be  first  im- 
parted to  the  bone  by  the  deposition  of  phos- 
phate of  lime.  It  will  be  further  found,  that 
the  greatest  resistance  being  wanted  at  this 
part,  the  walls  are  accordingly  rendered 
thicker  here  than  elsewhere,  and  the  degree 
to  which  this  excess  in  thickness  is  carried, 
bears  an  exact  ratio  to  the  degree  of  curva- 
ture, which  the  bone  has  undergone.” 

Mr.  Stanley’s  observations  also  prove,  that 
the  bony  fibres  are  arranged  obliquely  across 
the  axis  of  the  bone,  in  a direction  calcula- 
ted to  augment  its  strength.  Lastly,  we 
learn  from  the  same  authority,  that  if  a long 
bone,  like  the  tibia,  be  very  much  bent, 
while  it  has  to  support  a great  superincum- 
bent weight,  the  deposition  of  the  bony  mat- 
ter may  not  be  confined  to  the  thickening 
of  the  walls  of  the  concave  side,  but  may 
extend  across  the  medullary  cavity,  render- 
ing the  bone  here  perfectly  solid,  and  there- 
by greatly  strengthened.  (See  Obs.  on  the 
Condition  of  the  Bones  in  Rickets , fyr.  by  E. 
Stanley,  in  Medico- Chir.  Trans.  Vol.  7,  y. 
404,  et  seq.) 

We  learn  from  Mr.  Wilson,  that  for  many 
3rears  past,  he  has  also  exhibited  in  his  lec- 
tures preparations,  illustrating  the  fact  of 
the  abundant  deposition  of  osseous  matter, 
“ when  the  bones  begin  to  recover  from  the 
disease,  at  the  part  where  it  is  most  wanted, 
viz.  on  the  inner  part  of  the  concave  surface 
of  their  curve.”  (On  the  Skeleton , fyc.  p. 
167.) 

Many  very  rickety  and  deformed  infants 
improve  as  they  grow  up,  and  acquire 
strertgtb.  The  defermit  v of  their  limbs  snori- 
7'  >r  Jr 


taneously  diminishes,  and  the  bones  gain  a 
proper  degree  of  firmness,  a due  quantity  of 
the  phosphate  of  lime  being  deposited  in 
their  texture. 

it  is  a question,  whether  the  restoration 
of  the  proper  figure  of  the  bones  can  be  pro 
moled  by  the  constant  pressure  of  bandages, 
and  mechanical  contrivances,  sold  in  the 
shops.  Some  authors  contend,  that  in  very 
young  children  machines  are  useless,  as  the 
confinement  and  inactivity  of  the  muscles, 
necessarily  occasioned  by  such  contrivances, 
must  increase  the  general  debility,  and  con- 
sequently the  disease. 

Notwithstanding  the  praises  which  have 
been  bestowed  on  those  mechanical  means 
by  their  inventors,  and  even  by  respectable 
authors,  says  Boyer,  they  are  not  now  used 
by  any  enlightened  judicious  practitioners, 
it  being  generally  agreed,  that  it  is  best  to 
leave  to  nature  alone,  aided  by  good  medi- 
cal treatment,  the  duly  of  rectifying  bones 
deformed  by  the  rickets.  ( Trait e des  Mai. 
Chir.  T.  3 p.  627.)  Delpech  expresses  him- 
self still  more  strongly  against  the  employ- 
ment of  machinery.  (See  Precis  Elemen- 
tal re  des  Maladies  Chir.  T.  3,  p.  740,  fyc.) 
However,  these  opinions  against  mechani- 
cal contrivances  for  the  improvement  of 
rickety  bones,  are  not  meant  to  apply  to  ma- 
chines for  rectifying  distortions  of  the  fool. 
In  such  cases,  the  malformation  does  not  de- 
pend on  constitutional  causes,  and  mechani- 
cal means  will  do  whatever  is  possible. 

No  medicine  is  known,  which  possesses 
any  direct  efficacy  in  cases  of  rickets.  To- 
nics are  indicated,  and  should  be  employed. 
The  state  of  the  bowels  must  in  particular 
be  attended  to.  The  disease  appearing  to 
consist  in  a deficiency  of  lime  in  the  bones, 
proposals  have  been  made  to  exhibit  inter- 
nally the  phosphate  of  lime  ; but  this  chy 
mical  project  has  had  no  success.  (See  Bon 
homme’s  Memoir  on  Rachitis , in  Duncanhst 
Annals  for  1797. 

Several  circumstances  considered  by  M.‘ 
Wilson,  tend  to  prove,  that  this  scheme  could 
present  no  chance  of  benefit,  because  there 
is  no  proof  of  a deficiency  of  lime  in  the 
system,  though  the  arteries  of  the  bones  do 
not  deposit  it  in  the  natural  degree.  (See 
Wilson  on  the  Skeleton , fyc.  p.  163,  fyc.) 

More  good  is  generally  effected  by  keep- 
ing children  in  healthy  situations,  and  in  a 
salubrious  air,  than  by  any  medicines  what- 
ever. Light,  wholesome,  nutritious,  easily 
digestible  food;  cold  bathing;  good  nur- 
sing; regular  gentle  exercise;  or  airings  in 
a carriage  ; the  use  of  the  flesh-brush,  fee. 
are  also  highly  serviceable.  The  constitu- 
tional treatment  of  rickets  belongs  more 
properly  to  the  physician  than  the  surgeon  ; 
and  it  is  not  necessary  to  introduce  more  of 
the  subject  into  a Dictionary  expressly  al- 
lotted to  surgery. 

See  the  article  Mol, lilies  Ossium , and  con- 
sult particularly  Buchner  de  Rachitide  perfec- 
ta  et  imperfecta  Disput.  Argent.  1754.  G iis- 
son,  de  Rachiiide , sive,.  morbo  puerili.  Ludg. 
Batav.  1671.  Bonhomme’s  Mem.  on  Rachitis, 
in  Duncan's  Medical  Annals  for  1797.  Riche- 


-SAR 


SAR 


(A«2 


vmd,  JVosographie  Chir.  T.  3,  p.  142.  fyc. 
Edit.  4.  LcvMM,  in  Mem.  de  Physiologic  et 
de  Chirurgie , par  Scarpa,  fyc.  Boyer,  Trailt 
des  Maladies  Chir.  T.  3,  p.  607,  fyc.  Stan- 
ley's Ohs.  in  Med.  Chir.  Trans.  Vol.  7,p  404 
Delpech  Precis  EUmentaire  des  Mala  ies 
Chir.  T.  3,  p.  749,  fyc.  Tmka  de  Krzowltz, 
Jlistoria  Rachitidis,  8 vo.  Vindob.  1787.  R. 
Hamilton  Remarks  on  Scrofulous  Affections, 
fyc.  &ve.  Lond.  1791.  A.  Portal,  Obs.  sur  la 


Nature  et  sur  le  Trailemenl  du  Rachilisme, 
ou  des  Courbures  de  la  colonne  Vertebrate  et 
de  celles  des  Extremites.  8 vo.  Paris , 1797. 
And  particularly,  Lectures  on  the  Structure 
and  Physiology  of  the  Skeleton,  Diseases  of 
Bones,  fyc.  by  James  Wilson,  p.  159,  fyc.  8 vo. 
Lond.  1820. 

RINGWORM.  See  Herpes. 

RUPTURE.  A protrusion  of  the  abJomi 
nal  viscera.  See  Hernia. 


s. 


^4  \BINA.  (said  to  be  named  from  the  Sa- 
k3  bines,  whose  priests  used  it  in  their  re- 
ligious ceremonies.)  Savine.  The  use  of 
the  leaves  of  this  plant,  in  forming  the  active 
ingredient  in  the  ointment  commonly  pre- 
ferred for  keeping  open  blisters,  has  been 
explained  in  the  article  Blisters.  The  other 
chief  surgical  use  of  savine,  is  as  a stimula- 
ting application  for  destroying  wart?,  and 
other  excrescences.  For  the  latter  purpose, 
it  is  generally  powdered,  and  mixed  with  an 
equal  proportion  of  siibacetate  of  copper. 
The  same  powder  is  also  sometimes  employ- 
ed by  surgeons  for  maintaining  the  hollows 
into  which  peas  are  inserted  in  issues.  The 
best  plan  is,  first  to  wet  the  peas,  then  roll 
them  in  the  powder,  and  put  them  in  this 
state  on  the  issue.  But  when  the  whole  sur- 
face of  the  issue  has  risen  high,  above  the 
level  of  the  skin,  the  powder  must  be  sprin- 
kled all  over  the  sore,  so  as  to  produce  an 
absorption  of  the  high  granulations. — indeed, 
even  in  this  manner,  a good  cavity  often 
cannot  be  obtained  ; and  it  becomes  neces- 
sary to  destroy  the  surface  of  the  issue,  by 
rubbing  it  with  caustic  potassa,  or  potassa 
cum  caice. 

SACCHARUM  SATURNI.  Sugar  of 
Read.  Cerussa  Acetata.  Acetate  of  Lead. 
This  is  very  extensively  used  in  surgery, 
chiefly  as  a local  application  to  inflamed 
parts,  and  in  the  form  of  a lotion.  See  In- 
domination,  Collyrium,  Lotio,  Gonorrhoea , 
Ophthaimy,  and  numerous  other  articles  of 
tins  Dictionary,  for  an  explanation  of  (he 
uses  of  acetate  of  lead. 

SAL-AMMONIAC.  Ammonia  Muriata. 
Muriate  of  Ammonia.  Employed  a good 
deal  by  surgeons,  as  an  ingredient  in  discu- 
tient  lotions.  See  Lolio  Ammon.  Mur. 

SALIVARY  FISTULAS.  See  Parotid 
Duct. 

SANIES.  (Latin  ) A thin,  serous,  fetid 
matter,  discharged  from  fistulm,  unhealthy 
sores,  fee.  It  is  sometimes  tinged  with  blood. 

SAI'O  TE  RE  B I N T H I N 7E . ( Starkey's 

Soap.)  f^.  Potassa;  Subcarbonatis  calidi, 
Olei  Terebinth,  £iij. — The  oil  of  tur- 
pentine is  gradually  blended  with  the  hot 
suhearbonate  of  potassa  in  a heated  mortar. 
Indolent  swellings  were  formerly  rubbed 
with  this  application,  and,  perhaps,  some 
chronic  affections  of  the  joints  might  still  be 
bcuefliied  by  it. 

: A.RCOCE'*  E.  ffrom  <r«w|h  flesh  : and 


a tumour.)  A fleshy  enlargement  of 
the  testicle.  See  T>  slide,  Diseases  of.) 

SARCO'MA,  or  Sarcbsis.  (from  cctp£ , 
flesh.)  A fleshy  tumour  on  any  part  of  the 
body.  (See  Tumours,  Sarcomatous.) 

SARSAPARI  LLA  The  root  of  sarsapa 
rilla  was  brought  into  Europe  about  1530. 
It  was  at  first  reputed  to  possess  singular  effi- 
cacy in  venereal  cases  ; but  afterward  lost 
-all  its  fame.  Sarsaparilla  was  again  brought 
into  notice' by  Di.  \V.  Hunter,  who  advised 
Dr.  Chapman  to  make  trial  of  it  in  a bad 
case  of  phagedenic  bubo  ; and  the  benefit 
obtained  in  t his  instance,  led  Dr.  Hunter  to 
extend  the  recommendation  of  the  medicine 
Sir  W.  Fordyce  stated,  that  sarsaparilla 
would  quickly  relieve  venereal  headachs,  and 
nocturnal  pains,  and  if  persisted  in,  cure 
them  ; that  in  emaciated  or  consumptive  ha- 
bits, from  a venereal  cause,  it  was  the  great- 
est restorer  of  appetite,  flesh,  colour,  and 
strength,  which  he  knew  of;  that  when  mer- 
curial frictions  had  been  previously  employ- 
ed, it  would  generally  complete  the  cure  of 
the  disease  of  the  throat,  nose,  palate,  or 
spongy  bones  ; and  that  ii  would  promote 
the  cure  of  blotches  and  ulcers,  and  some- 
times accomplish  it,  even  without  mercury  ; 
though,  in  this  circumstance,  there  was  dan 
ger  of  a relapse.  Sir  YV.  Fordyce  pronoun- 
ced sarsaparilla  to  be  of  little  use  in  chan- 
cres ; but  that  when  these,  or  buboes,  could 
not  be  healed  by  mercury,  it  would  often 
cure,  and  always  do  good.  He  allows,  how 
ever,  that,  in  all  venereal  cases,  sarsaparilla 
is  nol  to  be  trusted,  unless  preceded  by,  or 
combined  with,  the  use  of  mercury  ; and  he 
thought  sarsaparilla  would,  probably,  always 
cure  what  resisted  mercury.  (Medical  Obs. 
and  Inq.  Col.  1.) 

The  celebrated  Cullen  considered  sarsa- 
parilla as  possessing  no  virtues  of  any  kind  ; 
for,  says  lie,  “tried  in  every  shape,  1 have 
never  found  it  an  effectual  medicine  in  sy- 
philis, or  any  other  disease.”  (Mat.  Med. 
Vol.  2.) 

Mr.  Bromfield  declares,  that  he  never 
saw  a single  instance  in  which  sarsaparilla 
cured  the  venereal  disease  without  the  aid 
of  mercury,  either  given  before,  or  in  con 
junction  with  it.  (Tract.  Obs.  on  the  Use  of 
Corrosive  Sublimate , tyc.  p.  78.)  Mr.  Pear- 
son also  contends  that  sarsaparilla  has  not 
the  power  of  curing  any  one  form  of  the  lues 
reverea  ; but  ho  allows  that  it  may  suspend,. 


SCROFULA 


40o 


Jtor  a tune,  tlx*  ravages  of  that  contagion,  the 
disease  returning  if  no  mercury  should  have 
been  used.  This  gentleman  ndinits,  also, 
that  sarsaparilla  will  alleviate  symptoms  de- 
rived from  the  venereal  virus.  He  maintains, 
that  the  exhibition  of  sarsaparilla  does  not 
diminish  the  necessity  for  giving  les«  mercu- 
ry. Nocturnal  pains  in  the  limbs,  painful  en- 
largements of  the  elbow  and  knee,  mem- 
branous nodes,  cutaneous  ulcerations,  and 
certain  other  symptoms,  resemhling  venereal 
ones,  are  often  experienced  after  a full  course 
of  mercury.  Such  complaints.  Mr.  Pearson 
allows,  are  greatly  benefited  by  sarsaparilla, 
and  exasperated  by  mercury  ; and  he  ob- 
serves, that  it  is  from  these  complaints  ha- 
ving been  mistaken  for  venereal  ones,  that 
the  idea  has  arisen,  that  sarsaparilla  has  cured 
syphilis  when  mercury  had  failed.  Mer- 
cury, and  the  venereal  poison,  may  jointly 
produce,  in  certain  constitutions,  symptoms 
W’hieh  are  not  strictly  venereal  and  are  some- 
times more  dreadful  than  the  simple  effects 
of  syphilis.  Some  of  the  worst  of  these  ap- 
pearances are  capable  of  being  cured  by  sar- 
saparilla, while  the  venereal  viris  still  re- 
mains in  the  system.  When  this  latter  dis- 
ease has  been  eradicated  by  mercury,  sarsa- 
parilla will  also  cure  the  sequelae  of  a course 
of  the  other  medicine.  ( Pearson  on  the  Ef- 
fects of  various  Articles  in  ihe  ire  of  Lues 
Venerea , 1807.) 

The  value  of  many  of  the  foregoing  opi- 
nions is  mucha  fleeted  by  the  results  of  mo 
dern  inquiries  into  ihe  nature  of  the  vene- 
real disease,  the  possibility  of  generally 
curing  which,  without  the  aid  of  mercury, 
seems  well  established,  though  the  expedien- 
cy of  the  method  is  another  question.  - 

SCALPEL,  (from  scalpo . to  scrape.) 
Originally  a raspatory,  or  instrument  for 
scraping  diseased  hones,  &c.  The  term  now 
generally  signifies  a common,  straight,  sur- 
gical knife. 

SCA'RIFICATION.  (from  scariflco , to 
scarify.)  The  operation  of  making  tittle  cuts, 
or  punctures,  in  a part,  for  the  purpose  ot 
taking  away  blood,  letting  out  fluid  in  ana- 
sarcous  cases,  or  air,  in  instances  of  emphy- 
sema. 

SCIRRHUS  ; SCIRRHOMA  5 SCIR- 
RHO^IS.  (from  trHippcoe,  to  harden.)  The 
etymological  import  ol  these  terms  seems 
merely  to  be  any  induration.  The  first  is 
now  generally  restricted  to  the  induration 
which  precedes  cancer  in  the  ulcerated  state. 

SCLER1ASIS  ; SCLER0-1S.  (from 
anKn^ou,  to  harden.)  A hard  tumour,  or  m- 
dui  lion. 

SCRO TULA,  or  SCROPHULA.  (from 
scrofa , a sow.)  So  named,  as  is  commonly 
supposed,  because  swine  an-  s>id  to  be  sub- 
ject to  it,  though  the  correctness  of  this  ety- 
mology is  rendered  very  questiona  le  by  the 
remarks  of  Dr.  Henning,  and  the  statement, 
that  pigs  are  really  liable  to  scroful  < \ould 
appear  to  be  erroneous.  (See  Critical  In- 
quiry into  the  Pathology  of  Scrofula , fyc.  p. 
1,9.)  Called  also,  struma , and  t he  King's 
evil,  from  the  custom  of  submitting  patients 


formerly  to  the  supposed  beneficial  effects  of 
the  royal  touch.  A disease,  one  of  1 lie  chief, 
or  most  palpable  symptoms  of  which  is  a 
chronic  swelling  of  the  absorbent  gland*,  in 
various  parts  of  the  body,  which  glands  ge- 
nerally tend  very  slowly  to  imperfect  suppu- 
ration. Oar  notions  of  scrofula,  however, 
would  be  very  imperfect,  were  we  to  define 
the  disorder  to  be  a morbid  state  of  the  Ijrn- 
phatie  glandular  system.  The  first  appear- 
ances, indeed,  frequent  ly  consist  of  spots  on 
different  parts  of  the  body,  and  of  eruptions 
and  ulcerations  behind  the  ears.  As  a ju- 
dicious author  remarks,  the  system  of  absorb 
ent  gland®,  it  is  true,  seldom  or  never  fails  to 
become  affected  in  the  progress  of  the  dis- 
ease ; but  there  is  reason  to  believe,  that 
scrofula  frequently  appears,  for  the  first  time, 
in  parts  which  are  not  of  a glandular  nature. 
Tin  re  are,  perhaps,  but  few,  if  any,  of  the 
textures  of  the  human  body,  or  of  the  or- 
gans, which  these  textures  form,  that  are  not 
liable  to  attacks  of  scrofula,  and  to  scrofula 
as  an  original  idiopathic  affection.  (Thomp  - 
son’s Lectures  on  Inflammation , p.  134.! 
These  sentiments  are  entirely  at  variance 
with  those  of  Alibert,  and  many  other  mo- 
derns, who  describe  the  disease  as  having  its 
commencement  in  the  conglobate  glands, 
especially  thosp  of  the  neck,  (Nosol.  Natu 
rclle , T.  l,p.  441,4/o.  Paris,  1817  ;)  and  they 
are  equally  opposite  to  the  doctrine  of  Dr 
Henning,  who  argues,  that  the  superficial  ab- 
sorbent glands  alone  are  susceptible  of  the 
original  ac»ion  of  the  cause  of  this  disease, 
and  that  if  other  parts  become  affV-  ted  by  it, 
such  affe’  tion  is  consequential.  (On  the  Pa- 
thology of  Scrofula.  Chap.  6.) 

Scrofula  generally  shows  itself  during  in- 
fancy, between  the  age  of  three  and  seven  ; 
sometimes  rather  sooner;  but  frequently  as 
late  as  puberty,  and  in  some  instances,  though 
a ver>  few,  not  till  a much  more  advanced 
period  of  life.  In  the  latter  cases,  the  dis- 
ease is  said  to  be  rarely  so  complete,  or  w ell 
marked,  as  it  is  in  young  subjects.  u Cette 
maladie  (says  Alibi  rt)  est  commun&ment  le 
partage  de  la  premiere  enfauce.  Ill  est  rare 
qu’elle  se  d6veioppe  chez  les  adultes.  Je 
Pai  pourtnnt  observee  chez  des  septuage- 
naire-  ; mais  presque  toujours,  ce  sont,  les 
effects  de  la  dentition  qui  la  font  eclore,  et 
ceux  de  la  | ubeite,  qui  la  font  evanouir 
(Nosol.  Nalurelle,p.  448.) 

By  some  authors,  it  is  stated,  that  the  di- 
ease seldom  attacks  the  glands  in  children 
under  two  years  of  age.  Dr.  Thomson,, 
however,  ha-  seen  the  glands  affected  before 
this  period,  and  Dr.  Cullen  used  to  mention 
a case,  in  which  the  disease  broke  out  in  ari 
i fant  only  th>ee  months  old;  which,  ac- 
cor  iing  to  Dr.  Thomson,  is  uncommon.  But 
though  glandular  scroful  . occurs  most  fre- 
qu  utly  in  child  en,  it  is  by  no  means  confi- 
ned to  that  period  of  life.  Di.  Thomson  has 
even  found  the  lacteal  gland-  affected  with 
scrofulous  inflammation  in  per-ons  of  v<-ry 
advanced  age.  (Lectures  on  Inflammation , 
p 136.)  Probably,  however,  such  patients 
had  laboured  unfijr  scrofulous  complaints  in 
their  earlier  days  : and  it  merits  notice;  that 


SCItOfU  L \ 


m 


some  authors,  like  Dr.  Henning,  ( Z\  110.)  do 
not  regard  enlargement  of  the  mesente- 
ric glands,  as  an  unequivocal  specimen  of 
scrofula  It  is  observed  by  Mr.  Lloyd,  that 
the  susceptibility  of  different  parts  to  the  dis- 
ease “ is  altered  by  age;  thus,  in  children, 
the  upper  lip,  eyes,  glands  of  the  neck,  and 
those  of  the  mesentery,  are  generally  the 
pan's  first  affected;  the  lungs,  bones,  and 
other  parts  being  subsequently  attacked. 
It  happens  sometimes  too  in  children,  that 
small  lumps  iorm  under  the  skin  in  various 
parts  of  the  bod),  which  suppurate,  ulce- 
rate, and  pursue  the  same  course  with  scrofu- 
lou-  abscesses  in  general.”  (On  the  Nature 
and  Treatment  of  Scrofula,  p.  5.)  The  same 
gentleman  likewise  states,  that  a species  of 
warts  also  often  forms  about  the  face  and 
neck  of  children  of  a scrofulous  habit,  but 
seldom  in  adults.  “ In  more  advanced  age, 
the  eyes,  upper  lip,  and  lymphatic  glands  are 
comparatively  seldom  affected  ; while  the 
lungs,  the  other  viscera,  and  the  spongy  parts 
of  the  boms  are  frequently  attacked.” 
Scrofula  is  also  as  hereditary  as  any  dis- 
ease can  be  ; that  is  to  say,  it  is  so  as  far  as 
any  particular  kind  of  temperament,  or  con- 
stitution, can  descend,  more  or  less  com- 
pletely, from  parents  to  children.  Mr. 
White,  Dr.  Henning,  and  others  have  strong- 
ly censured  calling  the  disease  hereditary  ; 
but  their  observations  only  lead  to  these 
conclusions,  that  children,  born  of  scrofulous 
parents,  are  not  invariably  affected  with 
scrofulous  diseases  ; and  that  sometimes  one 
child  has  some  strumous  affection,  w hile  the 
parents,  and  all  the  rest  of  the  family,  have 
no  appearance  of  scrofulous  habits.  How- 
ever, I still  conceive  that  neither  Mr.  White, 
nor  any  other  writer  will  maintain  the  opi- 
nion, that  scrofula  does  not  much  more 
frequently  afflict  the  children  of  scrofulous 
parents,  than  the  offspring  of  persons  who 
have  always  been  perfectly  free  from  every 
tendency  to  any  form  of  this  affliction.  Too 
numerous  are  the  facts  which  occur  to  my 
ow  n mind,  to  allow  me  to  entertain  the 
smallest  doubt,  that  scrofula  runs  very 
much  in  certain  families.  In  this  sense,  I 
think  the  term  hereditary  perfectly  accurate 
and  allowable.  But,  at  the  same  time,  I 
beg  the  reader  to  understand,  that  1 have 
no  intention  of  questioning  what  seem  to 
be  irrefragable  truths,  viz.  that  the  children 
of  scrofulous  parents  often  continue,  as  long 
they  live,  entirely  free  from  the  disease  ; 
and  that  one  child  is  sometimes  afflicted, 
while  its  father,  mother,  brothers,  sisters, 
and  all  the  rest  of  its  relations,  have  never 
had  any  tendency  to  strumous  disorders. 
It, should  also  be  recollected,  that  the  doc- 
trine of  a congenital  tendency  to  ihe  dis- 
ease in  particular  families  is  one  which  in- 
terferes with  some  theories  which  have 
been  offered  about  the  predisposing  cause 
of  the  disease,  as  for  instance,  with  that  of 
Dr.  Henning,  w ho  declares  that  such  cause 
is  foreign  to  the  body,  and  depends  upon 
peculiarities  of  climate;  (On  the  Pathology 
of  Scrofula,  p.  69,  &c.)  an  Opinion,  which  is 
incorrect  only  in  rej  ect  to  its  exclusion 


of  the  iniluence  of  oiher  circumstances. 
Two  curious  specimens  of  tuberculated  lungs 
in  the  foetus  are  preserved  in  Mr.  Langstaff’s 
museum,  and  have  been  adduced  by  Mr 
Lloyd,  as  positive  proofs  of  scrofula  being 
hereditary,  (On  Scrofula , p.  23 ;)  how- 
ever, I am  not  certain  that  they  will  be 
admitted  as  such  by  all  parties,  as  tubercles 
of  the  lungs  are  not  constantly  regarded 
as  a scrofulous  disease 

When  scrofula  does  not  actually  take 
place  at  a very  early  period  of  life,  it  is  ge- 
nerally staled  by  writers,  that  the  particular 
constitutions,  in  which  there  is  a disposition 
to  the  disease,  are,  in  a certain  degree,  dis- 
tinguishable. In  the  individuals,  possessing 
the  disposition  in  question,  a peculiar  soft- 
ness and  flaccidity  of  fibre  are  remarkable ; 
their  hair  is  more  frequently  light  coloured 
than  dark ; and  tbeir  eyes  are  said  to  be 
more  often  of  a blue,  than  any  other  colour. 
Their  skin  is  generally  very  fine,  and  even 
handsome,  both  in  regard  to  its  outward 
texture  and  complexion.  Subjects  with 
scrofulous  constitutions  frequently  have  a 
thickening  of  the  upper  lip  ; this  swelling  is 
sometimes  very  considerable,  and  occasion- 
ally extends  as  far  as  within  the  nostrils. 
Scrofula  is  also  very  often  complicated  with 
rachitis,  or  follows  the  latter  affection;  but 
there  is  as  little  reason  for  supposing  rickets 
to  arise  from  scrofula,  as  this  latter  from 
rickets.  In  some  instances,  however,  the 
complexion  is  dark,  and  the  skin  coarse  ; 
but  in  these  subjects,  at  least  wben  young, 
the  face  is  generally  tumid,  and  the  look 
unhealthy.  (Burns  on  Inflammation , Vol.  2, 
p.  232.) 

In  many  instances,  the  last  joints  of  the 
fingers  have  been  observed  to  be  enlarged, 
and  the  belly  is  generally  larger  than  usual. 
(Thomson,  p.  134.) 

Mr.  White,  as  I think,  with  some  appear- 
ance of  truth,  denies  that  gray,  or  blue  eyes, 
light  hair,  and  a fair  complexion,  ought  to 
be  considered  as  marks  of  a scrofulous  dis- 
position ; for  the  majority  of  children  in 
this  country  have  light  hair,  and  eyes  while 
young,  which  become  darker  as  they  ad- 
vance in  life.  Now,  as  the  majority  of  scro- 
fulous patients  are  children,  and  young  sub- 
jects, and  as  most  children  in  this  country 
have  naturally  the  kind  of  hair  and  eyes 
above  described,  it  seems  inaccurate  to  lay 
any  stress  on  persons  affected  with  struma, 
or  predisposed  to  this  disease,  having  such 
appearances.  (See  White  on  the  Struma  or 
Scrofula,  p.  38,  Ed.  3.)  However,  it  is  to 
be  recollected,  that  the  greater  frequency 
of  scrofula  in  fair  people  is  noticed  in 
France,  where  the  eyes  are  mostly  dark. 
Thus,  Alibert  in  his  description  of  a patient 
disposed  to  the  disease,  takes  notice  of  his 
swelled  nostrils  and  upper  lip;  his  florid 
complexion  ; his  fair,  delicate,  glossy  skin  ; 
his  cheeks  of  a lively  red  colour;  circum- 
scribed, however,  by  a pallid  bloatedness 
of  the  rest  of  the  face.  His  blue  eyes  ; di- 
lated pupils  ; light  hair  ; short  neck  ; largo 
head  and  lower  jaw  ; flabby  flesh  ; large, 
protuberant  belly  ; strong  intellectual 


SCROFULA 


405 


powers,  &e.  (Nosol.  Naturelle , p.  442 ; 
also,  Did.  des  Scietices  Med.  T.  50,  p.  2S1.) 

Dr.  Thomson  expressly  declares,  that 
some  of  the  worst  cases  of  scrofula,  which 
he  has  seen,  occurred  in  persons  whose  com- 
plexion and  hair  were  of  a very  dark  co- 
lour. ( Lectures , p.  134.)  Another  fact, 
which  I think  tends  to  impeach  the  accura- 
cy of  the  common  doctrine  about  complex- 
ion, is  the  circumstance  of  so  many  negroes 
being  afflicted  in  this  country  with  scrofula 
in  its  worst  forms.  Does  not  this  fact  indi- 
cate, at  the  same  time,  that  it  is  climate, 
which  is  most  powerfully  concerned  in  the 
production  of  the  disease  ; since  the  African 
black,  in  his  own  country,  is  nearly  ex- 
empt from  scrofula?  After  all,  however,  as 
the  disease  is  undoubtedly  very  frequent  in 
persons  of  fair  skin,  light  eyes,  he.  the  term 
alike , at  least  in  the  sense  of  equally , may 
not  be  altogether  correct  in  the  following 
inference,  viz.  ‘‘  that  persons  of  every  va- 
riety of  complexion  are  alike  subject  to  this 
disease,  and  that  it  is  only  necessary  to 
place  them  in  circumstances  favourable  to 
its  developement,  to  have  it  fully  formed.” 
( Lloyd  on  Scrofula , p.  7.) 

1 believe  the  fact  is  now  almost  generally 
admitted,  that  females  are  rather  more  sub- 
ject than  males,  to  scrofulous  disease.  (See 
Alibert , Nosol.  Vaturelle,  p.  449.) 

According  to  Mr.  White,  struma  prevails 
more  extensively  in  temperate  latitudes, 
than  in  very  hot  or  very  cold  climates.  It 
is  also  more  frequent  in  some  parts  of  Eu 
rope  than  others  ; and  in  this  country  it  has 
been  found  to  be  most  general  in  the  coun- 
ties of  Suffolk  and  Lancashire.  At  all  pe- 
riods, it  seems  to  have  been  a very  common 
complaint  in  this  island.  From  history,  we 
learn,  that  it  was  denominated  the  king’s 
evil  in  the  time  of  Edward  the  Confessor, 
who  is  supposed  to  have  been  the  first  that 
attempted  to  cure  it  by  the  royal  touch. 
From  a register  kept  in  the  royal  chapel, 
we  find  that  Charles  the  Second  touched 
92,107  persons,  in  a certain  number  of 
years  ; and  this  equally  bigoted  and  useless 
practice  was  not  discontinued  till  a recent 
period,  when  kings  were  found  to  be,  as 
well  as  their  poorest  subjects,  totally  desti- 
tute of  all  supernatural  pow'er. 

Scrofula  is  not  communicable  from  one 
person  to  another  ; neither  can  it  be  con- 
veyed into  the  system  by  inoculation.  The 
opinion  also  that  scrofulous  nurses  may  in- 
fect children,  seems  quite  destitute  of  foun- 
dation. (See  White,  p 56,  57.) 

Pinel  and  Alibert  have  purposely  kept 
scrofulous  and  healthy  children  together  in 
the  same  ward,  without  any  of  the  latter 
receiving  the  complaint.  Hebreard  could 
not  communicate  the  disease  to  dogs  by  ino- 
culation. And  G.T.  Korturn,  whose  valua- 
ble work  contains  every  thing  know  n about 
scrofula  at  the  period  when  it  was  written, 
tried  in  vain  to  impart  the  distemper  to  a 
child,  by  rubbing  its  neck  every  day  with 
the  pus  discharged  from  scrofulous  ulcers. 
Lepelletier,  desirous  of  ascertaining  the 
correctness  of  such  experiments,  has  of  late 


repeated  them,  he  has  made  guinea  pigs 
swallow  scrofulous  matter,  and  he  has  in 
jected  it  into  the  veins,  and  applied  it  to 
wounds  ; but  in  no  instance  was  there  even 
a temporary  appearance  of  the  disease  be 
ing  communicated.  The  same  author  also 
mixed  scrofulous  with  vaccine  matter,  and 
inoculated  with  it  ; yet  he  never  found  the 
vaccine  vesicle,  thus  produced,  deviate  in 
the  least  from  its  regular  course.  Lastly, 
Lepelletier  inoculated  himself  with  pus,  dis- 
charged trom  scrofulous  sores,  as  well  as 
with  the  serum,  collected  under  the  cuticle 
of  a strumous  patient  after  the  application 
of  a blister  ; but  he  has  remained  free  from 
every  scrofulous  ailment.  (See  Did  des 
Sciences  Med.  T.  50,  p.  294.)  Our  country- 
man, Mr.  Goodlad,  inoculated  himself  seve- 
ral times  with  the  discharge  from  scrofulous 
sores  and  abscesses,  and  the  result  was,  that 
the  disease  could  not  be  thus  transmitted. 
(On  the  Diseases  of  the  Vessels  and  Glands  of 
the  Absorbent  System,  p.  113.) 

The  parts  which  ^re  most  frequently  affect- 
ed by  scrofula,  next  to  the  lymphatic  glands, 
and  perhaps  the  skin,  are  the  spongy  heads 
of  the  bone*,  and  the  joints.  The  form 
which  the  disease  assumes  in  the  latter  parts, 
is  particularly  described  iu  the  article  Joints 
The  disorder  of  the  spine,  attended  with  a 
paralytic  affection  of  the  lower  extremities 
is  no  doubt  very  frequently  of  scrofulous  ori- 
gin. (See  Vertebree.)  The  spina  bifida  is  a 
congenital  disease,  which  is  found  to  occur 
most  frequently  in  children  whose  parents 
are  scrofulous.  (Thomson's  Lectures,  p.  133.) 
The  abscess,  which  forms  in  the  cellular  sub- 
stance, between  the  peritoneum  and  psoas 
muscle,  is  often  regarded  as  a strumous  dis- 
ease ; and  when  the  contents  of  the  abscess 
are  found  to  contain  flakes  of  a curdy  mat- 
ter, somewhat  resembling  white, -of-egg,  a 
substance  peculiar  to  scrofulous  abscesses, 
no  one  can  doubt  that  the  complaint  is  con- 
nected with  this  constitutional  affection. 
(See  Lumbar  Abscess .)  The  chronic  enlarge 
meat  ot  the  thyroid  gland,  is  sometimes  con- 
sidered as  scrofulous  : but  though  patients, 
with  this  affliction,  very  often  have,  at  the 
same  time,  other  complaints,  w hich  are  une- 
quivocally strumous,  though  the  enlargement 
of  the  thyroid  gland  most  frequently  com 
mences  at  an  early  period  of  life,  like  scro- 
fulous diseases,  and  (hough,  like  them,  it 
is  sometimes  benefited  by  the  carbonate  of 
soda,  the  opinion,  I think,  is  rather  on  the  de- 
cline. (See  Brontliocele.)  Scrofula  also 
frequently  makes  its  appearance  in  the  form 
of  imperfect  suppurations  in  various  parts  of 
the  body  ; the  contents  of  such  abscesses 
bping  a curdy  kind  of  matter,  and  the  skin 
covering  them  having  an  unhealty  red  ap- 
pearance, and  a thickened  doughy  feel.  The 
mesenteric  glands  are  often  found  univer- 
sally diseased  and  enlarged  in  scrofulous  sub- 
jects ; and  as  all  nutriment  has  to  pass 
through  these  parts,  before  it  can  arrive  in 
the  circulation,  we  cannot  he  surprised  at 
the  many  ili  effects  which  must  be  produced 
on  the  system,  when  such  glands  are  thus 
diseased.  However,  as  l have  already  hint 


406 


SCROFULA 


erf,  doubts  are  entertained  by  Dr.  Henning, 
whether  enlarged  mesenteric  glands  are  de- 
cidedly scrofulous  ; but  if  his  sentiment  be 
incorrect  1 fear  he  has  been  led  to  adopt  it 
by  wis  particular  theory,  which  limits  the  ori- 
gin of  scrofula  to  the  superficial  absorbent 
glands.  Scrofula  frequently  makes  its  attack 
on  the  testicle.  (See  Testicle , Diseases  of.) 
The  female  breast  is  also  subject  to  scrofu- 
lous tumours  and  abscesses 

Dr.  Thomson  believes,  that  more  or  less 
local  inflammation  occurs  in  every  form  and 
stage  of  scrofulous  diseases.  He  observes, 
that  the  swellings  are  very  often  from  the 
first  attended  with  a sensible  increase  of  heat 
and  redness,  and  lh  -t  the  pain,  though  sel- 
dom acute,  is  always  present  in  a greater  or 
less  degree.  Pressure  on  scrotulou-  swell- 
ings never  fails  to  create  pain  ; and  the  tem- 
perature of  the  skin  covering  them,  is  usu- 
ally two  or  three  degrees  hi  her  than  that  of 
the  contiguous  parts.  ( Lectures , fyc.  p. 
131.) 

Scrofulous  inflammation  (as  Mr  John 
Burns  observes.)  is  marked  by  a soft  swell- 
ing of  the  affected  part,  which  very  fre- 
quently is  one  of  the  lymphatic  glands. 
The  covering,  or  coat  of  tlje  gland,  be- 
comes slightly  thickened,  and  its  substance 
more  porous  and  doughy.  The  swelling 
increases,  and  the  doughy  feel  changes  by 
degrees  into  that  of  elasticity,  or  fluctuation, 
and  a firm,  circumscribed,  hardened  margin, 
can  be  felt  round  the  base  of  the  tumour. 
The  skin  is  slightly  red.  If,  at  this  time, 
an  incision,  or  puncture,  be  made,  either  no  . 
matter,  or  very  little  is  evacuated,  the  lips 
of  the  wound  inflame  and  open,  displaying 
a sloughy-looking  substance  within  ; and, 
betwixt  this  and  the  skin,  a probe  can  often 
be  introduced  for  some  way  all  round  If, 
however,  the  disease  should  have  advanced 
further,  then  there  is  very  little  elasticity  in 
the  tumour;  it  is  quite  soft,  rather  flaccid, 
and  fluctuates  freely;  the  skin  becomes  of 
a light  purple  colour,  and  small  veins  may 
be  seen  ramifying  on  its  surface.  Some 
time  after  these  appearances,  the  skin  be- 
comes thinner  at  one  particular  part,  and 
here  it  is  also  generally  rendered  of  a darker 
colour.  It  afterward  bursts,  and  discharges 
a thin  fluid,  like  w hey,  mixed  with  a curdy 
matter,  or  thick  white  floccuii.  The  red- 
ness of  the  skin  still  continues;  but  the 
aperture  enlarges  as  the  tumour  subsides, 
and  thus  a scrofulous  ulcer  is  produced. 
The  margins  of  this  kind  of  sore  are  gene- 
rally smooth,  obtuse,  and  overlap  the  ul- 
cer ; they  are  of  a purple  colour,  and 
rather  hard  and  tumid.  The  surface  of 
the  sore  is  of  a light  red  colour  ; the  gra- 
nulations are  flabby  and  indistinct,  and 
the  aspect  is  of  a peculiar  kind,  which, 
says  Mr.  Burns,  cannot  be  described.  The 
discharge  is  thin,  slightly  ropy,  and  copious, 
with  curdy  flakes.  The  pain  is  inconsidera- 
ble. When  this  ulcer  has  continued  for 
some  time,  it  either  begins  slowly  to  cica- 
trize, or  as  more  frequently  happens,  the 
discharge  diminishes  and  becomes  thicker. 
An  elevated  scab  is  next  formed,  of  a dirty 


white,  or  yellowish  colour.  This  continues 
on  the  part  a good  while  ; and  when  it  falls 
off',  leaves  the  place  covered  with  a smooth 
purple  cicatrix-  Mr.  Burns  adds,  that  the 
preceding  description  corresponds  to  the 
mild  scrofula,  or  the  struma  marisuela  of 
the  old  writers  This  gentleman  next  re- 
marks, that  occasionally,  especially  if  a 
bone  be  diseased  below  the  ulcer,  the  sore 
has  a more  liery  appearance,  the  surface  i 
dark-coloured,  the  margins  soft,  elevated, 
and  inflamed,  and  sometimes  retorted.  The 
discharge  is  watery,  the  pain  very  consider- 
able, and  the  surrounding  skin  inflamed. 
This  has  been  called  the  struma  maligna. 
Such  overacting  scrofulous  sores  are  most 
frequently  met  with  over  the  smaller  joints, 
particularly  those  of  the  toes.  (Burns.) 
Sometimes  a scrofulous  abscess,  after  it  has 
burst,  forms  a sinus  ; the  mouth  of  which 
ulcerates,  and  assumes  the  specific  scrofulous 
appearance,  w hile  the  track  of  the  sinus 
still  continues  to  emit  a discharge.  Mr. 
Burns  also  remarks,  that  scrofulous  swellings 
are  often  disposed  to  subside  in  w inter,  and 
recur  on  the  approach  of  summer;  but,  he 
adds,  that  this  is  not  an  invariable  law'. 
The  glandular  enlargements  are  very  apt  to 
become  smaller,  in  a short  time,  in  one 
place,  wrfiile  other  glandular  sw'ellings  origi- 
nate with  equal  suddenness,  somewhere  in 
the  vicinity  of  the  former  ones.  Ulcers, 
also,  very  often  heal  upon  the  appearance 
of  the  disease  in  other  parts.  (See  Disser- 
tations on  Inflammation , Vol  2,  1800.) 

The  glandular  swellings,  which  occur  in 
syphilis,  says  Dr.  Thomson,  are  of  a more 
acute  character,  than  those  wrhich  proceed 
from  scrofula.  They  arise  from  the  absorp- 
tion of  a specific  poison  ; and  they  do  not, 
like  those  of  scrofula,  admit  of  a spontane 
ouscure.  Chronic  swellings  of  the  lymphatic 
absorbent  glands  occur  also  in  carcinoma  ; 
but  these  manifest  little  or  no  disposition  to 
suppuration  ; they  succeed  most  frequently 
to  carcinomatous  indurations,  or  ulcers  ex- 
isting in  the  neighbourhood  of  the  glands 
affected  ; and  they  are  accompanied  in  their 
progress  and  grow  th  by  a peculiar  lancina- 
ting pain.  (See  Thomson  on  Inflammation , 
p.  135  ) 

With  regard  to  the  proximate  cause  oi 
scrofula,  medical  men  may  be  said  to  re- 
main, even  at  the  present  day*  ’n  entire  ig- 
norance of  it.  After  the  ridiculous  theory, 
referring  scrofula  to  certain  humours  in  the 
constitution,  or  chymical  changes  in  the 
blood,  had  been  exploded,  the  opinion  gra- 
dually arose,  that  it  was  a disease  of  the 
lymphatic  system  ; and  indeed,  that  the  ab- 
sorbent glands  are  often  visibly  the  seat  of 
its  attack,  when  no  changes  are  distinguish- 
able in  other  textures,  is  a fact,  that  admits 
of  no  dispute.  I believe,  at  the  same  time, 
that  whoever  supposes  scrofula  to  be  ex- 
clusively confined  to  the  lymphatic  system, 
must  have  a very  imperfect  conception  ot 
what  is  really  the  case.  On  the  contrary, 

I fully  participate  in  the  sentiments  of  Pro- 
fessor I homson,  already  adduced  upon  tins  • 
point,  and  in  the  belief  of  another  modem 


SCROFULA. 


•writer,  that  strumous  complaints  t{  are  not 
to  be  considered  as  dependent  on  disease  of 
any  particular  system,  as  the  lymphatic.” 
{Lloyd,  p.  10.)  Such  writers  as  have  fixed 
upon  the  absorbent  vessels,  as  the  particular 
seat  of  scrofula,  can  throw  no  useful  light 
upon  its  origin,  by  following  up  the  theory, 
whether  they  imagine  the  cause  to  be  ob- 
struction of  the  vessels  and  glands  ; or  take 
up  the  wild  speculation  of  Cabani,  that  in 
scrofula,  the  mouths  of  the  lymphatics  are 
in  a state  of  increased  activity,  while  the 
vessels  themselves  are  in  a state  of  atony  ; 
or  the  doctrine  of  Soemrnerring,  that  scro- 
fula depends  upon  a passive  relaxation  and 
dilatation  of  the  absorbents ; or  the  hypo- 
thesis of  Girtanner,  that  these  vessels  are  in 
a state  of  increased  irritability.  The  idea 
of  obstruction  being  the  cause,  has  of  late 
years  been  much  on  the  decline  ; and  that  the 
convolutions  of  lymphatic  vessels,  forming 
the  glands,  are  quite  pervious,  and  may 
readily  be  injected,  even  when  diseased,  is 
a fact,  first  demonstrated  by  Soemrnerring, 
which  must  weigh  heavily  against  this  opi- 
nion. Of  the  exciting  causes,  very  little  is 
also  known.  Mr.  John  Hunter  remarks, 
that  “ in  this  country,  the  tendency  to  scro- 
fula arises  from  the  climate,  which  is  in 
many  a predisposing  cause,  and  only  re- 
quires some  derangement  to  become  an  im- 
mediate cause,  and  produce  the  whole  dis- 
ease.” (Treatise  on  the  Venereal  Disease,  p. 
20.)  The  disease  is  remarked  to  be  most 
common  in  females  ; in  cold,  damp,  marshy 
countries,  and  in  all  places  near  high  moun- 
tains, where  the  temperature  is  subject  to 
great  vicissitudes.  “ Nous  voyons  presque 
toujours,  (says  Alibert)  que  les  tumeurs  et 
ies  ulceres  se  rouvrent  au  printemps  pourse 
fermer  ensuite  vers  la  canicule.”  (Nosol. 
Naturelle,  p.  449.) 

In  the  work  quoted  the  last  but  one,  Mr. 
Hunter  takes  notice  of  slight  fevers,  colds, 
small-pox,  and  measles,  exciting  scrofulous 
diseases.  He  observes,  that  in  particular 
countries,  and  in  young  people,  there  will 
sometimes  be  a predisposition  to  scrofula  : 
and  that,  in  such  subjects,  buboes  will  more 
readily  become  scrofulous.  ( P . 27.)  In 
short,  it  was  one  of  Mr.  Hunter’s  opinions, 
and  probably  a most  correct  one,  that  the 
venereal  disease  is  capable  of  calling  into 
action  such  susceptibilities  as  are  remarkably 
strong,  and  peculiar  to  certain  constitutions 
and  countries  ; and  that,  as  scrofula  is  pre- 
dominant in  this  country,  some  effects  of 
other  diseases  may  partake  of  a scrofulous 
nature.  (P.  96.)  Mr.  Hunter,  speaking  of 
venereal  buboes,  mentions  his  having  long 
suspected  a mixed  case,  and  add3,  I am 
now  certain  that  such  exists.  I have  seen 
j/jases,  where  the  venereal  matter,  like  a 
col.d,  or  fever,  has  only  irritated  the  glands 
1 to  disease,  producing  in  them  scrofula,  to 
which  they  were  predisposed.  In  such  ca- 
ses, the  swellings  commonly  arise  slowly, 
give  but  little  pain,  and  seem  to  be  rather 
hastened  in  their  progress,  if  mercury  is 
given  to  destroy  the  venereal  disposition, 
^ome  come  to  suppuration,  while  under 


407 

this  resolving  course  ; and  others,  which 
probably  had  a venereal  taint  at  first,  be- 
come so  indolent,  that  mercury'  has  no  ef- 
fect upon  them  ; and  in  the  end,  they  get 
well  of  themselves,  or  by  other  means.” 
(P.  269.)  For  such  buboes,  Mr.  Hunter 
used  to  recommend  sea-bathing  ; and,  in 
case  of  suppuration,  poultices  made  of  sea- 
water. 

In  the  words  of  a well-informed  Profes- 
sor, scrofula  readily  forms  an  alliance  with 
almost  every  morbid  affection,  occurring 
either  from  external  injury,  or  from  internal 
disease  ; it  modifies  the  appearance  of  other 
diseases,  and  seems  to  convert  them  gradu- 
ally into  its  own  nature.  Indeed,  there  are 
few  of  the  local  inflammatory  affections, 
which  occur  in  this  country  in  which  the 
symptoms  and  effects  of  these  affections, 
and  the  operation  of  the  food  and  remedies 
employed  for  their  cure  are  not  morn  or 
less  modified  by  the  -degree  of  scrofulous 
diathesis,  which  prevails  in  the  constitution 
of  those  who  are  affected  by  them.  The 
scrofulous  diathesis,  wherever  it  exists,  usu- 
ally gives  more  or  less  of  a chronic  charac- 
ter to  local  inflammatory  affections.  (Thom- 
son's Lectures,  p.  131.) 

It  ba-  been  the  fashion  of  late  years  to 
ascribe  the  origin  of  a vast  number  of  dis- 
eases to  disorder  of  the  digestive  organs, 
little  tro able  being  generally  taken  to  con- 
sider with  any  impartiality  whether  the  de- 
rangement of  those  organs  may  not  be 
rather  the  common  effect,  than  the  common 
cause,  of  so  many  various  diseases.  Nume- 
rous circumstances  tend  to  perpetuate  the 
delusion,  into  who  h y<  ung  practitioners  are 
falling  upon  this  topic.  They  see  various 
diseases, attended  with  dyspepsia,  flatulence, 
loss  of  appetite,  costiveness-,  and  a torpid 
state  of  the  bowels  ; they  observe  that  such 
diseases  and  the  latter  con, plaints  of  the 
alimentary  canal,  generally  diminish  toge- 
ther ; that,  when  the  functions  of  the  sto- 
mach and  bowels  are  deranged,  any  other 
diseases,  which  the  patient  may  be  labouring 
under,  either  grow  worse,  or  are  retarded 
in  their  amendment ; and,  lastly,  the  treat- 
ment, to  which  the  theory  leads,  improves 
the  health,  by  rectifying  the  state  of  the 
alimentary  canal,  and  the  sore,  tumour,  or 
other  complaint,  in  the  end,  with  the  addi- 
tional aid  of  time,  nature,  and  other  favour- 
able circumstances,  gets  well  But,  how- 
ever simple,  %safe,  and  benefioiaftbe  prac- 
tice may  be,  and  plain  as  the  facts  are 
which  lead  to  it,  there  is  no  proof,  that  the 
other  disease  was  truly  a consequence  of 
the  disorder  of  the  digestive  organs.  The 
latter  symptom  i believe,  is  very  frequently 
an  effect  mistaken  for  a cause,  and  perhaps, 
always  so,  in  relation  to  scrofula.  Besides, 
if  it  were  to  be  assumed,  (as  indeed  it  actu- 
ally is)  that,  in  scrofula  “ there  always  is 
more  or  less  disorder  of  the  digestive  or- 
gans, and  primarily  ;.f  no  other  important 
function, ” 1 do  not  see  that  we  advance  one 
step  hearer  the  truth  ;.  because  as  the  same 
cause  is  generally  assigned,  by  gentlemen 
attached  to  this  theory,  for  a vast  number 


40S 


SCROFULA. 


of  other  eases,  we  stilt  remain  in  the  dark, 
as  to  the  circumstances,  which  make  so 
many  complaints  of  different  kinds  spring 
from  one  and  the  same  cause.  These  cir- 
cumstances, though  buried  in  silence,  are 
still  the  mystery — still  the  secret  which  is 
desired  ; and,  if  it  be  answered,  that  the  ef- 
fect will  only  happen  in  particular  constitu- 
tions, then  we  are  brought  back  at  once  to 
the  point  from  which  we  lirst  started,  viz. 
that  scrofula  is  a disease  depending  upon 
some  unknown  peculiarity  of  constitution, 
congenital  or  acquired,  and  capable  of  be- 
ing excited  into  action  by  various  causes,  as 
climate,  mode  of  living,  &.c.  However, 
lest  I may  not  have  attached  sufficient  im- 
portance to  the  doctrine  of  gastric  disorder 
being  the  cause  of  scrofula,  I feel  pleasure 
in  referring,  for  the  arguments  in  its  support, 
to  the  writings  of  Mr.  Abernethy,  Dr  Car- 
michael, and  Mr.  Lloyd,  whose  sentiments 
appear  highly  commendable,  as  far  as  they 
tend  to  teach  surgeons  rather  to  place  con- 
fidence in  means  calculated  to  improve  the 
health  in  general,  as  the  most  likely  mode 
of  benefiting  the  scrofulous  patients,  than 
to  encourage  foolish  dreams  about  new  spe- 
cifics for  the  distemper.  Thus  far,  1 can 
follow  these  gentlemen  safely  ; but  no  far- 
ther, except  as  a sceptic.  However,  per- 
haps none  of  the  believers  in  the  effect  of 
disorder  of  the  digestive  organs  mean  to 
say,  that  such  disorder  is  any  thing  more 
than  one  of  the  many  exciting  causes  of 
scrofula  ; and  with  this  qualification,  then- 
theory  may,  or  may  not,  be  correct.  It  is 
the  doctrine  of  Alibert,  and  indeed  of  near- 
ly all  writers : “ ce  sont,  les  vices  de  la 
puissance  digestive,  qui  preparent  de  loin 
ies  scrophules.  Rien  n’  infiue  davantage 
sur  leur  developpcment  que  la  mauvaise 
qualite  des  alimens,  &.c.”  ( Nosol  Naturelte, 
p.  449.)  “ Ajoutez  a cet  cause  le  sejour 

dans  les  habitations  malsaines;”  But,  every 
explanation,  even  of  exciting  causes,  re- 
mains unsatisfactory,  as  long  as  we  find 
children  living  in  the  same  air,  under  the 
same  roof,  and  feeding  and  sleeping  toge- 
ther, and  clothed  also  exactly  alike,  yet, 
only  one  or  two  of  them  become  scrofulous, 
while  all  the  rest  continue  perfectly  free 
from  the  dise'ase.  Here,  then,  we  are  again 
compelled  to  return  to  predisposition,  con- 
stitution, diathesis,  and  a congenital  tenden- 
cy to  the  complaint,  as  a solution  of  the  dif- 
ficulty. In  short,  then,  respecting  the  eti- 
ology of  scrofula,  little  is  known,  except 
that  certain  constitutions  probably  have  a 
congenital  disposition  to  the  disease  ; that 
such  disposition  may  probably  be  increased, 
or  diminished,  by  the  operation  of  climate, 
mode  of  life,  age,  tkc. ; and  that  irritations 
of  a thousand  kin  s nay  excite,  the  disease 
into  action,  when  the  system  is  predisposed 
to  it,  by  inexplicable  causes.  That  otirnate 
has  great  influence  cannot  be  doubted, 
when  it  is  reflected,  that  the  inhabitarWs  of 
certain  countries,  in  which  the  temperature 
is  invariably  warm,  never  suffer  from  scro- 
fula. There  can  be  no  doubt  that,  with 


age,  the  disposition  to  scrofula  diminishes) 
for,  children  much  afflicted  while  young, 
frequently  get  quite  well  when  they  ap- 
proach the  adult  state  ; and,  if  a person 
has  remained  perfectly  free  from  any  mark 
of  a scrofulous  constitution  till  the  age  of 
twenty-five,  he  may  be  considered  as  near- 
ly  out  of  all  danger  of  the  disease. 

TREATMENT  OF  SCROFULA. 

“ For  the  cure  of  scrofula,  (says  the  cele- 
brated Cullen,)  we  have  not  yet  learned  any 
practice  that  is  certainly,  or  even  generally 
successful.  The  remedy  which  seemstobethe 
most  successful,  and  which  our  practitioners 
especially  trust  to,  or  employ,  is  the  use  of 
mineral  waters  But,  (adds  this  eminent 
physician,)  in  very  many  instances  of  the  use 
of  these  writers,  l have  not  been  well  satisfied, 
that  they  had  shortened  the  duration  of  the 
disease  more  than  had  often  happened  when 
no  such  remedy  had  been  employed.  With 
regard  to  the  choice  of  the  mineral  waters 
most  fit  for  the  purpose,  (says  Cullen,)  1 can- 
not with  any  confidence  give  an  opinion. 
Almost  all  kinds  of  mineral  waters,  whether 
chalybeate,  sulphureous,  or  saline,  have  been 
employed  for  the  cure  of  scrofula,  and  seem- 
ingly, with  equal  success  and  reputation  ; a 
circumstance,  which  leads  me  to  think,  that 
if  they  are  ever  successful,  it  is  the  element- 
ary water  that  is  the  chief  part  of  the  remedy. 
Of  late,  sea-water  has  been  especially  re- 
commended, and  employed  ; but,  after  nu- 
merous trials,  I cannot  yet  discover  its 
superior  efficacy. ” ( First  Lines  of  Physic, 

Vol.  4.)  On  the  subject  of  mineral  waters, 
Dr.  Thomson  very  properly  remarks,  that 
they  are  now  usually  employed  as  pur- 
gative and  tonic  remedies,  and  not  as  speci- 
fics. In  employing  them  it  is  often  difficult 
to  distinguish  between  the  effects,  which 
they  in  reality  produce,  and  those  which  are 
to  be  attributed  to  the  slow  operation  of 
time,  thfe  season  of  the  year,  change  of 
situation,  alteration  in  the  mode  of  life,  or 
exercise  in  the  open  air.  ( Lectures  on  Jn- 
flammatiom,  <^c.  p.  195.) 

In  scrofulous  diseases,  Dr  Fordyce  had  a 
high  opinion  of  bark  ; and  he  endeavoured  to 
prove,  that,  in  cases  of  tumefied  glands,  at- 
tended with  a feeble  habit,  and  a weak  cir- 
culation, it  is  a most  efficacious  medicine, 
and  acts  as  a resolvent  and  discutient.  He 
also  brings  forward  a case,  in  support  of  bark 
being  a means  of  cure  for  the  ophthalmia 
strumosa.  (See  Med.  Obs.  andlnq.  Vol.  \,p 
184.)  Dr  Fothergill,  in  the  same  work,  p. 
303,  writes  in  favour  of  the  good  effects 
of  bark  in  similar  cases  ; small  doses  of  ca- 
lomel bei  »g  sometimes  given  with  it. 

Dr.  Cullen  considered  the  efficacy  of  bark 
in  scrofula  very  dubious  and  trivial.  ^ First 
Lines}  fyc.  Vol.  4.) 

According  to  Mr.  Burns,  bark  has  been 
frequently  found  useful  in  the  cure  of  scro- 
fulous inflammation,  but  more  often  of  ulce- 
ration, than  tumefaction  of  the  glands.  But, 
says  he,  it  does  not  appear  to  possess,  bv  any 
means,  that  certain  power  of  curing  scrofulous 


SCROFULA. 


i u'J 


affections,  which  is  attributed  to  it  by  Dr. 
Fothergill  and  several  other  authors.  He 
observes,  that  we  are  not  to  suppose  it  will 
infallibly  cure  scrofulous  inflammation,  or 
ulceration  of  parts,  which,  even  when  af- 
fected with  simple  inflammation,  are  very 
difficult  of  cure.  If  it  be  difficult  to  cure  a 
simple  inflammation,  or  ulceration,  of  a 
rendon,  cartilage,  or  bone,  we  must  not  be 
disappointed  if  even  a specific  remedy  for 
scrofula,  (were  such  ever  discovered)  should 
prove  ineffectual  in  procuring  a speedy  re- 
storation to  health.  Mr.  Burns  contends, 
that  bark  is  often  ineffectual,  because  impro- 
perly administered.  Given  in  small  quan- 
tities, once  or  twice  a day,  it  may  prove  a 
stomachic,  and  increase,  like  other  tonic 
bitters,  the  power  of  the  stomach,  or  the 
functions  dependent  on  it ; but,  in  order  to 
obtain  the  benefits  of  the  specific  action  of 
bark,  he  maintains,  that  it  should  be  given 
in  large  quantities,  for  several  weeks,  with  a 
good  diet,  air,  and  proper  exercise. — Disser- 
tations on  Inflammation,  Vol.  2,  p.  371.)  Dr. 
Thomson  does  not  believe,  that  bark,  or  iron, 
has  any  specific  virtue  in  curing  scrofula  ; 
but,  he  admits,  that  either  of  these  medi- 
cines may  sometimes  prove  useful  in  proving 
the  tone  of  the  digestive  organs,  when  given 
after,  or  occasionally  along  with,  a course 
of  purgative  mineral  waters.  {Lectures,  p. 
197.) 

As  far  as  I can  judge,  Mr.  White  has  with 
much  reason  recommended  paying  attention 
to  such  circumstances  as  may  have  effect  in 
preventing  the  disease,  viz.  air,  cleanliness, 
exercise,  and  diet.  He  mentions  cold-bath- 
ing among  the  preventives  of  struma,  and 
speaks  of  sea-bathing  as  being  the  best.  He 
advises  attention  also  to  be  paid  to  the 
manner  of  clothing  children,  keeping  them 
more  covered  in  winter  than  summer.  Mr. 
White  thought,  that  allowing  children  to 
sleep  a great  deal  was  prejudicial ; but  this 
seems  to  me  only  conjecture. 

In  noticing  the  treatment  of  the  disease, 
Mr.  White  states,  that  “ the  general  idea  of 
the  struma  is,  that  it  is  a disease  of  debility  ; 
and  therefore,  the  great  object  is,  to  invigo- 
rate the  habit  by  every  possible  means  ; the 
chief  of  which  are  tonic  medicines,  and  sea- 
bathing. Some  are  of  opinion,  that  in  the 
case  of  young  patients,  this  should  be  con- 
tinued, during  the  summer  months,  every 
year,  to  the  age  of  fourteen  or  sixteen. 
Many  recommend  it,  not  only  in  the  sum- 
mer, but  throughout  the  year;  whilst  others 
are  for  administering  alteratives,  principally 
the  alkaline  salts,  with  or  without  anti- 
monials,  and  the  different  tonics,  during  the 
winter ; a nd  the  sea-water  and  sea-bathing,  or 
cold-bathing,  during  the  summer,  for  a conti- 
nuance of  two  or  three  years  from  the  com- 
mencement of  the  disease  ; with  this  general 
observation,  that  they  will  outgrow  the  com- 
plaint.” Mr.  White  adds,  that  the  chief  exter- 
nal means  are  fomentations  of  sea- water,  and 
cataplasms,  made  with  the  same.  With  re- 
spect to  regimen,  some  recommend  a milk 
and  vegetable  diet ; others  animal  food  and 
fermented  liquors. 

Vol,  II. 


Mr.  White  maintains,  that  the  preceding 
plans  of  treatment  are  not,  in  general,  effi- 
cacious, though,  in  some  instances,  they  may 
prove  useful.  “ In  early  affections  of  the 
lymphatic  glands,  (says  this  gentleman,)  and 
from  the  want  of  a pure  air,  and  proper 
exercise,  where  children  are  delicate  and 
irritable,  a change  of  situation  to  the  sea- 
side, together  with  bathing,  when  they  have 
acquired  some  strength,  must  be  exceeding- 
ly proper  ; and,  in  gross  plethoric  subjects, 
who  have  diseased  lymphatics,  from  impro- 
per feeding,  and  want  of  necessary  exercise, 
a journey  to  the  sea-coast  may  be  very  use- 
ful, particularly  if  the  salt-water  is  drank 
often,  and  in  a sufficient  quantity  to  become 
purgative.  This,  with  the  novelty  of  their 
situation,  which  may  naturally  produce  an 
increase  of  exercise,  might  answer  every 
expectation ; but  these  are  the  kind  of  cases 
that,  with  a very  little  attention,  are  easily 
cured.  ( White  on  the  Struma,  Edit.  3 ,p.  104.) 

The  conclusion,  to  which  Mr.  White’s  re- 
marks upon  this  part  of  the  subject  tend,  is, 
that  sea-bathing  only  deserves  praise,  as  a 
preventive,  and  in  the  early  stages  of  the 
disease.  He  particularly  condemns  cold-bath- 
ing, for  poor,  weakly,  debilitated  children, 
whose  thin  visage,  enlarged  belly,  and  fre- 
quent tickling  cough,  sufficiently  indicate 
diseased  viscera  ; such  do  not  recover  their 
natural  warmth,  after  cold-bathing,  for  hours, 
and  their  subsequent  headach,  livid  lips,  and 
pale  countenance,  are  sufficient  marks  of  its 
impropriety.  ( P . 107.) 

Dr.  Cullen  entertained  a very  favourable 
opinion  of  cold-bathing,  since  he  affirms, 
that  he  had  seen  scrofulous  diseases  more 
benefited  by  it,  than  any  other  remedy. 
( First  Lines  of  Physic , Vol.  4.) 

“ Cold-bathing,  especially  cold  sea-bath- 
ing (says  Mr.  Russell)  is  a remedy  universally 
employed  in  scrofula,  and  I believe  with 
great  advantage  in  many  cases ; for  it  not 
only  appears  to  improve  the  patient’s  gene- 
ral health  and  strength,  but  likewise  to  pro- 
mote the  tumescence  of  enlarged  glands,  and 
the  resolution  of  indolent  swellings  in  the 
joints,  even  after  they  have  attained  a 
considerable  size,  and  have  existed  for  a 
great  length  of  time.  But,  in  order  that 
cold-bathing  may  be  practised  with  safety 
and  advantage,  the  constitution  must  have 
vigour  to  sustain  the  shock  of  immersion 
without  inconvenience.  If  the  immersion  be 
succeeded  by  a general  glow  over  the  surface 
of  the  body,  and  the  patient  feels  cheerful, 
and  has  a keen  appetite,  we  may  conclude 
that  the  cold  bath  agrees  with  him  ; but  if 
he  shivers  on  coming  out  of  the  water,  con- 
tinues chill,  and  becomes  drowsy,  we  may 
be  assured  that  the  practice  of  cola-bathing 
does  no  good,  and  had  better  be  omitted. 

li  In  estimating  the  comparative  merit  of 
cold-bathing  and  warm-bathing,  in  the  cure 
of  scrofulous  complaints,  my  own  experience, 
together  with  the  result  of  different  conver- 
sations on  the  subject  with  some  of  the  most 
judicious  practitioners  of  my  acquaintance, 
would  lead  me  to  bestow  much  more  com- 
mendation on  the  effects  of  warm-bathing.  1 


52 


410 


SCROFULA. 


should  not  even  be  inclined  to  circumscribe 
the  practice  to  cases  of  emaciation  and  de- 
bility, since  from  observation,  I am  fully 
satisfied  with  regard  to  the  beneficial  etfects 
of  the  warm  bath  to  patients  of  plethoric 
constitutions,  who  were  much  affected  with 
those  swelled  scrofulous  glands.  Several  of 
instances  occurred  in  young  women,  about 
the  prime  of  life,  who  were  in  all  res- 
pects healthy  and  vigorous,  abating  the 
swellings  of  the  glands,  and  those  symptoms 
of  distress  which  were  connected  with  ful- 
ness of  blood. 

“ The  sensation  of  the  warm  bath  is  ex- 
ceedingly grateful  to  most  patients,  and  the 
practice  is  universally  safe.  It  may  be  em- 
ployed at  all  seasons  of  the  year,  and  in  all 
weather,  without  danger  or  inconvenience  ; 
the  risk  of  suffering  from  exposure  to  cold, 
immediately  after  immersion  in  the  warm 
bath,  having  been  much  magnified  by  preju- 
dice. There  is  not  even  any  good  reason  to 
believe  in  the  existence  of  such  a risk.  The 
precautions,  however,  which  are  employed 
to  avert  it,  are  perfectly  innocent ; and  pro- 
vided they  do  not  impose  any  unnecessary 
and  incommoding  restraints  upon  the  prac- 
tice, may  be  encouraged,  so  far  as  to  relieve 
the  patient’s  mind  from  uneasiness  and 
groundless  apprehensions. 

“ It  requires  many  weeks,  and  sometimes 
several  months,  to  ascertain  the  full  effects 
of  warfil-bathing  in  relieving  scrofulous  com- 
plaints ; but,  as  the  practice  is  not  attended 
with  any  inconvenience,  nor  followed  by 
any  bad  consequence,  there  can  be  no  rea- 
son to  intermit  the  course,  till  the  trial  is 
completely  satisfactory  ; and  I am  convin- 
ced, that  the  practice  of  warm-bathing,  in 
cases  of  scrofula,  will  be  more  universally 
adopted,  after  the  knowledge  of  its  benefi- 
cial effects  is  more  widely  diffused.”  (See 
Russell's  Treatise  on  Scrofula.) 

Nothing  can  be  more  satisfactory  (says 
Professor  Thomson,)  than  the  evidence 
which  is  on  record,  of  the  efficacy  of  the 
muriate  of  soda,  as  it  exists  in  sea-water.  In 
reading  this,  one  only  wonders  how  so  effi- 
cacious a remedy  should  ever  have  fallen  into 
neglect.  (P.  196.)  In  a subsequent  passage, 
however,  the  same  gentleman  evinces  only 
a limited  confidence  in  this  means  of  relief. 
u Local  sea-bathing,  both  cold  and  warm, 
has  often  appeared  to  be  of  use  in  procuring 
the  resolution  of  scrofulous  swellings.  The 
temperature  of  the  bath  must  always  be 
varied  according  to  circumstances, according 
to  the  season  of  the  year,  the  strength  and 
habits  of  the  patient,  and  the  particular 
effect,  which  the  bath  seems  to  produce.  It 
is  at  all  times  difficult  to  distinguish  between 
the  effects  immediately  arising  from  the  ap- 
plication of  salt  water  to  the  body,  and  those 
which  arise  from  the  increased  warmth  of 
temperature  in  the  bathing  seasons  of  the 
year ; from  the  exercise  which  patients 
going  to  sea-bathing  generally  take  in  the 
open  air ; from  the  change  of  situation  and 
amusements  ; and,  among  the  poorer  classes, 
from  the  more  nourishing  diet  and  exemption 
from  labour,  in  which  they  are  usually  per- 


mitted to  indulge,  during  their  residing  at 
sea-bathing  ^quarters.  It  is  not  improbable, 
that  those  living  on  the  sea-coast,  who 
become  atfected  with  scrofula,  would  for 
similar  reasons,  derive  equal  benefit  by  going 
from  the  sea-coast  to  reside  for  a time 
in  the  interior  of  the  country.”  (See  Thom - 
son’s  Lectures,  fyc.  p.  203,  204.)  A still 
later  writer  declares  his  belief,  that  cold 
sea-bathing  has  no  specific  power  over  the 
disease.  ( Lloyd  on  Scrofula,  p.  43.)  Yet 
the  plain  surgeon,  in  search  of  practical 
truths,  will  not  care  whether  any  plan  has 
a specific  power  or  not  over  a complaint,  if 
that  disorder  is  sometimes  relieved  by  it. 
And,  that  this  is  the  fact  is  admitted  by  Mr. 
Lloyd,  when  he  says,  u cold  sea-bathing, 
however, is  certainly  useful  when  judiciously 
applied,  &c.  &c.-’  (P.44.) 

With  regard  to  electricity,  Mr.  While 
thinks  it  useful,  when  from  length  of  time 
the  enlarged  glands  have  acquired  a degree 
of  hardness  and  insensibility. 

Mr.  White,  after  enjoining  attention  to 
air,  exercise,  and  diet,  as  promotive  of  a 
recovery,  as  well  as  a preventive  of  the 
disease,  proceeds  to  explain  his  own  prac- 
tice. The  internal  cases,  which  properly 
belong  to  the  physician,  we  shall  dismiss 
from  consideration.  The  first  external 
symptoms,  such  as  swellings  of  the  lips, 
side  of  the  face,  and  of  glands  under  the 
chin,  and  round  the  neck  ; also  other  symp- 
toms, usually  considered  as  strumous,  viz. 
roughness  of  the  skin,  eruptions  on  the  back 
of  the  hand,  and  different  parts  of  the  body, 
redness,  and  swelling  of  the  eyelids,  and 
eyes  ; are  accompanied,  according  to  Mr 
While’s  conceptions,  with  an  inflammatory 
diathesis,  though  seldom  such  a one  as  to 
require  bleeding.  Calomel  is  the  medicine, 
which  this  gentleman  recommends  for  the 
removal  of  the  foregoing  complaints.  It  is 
not  to  be  given  in  such  quantities,  as  to 
render  it  a powerful  evacuant,  either  by  the 
intestines,  or  any  other  way;  but,  in  small 
doses,  at  bedtime.  Thus,  says  Mr.  White, 
“ it  remains  longer  in  the  intestinal  canal, 
a greater  quantity  is  taken  into  the  habit, 
and  the  patient  is  less  susceptible  of  cold, 
than  when  taken  in  the  daytime.  The  first, 
and,  perhaps,  the  second  dose  may  prove 
purgative,  which  is,  in  general,  a salutary 
effect;  but,  afterward,  the  same  quantity 
will  seldom  do  more,  than  is  sufficient  to 
keep  the  body  open  ; and  should  it  fail  of 
answering  that  purpose,  I have  usually  re- 
commended some  gentle  purgative,  every 
third  or  fourth  morning,  according  to  cir- 
cumstances. If  there  should  be  a prevail- 
ing acidity,  a few  grains  of  the  sal  sodec, 
magnesia,  or  some  testaceous  powder,  may 
be  added  to  the  medicine.  By  this  simple 
method  (continues  Mr.  White)  most  of  the 
symptoms  before  mentioned  will,  in  a short 
time,  disappear;  but  if  the  tumours  should 
continue  hard,  and  retain  their  figure,  with- 
out dividing  into  smaller  ones,  we  may  de 
rive  some  benefit  from  external  applications, 
particularly  the  steam  of  warm  water.  I 
have  used  a variety  of  medicinal  herbs  with 


SCROFULA. 


41  j 


success;  but  am  inclined  to  believe,  that 
the  advantage  was  principally  derived  from 
the  warm  water,  kc.  At  other  times,  I 
have  stimulated  the  part  affected  with  elec- 
tricity, insulating  the  patient,  and  drawing 
sparks  from  the  tumour,  until  a slight  de- 
gree of  inflammation  was  excited.  After 
the  application  of  the  steam,  or  the  use  of 
the  electrical  machine,  I have  sometimes 
rubbed  a little  of  the  unguentum  mercuriale 
into  the  tumour,  and  neighbouring  parts,  or 
applied  the  emplastrum  saponaceum,  or 
mercuriale  cum  ammoniaco,  over  the  swell- 
ing, or  a liniment  with  camphor,  ol.  oliva- 
rum,  and  sp.  terebinth.”  Mr.  White  adds, 
that  in  such  cases,  if  the  tumours  should 
suppurate,  and  burst,  the  parts  will,  in  most 
instances,  heal  without  much  trouble.  For 
eruptions  on  the  head,  he  recommends  ap- 
plying the  ung.  saturn.  album  camphoratum, 
or  the  cerat.  alb.  cum  hydrarg.  prrecip.  alb. 
For  the  roughness  of  the  skin,  which  is  ge- 
nerally followed  by  eruptions,  he  also  ad 
vises  the  aqua-vegeto-mineralis,  aqua  calcis, 
solutions  of  sal.  tartar,  or  of  the  hydrarg. 
raur.  as  outward  applications.  “ This  last 
(says  Mr  White)  will  seldom  fail  to  check 
the  progress  of  the  complaint,  and  dry  the 
sores  ; and  in  the  quantity  of  ten  or  twelve 
grains,  to  a quart  of  warm  water,  the  use  of 
it  will  not  be  productive  of  any  pain.  If 
the  eruption  should  ulcerate,  and  require 
any  unctuous  application,  to  prevent  the 
adhesion  of  the  linen,  the  ointment  before- 
mentioned  may  be  applied  ;.  the  best  re- 
medy will  be  warm-bathing,  and  when  prac- 
ticable, the  sea- water  claims  a preference.” 
(P.  114)  The  author  next  mentions  his 
having  occasionally  recommended  the  vi- 
num  antimoniale,  tartarum  emeticum,  de- 
coctum Lusitanicum,  decoctum  lignorum, 
or  sarsaparillae  ; and  that  he  sometimes 
found  advantage  derived  from  artificial 
drains.  We  need  not  detail  this  gentleman’s 
mode  of  treating  affections  of  the  eyelids, 
as  notice  is  taken  of  scrofulous  diseases  of 
the  eye  and  eyelids,  in  the  articles  Ophthal- 
my  and  Psorophlhalmy. 

For  the  cure  of  indurations  in  the  breast, 
remaining  after  mammary  abscesses,  Mr. 
White  speaks  very  highly  of  the  effects  of 
the  steam  of  warm  water;  and  cautions  us 
against  indiscriminately  employing  calomel, 
which  will  often  affect  the  mother  little,  but 
the  child  violently.  Mr.  White  mentions 
his  employing  a small  tin  machine,  large 
enough  to  hold  a pint  and  a half,  or  two 
pints  of  boiling  water.  From  the  top  pro- 
ceeded a narrow  tube,  ten,  or  twelve  inches 
long,  through  which  the  steam  passed. 
.Near  its  end,  which  was  moveable  and 
curved,  was  a joint,  for  the  greater  conve- 
nience of  directing  the  steam  to  the  diseased 
parts.  The  water  was  easily  kept  boiling, 
by  means  of  a lamp  under  the  machine. 
Mr.  White  says,  that  the  steam  should  be 
employed  twice,  or  thrice  a day,  and  a piece 
of  flannel,  or  skin,  afterward  applied.  The 
body  should  also  be  kept  open.  In  obsti- 
nate, neglected  cases,  mercurial  prepara- 
tions, according  to  Mr.  White,  must  likewise 


be  given,  and,  if  they  affect  the  child  much, 
sucking  should  be  suspended.  (P.  117.118.) 

Mr.  White  speaks  largely  of  the  treatment 
of  cases,  in  which  the  mesenteric  glands 
are  diseased  ; but,  this  subject  strictly  be- 
longs to  the  physician.  When,  in  these  in- 
stances, the  glands  of  the  neck,  or  other 
parts  of  the  body,  tend  to  a state  of  suppu- 
ration, it  is  very  slowly,  the  skin  appearing 
uniformly  thin,  and  of  a deep  red  colour, 
and  the  tumour  seeming  flaccid.  In  such 
cases,  Mr.  White  recommends  the  use  of  the 
lancet  or  caustic  ; for  if  no  artificial  open 
ing  is  made,  it  will  be  a long  time  before 
the  skin  gives  way;  and  when  it  does,  the 
aperture  will  not  only  be  very  small,  but 
often  unfavourable  in  its  situation.  Mr. 
White  adds,  that  the  contents  will  often  be 
more  like  mucus  than  pus,  or  like  a mixture 
of  both ; and  the  discharge  wili  continue  for 
a great  length  of  time,  if  no  remedy  is  ap- 
plied. This  gentleman  mentions  his  having 
found  a solution  of  gum  myrrh®  in  aqua 
calcis,  used  as  a lotion,  and  the  ceratum 
saponaceum,  or  some  similar  outward  ap- 
plication, the  best  method  of  treating  this 
symptom. 

We  need  not  describe  Mr.  White’s  prac- 
tice in  the  treatment  of  scrofulous  joints,  as 
the  subject  is  fully  considered  in  the  article 
Joints.  It  appears,  however,  that  he  con- 
firms the  efficacy  of  stimulating  applications, 
and  pressure  with  bandages,  w hen  the  fin- 
gers and  toes  are  affected  with  strumous 
disease.  (P.  143.) 

Whoever  compares  the  practice  of  Mr. 
White  in  administering  calomel,  occasional 
purgatives,  the  decoctum  Lusitanicum  sar- 
saparilla, kc.  with  the  blue-pill,  sarsaparilla, 
and  laxative  treatment  of  the  present  day, 
will  perceive  no  very  material  difference 
between  them,  especially  when  the  stress, 
which  Mr.  White  laid  upon  attention  to 
diet,  clothing,  &,c.  is  taken  into  the  account. 
Mr.  Lloyd,  who  has  detailed  Mr.  Abernethy's 
practice  in  scrofula,  lays  it  dow  n as  an  ax- 
iom, that  “ the  disease  is  only  to  be  cured 
by  avoiding  all  sources  of  irritation,  and  re- 
storing the  natural  and  healthy  functions  of 
the  digestive  organs.”  ( P . 48.)  By  sources 
of  irritation,  Mr.  Lloyd  means  exciting 
causes  ; the  advice  is  therefore  excellent,  as 
far  as  it  can  be  followed,  or  such  causes 
are  decidedly  known.  The  restoration  of 
the  functions  of  the  digestive  organs  is  also 
a tiling  worth  aiming  at,  and  the  only  dif- 
ference in  my  views  from  those  of  Mr. 
Lloyd  is,  that  as  I look  upon  the  disorder 
of  the  digestive  organs  to  be  in  general  only 
a complication,  or  effect  of  the  scrofulous 
disease,  ulcer,  abscess,  diseased  joint,  kc. 
and  not  the  exciting  cause,  the  treatment, 
when  beneficial,  becoming  so  only  on  the 
principle  of  improving  the  general  health, 
by  the  removal  or  diminution  of  one  of  the 
most  hurtful  consequences  of  the  original 
disease.  It  is  hardly  necessary  to  inform 
the  profession,  that  the  treatment,  described 
by  Mr.  Lloyd,  in  addition  to  the  usual  ad- 
vice about  diet,  clothing,  the  avoidance  of 
damp  and  cold,  and  the  utility  of  good  air. 


SCROFULA. 


4j2 


exercise,  &c.  consists  in  giving  the  patient 
five  grains  of  the  pil.  hydrarg.  every  night, 
and  half  a pint  of  decoct,  sarsap.  c.  twice  a 
day.  And,  if  at  a certain  hour  of  the  day, 
there  has  been  no  motion,  recourse  is  had 
to  opening  medicines.  This  plan  is  pur- 
sued, till  the  bowels  become  regular;  and 
then,  with  the  view  of  preventing  a relapse 
of  the  bowels  into  their  former  state,  Mr. 
Lloyd  continues  the  exhibition  of  alterative 
doses  of  mercury  for  an  indefinite  time,  the 
preference  being  given  to  the  compound 
calomel  pill,  in  doses  of  five  grains  every 
night.  In  children,  the  practice  is  exactly 
like  that  of  Mr.  White,  viz.  small  doses  of 
calomel  with  purgatives.  When  acidity 
prevails  in  the  stomach,  small  doses  of  soda 
are  commended  ; and  when  the  stomach  is 
weak,  with  loss  of  appetite,  cinchona,  steel, 
and  mineral  acids.  A full  diet,  with  porter 
and  wine,  is  disapproved  of,  and,  as  already 
stated,  not  much  confidence  is  placed  in 
sea-bathing.  ( Lloyd  on  Scrofula,  p.  38.) 

Crawford,  Pinel,  and  others,  have  tried 
the  muriated  barytes,  as  a remedy  in  scro- 
fulous cases.  (Med.  Communications,  Vol.  2. 
JYosogr.  Philo sophique,  Pol.  2.  p.  238.)  It 
has  the  recommendation  of  the  celebrated 
Hufeland.  Mr.  Burns  says,  that  the  muriate 
of  barytes  has  no  effect  on  diseased  glands  ; 
but  that  it  is  occasionally  serviceable  in 
scrofulous  ulceration,  though  he  adds  that 
it  deserves  little  dependence.  ( Dissert . on 
Inftam.  Vol.  2,  p.  372.)  This  gentleman  re- 
commends the  following  formula  : fy.  Terrae 
Ponder.  Salit.  Chryst.  gr.  x.  Aq.  Font.  Aq. 
Cassiae,  utriusque,  ^iij.  Syrup.  Aurent.  ^ij. 
Half  an  ounce  of  this  may  be  given  at  first 
twice  or  three  times  a day,  and  gradually 
increased  to  such  quantity,  as  the  stomach 
can  bear  without  sickness.  At  present  few7 
practitioners  have  any  faith  in  the  antiscro- 
fulous  virtues  of  the  muriate  of  barytes ; 
and,  as  Dr.  Thomson  remarks,  it  has  had  a 
much  shorter-lived  reputation  than  sea- 
water, or  its  successor  the  muriate  of  lime. 
(See  Lectures  on  Inflammation,  p\  196.) 

Fourcroy  proposed  trying  the  muriate  of 
lime  ; but  its  efficacy  is  very  doubtful,  and 
inconsiderable.  “ Professor  Thomson  (says 
Mr.  Russell)  has  favoured  me  with  the  fol- 
lowing observations  on  the  effects  of  muri- 
ate of  lime.  He  employed  muriate  of  lime 
in  various  cases  of  scrofula,  without  having 
derived  benefit  from  it  in  a single  instance. 
Some  patients, indeed,  he  admits,  got  well, 
while  under  a course  of  muriate  of  lime  ; 
but  then  he  had  no  reason  to  ascribe  the 
cure  to  the  effect  of  the  medicine.  In  other 
cases,  on  the  contrary,  the  muriate  of  lime 
produced  severe  sickness  and  oppression  at 
the  stomach,  and  the  patients  got  daily 
worse,  till  the  muriate  of  lime  w as  intermit- 
ted, and  other  medicines  employed.  The 
relief  experienced  from  the  intermission  of 
the  muriate  of  lime,  left  no  doubt  with  re- 
gard to  the  injurious  effects  which  the  use 
of  it  had  produced  ; and  from  extensive  ex- 
perience and  accurate  observation  on  the 
subject,  Professor  Thomson  is  satisfied,  that 
muriate  of  lime  is  attended  writh  prejudicial 


effects  in  many  cases  ot  scrofula. ' (See 
Russell's  Treatise  on  Scrofula.)  Since  the 
publication  of  the  last  edition  of  this  Dic- 
tionary, I have  seen  the  muriate  of  lime 
given  in  several  cases  of  scrofula  ; hut  with- 
out any  beneficial  effect  on  the  disease. 
How  long  the  muriate  of  lime  will  be  per- 
mitted to  enjoy  its  present  fame,  Dr.  Thom- 
son will  not  venture  to  say  ; but  from  what 
he  has  seen  of  its  use,  he  imagines  its  repu- 
tation will  only  last,  till  some  other  new 
remedy  is  proposed  by  those,  who  are  still 
sanguine  in  their  hopes  of  discovering  a 
specific  for  scrofula.  (Lectures,  tyc.  p.  196.) 
Iron,  given  either  alone,  or  joined  with  the 
fixed,  or  volatile  alkali,  also  deserves  very 
little  confidence.  Burnt  sponge,  millipedes, 
and  sulphate  of  jspotassa,  have  all  been  ex- 
tensively tried  ; the  first  of  these  is,  in  my 
opinion,  sometimes  useful  in  diminishing 
enlarged  scrofulous  glands  ; and  that  it  has 
this  effect  on  bronchoceles,  is  indisputable. 

The  Mariscbal  de  Rougeres  employed  a 
remedy  composed  of  iron  filings,  muriate  of 
ammonia,  subcarbonate  of  potassa,  &c. 
(Journ.  de  Med.  tom.  40,  p.  219.) 

Several  narcotics  have  been  tried,  such 
as  opium,  hyoscyamus,  the  solanum  dulca- 
mara, &.c. ; but,  though  their  virtues  against 
scrofula  have  been  sometimes  cried  up  very 
highly,  the  moderns  have  lost  all  faith  in 
them.  The  attention  of  the  public  to  the 
effects  of  cicuta,  in  cases  of  cancer  and 
scrofula,  was  first  particularly  excited  by 
the  accounts  of  its  virtues  published  by  Ba- 
ron Stork. 

Fothergill  also  praises  cicuta,  and  per- 
haps it  is  as  good  an  internal  medicine  as 
can  be  tried  ; but  it  is  far  from  being  gene- 
rally efficacious.  It  is  highly  deserving  of 
recommendation  for  irritable  scrofulous  ul- 
cers. There  is  now  not  the  least  doubt, 
however,  that  the  statements  of  Baron 
Stork  are  greatly  exaggerated.  He  consi- 
dered cicuta  indicated,  whenever  obstruc- 
tions and  tumours  existed  ; and,  under  this 
treatment,  he  says  that  he  found  the  swell- 
ings melt  aw^ay  like  ice.  What  is  extraor- 
dinary, every  sort  of  tumour  yielded  to  ci- 
cuta. But,  (as  Dr.  Thomson  judiciously  re- 
marks) universal  success  is  alwrays  one  of 
the  most  suspicious  circumstances,  which 
can  be  mentioned  in  the  history  of  the  ef- 
fects produced  by  any  new'  remedy.  (Lec- 
tures, fyc.  p.  199.)  Dr.  Cullen  frequently 
employed  hemlock,  and  sometimes  found  it 
useful  in  discussing  obstinate  swellings  ; 
but,  he  says,  it  also  frequently  disappointed 
him,  and  he  never  saw  it  dispose  scrofulous 
ulcers  to  heal. 

With  regard  to  mercury,  we  have  already 
noticed,  that  calomel  was  much  employed 
by  Mr.  White.  Some  have  exhibited  the 
sublimate  : others  the  acetite  of  mercury. 
All  these  preparations  have  been  at  times 
conjoined  with  cicuta,  antimony,  &io.  Ca- 
lomel is,  perhaps,  the  best  mercurial  prepa- 
ration in  scrofulous  cases;  but  mercury, 
given  internally  with  any  view  of  exciting 
a salivation,  is  justly  deemed  hurtful  by  all 
the  best  practitioners.  As  ap  alterative,  and 


SCROFULA 


413 


an  occasional  purgative,  it  is  undoubtedly  a ly  against  antimony.  As  a modern  writer 
good  medicine  for  strumous  patients.  Mer-  observes,  no  great  dependence  seems  ever 
cury  was  much  disapproved  of  by  the  to  have  been  placed  in  the  use  of  diaphoretic 
celebrated  Cullen,  as  a medicine  for  scrofu-  medicines  for  the  cure  of  scrofula.  The 
Ja.  As  a distinguished  Professor  observes  : different  preparations  of  antimony,  indeed, 
“From  the  great  apparent  similarity  of  the  have  been  occasionally  administered  ; but 
symptoms,  progress,  and  seats  of  scrofula,  chiefly  in  cutaneous  affections,  supposed  to 
to  those  of  syphilis,  and  from  the  well-  he  of  a scrofulous  nature.  Guaiacum,  sar- 
known  effects  of  mercury  in  curing  syphilis,  saparilla,  sassafras,  and  mezereon,  singly, 
it  need  not  seem  strange,  that  medical  men  and  in  combination,  have  all  been  supposed 
should  have  been  a little  obstinate  in  their  to  be  useful  in  the  cure  of  scrofula  ; but 
attempts  to  obtain  benefit  from  the  use  of  they  are  now  seldom  given  with  this  view, 
mercury  in  scrofula.  These  expectations  except  in  cases  of  scrofula  combined  with 
are  in  general  abandoned,  and  mercury  is  syphilis,  or  excited  by  the  too  free  and 
now  given  for  the  cure  of  scrofula  as  a injudicious  use  of  mercury.  ( Thomson's 
purgative  only.  Along-continued,  or  ini-  Lectures,  fyc.  p.  199.) 

properly-administered  course  of  this  medi-  With  respect  to  Alibert’s  practice,  among 
cine,  has  often  been  known  to  aggravate  all  the  vegetable  bitters,  he  prefers  the  hop, 
the  symptoms  of  scrofula;  and,  in  many  burdock,  gentian,  and  bark.  He  seems  to 
instances,  to  excite  these  symptoms  in  have  no  confidence  in  specifics,  like  hem- 
persons,  in  whom  they  did  not  previously  lock,  belladonna,  aconitum,  &.c.  Neither 
exist.”  (See  Thomson's  Lectures  on  Infiam-  does  he  express  himself  favourably  of  alka- 
motion,  p.  194,  195.)  line  medicines,  the  muriate  of  ammonia, 

Mr.  Burns  thinks  the  nitrous  acid  has  and  the  muriate  of  barytes.  However,  he 
some  effect  in  promoting  the  suppuration  of  praises  the  good  effects  of  steel  medicines 
scrofulous  glands  and  tumours,  and  disposing  on  enlarged  glands.  He  affirms,  that  he  has 
ulcers  to  heal.  He  says,  two  or  three  drams  seen  most  good  derived  from  external  means ; 
may  be  given  every  day,  for  a fortnight ; aromatic  fumigations  in  an  apparatus  prepa- 
but  if  in  this  time  it  should  do  no  good,  its  red  by  the  cbymist  Darcet.  What  he  calls 
employment  ought  to  be  discontinued.  The  scrofulous  eruptions,  he  covers  with  a 
mineral  acids,  diluted  with  water,  (says  Pro-  strong  solution  of  the  nitrate  of  silver, 
fessor  Thomson,)  are  often  used  with  views  Swelled  glands  he  rubs  with  the  antimonial 
similar  to  those,  which  guide  us  in  the  em-  ointment.  He  commends  also  change  of 
ployment  of  tonic  remedies.  Their  medici-  air,  and  the  avoidance  of  low  damp  places  ; 
nal  powers  appear  to  be  nearly  the  same  ; and  speaks  favourably  of  sea-bathing,  sea 
but  the  nitric  acid  has  of  late  been  preferred,  voyages,  sulphureous  mineral  waters,  and 
particularly  in  the  scrofulous  affections,  particularly  of  the  good  effects  derived  from 
which  are  sometimes  induced  by  the  action  the  solar  warmth.  (See  Nosol.  JVat.  p.  449.) 
of  mercury.  {Lectures,  fyc.  p.  197.)  The  local  treatment,  preferred  by  Mr. 

The  pills  containing  carbonate  of  soda,  White,  has  been  already  described.  I hav« 

(see  Pilulce,)  and  the  different  soda  waters,  only  a few  words  to  add  concerning  this 
sold  at  the  shops,  have  repute,  for  their  good  part  of  the  subject.  Dr.  Cullen  states,  that, 
effects  on  scrofulous  constitutions  and  dis-  in  his  practice,  he  had  very  little  success  in 
eases.  A spirituous  infusion  ot  gentian,  into  discussing  incipient  scrofulous  tumours  bv 
six  ounces  of  which  are  put  thirty-six  grains,  topical  applications  ; and  that  a solution  of 
of  the  carbonate  of  soda,  or  the  same  quan-  the  saccharum  saturni,  though  sometimes 
tity  of  the  carbonate  of  ammonia,  is  a useful,  more  frequently  failed.  Dr.  Cullen 
medicine  highly  spoken  of  by  Richerand  found  the  aqua  ammonias  acet.  not  more 
for  scrofulous  cases.  (Nosogr.  Lhir.  T.  1,  p.  successful.  “ Fomentations  of  every  kind 
184,  Ed.  4.)  (says  he)  have  been  frequently  found  to  do 

Potassa  in  large  doses,  with  mercurial  harm  ; and  poultices  seem  only  to  hurry  on 
frictions,  is  the  practice  lately  extolled  by  a suppuration.  1 am  doubtful  if  this  last 
Mr.  Farr;  but  it  appears  to  me,  that  mer-  be  ever  practised  with  advantage;  forscro- 
cury  and  potassa  had  been  repeatedly  tried,  fulous  tumours  sometimes  spontaneously 
long  before  this  author  delivered  his  senti-  disappear,  but  never  after  any  degree  of 
ments  to  the  public  ; and  that  such  practice  inflammation  has  come  upon  them;  and 
cannot  be  entitled  to  be  called  a method  therefore,  poultices,  which  commonly  in- 
for  the  eradication  of  the  disease.  (See  duce  inflammation,  prevent  that  discussion 
Farr  on  Scrofula,  8vo.  Lond.  1820.)  of  tumours,  which  might  otherwise  have 

According  to  Mr.  Burns,  eight  or  ten  happened.”  Even  when  scrofulous  tumours 
drops  of  hydrosulphuret  of  ammonia,  given  have  advanced  towards  suppuration,  Dr. 
thrice  a day,  are  useful  in  irritable  strumous  Cullen  thought,  that  hastening  the  sponta- 
ulcers.  The  breathing  of  oxygen  gas  has  neous  opening,  or  making  one  with  a lancet,  % 
oeen  proposed;  but  of  this  plan  l know  was  hurtful. 

nothing  from  experience,  and,  as  it  now  With  respect  to  ulcers,  Dr.  Cullen  re 
makes  less  noise  in  the  world  than  formerly,  marks,  that  escharotic  preparations,  of  either 
1 conclude  that  either  its  usefulness  has  been  mercury,  or  copper,  have  been  sometimes 
exaggerated,  or  the  difficulty  of  the  practice  useful  in  bringing  on  a proper  suppuration, 
is  too  great  to  allow  of  its  extensive  adop-  and  thereby  disposing  the  ulcers  to  heal ; 
lion.  but  they  have  seldom  succeeded,  and  more 

The  sentiments  of  Dr.  Cullen  are  decided-  commonly,  they  have  caused  the  ulcer  * 


4B  /vSCBOFULA. 


spread  more.  The  escharotic,  from  which 
Cullen  saw  most  benefit  result,  is  burnt 
alum,  mixed  with  some  mild  ointment. 
But  this  celebrated  writer  gives  the  prefer- 
ence to  keeping  the  sores  continually  co- 
vered with  linen  wet  with  cold  water  in  the 
daytime,  and  some  ointment  or  plaster  at 
night.  Cullen  says,  that  he  usually  found 
sea-water  too  irritating,  and  no  mineral 
water  better  than  common  water.  ( First 
Lines  of  the  Pract.  of  Physic , Vol.  4.) 

Formerly,  the  extirpation  of  scrofulous 
tumours  was  advised  ; but  this  method  is 
now  considered  as  being,  for  the  most  part, 
injudicious  and  unnecessary,  with  the  ex- 
ception of  diseased  joints,  and  a few  other 
parts,  which  frequently  require  being  am- 
putated for  the  sake  of  saving  the  patient’s 
fife.  Certainly,  no  particular  danger  (gene- 
rally speaking)  would  attend  cutting  out 
scrofulous  glands  and  tumours;  the  objec- 
tions to  the  plan  are  founded  on  the  pain  of 
the  operation ; on  the  number  of  such 
glands  frequently  diseased ; on  their  often 
subsiding,  either  spontaneously,  or  by  surgi- 
cal treatment ; on  the  operation  doing  no 
good  to  the  general  affection  of  the  system, 
&x.  When,  however,  a scrofulous  testicle, 
breast,  or  joint,  seriously  impairs  the  health, 
and  endangers  life,  the  very  existence  of 
the  patient  demands  the  immediate  removal 
of  the  diseased  part.  W iseman  relates,  that 
he  was  in  the  habit  of  cutting  out  scrofulous 
glands  and  tumours  with  great  success  ; but 
for  reasons  already  alleged,  most  of  the 
moderns  think  such  operations  in  general  at 
least  unnecessary. 

Caustics  have  been  employed  for  the 
same  purpose,  instead  of  the  knife ; but,  as 
they  effect  the  object  in  view  less  certainly, 
more  painfully  and  tediously,  and  cause 
extensive  ulcers,  they  are  disused  by  all  th£ 
best  surgeons  of  the  present  day. 

Some  authors  have  advised  making  issues, 
and  keeping  them  open,  in  order  to  prevent 
any  ill  effects  from  healing  scrofulous  ulcers. 
Issues  are  certainly  quite  unnecessary  for 
any  purpose  of  this  kind  ; but  they  are  emi- 
nently useful  as  a part  of  the  local  treatment 
of  scrofulous  joints  and  abscesses,  as  we 
have  more  particularly  explained  in  the  ar- 
ticles Joints , Lumbar  Abscess , and  Vertebra. 

Mr.  Burns  notices,  that  issues  have  hither- 
to been  chiefly  used  in  diseases  of  the  bones 
and  joints  ; hut  he  adds,  that  it  is  reasonable 
to  suppose  that  they  ought  likewise  to  be  use- 
ful in  the  cure  of  enlargements  of  the  glands, 
and  other  scrofulous  tumours,  if  inserted  in 
the  immediate  vicinity  of  the  part.  The 
only  objection  to  their  use  is  the  scar  which 
they  leave,  and  which,  in  certain  situations, 
one  would  particularly  wish  to  avoid.  When 
the  tumour  is  thickly  covered  with  the  in- 
teguments, the  issue  may  be  made  directly 
over  it,  and  kept  open  with  the  savine  oint- 
ment. In  other  cases,  a small  pea  issue  or 
seton  may  be  inserted  by  the  side  of  the 
tumour.  This  method  would  be  objection- 
able, for  scrofulous  glands  in  the  neck,  in 
consequence  of  the  scar;  but  it  might  be 
employed  when  the  mamma  is  disused. 


(Dissertations  on  Inflammation,  Vol.  2.)  The 
late  Mr.  Crowther  used  to  apply  blisters  to 
scrofulous  swellings,  and  maintain  a dis- 
charge from  the  part.  And  a more  modern 
practice  is  that  of  producingjj  irritation  of 
the  integuments,  covering  tumours  and 
abscesses,  by  means  of  the  tartar  emetic 
ointment.  ( Alibert  Nosol.  Naturtlle,  p.  449  ; 
Goodlad  on  Diseases  of  the  Absorbents,  p.  162, 
fyc.) 

Preparations  of  lead;  cloths  dipped  in 
cold  water,  sea-water,  or  weak  vegetable 
acids  ; aether  ; sea-salt  mixed  with  bile  ; 
the  linimentum  camphorae ; a mixture  of 
aether  and  the  linimentum  opiatum ; and 
hemlock  poultices  ; form  a long  list  of 
applications,  which  have  been  employed  for 
scrofulous  tumours. 

According  to  Mr.  Burns,  moderate  pres- 
sure, by  means  of  adhesive  plaster,  con- 
joined with  the  application  of  cold  water, 
is  one  of  the  best  plans  of  treating  mild 
scrofulous  ulcers,  when  their  situation  ad- 
mits of  it.  In  other  cases,  he  recommends 
applying  a powder,  five  parts  of  which 
consist  of  cerussa  acetata,  and  the  sixth  of 
burnt  alum.  A piece  of  dry  lint  is  next  to 
be  applied,  and  a compress,  with  such  pres- 
sure as  can  be  used.  Benefit  occasionally 
results  from  dipping  the  compress  in  cold 
water. 

The  ceratum  e lapid.  calamin.  is  a good 
common  dressing,  when  it  is  wished  not  to 
interfere  much  with  the  progress  of  the 
ulcer.  The  ung.  hydrarg.  nitrat.  rub.  and 
the  ung.  hydrarg.  nitrat.  are  the  best  stimu- 
lating ointments.  Poultices  of  bread  and 
sea-water;  solutions  of  alum,  cuprum  vi- 
triolatum,  and  the  hydrarg.  mur. ; solutions 
of  the  nitrates  of  copper,  bismuth,  and 
silver ; the  recent  leaves  of  the  wood-sorrel 
bruised  ; lint  dipped  in  lemon-juice,  or 
vinegar  and  water  , are  among  the  applica- 
tions to  common  scrofulous  ulcers. 

For  irritable  sores,  diluted  hydrosulphuret 
of  ammonia  ; ointments  containing  opium  ; 
carrot  and  hemlock  poultices  ; a solution  ot 
opium;  and  carbonic  acid  gas;  are  com- 
monly recommended.' 

The  following  are  Mr.  Russell’s  sentiments 
respecting  the  treatment  of  scrofulous  ul* 
cers  : “ Scrofulous  complaints  in  general  do 
not  agree  well  with  stimulant  applications, 
la  the  treatment  of  scrofulous  ulcers,  under 
the  ordinary  circumstances  ot  complaint, 
the  simplest  and  mildest  dressings  answer 
best.  When  the  patients  are  using  a course 
of  sea-bathing,  it  is  usual  to  wash  the  sores 
with  sea-water,  over  and  above  the  momen- 
tary application  of  the  sea-water  during  the 
immersion  of  the  whole  body.  Cold  spring- 
water  is  likewise  a favourite  application  with 
many  practitioners;  and  from  much  obser- 
vation, it  appears  that  the  operation  of  cold 
is  well  suited  to  counteract  the  slate  of  in- 
flammation, which  accompanies  scrofulous 
sores.  Preparations  of  lead  are,  upon  the 
whole,  very  convenient  and  useful  applica- 
cations,  provided  the  solutions  be  used  in  a 
state  of  sufficient  dilution  to  prevent  irrita- 
tion Liquid  applications  are  applied  by 


means  of  wet  linen,  which  is  renewed 
whenever  it  dries,  so  that  the  suiface  of  the 
sore  may  be  kept  constantly  moist  when  un- 
der this  course  of  management.  Upon  the 
same  principle,  simple  ointment  and  Gou- 
lard’s cerate,  furnish  the  best  dressing  in 
ordinary  cases. 

“ Scrofulous  congestions,  of  a solid  na- 
ture, in  the  more  external  parts  of  the  body, 
are  little  adapted  to  the  practice  of  local 
bleeding,  unless  they  be  attended  with 
symptoms  of  inflammation  ; but  as  some 
degree  of  inflammation  is,  in  general,  pre- 
sent during  the  incipient  stage,  it  may  be 
prudent  to  employ  local  bleeding  in  modera- 
tion at  the  commencement  of  the  attack, 
although  there  may  be  no  indication  to  per- 
sist in  the  practice,  after  the  complaint  has 
advanced  farther  in  its  progress.  If,  how- 
ever, these  congestions  are  more  of  an  indo- 
lent nature,  unaccompanied  with  heat  or 
pain,  there  is  no  benefit  to  be  expected  from 
the  local  detraction  of  blood ; warm  fo- 
mentations, together  with  the  use  of  stimu- 
lants, and  a repetition  of  blisters,  are  the 
most  serviceable  class  of  remedies  : such 
cases,  too,  are  the  best  adapted  to  the  use 
of  friction  as  a discutient.  Friction,  indeed, 
has  long  been  employed  for  this  purpose  ; 
but,  of  late  years,  it  has  been  introduced  to 
an  extent,  and  with  an  effect,  far  beyond 
the  experience  of  all  former  practice.  As 
yet  it  has  been  circumscribed  to  the  prac- 
tice of  a very  few  individuals,  with  whom 
it  is  said  to  have  performed  very  great  cures  ; 
and  if,  upon  the  test  of  more  extensive  ex- 
perience, it  is  found  to  answer  its  present 
high  character,  I shall  consider  the  use  of 
repeated  frictions  to  be  one  of  the  most  valu- 
able improvements  which  has  been  introdu- 
ced into  practice  in  modern  times.  The 
safety  and  simplicity  of  the  practice  recom- 
mend it  very  strongly  to  favour,  though  I 
am  afraid  they  are  the  very  circumstances 
which  retard  its  adoption  by  the  public  in 
general.  I only  regret  that  I do  not  feel 
myself  entitled  to  give  a decided  opinion 
upon  the  subject  from  my  ow  n experience, 
though  I have  known  some  instances  of 
successful  cures;  but  the  reports  of  success 
are  so  numerous  and  so  well  supported,  that 
I am  inclined  to  think  very  favourably  of  the 
practice. 

u There  is  no  substance  interposed  be- 
tween the  surface  of  the  swelling  and  the 
hand  of  the  person  who  administers  the  fric- 
tion, excepting  a little  flour,  to  prevent  the 
abrasion  of  the  skin.  The  friction  is  applied 
regularly  two  or  three  hours  every  day,  with 
great  celerity,  the  hand  being  made  to  move 
to  and  fro  one  hundred  and  twenty  times  in 
a minute,  and  the  course  may  require  to  be 
continued,  without  interruption,  for  some 
months.’'  (See  Russell  on  Scrofula.) 

I shall  not  enlarge  upon  this  endless  sub- 
ject, which  still  stands  in  need  of  elucida- 
tion as  much  as  any  disease  that  can  be  in- 
stanced- The  scrofulous  affections  of  the 
joints  are  explained  in  Joints ; Bronchocele  ; 
Lumbar  Abscess  ; Spina  bifida;  and  Vertebras, 


are  other  articles,  containing  matter  con- 
nected with  the  preceding  observations. 

The  reader  may  consult  Wiseman's  Chi- 
rurgical  Treatises.  J.  Brown , Adenochoira- 
dtlogia , or  an  anatomick-chirurgical  Treatise 
of  Glandules  and  Strumals , or  King's  Evil 
Swellings , together  with,  the  Royal  Gift  of 
Healing , or  Cure  thereof  by  contact , or  impo- 
sition of  hands,  fyc.  8i>o.  Lend.  1684.  Wm , 

Clowes , A right  f rule  full  and  approved  Trea- 
tise, for  the  Artificial  Cure  of  the  Struma,  or 
Evil,  cured  by  Kings  and  Queens  of  England , 
4 to.  Lond.  1602.  Cullen's  First  Lines  of  the 
Practice  of  Physic , Vol.  4.  Feme  on  the 
King's  Evil.  Cfieyne  on  the  King's  Evil.  R. 
Russell,  A Dissertation  on  the  Use  of  Sea- 
Waler  in  the  Diseases  of  the  Glands,  fyc.  8 vo. 
Lond.  1769.  B.  Bell's  Surgery,  Vol.  5.  B. 
Bell  on  Ulcers.  Tumor  Strumosus  Colli 
post  vomitorium  imminutus.  8 vo.  ( Weikard , 
Collect.  88.)  Kirkland's  Medical  Surgery,  Vol. 
2.  J.  Morley,  Essay  on  the  Nature  and  Cure 
of  Scrofulous  Disorders,  <^c.  New  Ed.  8 vo. 
Lond.  1778.  While  on  the  Struma,  Edit.  2, 
1 794.  P . Lalonette,  Traite  des  Scrophules,  fyc, 
Paris,  1780.  A.  G.  Kort urn's  Comment,  dc 
Vilio  Scrophuloso , in  2 Vol.  4 to.  Lemgovice, 
1789.  R.  Hamilton,  Observations  on  Scrofu- 
lous Affection,  fyc.  8 vo.  Lond.  1791.  London 
Med.  Obs  and  Inq.  Vol.  1.  5.  T.  Soemmer 

ring,  De  Morbis  Vasorum  Absorbentium  Cor- 
poris Humani.  8 vo.  Traj.  1795.  C.  W. 
Hufeland,  Ueber  die  Natur,  fyc.  dtr  Skrophel - 
krankheit.  Svo.  Jena.  1795.  Dissertations  on 
Inflammation,  by  John  Burns , Vol.  2.  M. 
Underwood,  Treatise  upon  Ulcers,  <^c.  with. 
Hints  on  a Successful  Method  of  treating  some 
Scrofulous  Tumours,  fyc  Svo.  Lond.  1785, 
Crowther's  Obs.  on  the  Disease  of  the  Joints , 
commonly  called  White  Swelling ; with  re- 
marks on  Caries , Necrosis,  and  Scrofulous 
Abscesses,  fyc.  Edit.  2,  1808.  A Treatise  on, 
Scrofula , by  James  Russell,  Svo.  Edinburgh , 
1808.  Lectures  on  Inflammation  by  John 
Thomson,  M.  D.  p.  130,  etseq.  p 155— 191* 
<fy>c.  Edinb.  1813.  This  work  contains  as  good 
and  as  rational  an  account  of  the  subject  as 
any  book  which  I have  examined.  Wm.  Good- 
lad,  A Practical  Essay  on  the  Diseases  of  the 
Vessels  and  Glands  of  the  Absorbent  System, 
Svo.  Lond.  1814.  G.  Henning,  A Critical 
Inquiry  into  the  Pathology  of  Scrofula,  Svo, 
Lond.  1815.  Richerand,  Nosographie  Chirj 
T.  1,  p.  165,  etseq.  Edit.  4.  Delpech , Precis 
EUmentaire  des  Maladies,  Chir.  T.  3 ,p.  617, 
fyc.  Paris,  1816.  Lassus,  Pathologie  Chir. 
T 2,  p.  383,  fyc.  Edit.  1809.  Callisen , Sys  - 
tem a Chirurgice  Hodiernce,  Vol.  2,  p.  113t 
Hafnits,  1800.  Boyer , Trait6  des  Maladies 
Chir.  T 2,  p.  414,  fyc.  Paris,  1814.  Ciu 
Brown,  Treatise  on  Scrofulous  Diseases,  show- 
ing the  good  Effects  of  factitious  Airs.  Svo. 
Lond.  1798.  Baume,  Traite  sur  It  vice  Scro - 
phuleux,  Svo.  Paris,  1808.  J.  Brandish , Obs. 
on  the  use  of  caustic  alkali  in  Scrofula,  and 
other  chronic  Diseases,  Svo.  Lond.  1811.  C\ 
Armstrong,  Essay  on  Scrofula,  in  which  an 
account  of  the  Effects  of  the  Carbonas  Ammo- 
nias is  submitted  to  the  Profession , Svo.  Lond. 
1812.  W . Lambe,  Inquiry  into  the  origin , ijc. 
of  Constitutional  Disorders , particularly  Scro  - 


SCROTUM. 


416. 


fala, Consumption^ Cancer,  tyc.8vo.  Lond.  1805. 
Also  Additional  Reports  on  the  Effects  of  a 
peculiar  Regimen  in  cases  of  Cancer,  Scrofu- 
la, fyc.  8 vo.  Lond.  1815.  R.  Carmichael , 
Essay  on  the  Nature  and  Cure  of  Scrofula, 
and  a demonstration  of  its  origin  from  Disor- 
der of  Digestive  Organs,  8 vo.  Dubl.  J.  Rab- 
ben,  De  Prcecipuis  Causis  Mali  Scrofulosi 
cjusque  Remediis  efficacissimis  commentatio, 
12 mo.  Goth.  1817.  Alibert,  Nosologie  Natu- 
relle,  p.  448,  fol.  Paris,  1820.  Did.  des 
Sciences  Med.  T.  50,  art.  Scrofules,  8vo.  Paris, 
1820.  E.  A.  Lloyd  on  the  Nature  and  Treat- 
ment of  Scrofula,  8vo  Lond.  1821. 

SCROTOCE'LE.  (from  Scrotum,  and  ma», 
a tumour.)  A rupture  or  hernia  in  the 
scrotum. 

SCROTUM,  CANCER  OF.  ( Chimney- 

sweeper's Cancer.  The  soot-wart .)  Mr.  Pott 
gives  the  following  account  of  this  peculiar 
disorder. 

u It  is  a disease  which  always  makes  its 
first  attack  on,  and  its  first  appearance  in, 
the  inferior  part  of  the  scrotum  ; where  it 
produces  a superficial,  painful,  ragged,  ill- 
looking  sore,  with  hard  and  rising  edges ; 
the  trade  call  it  the  soot-wart.  I never  saw 
it  under  the  age  of  puberty,  which  is,  I sup- 
pose, one  reason  why  it  is  generally  taken, 
both  by  patient  and  surgeon,  for  venereal, 
and  being  treated  with  mercurials,  is  thereby 
soon  and  much  exasperated : in  no  great 
length  of  time,  it  pervades  the  skin,  dartos, 
and  membranes  of  the  scrotum,  and  seizes 
the  testicle,  which  it  enlarges,  hardens,  and 
renders  truly  and  thoroughly  distempered ; 
from  whence  it  makes  its  way  up  the  sper- 
matic process  into  the  abdomen,  most  fre- 
quently indurating  and  spoiling  the  inguinal 
glands  : when  arrived  within  the  abdomen, 
it  affects  some  of  the  viscera,  and  then  very 
soon  becomes  painfully  destructive. 

“ Other  people,  besides  chimney-sweep- 
ers, (says  Pott)  have  cancers  of  the  same 
part ; and  so  have  others,  besides  lead- 
workers,  the  Poictou  colic,  and  the  conse- 
quent paralysis  : but  it  is  nevertheless  a dis- 
ease to  which  they  are  peculiarly  liable  ; 
and  so  are  chimney-sweepers  to  the  cancer 
of  the  scrotum  and  testicles. 

“ If  there  be  any  chance  of  putting  a stop 
to,  or  preventing  this  mischief,  it  must  be 
by  the  immediate  removal  of  the  part  affect- 
ed ; I mean  that  part  of  the  scrotum  where 
the  sore  is  ; for  if  it  be  suffered  to  remain 
until  the  virus  has  seized  the  testicle,  it  is 
generally  too  late  even  for  castration.  I 
have  many  times  made  the  experiment;  but 
though  the  sores,  after  such  operation,  have, 
in  some  instances,  healed  kindly,  and  the 
patients  have  gone  from  the  hospital  seem- 
ingly well,  yet,  in  the  space  of  a few  months, 
it  has  generally  happened  that  they  have 
returned,  either  with  the  same  disease  in  the 
other  testicle,  or  in  the  glands  of  the  groin, 
or  with  such  wan  complexions,  such  pale 
leaden  countenances,  such  a total  loss  of 
strength,  and  such  frequent  and  acute  inter- 
nal pains,  as  have  sufficiently  proved  a dis- 
eased state  of  some  of  the  viscera,  and  which 
have  soon  been  followed  by  a painful  death. 


“ If  extirpation  ever  bids  fair  for  the  cure 
of  a cancer,  it  seems  to  be  in  this  case  ; but 
then  the  operation  should  be  immediate; 
and  before  the  habit  is  tainted.  The  disease, 
in  these  people,  seems  to  derive  its  origin 
from  a lodgment  of  soot  in  the  rugae  of  the 
scrotum,  and  at  first  not  to  be  a disease  of 
the  habit.  In  other  cases  of  a cancerous 
nature,  in  which  the  habit  is  too  frequently 
concerned,  we  have  not  often  so  fair  a pros- 
pect of  success  by  the  removal  of  the  dis- 
tempered part ; and  are  obliged  to  be  con- 
tent with  means  which  I wish  I could  say 
were  truly  palliative  ; but  here  the  subjects 
are  young,  in  general  in  good  health,  at 
least  at  first ; the  disease  brought  on  them 
by  their  occupation,  and  in  all  probability 
local ; which  last  circumstance  may,  I think, 
be  fairly  presumed  from  its  always  seizing 
the  same  part : all  this  makes  it  (at  first)  a 
very  different  case  from  a cancer  which 
appears  in  an  elderly  man,  whose  fluids  are 
become  acrimonious  from  time,  as  well  as 
other  causes  ; or  from  the  same  kind  of 
complaint  in  women  who  have  ceased  to 
menstruate.  But  be  all  this  as  it  may,  the 
scrotum  is  no  vital  organ,  nor  can  the  loss 
of  a part  of  it  ever  be  attended  with  any, 
the  smallest  degree  of  inconvenience  ; and 
if  life  can  be  preserved  by  the  removal  of 
all  that  portion  that  is  distempered,  it  will 
be  a very  good  and  easy  composition  ; for 
when  the  disease  has  got  head,  it  is  rapid  in 
its  progress,  painful  in  all  its  attacks,  and 
most  certainly  destructive  in  its  event.” 
(PoH  s Works,  Vol.  3.  See  also  W.  Simmons’s 
Cases  and  Obs.  on  Lithotomy,  to  which  are 
added  Obs.  on  Chimney-sweeper's  Cancer,  8vo 
Manchester,  1808.) 

SCROTUM.  Sarcomatous  Thickening  and. 
Enlargement  of.  The  investigations  of  Ba- 
ron Larrey  lead  him  to  believe,  that  cases  of 
enormous  growth  of  the  scrotum  are  ende- 
mial  in  warm  countries,  or,  at  least,  that 
they  are  seldom  observed  in  cold  climates 
since  most  of  the  examples  which  have  been 
seen  in  Europe  came  from  Asia  and  Africa. 
The  scrotal  tumour  of  Delacroix,  formerly 
minister  of  externa!  relations,  says  Larrey, 
is  perhaps  the  only  well-authenticated  in- 
stance of  the  origin  of  such  a disease  in  our 
own  climate  ; and  it  was  also  much  smaller 
than  the  instances  related  in  the  Epheme- 
rides  German,  for  the  year  1692,  in  the 
surgical  writings  of  Dionis,  in  the  9th  vol. 
of  the  Bibliotheque  de  M6decine,  and  those 
which  Larrey  was  surprised  to  meet  with 
in  Egypt.  The  smallest  of  these  latter,  after 
they  had  attained  their  full  size,  weighed 
more  than  25  kilograms  (between  60  and 
70  pounds.) 

Several  cases  of  this  curious  disease  are 
recorded  by  other  writers,  particularly  by 
Dr.  Cheston,  Dr.  Titley,  and  the  celebrated 
Sandifort.  I lately  saw  in  Mr.  AbernethyV. 
museum,  a considerable  fleshy  substance, 
which  was  a portion  of  diseased  scrotum. 

In  the  cases  which  Larrey  had  an  oppor- 
tunity of  seeing  in  Egypt,  the  fleshy  mass, 
into  which  the  scrotum  was  converted,  was 
broad  below,  and  suspended  from  the  pube* 


A ETON  417 


by  a sort  ot  peuicle.  “ Externally,  (as  Lar- 
>'ey  observes)  the  tumour  presents  rugosi- 
ties of  different  sizes,  separated  by  particu- 
lar lines  or  sinuses,  to  which  the  mucous 
cryptae  and  roots  of  the  hairs  correspond. 
Upon  a large  portion  of  its  surface,  espe- 
cially when  the  case  is  of  long  standing,  yel- 
lowish scaly  crusts  are  always  seen,  the 
detachment  of  which  constantly  leaves  so 
many  small  herpetic  ulcers,  which  emit  an 
ichorous  discharge.  The  tumour  is  indolent 
and  hard  at  some  points,  but  softish  at 
others.  It  may  be  handled,  and  pressed  in 
different  directions,  without  the  least  pain. 
The  patient  is  only  incommoded  by  its 
weight,  and  the  impediment  which  it  causes 
to  his  walking  well.  Hence  he  is  necessi- 
tated to  employ  a suspensory  bandage.  In 
consequence  of  the  situation  of  the  urethra, 
the  urine  dribbles  over  the  swelling;  but 
without  causing  any  excoriation.”  Inmost 
of  the  cases  seen  by  Larrey,  the  spermatic 
chord  and  testicles  were  in  the  natural  state, 
situated  at  the  sides  and  at  the  root  of  the 
swelling.  The  spermatic  vessels,  however, 
are  somewhat  enlarged  and  elongated.  All 
the  patients  were  likewise  more  or  less 
affected  with  elephantiasis. 

Baron  Larrey  attempts  to  explain  the  cau- 
ses of  the  complaint  in  Egypt, but,  as  I think, 
without  any  degree  of  success.  As  the  af- 
fection is  seldom  seen  in  old  countries,  cli- 
mate has  certainly  a chief  effect.  Employ- 
ments w hich  keep  persons  a good  deal  in  a 
sitting  posture  ; the  loose  breeches  wrorn  by 
the  Egyptians,  and  the  consequently  pendu- 
lous state  of  the  scrotum  ; diseases  of  the 
humours,  and  particularly  itchy  pustules  on 
the  part,  an  ordinary  consequence  of  syphi- 
lis in  that  country  ; bad  regimen  ; abuse  of 
venery  ; and  the  immoderate  use  of  the 
warm  bath  ; are  merely  conjectures,  which 
will  not  bear  the  test  of  reasoning. 

The  enormous  magnitude,  w'hich  this  sort 
of  disease  may  attain,  is  almost  incredible. 
The  case,  recorded  in  the  Ephemerides  Ger- 
man, weighed  about  a hundred  kilograms, 
or  more  than  two  hundred  weight.  Another, 
described  by  Larrey,  wras  calculated  to 
weigh  about  one  hundred  and  twenty 
pounds,  and  this  surgeon  likewise  saw  in 
Egypt  ten  or  twelve  more  instances,  nearly 
as  large,  and  all  of  the  same  character 

A very  curious  example,  in  which  a simi- 
lar disease  affected  the  labia  pudendi  in  a 
surprising  degree,  is  also  detailed  by  Larrey. 
The  woman  was  a native  of  Cairo. 

In  the  early  stage  of  the  disorder,  we  may 
try  preparations  of  antimony  combined  with 
sudorifics ; drinks  acidulated  with  sulphuric 
acid,  lotions  containing  the  same  acid,  or 
the  oxymuriate  of  mercury,  the  oxyde  of 
copper,  or  the  muriate  of  ammonia.  These 
means  are  to  be  assisted  by  a gradual,  uni- 
form compression  of  the  whole  tumour.  In 
one  case,  incisions  and  the  application  of 
caustic,  proved  of  no  service,  and  Larrey 
very  properly  condemns  such  experiments. 

When  the  disease  resists  every  plan  tried 
for  its  relief,  and  its  increase  renders  the  pa- 
tient’s life  irksome,  and  vyretched,  the  extir- 
■Vqt.  If  53 


pation  ot  the  turnout  with  a knife  becomes 
proper.  In  this  proceeding,  the  chief  skill 
consists  in  doing  no  injury  to  the  spermatic 
chords  and  testicles,  which  are  generally 
perfectly  sound.  As  the  substance  of  the 
swelling  is  uQt  furnished  with  large  vessels, 
the  hemorrhage  need  not  be  feared.  Care 
must  also  be  taken  not  to  injure  the  corpora 
cavernosa  penis,  and  the  urethra.  After  the 
operation,  the  skin  is  to  be  brought  over  the 
exposed  testicles,  as  much  as  possible,  with 
adhesive  plaster  and  a bandage. 

M.  Delonn.es  successfully  removed  the  dis- 
eased mass  in  the  celebrated  case  of  the 
French  minister  Delacroix,  and  Larrey  per- 
formed the  same  operation  with  success, 
when  he  w as  in  Egypt.  Dr.  Titley,  of  the 
island  of  St.  Christopher,  also  cut  away 
such  a tumour,  which  weighed  seventy 
pounds,  and  the  patient,  who  was  a negro, 
and  also  affected  with  elephantiasis,  speedily 
recovered.  (See  Medico- Chir  urgical  Trans. 
Vol.  6,  p.  73,  fyc.) 

It  is  probable,  that  some  of  the  cases, 
which  occur  in  w arm  countries,  are  analo- 
gous to  the  elephantiasis ; but  I do  not  be- 
lieve, that  the  scaly  incrustations,  which  are 
represented  by  Larrey  as  occurring  in  the 
cases  which  he  saw  in  Egypt,  have  been 
always  noticed  in  the  instances  which  have 
taken  place  in  colder  countries.  Nor,  in- 
deed, did  they  take  place  in  the  instance  re- 
corded by  Dr.  Titley,  the  surface  of  the  tu- 
mour having  been  quite  smooth.  (/Larrey, 
Mimoires  de  Chirurgie  Militaire , T.  2.  p.  110, 
et  seq.  Richerand  JVosograpliie  Chir.  T.4,p. 
314,  fy-c.  Edit.  4.  Jllso  Delonnes ’ Memoir. 
Dr.  Cheston's  Case , &c.  Med.  Chir.  Trans. 
Vol.  6.) 

SEARCHING.  The  operation  of  intro- 
ducing a metallic  instrument,  through  the 
urethra  into  the  bladder,  for  the  purpose  of 
ascertaining  whether  the  patient  has  a stone 
or  not.  See  Sounding. 

SETON.  ( Setaceum , from  seta , a bristle, 
because  horse- hairs  were  formerly  used  for 
keeping  open  the  wround.)  A kind  of  issue. 
It  is  usually  made  by  means  of  a particular 
needle,  which  is  of  various  breadths,  from 
half  an  inch  to  a full  inch.  The  needle  is 
commonly  a little  curved,  but,  if  straight,  it 
would  be  better  calculated  for  the  purpose. 
From  the  point  to  its  broadest  part,  it  is  dou- 
ble edged,  and  behind  it  has  a transverse 
eye,  through  which  a skein  of  thread  or  silk, 
of  exactly  the  same  breadth  as  the  needle, 
is  placed. 

A fold  of  skin  is  to  be  pinched  up  at  the 
part  where  the  seton  is  designed  to  be 
made,  and  the  needle  is  to  be  pushed  through 
it,  together  with  the  skein  of  thread,  which 
is  first  dipped  in  sweet  oil.  The  instrument 
is  not  to  be  introduced  too  low  into  the  base 
of  the  fold,  nor  too  high,  near  its  edge.  In 
the  first  case,  the  muscles,  and  parts  which 
ought  to  be  avoided,  might  be  wounded ; in 
the  second,  the  interspace  between  the  twro 
wounds  would  be  very  narrow,  and  the  se- 
ton soon  make  its  way  through  it. 

When  no  seton  needle  is  at  hand,  the  fold 
of  the  skin  may  be  punctured  with  a lancet. 


oKrlli 


418 


and  the  skein  ot  thread  intuniuced  by  means 
of  an  eye-probe.  A seton  may  be  applied 
almost  to  any  part  of  the  surface  of  the  body, 
■ when  circumstances  require  it;  but  one  of 
its  openings  should  always  be  made  lower 
than  the  other  that  the  matter  may  readily 
flow  out.  The  skein  of  thread  is  to  remain 
untouched  for  a few  days  after  the  operation, 
until  the  suppuration  loosens  it.  Afterward 
the  part  of  the  thread  nearest  the  wound  is 
to  be  smeared  with  oil,  white  cerate,  or  any 
digestive  ointment,  and  drawn  under  the 
fleshy  interspace  between  the  two  wounds, 
and  what  was  there  before  is  to  be  cut  off. 
The  seton  is  to  be  drawn  in  this  manner 
once  or  twice  a day,  according  as  the  quan- 
tity of  matter  may  require.  A new  skein  of 
silk,  or  thread,  is  to  be  attached  to  the  pre 
ceding  one,  as  often  as  necessary.  Care  is 
to  be  taken  to  keep  the  thread  on  the  outside 
of  the  wound  well  covered,  and  free  from 
the  discharge,  which  would  make  it  stiff 
and  hard,  and  apt  to  occasion  pain  and 
bleeding  on  being  drawn  into  the  wound. 
If  the  discharge  should  be  deficient  in  quan- 
tity, powdered  cantharides  may  be  mixed 
with  the  digestive  ointment. 

SH5  -GLES.  See  Herpes. 

SIGHT,  DEFECT  OF.  There  are  per- 
sons, who,  from  their  infancy,  are  incapable 
of  distinguishing  one  colour  from  another. 
A man  who  was  affected  with  this  infirmity, 
could  not  distinguish  green  at  all.  Green 
and  red  appeared  to  him' the  same.  Yellow 
and  blue  be  could  discern  very  well.  With 
regard  to  dark-red  and  dark-blue,  he  fre- 
quently made  mistakes.  In  other  respects, 
his  vision  was  sound  and  acute.  The  father 
of  this  patient  was  afflicted  with  the  same 
infirmity.  The  mother  and  one  sister  were 
free  from  it  Another  sister  and  two  of  her 
children  had  it.  The  patient  himself  had  two 
children,  who  did  not  labour  under  the  dis- 
order. (See . Phil.  Trans.  Vol.  68,  Part  2.) 
Another  subject,  whose  eyes  were  in  other 
respects  healthy,  and  whose  eyesight  was 
sharp,  could  not  distinguish  a dark-green 
from  a dark-red. 

An  interesting  example  of  this  curious 
imperfection  of  vision  has  lately  been  pub- 
lished by  Dr.  Nicholl,  of  Cowbridge.  (See 
Med.  Chir.  Trans.  Vol.  7,  p.  477,  fyc.)  The 
subject  was  a healthy  boy,  eleven  years  of 
age,  whose  eyes  were  gray,  with  a yellow 
tinge  surrounding  the  pupil.  He  never  call- 
ed any  colour  green.  Dark  bottled  green 
he  called  brown.  He  could  distinguish  light 
yellow  ; but  darker  yellows  and  light  browns- 
he  confounded  with  red.  Dark  brown  he 
mistook  for  black.  Pale  green  be  called 
light  red;  common  green  he  termed  red. 
Light  red  and  pink  he  called  light  blue. 
Red  be  called  by  its  proper  name.  He  could 
distinguish  blue,  both  dark  and  light.  On 
the  mother’s  side  the  boy  had  some  rela- 
tions whose  sight  was  similarly  affected. 
An  interesting  chapter  on  what  is  termed 
coloured  vision,  may  be  read  in  a modern 
valuable  work,  to  which  I have  great  plea- 
sure in  “referring.  (See  War  dr  op's  Esmys  on 


the  Morbid  Anatomy  of  the  Human  Eye,  Vol. 
2,  p.  196,  8 vo.  Load.  1818.) 

Sometimes  objects  appear  to  the  eye  to 
be  of  a different  colour  from  what  they  real- 
ly are,  not  because  there  is  any  thing  wrong 
in  the  eye  itself,  but  in  consequence  of  tbe 
unclear  and  coloured  light  by  which  the  ob 
ject  is  illuminated.  Thus,  for  instance,  a. 
bad  tallow  candle,  which  emits  a yellow 
flame,  makes  every  thing  appear  yellow 
When  brandy  is  burning,  all  objects  appear 
blue.  In  short,  it  is  only  by  the  light  of  the 
sun,  that  any  object  can  be  seen  in  its  clear 
natural  hue.  In  certain  cases,  the  infirmity 
is  owing  to  the  transparent  parts  and  hu- 
mours of  the  eye,  which  do  not  happen  to 
be  of  a proper  colour.  Thus,  persons  hav- 
ing the  jaundice  in  a high  degree,  see  all 
things  yellow,  because  the  transparent  parts 
of  the  eye  are  of  that  colour.  When,  in 
consequence  of  external  violence  applied  to 
the  eye,  blood  is  effused,  and  the  aqueous 
humour  rendered  red  by  this  fluid,  all  ob- 
jects seem  to  the  patient  to  be  red;  and 
white,  when  the  aqueous  humour  has  been 
made  of  this  colour  by  the  couching  of  a 
milky  cataract.  Sometimes  this  defect  in 
vision  is  ascribable  to  the  duration  of  an 
impression.  When  one  has  surveyed  a 
bright-coloured  object  a long  while,  as,  for 
example,  a bright  red  or  yellow  wall,  on 
which  the  sun  shines,  fi^at  colour  will  often 
remain  a good  while  before  tbe  eyes,  al- 
though one  may  not  be  looking  any  more 
at  au  object  of  this  hue.  There  are  some 
eyes,  which  seem  much  disposed  to  retain 
the  impression  of  objects,  which  are  not 
very  bright  coloured  ; but,  such  a disposition 
always  betrays  great  weakness  and  irrita- 
bility of  those  organs.  The  most  frequent 
cause  of  this  defect  in  vision,  is  an  irrita- 
tion operating  upon  the  optic  nerves,  so  as 
to  produce  the  irritability  in  them,  which 
alone  makes  objects  appear  of  one  colour. 
The  seat  of  such  irritation,  according  to 
Richter,  is  also  most  commonly  in  the  abdo- 
minal viscera,  and  the  case  demands  evacu- 
ations, tonics, and  anodyne  medicines.  But, 
the  disorder  may  also  originate  from  other 
causes.  The  operation  of  bright-coloured 
or  shining  objects  upon  the  eye,  sometimes 
has,  for  a certain  time  afterward,  the  effect 
of  making  objects  of  diverse  colours  appear 
to  be  moving  before  the  eyes.  In  extreme 
terror,  or  fright,  things  may  also  seem  to 
have  a different  colour  from  their  real  one. 
The  same  often  happens  in  fevers  attended 
with  delirium.  A sudden  exposure  of  the' 
head  to  cold,  at  a period  when  it  was  per- 
spiring much,  in  one  instance,  caused  many 
coloured  appearances  before  tbe  eyes  ; but, 
the  disorder  subsided  in  a couple  of  days. 
(Richter,  A nfangsgr.  der  Wundarsn.  B.  8,  p 
523.) 

Also  a healthy  eye  sees  a distant  object 
with  uncertainty,  and  error,  in  a room,  or 
space,  the  extent,  length,  and  breadth,  of 
which  are  unknown,  when  the  size  of  the 
object  itself  is  unascertained,  and  when 
there  are  few  or  no  other  objects  interve- 
ning at  a smaller  distance  between  the  cyo 


SOL 


ski 

and  the  thing  looked  at.  The  mope  nume- 
rous the  objects  are  between  the  eye  and 
the  principal  thing  looked  at,  the  more  dis- 
tant it  is  made  to  appear;  the  fewer  they 
are,  the  nearer  it  seems  to  be.  In  a coun- 
try covered  with  snow,  and  upon  the  sea, 
very  distant  objects  appear  to  be  close. 
The  smaller  an  object  is  to  the  eye,  in  rela- 
tion to  its  known  magnitude,  the  further  off’ 
it  seems.  The  errors  which  the  eye  makes, 
in  regard  to  the  distance  of  objects,  also 
tend  to  deceive.  But,  there  are  certain  ca- 
ses, in  which  the  eye  is  almost  entirely  inca- 
pable of  judging  of  the  distance  of  objects. 
The  first  is,  when  the  object,  of  which  we 
wish  to  ascertain  the  distance,  is  looked  at 
with  only  one  eye.  Hence  all  one-eyed 
persons,  and  persons  affected  with  strabis- 
mus, are  unable  to  judge  well  of  the  real 
distance  of  objects.  However,  they  are 
only  so  for  a certain  time  ; and.  by  practice 
they  gradually  acquire  the  faculty.  Even 
when  two  eyes  are  employed,  it  requires 
some  exercise,  in  order  to  enable  them  to 
judge  of  the  right  distance  of  objects.  Per- 
sons, born  blind,  but  who  have  their  sight 
restored  in  both  eyes  by  the  operation  for 
the  cataract,  are  a long  while  incapable  of 
judging  of  distances,  and  only  obtain  this 
power  very  gradually.  Lastly,  this  infirmity 
is  sometimes  owing  to  an  irritation  affecting 
the  optic  nerves,  whereby  their  sensibility 
is  so  altered,  that  distant  objects  make  the 
impression  upon  them  of  near  ones.  In  this 
circumstance,  all  objects  appear  to  the  pa- 
tient closer  than  they  really  are.  This  is  the 
only  case,  which  admits  of  being  treated  as 
a disease.  The  irritation,  producing  the 
disorder,  is  mostly  seated  in  the  abdominal 
viscera,  and  requires  evacuations  and  such 
medicines  as  invigorate  the  nerves.  A sup- 
pression of  the  perspiration  is  alleged  to  be 
sometimes  a cause  ( Richter , Anfangsgr. 

der  IVundarzn.  B.  3,  p.  525.) 

A sound  eye  likewise  does  not  always 
judge  with  accuracy  and  uniformity  of  the 
magnitude  of  objects.  This  may  arise  from 
three  causes.  In  order  to  judge  rightly  of 
the  size  of  any  thing,  its  precise  distance 
must  be  known  ; for  the  more  remote  it  is, 
the  smaller  will  it  seem  to  the  eye.  Hence, 
any  conjecture  respecting  the  magnitude 
of  an  object  is  constantly  erroneous,  unless 
the  distance  be  ascertained.  Size  is  invari- 
ably something  relative.  A single  large  ob- 
ject, surrounded  by  many  small  ones,  always 
appears  to  be  larger  than  it  really  is,  et  vice 
' versa.  An  object  whose  magnitude  is  known, 
seems  smaller  than  it  actually  is,  when  one 
has  been  a little  previously  looking  at  ano- 
ther that  is  still  larger.  Lastly,  the  refrac- 
tion of  the  rays  of  light  in  the  eye,  by  which 
operation  an  object  is  made  to  appear  large 
or  small,  is  not  always  accomplished  in  the 
same  degree,  as  the  eye  is  not  at  all  times 
equally  full  and  distended  with  its  humours. 
Hence,  at  one  time,  the  same  object  will 
appear  to  the  same  eye,  and  at  the  same 
distance  larger ; at  another  time  smaller. 
Sometimes,  however,  the  eye  judges  so  er- 
roneously of  the  magnitude  of  objects,  that 


419 

there  is  reason  for  regarding  the  case  as  an 
infirmity,  or  disease.  It  is  for  the  most  part 
owing  to  a defective  sensibility  in  the  nerves, 
caused  by  some  species  of  irritation  acting 
upon  the  eye,  and  generally  seated  in  the 
gastric  organs.  A man,  to  whom  every 
thing  seemed  one  half  smaller  and  nearer 
than  it  really  was,  was  cured  by  means  of 
an  emetic,  bark,  an  issue  and  valerian, 
( Ltulin , obs.fascic.) 

Sometimes  to  the  eye,  under  circum- 
stances of  disease,  straight  lines  appear  ser- 
pentine ; perpendicular  objects,  sloping, 
things  standing  upright,  to  be  inverted,  &,c. 
All  these  cases  are  set  down  by  Richter  as 
depending  upon  a wrong  sensibility  of  the 
nerves,  occasioned  by  the  effect  of  some 
irritation.  The  irritation,  he  says,  may  be 
of  many  kinds  ; but  experience  proves  that 
it  is  mostly  seated  in  the  gastric  organs. 
These  defects  of  sight  may  generally  be 
cured  by  first  exhibiting  emetics  and  purga- 
tives, and  afterward  having  recourse  to  re- 
medies for  strengthening  the  nerves,  bark, 
oleum  animale,  valerian,  issues,  &c.  One 
mark  of  a very  weak  and  irritable  eye,  is 
when  objects,  after  being  looked  at  a good 
while,  and  presenting  a right  appearance, 
begin  to  move,  swim  about,  mix  together, 
and,  at  length,  become  quite  indistinguish- 
able. This  principally  happens  when  the 
objects  regarded  are  small  and  strongly 
illuminated.  Here  such  remedies,  both 
general  and  topical,  as  have  the  effect  of 
invigorating  the  nerves,  are  indicated.  How- 
ever, sometimes,  the  infirmity  is  partly  ow= 
ingtothe  operation  of  some  species  of  irri- 
tation, which  will  require  removal,  ere  the 
tonic  medicines  and  applications  can  avail. 
Indeed,  in  particular  cases,  the  dispersion 
of  such  irritation  is  alone  sufficient  to  ac 
complishtbe  cure. 

Sometimes,  all  objects  appear  to  the  eye, 
as  if  they  were  in  a more  or  less  dense  mist  . 
This  defect  in  vision  is  always  owing  either 
to  some  slight  opacity  of  one  of  the  humours 
of  the  eye,  or  to  excessive  debility  of  the 
optic  nerves.  (See  Richter,  Anfangsgr.  da 
IVundarzn.  B.  3,  p.  521,  fyc.) 

SINUS. — A long, .narrow,  hollow  track, 
leading  from  some  abscess,  diseased  bone, 
&c. 

SOLUTIG  ARGENTI  NITRATI. — Ar 
genii  nitrati  3j.  Aq.  distillat.  ^ss  M.  This  is 
a very  good  application  for  sores,  which  are 
frequently  met  with  round  the  roots  of  the 
nails,  both  of  the  fingers  and  toes.  It  is 
also  useful  in  herpetic  affections,  noli-me 
tangere,  and  several  kinds  of  ulcers.  The 
proportion  of  the  argentum  nitratum  may 
be  lessened,  or  increased,  as  occasion  re- 
quires. A strong  solution  of  this  substance 
is  a good  application  for  destroying  warts, 
to  which  it  must  be  applied,  by  means  of  a 
hair-pencil.  When  used  for  sores,  it  is  best 
to  dip  little  bits  of  soft  lint  in  it,  lay  them 
on  the  part  affected,  and  cover  them  with  a 
common  pledget. 

SOLUTIO  FERRI  SULPHATIS.— ft, 
Ferri  sulphatis  ad  albidinem  calcinati  3j 
Aq.  Distillat,  ?viij.  Misce.  Has  been  re*- 


commended  as  an  application  tor  sores  on 
the  nipple,  and  other  ulcers. 

SOUND.  An  instrument,  which  surgeons 
introduce  through  the  urethra  into  the  blad- 
der, in  order  to  discover,  whether  there  is  a 
stone  in  this  viscus,  or  not.  The  sound  is 
usually  made  of  very  highly  polished  steel, 
that  it  may  be  well  calculated  for  Conveying 
to  the  surgeon’s  fingers  the  sensation  of  any 
thing,  against  which  its  end  may  strike.  It 
is  also  generally  rather  less  curved,  than  a 
catheter,  so  that  its  extremity  may  be  more 
easily  inclined  to  the  lower  part  ot  the  blad- 
der, where  the  stone  is  most  frequently  si- 
tuated. 

SOUNDING.  The  operation  of  introdu- 
cing the  foregoing  instrument. 

Sounds  are  generally  introduced  much  in 
the  same  way  as  catheters,  either  with  the 
concavity  towards  the  abdomen,  or  the  con- 
vexity, in  which  last  method,  it  is  necessary, 
as  soon  as  the  beak  of  the  sound  has  arrived 
in  the  perineum,  to  bring  the  handle  of  the 
instrument  downward  by  a semicircular 
movement  to  the  right,  while  the  other  end 
is  kept  as  much  fixed  as  possible.  This  is 
what  the  French  term  the  coup,  or  tour  de 
maitre  •,  a plan,  that  is  often  followed  at 
the  present  day,  though,  except  in  very  cor- 
pulent subjects,  it  has  no  particular  recom- 
mendation. 

When  a patient  is  to  be  sounded,  he  is 
visually  put  into  a posture  very  similar  to 
that  adopted  in  the  lateral  operation  for  the 
stone,  with  the  exception  that  he  is  not 
bound  in  this  position,  as  there  is  sometimes 
an  advantage  in  making  the  patient  stand 
up,  in  order  that  the  stone  may  come  into 
contact  with  the  end  of  the  sound.  The 
instrument  having  been  introduced,  its  ex- 
tremity is  to  be  turned,  and  moved  in  every 
direction,  when  if  there  be  a calculus,  its 
presence  will  usually  he  indicated  by  the 
collision  against  the  beak  of  the  sound. 

Stones  have  sometimes  been  found  in  the 
bladder  after  death,  although  they  could 
never  be  discovered  with  a sound  while  the 
patient  was  alive,  suffering  all  the  symptoms 
of  the  complaint.  The  celebrated  French 
surgeon  La  Peyronie  jvas  thus  circumstan- 
ced : he  was  so  fully  convinced  of  there 
being  a stone  in  his  bladder,  notwithstand- 
ing neither  he,  nor  any  of  his  friends  could 
feel  it  with  a sound,  that  on  bis  death-bed, 
lie  gave  directions  for  ascertaining  the  fact. 
Hence,  when  the  usual  symptoms  of  a 
stone  in  the  bladder  continue,  patients 
should  be  searched  several  times,  before  a 
positive  opinion  is  delivered  respecting  the 
nature  of  the  disease.  When  during  the 
operation  of  sounding,  all  the  urine  has 
escaped  from  the  biadder,  the  inner  surface 
of  this  viscus  comes  into  contact  with  U-e 
end  of  the  sound,  and  such  a sensation  may 
be  communicated  to  the  surgeon’s  fingers  as 
leads  him  to  suspect  that  a fungus,  or  some 
other  hardish  extraneous  substance  is  con- 
tained in  the  bladder.  In  such  cases,  pa- 
tients have  actually  been  cut  for  the  stone, 
when  no  foreign  body  whatever  was  pre- 
sent. (See.  Mtdecine  Operatoire , 


Tom.  3,  p.  127,  128,  Edit.  2.  See  UiiiG - 
lomy.) 

SPECULUM.  An  instrument  intended 
for  facilitating  the  examination  of  parts, 
and  also  the  performance  of  operations  on 
them  : thus  we  have  specula  ani,  specula 
oculi,  auris,  &.c. 

SPHACELUS.  (from  to  de- 

stroy.) Surgeons  imply,  by  this  word,  com- 
plete mortification,  which  is  mostly  prece- 
ded by  a stage  of  the  disorder,  termed  gan- 
grene. See  Mortification. 

SPICA.  (from  rv&yyc,  an  ear  of  corn.) 
A name,  given  to  a kind  of  bandage,  in 
consequence  of  its  turns  being  thought  to 
resemble  the  rows  of  an  ear  of  corn. 

In  order  to  apply  the  spica  bandage  to 
the  shoulder,  the  margins  of  the  axillae  must 
first  be  protected  from  the  effects  of  the 
pressure,  by  means  of  soft  compresses,  and 
the  end  of  a common  roller  is  then  to  be 
placed  under  the  opposite  arm-pit.  After 
conveying  the  bandage  backward,  obliquely 
over  the  scapulai,  the  surgeon  is  to  bring  it 
forward  over  the  injured  shoulder.  The 
roller  is  next  to  descend  under  the  arm-pit, 
then  be  carried  upward  again,  and  made  to 
cross  on  the  deltoid  muscle.  It  is  now  to  be 
carried  obliquely  over  the  front  of  the  chest, 
and  under  the  opposite  arm-pit,  where  the 
end  of  it  is  to  be  pinned,  or  stitched.  The 
bandage  is  next  to  pass  across  the  back, 
over  the  part  of  the  roller  previously  applied 
in  this  situation,  and  is  to  be  conveyed 
round  the  head  of  the  os  brachii,  so  as  to 
form  a turn,  or  doloire,  with  the  first  circle 
of  the  roller.  Three  or  four  doloires,  or 
turns,  each  of  which  covers  about  one-third 
of  the  preceding  one,  are  to  be  made,  and 
then  the  upper  part  of  the  arm  is  to  be  once 
surrounded  with  a plain  circle  of  the  ban 
dage.  This  last  circular  application  leaves 
between  it  and  the  cross  previously  made,  a 
triangular  equilateral  space,  technically 
named  by  writers  geranis.  The  roller  is  now 
be  to  carried  upward  in  a spiral  manner  ; its 
head  is  to  be  brought  to  the  opposite  arm- 
pit,  and  the  application  of  the  whole  con- 
cludes with  a few  turns  round  the  body. 
The  bandage  is  to  be  fastened  with  pins  at. 
the  place  where  it  commenced. 

In  applying  the  spica  inguinis , the  end  of 
the  roller  is  to  be  placed  on  the  spine  of 
the  os  ilium,  ot  the  affected  side.  The  ban- 
dage is  then  to  be  carried  obliquely  over 
the  groin,  and  under  the  perinaeum.  Then 
it  is  to  pass  over  the  back  of  the  thigh,  and 
next  forward,  so  as  to  cross  the  part  pre- 
viously applied  on  the  front  of  the  groin 
The  application  is  continued  by  carrying 
the  roller  over  the  pubes,  over  the  opposite 
os  ilium,  and  next  round  the  body  above 
the  buttocks.  The  bandage  thus  returns  to 
the  place  where  it  began.  Its  application 
is  completed  by  making  a few  turns,  like 
the.  preceding  ones,  and  lastly,  a few  circles 
round  the  body, 

SPINA  BIFIDA,  (i.  e.  the  Cloven  Spine.) 
Hydro-Rachitis.  A disease,  attended  with 
an  incomplete  state  of  some  of  the  verte- 
brae, and  a fluid  swelling,  which  is  most  coni' 


SPINA  BIFIDA. 


421 


in  only  situated  over  the  lower  lumbar  verte- 
tebrai,  sometimes  over  the  dorsal  and  cervi- 
cal ones,  and  in  some  instances,  over  the  os 
sacrum.  The  same  name  has  also  been  given 
to  an  analogous  tumour,  which  sometimes 
occurs  on  children’s  heads,  attended  with  an 
imperfect,  ossification  of  a part  of  the  crani- 
um. The  malformation  of  the  spine  seems 
to  consist  in  a deficiency  of  one  or  more  of 
the  spinous  processes.  Sometimes,  indeed, 
these  processes  are  wanting  the  whole 
length  of  the  vertebral  column,  as  was 
seen  in  the  case  reported  by  Fieliz.  (See 
Richter’s  Ckir.  Bibl.  B 9,  p.  185.) 

The  Arabians,  who  first  treated  of  this 
disease,  erroneously  imputed  the  deficiency 
of  one,  or  more  of  the  spinous  processes 
to  the  tumour,  while  it  is  well  known,  that 
the  incomplete  state  of  the  affected  verte- 
brae is  a congenital  malformation,  and  that 
the  swelling  is  only  an  effect.  In  fact,  the 
tumour  generally  becomes  larger  and  larger, 
the  longer  it  continues.  The  spina  bifida 
may  be  regarded  as  an  affliction  only  met 
with  in  children : few.  very  few,  live  to 
the  adult  age  with  this  incurable  affection. 
Warner,  however,  has  related  a case,  in 
which  the  patient  lived  till  he  was  twenty. 
(Cases  in  Surgery, p.  134.  Edit.  4.) 

As  I have  remarked,  the  swelling  is  most 
frequently  situated  towards  the  lower  part 
of  the  spinal  canal,  particularly  at  the  place 
where  the  lumbar  vertebrae  join  the  sacrum. 
The  fluid  which  it  contains  resembles  serum, 
being  somewhat  more  liquid  than  the  white 
of  egg,  and,  like  the  latter,  frequently  coa- 
gulable.  It  is  in  general  limpid  and  colour- 
less; but,  occasionally,  it  is  turbid,  and 
tinged  w ith  blood.  On  pressing  the  tumour, 
a fluctuation  is  very  perceptible,  and  a pre- 
ternatural space  may  also  be  felt  existing 
between  some  of  the  spinous  processes.  The 
fluid  is  contained  in  a kind  of  cyst,  which  is 
composed  of  the  continuation  of  the  dura 
mater,  investing  the  spinal  canal,  and  is 
usually  closely  adherent  to  the  integuments. 

According  to  Morgagni,  spina  bifida  is 
mostly  attended  with  hydrocephalus,  and 
the  enlargement  of  the  head  has  been  known 
to  undergo  a considerable  diminution  after 
the  tumour  of  the  spine  had  casually  burst. 
(De  Sed.  et  Cans.  Morb.  Epist.  7.  art.  9. 
Epkern.  Cur.  Nat.  Dtcad.  3,  Art.  1,  Decad. 
2.  Art.  2.)  The  fluid  which  was  lodged  in 
the  lateral  ventricles,  and  third  ventricle, 
passed  into  the  fourth,  through  the  aqua- 
ductus  Sylvii,  ruptured  the  calamus  scripto- 
rius,  and  thus  passed  into  the  spinal  canal. 

Spinas  bifida?  usually  occur  on  the  lower 
part  of  the  spine  ; but  they  occasionally 
take  place  on  the  cervical  vertebrae,  where 
the  tumours  have  the  same  characteristic 
marks  as  those  near  the  sacrum.  Many 
facts  recorded  by  lii/ysch,  in  his  Anatomical 
Observations,  confirm  the  preceding  account. 

The  present  affliction  is  one  of  a most 
incurable  nature  ; for,  w’ith  the  exception  of 
one  case  mentioned  by  Morgagni,  (De  Sed. 
et  Cause  Morb.  Epist.  12,  art.  9,)  a second, 
recorded  by  Keilmann,  { Prodrom . Act.  Havn. 
p.  136.)  and  two  or  three  others  more  re- 
cently published  by  Sir  Astt^v  Cooper, there 


is  not,  I believe,  in  all  the  records  of  medi 
cine,  or  surgery,  any  case,  which  either  got 
w'ell  of  itself,  or  was  benefited  by  any  mode 
of  treatment.  Opening  the  tumour,  either 
with  caustics,  or  cutting  instruments,  has 
generally  only  tended  to  hasten  the  fatal 
event  of  the  disease.  Death  soon  follows 
an  operation  of  this  kind,  and  sometimes  in- 
stantly. Tulpius  observes  on  this  subject; 
quam  calarnitateyn  si  quidem  reformides , chi 
7-urge,  cave  sis  iw  provide  aperias  quod  tarn, 
facile  occidit  hominem.  (Observ.  Med.) 

Bui  whether  the  tumour  he  opened  or  notj 
still  the  disease  is  one  of  the  most  fatal,  to 
which  children  are  exposed.  When  afflicted 
with  it,  they  very  seldom  live  till  three 
years  of  age  : but  after  lingering  several 
months  from  their  birth,  suddenly  die.  It 
has  been  said,  that  children  with  spina  bifida 
always  have  their  legs  in  a paralytic  state 
However,  this  is  not  true  ; for  the  largest 
spina?  bifidia?  I ever  saw,  was  under  my 
friend  .Vir.  Maul,  of  Southampton,  and  was 
unattended  with  any  weakness  of  the  legs 
Indeed  the  child  was,  to  all  appearance,  as 
stout,  healthy, and  full  of  play  as  possible.  The 
fatal  event,  how  ever,  took  place  after  a time, 
as  usual  ; and  if  my  memory  does  not  fail 
me,  Mr.  Maul  noticed,  that  a little  before 
death,  a remarkable  subsidence  of,  the 
swelling  occurred,  though  it  never  burst  ex 
ternally  It  is  a fact  notwithstanding,  that 
many  infants  with  spina  bifida,  have  paralytic 
lei:s,  and  can  neither  retain  their  feces  nor 
urine. 

If  we  draw  our  inferences  from  the  cases 
and  remarks  offered  by  almost  every  writer 
on  spina  bifida,  we  must  regard  all  attempts 
to  cure  the  disorder,  by  making  any  kind  of 
opening,  as  exceedingly  perilous,  if  not  posi- 
tively fatal.  It  is  to  be  observed  at  the  same 
time,  that  some  practitioners  have  not  alto- 
gether abandoned  the  idea  of  devising  a 
mode  of  accomplishing  a cure,  at  least  in  a 
few  instances.  Mr.  B.  Bell  says,  that  if  the 
tumour  proceeded  from  disease  of  the  spinal 
marrow  or  its  membranes,  no  means  of  cure 
will  probably  ever  be  discovered.  But  if  the 
the  deficiency  in  the  spinous  processes  of  the 
vertebra?,  with  which  the  disease  is  always 
accompanied,  is  not  an  effect  of  the  com- 
plaint as  was  commonly  imagined,  and  if  the 
collection  of  fluid  takes  place  from  the  want 
of  resistance  in  the  dura  mater,  in  conse- 
quence of  the  imperfection  of  the  bones, 
Mr.  B.  Bf-ll  questions,  whether  it  would  not 
be  proper  io  tie  the  base  of  the  tumom  with 
a ligature,  not  merely  with  a view  of  remo- 
ving the  swelling,  but  in  order  to  resist  the 
propulsion  of  the  cyst  further  outward.  Mr 
Beil  acknowledges,  that  the  event  of  this 
practice  must  be  considered  as  very  dubious; 
but  expresses  his  w ish  to  devise  any  plan  , 
that  would  afford  even  the  least  chance  of 
success,  in  a case  which  must  terminate  in 
an  unfavourable  manner.  Mr.  Bell  men- 
tioned the  design  of  putting  the  method  to  a 
trial,  on  the  first  opportunity,  and  after  the 
detachment  of  the  swelling  on  the  outside  of 
the  ligature,  he  intended  to  keep  a soft' com- 
press on  the  part  with  a proper  bandage.  I 
do  not  know  whether  this  gentleman  ever 


SPINA  BIFIDA 


422 


pat  file  above  scheme  in  practice ; but  sup- 
pose not.  It  is  properly  objected  to  by  the 
author  of  the  article  Spina  Bifida,  in  the  En- 
cyclopedic Mithodiquc , Parl.Chir.  because  the 
disease  is  often  attended  w ith  other  mischief 
of  the  spinal  marrow  and  brain,  and  the  base 
of  the  swelling  is  almost  always  too  large  to 
admit  of  being  tied  at  all,  or  not  without 
hazard  of  dangerous  consequences. 

Richter  has  proposed  the  trial  of  two  caus- 
tic issues  at  a little  distance  from  the  swell- 
ing ; but  I am  not  acquainted  with  any  facts 
in  favour  of  this  practice. 

Mr.  Abernethy  first  suggested  the  trial  of 
a gentle  degree  of  pressure  on  the  tumour 
from  its  commencement,  with  the  view  of 
producing  absorption  of  the  fluid,  and  pre- 
venting the  distention  of  the  unsupported 
dura  mater.  Were  the  fluid  to  continue  to 
increase,  notwithstanding  such  pressure,  Mr. 
Abernethy  thinks,  that  as  death  would  be 
inevitable  on  the  tumour  bursting,  it  might 
be  vindicable  to  let  out  the  fluid  by  means 
of  a puncture  made  with  a finely-cutting  in- 
strument. The  wound  is  to  be  immediately 
afterward  closed  with  sticking  plaster,  and 
if  possible,  healed.  Another  accumulation 
is  then  to  be  prevented  if  practicable,  with 
bandages  and  topical  applications.  Mr. 
Abernethy  actually  made  the  experiment  of 
a puncture  in  one  hopeless  instance,  in 
which,  indeed,  the  swelling  had  previously 
just  begun  to  burst.  The  puncture  was  re- 
peated every  lourth  day  for  six  weeks,  during 
which  time  the  child’s  health  continued  un- 
affected. The  wounds  were  regularly  heal- 
ed ; but  the  plaster  having  been  rubbed  off 
one  of  the  punctures,  the  part  ulcerated,  the 
opening  could  not  be  healed,  t tie  discharge, 
from  having  been  of  an  aqueous  quality,  be- 
came purulent,  and  death  ensued.  This 
case  was  also  unfavourable  for  the  trial  of 
the  method,  as  the  integuments  covering  the 
tumour  w ere  diseased,  and  had  no  disposi- 
tion to  contract. 

. The  annexed  case,  published  by  Sir  Ast- 
ley  Cooper,  will  serve  to  show  the  benefit 
which  may  be  derived  from  pressure. 

“ James  Applebee,  Baldwin-Street,  Old- 
Street,  was  born  on  the  19ih  of  May,  1807, 
and  his  mother,  immediately  after  his  birth, 
observed  a round  and  transparent  tumour  on 
the  loins,  of  the  size  of  a large  walnut.  On 
the  22d  of  June,  1807,  the  child  was  brought 
to  my  house,  and  I found,  that  although  it 
bad  spina  bifida,  the  head  was  not  unusually 
large  ; and  the  motions  of  its  legs  were  per- 
fect ; and  its  stools  and  urine  were  dischar- 
ged naturally.  I applied  a roller  around  the 
child’s  waist,  so  as  to  compress  the  tumour, 
being  induced  to  do  so  from  considering  it 
as  a species  of  hernia,  and  'hat  the  deficien- 
cy of  the  spine  might  be  compensated  for  by 
external  pressure.  The  pressure  made  by 
the  roller,  had  no  unpleasant  influence  on  its 
voluntary  powers;  its  stools  and  urine  con- 
tinued to  be  properly  discharged,  but  the 
mother  thought  that  the  child  was  occasion- 
ally convulsed.  At  the  end  of  a week,  a 
piece  ol  plaster  of  Paris,  somewhat  hollow 
ed,  and  that  hollow  partly  filled  with  a piece 


of.  loose  lint,  was  placed  upon  tne  surface  of 
the  tumour:  a strap  of  adhesive  plaster  vyas 
applied  to  prevent  its  changing  its  situation, 
and  a roller  wras  carried  around  the  waist,  to 
bind  the  plaster  of  Paris  firmly  upon  the  back, 
and  to  compress  the  tumour  as  much  as  the 
child  could  bear.  This  treatment  was  con 
tinned  until  the  month  of  October,  during 
which  time,  the  tumour  was  examined  about 
three  times  a week,  and  the  mother  reported 
that  the  child  was  occasionally  convulsed. 
When  the  child  was  five  months  old,  a truss 
was  applied,  similar  in  form  to  that  which  i 
sometimes  use  tor  umbilical  hernia  in  chil- 
dren, and  this  has  been  contained  ever 
since.  At  the  age  of  fifteen  months,  it  be- 
gan to  make  use  of  its  limbs ; it  could  crawl 
along  a passage,  and  up  two  pair  of  stairs 
At  eighteen  months,  by  some  accident,  the 
truss  slipped  from  the  tumour,  which  had 
become  of  the  size  of  a small  orange,  and 
the  mother  observed,  when  it  was  reduced, 
that  the  child  appeared  in  some  degree  dull ; 
and  this  was  always  the  case  if  the  truss  was 
left  off  fora  few  minutes,  and  then  reapplied. 
At  fifteen  months  he  began  to  talk  ; and  at 
two  years  of  age,  he  could  walk  alone.  He 
now  goes  to  school,  runs,  jumps,  and  plays 
about  as  other  children.  His  powers  of 
mind  do  not  appear  to  differ  from  those  of 
other  children.  His  memory  is  retentive, 
and  he  learns  with  facility.  He  had  the 
measles  and  small-pox  in  the  first  year,  and 
the  hooping-cough  at  three  years.  His  head 
previously  and  subsequently  to  the  bones 
closing,  has  preserved  a due  proportion  to 
other  parts  of  the  body.  The  tumour  is 
kept  by  the  truss  entirely  within  the  channel 
of  the  spine  ; but  when  the  truss  is  removed, 
it  soon  becomes  of  the  size  of  half  a small 
orange,  it  is  therefore  necessary,  that  the 
use  of  the  truss  should  be  continued.  When 
the  truss  is  removed,  the  finger  can  be  readily 
pressed  through  the  tumour  into  the  channel 
of  the  spine.”  {Med.  Chit.  Trans.  Vol.2,p 
323  4-c.) 

The  next  case,  also  published  by  Sir 
Astley  Cooper,  will  prove,  that  spinse  bifi- 
da? may  sometimes  be  treated  on  another 
plan,  so  as  to  accomplish  a permanent  cure 

“January  21sf,  1809,  Mrs.  Little  of  No 
27  Limehouse  Causeway,  brought  to  my 
house  her  son,  aged  ten  weeks,  who  was 
the  subject  of  spina  bifida.  The  tumour 
was  situated  on  the  loins ; it  was  soft,  elas- 
tic, and  transparent ; and  its  size  about  as 
large  as  a billiard  ball  when  cut  in  half;  his 
legs  were  perfectly  sensible,  and  his  urine 
and  feces  were  under  the  power  of  the  will, 
&,c.  Having  endeavoured  to  push  the  water 
contained  iu  the  tumour,  into  the  channel 
of  the  spine,  and  finding  that  if  the  whole 
was  returned,  the  pressure  would  be  too 
great  upon  the  brain  ; I thought  it  a fair 
opportunity  of  trying  what  would  be  the 
effect  of  evacuating  the  swelling  by  means 
of  a very  fine  pointed  instrument,  and  by 
subsequent  pressure  to  bring  it  into  the  state 
of  the  spina  bifida  in  Applebee’s  child.  1 
therefore  immediately  punctured  the  tumour 
with  a needle,  and  drew  off  about  two 


SPhN'A  VENTOSA, 


ounces  ot  water.  Un  Hie  25th  January, 
finding  the  tumour  as  large  as  before  it  bad 
been  punctured,  I opened  it  again,  and 
in  the  same  manner,  and  discharged  about 
four  ounces  of  fluid.  The  child  cried  when 
the  fluid  was  evacuated,  but  not  whilst  it 
was  passing  off.  On  January  28th,  the  tu- 
mour was  ns  large  as  at  first  ; I opened  it 
again,  and  discharged  the  fluid.  A roller 
was  applied  over  the  tumour,  and  around 
the  abdomen.  February  1st,  it  was  again 
pricked,  and  two  ounces  of  fluid  discharged. 
On  the  4tb,  three  ounces  of  fluid  were  dis- 
charged. On  the  9th,  the  same  quantity  of 
fluid  was  evacuated  as  on  the  4th  ; but  in- 
stead of  its  being  perfectly  clear  as  at  first, 
it  was  now  sanious,  and  it  had  been  gradu- 
ally becoming  so  in  the  three  former  opera- 
tions. On  the  13th,  the  same  quantity  of 
fluid  was  taken  away;  a flannel  roller  was 
applied  over  the  tumour  and  around  the  ab- 
domen ; a piece  of  pasteboard  was  placed 
upon  the  flannel  roller  over  the  tumour,  and 
another  roller  over  the  pasteboard  to  confine 
it.  On  the  17th,  three  ounces  of  fluid,  of  a 
more  limpid  kind,  were  discharged  the 
pasteboard  was  again  applied:  On  the  27th, 
the  surface  of  the  tumour  inflamed  ; the  fluid 
not  more  than  half  its  former  quantity,  was 
mixed  with  coagulable  lymph,  and  the  child 
suffering  considerable  constitutional  irrita- 
tion, was  ordered  calomel  and  scaromony, 
and  the  rollers  were  discontinued.  On  the 
26th,  the  tumour  was  not  more  than  a quar- 
ter of  its  former  size  ; it  felt  solid  ; the  inte- 
guments were  thickened,  and  it  had  all  the 
appearance  of  having  undergone  the  adhe- 
sive inflammation.  On  the  28ib,  it  was  still 
more  reduced  in  size,  and  felt  solid.  March 
8th,  the  swelling  was  very  much  lessened ; the 
skin  over  it  thickened  and  wrinkled  ; a roller 
was  again  had  recourse  to  a card  was  put 
over  the  tumour,  and  a second  roller  was 
applied.  March  1 1 tb,  the  tumour  was  much 
reduced  ; the  skin  covering  it  was  a little 
ulcerated.  On  thq  15th,  it  was  flat,  but  still 
a little  ulcerated.  On  the  27ih,  the  effused 
coagulable  lymph  was  considerably  reduced 
in  quantity,  and  of  a very  firm  consistence. 

the  2d  of  May,  nothing  more  than  a 
loose  pendulous  bag  of  skin  remained,  and 
the  child  appearing  to  be  perfectly  well,  the 
bandage  was  soon  left  off.  On  December 
the  18lh,  the  child  was  attacked  with  the 
small-pox,  ar.d  went  well  through  the  dis- 
ease. The  skin  now  hangs  flaccid  from  the 
basis  of  the  sacrum  ; its  centre  is  drawn  to 
the  spine,  to  which  it  is  united,  and  thus  the 
appearance  of  the  navel  is  produced  in  the 
tumour  by  retraction  of  the  skin.  The  pricks 
of  the  needles  are  very  obvious,  forming 
slight  indentations.”  (See  Med.  Chir.  Trans. 
Vol.  2,  p.  326—329.) 

At  the  time  when  Sir  A.  Cooper  trans- 
mitted this  case  to  the  Medical  and  Chirur- 
gical  Society,  it  had  been  under  bis  observa- 
tion two  years  and  a half. 

'I  he  first  of  the  preceding  observations 
exemplifies  the  palliative  treatment,  adopted 
by  the  latter  gentleman,  and  consisting  of 
’he  application  of  pressure,  in  the  manner  of 


423 

a truss  for  hernia ; the  second  shows  the 
radical  mode  of  cure  by  puncturing  the 
swelling  from  time  to  time  with  a needle, 
and  exciting  the  adhesive  inflammation, 
which,  with  the  assistance  of  pressure, 
stops  the  disease  altogether,  that  is  to  say,  in 
such  examples  as  admit  of  cure. 

Children  are  sometimes  born  with  tu- 
mours, analogous  to  spinae  bifidae,  but  situa 
ted  on  the  bead.  There  is  a deficiency  of 
bone  at  some  part  of  the  skull,  and  through 
the  opening  a sac,  composed  of  the  dura  ma 
ter,  protrudes,  covered  only  by  the  integu- 
ments. Mr.  Earle  lately  met  with  such  a 
swelling  situated  upon  the  occipnt  of  a fe 
male  infant.  The  plan  of  repeatedly  making 
small  punctures  with  a common  needle,  dis 
charging  the  fluid,  healing  up  the  punctures 
and  applying  pressure,  was  tried,  and  fol 
lowed  up  for  some  time  without  the  occur- 
rence of  any  unpleasant  symptoms.  Even 
punctures  were  sometimes  made  with  an 
ordinary  lancet ; yet  the  child  suffered  no 
harm  from  the  operation,  and  somtf'hopes 
of  a cure  were  indulged.  At  length,  howe- 
ver, ulceration  of  the  swelling  took  place, 
the  child  became  indisposed,  and  rapidly  sunk 
(See  Med.  Chir.  Trans.  Vol.  7,  p.  427.)  Con 
suit  Ruyschii  Obs.  Anat.  Warner's  Cases  in 
Surgery.  B.  Bell’s  System  of  Surgery , Vol. 
5.  Acrel  in  Schwed.  Abhandl.  x.  B.  p.  291,, 
&pc.  Murray , Opusc.  2,  No.  5,  et  Med.  Pract. 
Bibl.  3,  p.  612.  Portal  Cours  d'Anat,  Med 
T.  4,  p.  66.  Lassus,  Pathologic  Chir.  T.  3, 
p . 260,  et  seq.  Edit.  1809.  Abernethy’s  Sur- 
gical and  Physiological  Essays,  Part  1 and  3. 
T.  V.  Okes,  An  Account  of  Spina  Bifida,  with 
Remarks  on  the  Method  of  Treatment  pro 
posed  by  Mr  Abernelhy,  Sro.  Cambridge , 
1810.  Encyclopedic  M6lhodiqve,  Part . Chir 
Art.  Spina  Bifida.  Richter.  Ahfangsgr.  dec 
JVtmdarzn.  B.  5,  Kap.  A.  Cooper,  Med , 
Chir.  Trans.  Vol.  2.  p.  322,  fyc.  H.  Earle , 
in  the  same  work,  Vol.  7,  p.  427,  fyc.  Edinb 
Med.  and  Surg.  Journ.  No.  67. 

SPINA  VENTOSA.  The  Arabian  writers 
first  employed  this  term',  to  express  a dis- 
ease, in  which  matter  formed  in  the  interior 
of  a bone,  and  afterward  made  its  way  out- 
ward beneath  the  skin.  Until  the  matte; 
had  escaped  from  within  the  bone,  these  au- 
thors describe  the  pain  as  being  incessant 
and  intolerable  ; but  that  after  the  pus  had 
made  its  way  outward  by  fistulous  openings, 
the  pain  underwent  a considerable  diminu- 
tion. The  matter  sometimes  insinuated  it- 
self, from  the  interior  of  the  bone,  into  the 
cellular  substance,  so  as  to  render  it  soft  and 
flabby,  though  not  always  attended  with 
any  change  of  colour  in  the  skin.  The 
swelling  had  some  of  the  appearance  of 
emphysema.  To  express  this  state,  the 
Arabians  added  the  term  ventosa  to  that  of 
spina,  which  was  employed,  before  their 
time,  to  express  the  nature  of  the  pain  at- 
tendant on  the  disease.  (See  an  account  of 
this  subject  in  the  Encyclopedic  M6thodique, 
Part.  Chir.  Art.  Spina' Ventosa.) 

The  term  spina  ventosa  has,  since  the  time 
of  the  Arabian  writers,  been  used  by  many 
to  signify  the  disease  named  white-swelling, 


424  i»ri 

find  the  former  might  also  mean  by  it  a simi- 
lar affection,  though  the  contrary  may  be 
inferred  from  their  account  of  the  matter 
passing  from  the  interior  of  the  bone  under 
the  integuments,  a thing  which  I believe 
never  yet  happened  in  any  case  of  white- 
swellin/.  Another,  and  perhaps  a decisive 
argument,  against  the  original  signification 
of  the  word  being  the  same  as  that  of 
white-swelling,  is,  that  it  was  not  restricted 
to  diseases  of  the  joints  and  heads  of  the 
bones ; but  was  also  applied  to  abscesses, 
which  commenced  in  the  cavities  of  the 
middle  portions  of  the  long  bones,  where,  I 
need  hardly  observe,  white -swellings  never 
make  their  attack. 

For  these  reasons,  many  respectable  au- 
thors have  implied  by  the  term  spina  vento- 
Mi  an  abscess  in  the  interior  of  the  bone. 
(See,  on  this  subject,  Lalta's  System  of  Sur- 
gery, Vol.  t,  p.  165.)  Cases  of  this  latter 
kind,  I know,  are  infinitely  rare,  compared 
with  that  common  disorder,  the  white- 
swelling  ; and,  I am  also  certain,  from  the 
descriptions  given  by  some  authors,  that 
*heir  cases  of  spina  ventosa  were  in  reality 
instances  of  necrosis.  But  that  abscesses 
do  occur,  and  begin  in  the  interior  of  the 
bones,  more  particularly  of  those  of  young 
persons,  1 have  no  doubt  myself,  both  from 
two  or  three  cases,  which  1 remember  ha- 
ving seen  in  St.  Bartholomew  s Hospital, 
and  from  some  cases  recorded  by  the  most 
authentic  writers.  1 cannot  conceive,  how- 
ever, that  suppuration  can  take  place  to  any 
extent  within  a long  bone,  without  being 
followed  by  necrosis.  . 

J L Petit  relates,  that  a man,  with  a tu- 
mour on  the  middle  of  the  tibia,  who  had 
been  treated  by  him  as  a venereal  patient, 
found,  a fortnight  afterward,  that  the  pains 
which  had  never  ceased,  now  began  to  grow 
more  violent.  The  patient  was  feverish, 
his  legs  became  red,  and  even  painful,  exter- 
nally. An  incision  was  made  in  the  situa- 
tion of  the  tumour  with  a view  of  letting 
out  the  matter  which  was  suspected  to  be 
the  occasion  of  the  bad  symptoms,  and  to 
have  insinuated  itself  under  the  periosteum. 
The  incision  was  of  no  service,  and,  two 
days  afterward,  the  trepan  was  applied,  by 
which  means,  a large  quantity  ol  matter 
was  let  out.  The  medullary  part  of  the 
bone  seemed  quite  annihilated,  and  the  ca- 
vity almost  empty.  Petit  made  three  other 
perforations  with  the  trepan,  and  cut  away 
die  intervening  pieces  of  bone,  lbe  actual 
cautery  was  also  used  several  times  to  de^ 
stroy  the  caries,  and  the  patient  at  length 
got  well.  ( Traili  des  Maladies  des  Os,  de  J. 
L.  Petit.)  If  any  one  doubt,  that  abscesses 
now  and  then  form  in  the  middle  of  the 
long  bones,  1 must  request  him  to  consult 
Mr.  Hey’s  Practical  Observations  in  Surgery , 
p 22,  where  he  mav  peruse  two  very  inter- 
esting eases  illustrative  of  what  Mr.  Hey 
calls  Abscess  in  the  Tibia  with  Caries.  . 

It  must  be  confessed,  however,  that  these 
were  only  cases  of  necrosis,  for  which  af- 
fection the  term  caries  is  too  often  inaccu- 
rately used.  Indeed,  it  would  appear,  from 


3PL 

tin,  observations  of  Dr.  Macartney,  that  a 
very  small  suppuration  in  the  medulla  is  ac- 
companied with  the  beginning  of  those 
changes  of  the  periosteum,  which  attend 
necrosis.  (See  Necrosis,  p.  762.) 

For  an  account  of  spina  ventosa,  in  the 
sense  of  white-swelling,  refer  to  Joints.  J. 
Pandolphinus,  De  Venlositalis  Spince  Scevissi- 
mo  Morbo,  12 mo.  Norib.  1674.  A.  J.  van  dec 
Meer,  de  Spina  Ventosa,  Duisb.  1 729.  F.  L 
Augustin,  de  Spina  Ventosa  Ossium,  Icon.  4, 
4 io  Halce,  1797.  F.  H.  Schuchardt,  Annota- 
ta  quoedam  de  Spina  Ventosa,  cum  annexa 
singulari  hujus  morbi  observatione , 12 mo 

Marburg.  1817. 

SP1RITUS  AMMONliE  COMPOSJTUS. 
Besides  the  well-known  uses  of  this  medi 
cine  internally  exhibited,  its  vapours  are  an 
exceedingly  proper  application  to  the  eye 
in  some  cases  of  chronic  ophthalmy.  Scar- 
pa recommends  a remedy  of  a similar  na- 
ture. 

SPLINTS.  Long  thin  pieces  of  wood, 
or  tin,  or  strong  pasteboard,  employed  for 
preventing  the  ends  of  broken  bones  from 
moving  so  as  to  interrupt  the  process  by 
which  fractures  unite.  These  instruments 
are  sometimes  used  in  other  cases,  for  the 
purpose  of  keeping  limbs  from  moving, 
particularly  in  some  kinds  of  dislocationsj 
wounds,  &.c. 

In  simple  fractures  of  the  arm,  forearm, 
or  even  of  the  thigh,  or  leg,  in  young  in- 
fants, it  matters  not  whether  the  splints  be 
made  of  wood,  pasteboard,  or  tin.  In  this 
country,  surgeons  usually  keep  sets  of  splints 
made  expressly  for  the  leg.  These  are  of 
different  sizes,  excavated  and  shaped  to  the 
part,  and  furnished  below  with  apertures 
for  the  projecting  malleoli.  When  the  limb 
is  laid  upon  its  outside,  the  foot  is  also  usu- 
ally supported  and  kept  steady  by  the  under 
splint,  extending  some  distance  towards  the 
toes.  Very  excellent  splints  for  the  legs  of 
young  children  are  made  of  strong  paste- 
board, accommodated  in  shape  to  the  con- 
tour of  the  limb.  Splints  for  the  thigh,  arm, 
and  forearm,  whether  made  of  tin,  or  wood, 
should  always  be'  slightly  concave  on  the 
side,  which  is  to  be  applied  to  the  broken 
limb.  They  should  likewise  be  made  as 
thin  and  light,  as  is  consistent  with  the  neces- 
sary degree  of  strength  for  preventing  the  bro- 
ken bone  from  bending.  The  sets  of  splints, 
which  are  usedfor  fractured  legs  and  thighs  in 
England,  are  frequently  furnished  with  straps, 
which  have  a great  many  small  perforations 
in  them  at  stated  distances,  and  can  thus  be 
easily  fastened  by  means  of  little  pegs  for 
the  purpose.  Tapes  are  also  sometimes  em- 
ployed ; but  they  often  get  loose,  and  can- 
not be  depended  upon  so  well  as  leather 
straps.  Pasteboard,  as  a material  lor  splints, 
has  one  advantage,  viz.  j when  wet,  it. 
becomes  soft,  and  admits  of  being  accurate- 
ly applied  to  every  point  of  the  surface  of 
the  limb:  consequently,  as  soon  as  it  dries 
and  recovers  its  firmness  again,  it  retains 
the  exact  shape  of  the  part,  and  makes  every 
where  equal  pressure  on  it,  without  incom- 
moding the  patient,  Pasteboard,  however. 


SP  0 


Si  A 42a 


js  hardiy  strong  and  durable  enough  for 
many  fractures  ; nor  will  it  answer  when 
there  is  any  discharge,  nor  when  the  sur- 
geon wishes  to  employ  any  fluid  applica- 
tions. But,  it  is  generally  allowed,  that  no 
substance  is  better  calculated  for  supporting 
the  fractured  lower  jaw  ; for,  it  is  perfectly 
strong  enough  for  this  particular  case,  and 
if  wet  before  being  applied,  it  forms  when 
dry  a solid  covering,  most  accurately  corres- 
ponding to  the  shape  of  the  jaw. 

Whatever  may  be  the  substance  of  which 
splints  are  made,  they  ought  always  to  be 
at  least  as  long  as  the  fractured  bone  ; and, 
if  the  situation  of  the  limb  will  allow,  they 
ought,  says  Boyer,  to  extend  its  whole 
length.  a For  instance,  (says  he)  for  sim- 
ple fractures  of  the  thighs  of  very  young 
children,  the  pasteboard  splints,  which  I 
employ,  reach  from  the  upper  part  of  the 
thigh,  to  the  lower  part  of  the  leg.  Gene- 
rally speaking,  the  longer  splints  are,  the 
better  they  fix  the  limb,  and  keep  the  frac- 
ture steady.”  ( Boyer  Traitd  dts  Mai.  Chir. 
T.  3,  p.  60.) 

The  number  of  splints  must  depend  upon 
their  breadth,  and  the  thickness  of  the  limb. 
For  the  forearm,  two  are  sufficient;  for 
the  upper  arm  and  thigh  four  are  often 
used  and  for  the  leg  two,  and  sometimes 
three. 

In  cases  of  fractured  thighs,  when  the 
straight  position  is  preferred,  the  external 
splint  should  extend  from  the  crista  of  the 
ilium  to  some  little  distance  beyond  the 
sole  of  the  foot ; while  the  inner  one  should 
reach  from  the  upper  and  internal  part  of 
the  thigh  also  beyond  the  sole  of  the  foot. 
With  respect  to  the  anterior  splint  it  is  indif- 
ferent whether  itonly  reachesfrom  the  groin 
to  the  knee,  or  as  far  as  the  lower  part  of 
the  leg. 

The  lateral  splints  for  a broken  leg  ought 
to  be  sufficiently  long  t6  embrace  the  knee, 
and  confine  the  motions  of  the  foot  and 
ankle.  When  the  straight  posture  is  adopt- 
ed, a splint  is  frequently  laid  along  the  front 
of  the  leg,  from  the  patella  to  the  lower 
part  of  the  tibia.  None  however  can  ever 
be  required  under  the  limb,  as  there  the 
bedding  itself  more  conveniently  affords  the 
necessary  degree  of  support. 

Of  all  the  different  pieces  of  the  appara- 
tus for  the  treatment  of  fractures,  the 
splints  are  by  far  the  most  important  and 
essential.  Without  them,  indeed,  it  would 
be  in  vain  to  attempt  to  keep  the  extremities 
of  the  fracture  from  being  displaced. 

As  splints  are  generally  composed  of 
hard  materials,  the  bad  effects  of  their  pres- 
sure upon  the  skin  must  always  be  counter- 
acted by  placing  a sufficient  quantity  of  tow, 
wool,  or  other  soft  substance  between  them 
and  the  limb. 

In  order  to  understand,  however,  the 
principles,  which  should  guide  the  surgeon 
in  the  choice  and  application *of  splints, 
many  remarks,  offered  in  the  article  i Frac- 
ture, must  be  consulted. 

SPONGIA  PR.®  PAR  AT  A.  {Prepared 
Sponge;  Sponge-tent.)  Formed  by  dipping 
Vol,  II,  54 


pieces  of  sponge  in  hot  melted  emplastrum 
cerae  compositum,  and  pressing  them  be- 
tween two  iron  plates.  As  soon  as  cold, 
the  substance  thus  formed  may  be  cut  into 
pieces  of  any  shape.  It  was  formerly  much, 
used  for  dilating  small  openings,  for  which 
it  was  well  adapted,  as  when  the  wax  melt- 
ed, the  elasticity  of  the  sponge  made  it  ex 
pand  and  disteud  the  opening.  However, 
the  best  modern  surgeons  seldom  emplov  it. 

SPONGIA  USX  A.  {Burnt  Sponge.)  This 
is  often  given  in  the  torus  of  lozenges,  in 
cases  of  bronchocele,  in  which  particular 
instances  much  efficacy  is  imputed  to  allow- 
ing the  lozenges  to  dissolve  gradually  in  the 
mouth,  after  putting  them  under  the  tongue. 
Burnt  sponge  is  also  exhibited  in  many  scro- 
fulous diseases,  and  in  cases  of  chronic  en- 
largement of  the  prostate  gland.  The  dose 
is  from  a scruple  to  a dram. 

STAFF.  An  instrument  of  considerable 
importance  in  the  operation  of  lithotomy, 
being  in  fact  the  director  for  the  gorget,  or 
knife.  It  is  made  of  steel,  and  its  handle 
is  generally  rough,  in  order  that  it  may  be 
more  securely  held.  As  it  is  intended  to  be 
introduced  through  the  urethra,  its  shape- 
ought  to  be  principally  determined  by  the 
natural  course  of  that  passage.  The  English 
generally  employ  a staff,  the  curvature  of 
which  forms  the  segment  of  a larger  circle 
than  that  described  by  the  curvature  of  o. 
staff  used  by  the  French  practitioners.  (See 
Roux , Voyage  fait  a Londres  en  1S14,  ou  Pa- 
rallele  de  La  Chirurgie  Angloise , tyc.  p.  319.) 
In  other  words,  the  French  staff  turns  more 
upward  than  ours,  as  it  approaches  and  en- 
ters the  bladder.  There  may  be  some  ad- 
vantage in  this  construction,  inasmuch  as  it 
tends  to  make  the  gorget  enter  in  the  direc- 
tion of  the  long  axis  of  the  bladder;  yet,  a 
great  deal  more  seems  to  me  to  depend  upon 
the  position  in  which  the  staff  is  held,  than 
upon  its  shape.  Lithotomists  should  always 
employ  as  large  a staff  as  can  be  easily  in- 
troduced, because  the  operation  will  thereby 
be  facilitated.  The  groove,  the  most  im- 
portant part  of  the  staff,  is  of  course  situated 
upon  the  convexity  of  the  curved  part  of 
the  instrument,  or  upon  that  portion,  which, 
when  introduced,  lies  in  the  membranous 
part  of  the  urethra,  prostate  gland,  and  the 
bladder.  It  should  always  be  made  very 
broad  and  deep,  as  recommended  by  Lan- 
genbeck,  and  Mr.  Martineau.  (See  Lithoto- 
my.) The  termination  of  the  groove  at 
the  end  of  the  instrument  should  be  closed, 
so  as  to  stop  the  further  entrance  of  the 
gorget,  and  prevent  the  beak  of  the  latter 
instrument  from  doing  mischief.  English 
surgeons  have  been  justly  censured  by  De- 
sault and  Sabatier,  for  neglecting  this  es- 
sential caution  ; for,  certainly,  the  most  fa- 
tal injury  may  be  done  by  the  gorget  slipping 
beyond  tbe  end  of  the  staff.  (See  Lithoto- 
my.) For  ray  own  part,  if  I am  more  sure 
of  any  one  thing  in  surgery,  than  another, 
it  is  this,  that  the  beak  of  a gorget  in  the 
bladder  ought  never  to  pass  out  of,  or  be» 
yond  the  groove  of  the  staff. 
STAPHYLOMA,  (frouti  sratpvMf  a grape. 


oi'AMIYLOMA; 


4 26 

from  its  being  thought  to  resemble  a grape.) 
Is  that  disease  of  the  eyeball,  in  which  the 
cornea  loses  its  natural  transparency,  rises 
above  the  level  of  the  eye,  and  even  pro- 
jects beyond  the  eyelids,  in  the  form  of  an 
elongated,  whitish,  or  pearl-coloured  tu- 
mour, which  is  sometimes  smooth,  some- 
times uneven,  and,  according  to  Scarpa, 
attended  with  total  loss  of  sight.  However, 
staphyloma  is  either  partial  or  total,  that  is 
to  say,  it  affects  only  a part  or  the  whole 
of  the  cornea;  and  in  the  first  case,  if  th<re 
be  not  too  much  additional  injury  of  the 
eye,  a degree  of  vision  may  yet  be  left,  and 
even  admit  of  further  improvement.  The 
circumstance  of  Scarpa’s  observations  ap- 
plying only  to  cases  in  which  the  eyesight 
is  already  destroyed,  accounts  for  some  im- 
portant differences  between  him  and  other 
writers,  who,  in  the  practice  which  they 
advise,  refer  to  the  partial  staphyloma,  and 
cases  in  which  the  sight  is  not  quite  annihi- 
lated. Scarpa  does  not  mention  adhesion 
of  the  iris  to  the  diseased  cornea,  as  a part 
of  the  definition  of  staphyloma  ; a point  in 
which  he  differs  both  from  Richter  and 
Beer.  ( Lehre  von  den  Augenkr.  B.  2,  p.  69.) 
Yet  Scarpa  may  be  correct ; for  though,  as 
Mr.  Wardrop  remarks,  “ the  internal  sur- 
face of  the  cornea  adheres  to  the  iris  in  al- 
most every  case  of  staphyloma.”  ( Essays  on 
the  Morbid  Anal,  of  the  Eye,  Vol.  1,  p.  101.) 
yet,  as  it  does  not  invariably  do  so,  the  cir- 
cumstance forms  no  essential  part  of  the 
nature  of  the  disease.  In  some  instances, 
Mr.  Wardrop  has  seen  the  opacity  confined 
to  one  half  of  the  cornea,  and  this  generally 
the  lower  one.  (Vol.  cit.p.  100.) 

Scarpa  observes,  that  infants  are  often  at- 
tacked by  this  disease  soon  after  their  birth, 
and  mostly  in  consequence  of  the  purulent 
ophthalmy.  It  is  also  produced  by  the  small- 
pox, yet  never  during  its  eruption,  which 
is  singular;  nor  during  the  stage  of  suppura- 
tion ; but,  when  the  pustules  dry,  and  even 
after  the  detachment  of  the  variolous  scabs. 

In  a great  number  of  subjects,  says  Scarpa, 
when  the  staphyloma  has  attained  a certain 
elevation  above  the  cornea,  it  becomes  sta- 
tionary, or  only  increases  in  due  proportion 
to  the  rest  of  the  eye.  In  other  instances, 
the  small  tumour  of  the  cornea  enlarges  in 
all  its  dimensions,  and  in  such  a dispropor- 
tion to  the  rest  of  the  eye,  that  at  length  it 
protrudes  considerably  between  the  eyelids, 
to  the  great  molestation  and  deformity  of 
the  patient. 

This  disease  is  justly  considered  as  one  of 
the  most  serious  to  which  the  eyeball  is  sub- 
ject ; for,  to  the  total  and  irremediable  loss 
of  sight  that  it  occasions,  are  added  all  the 
evils  which  necessarily  result  from  the  bulk 
and  protuberance  of  the  staphyloma,  after 
the  swelling  of  the  cornea  has  acquired 
such  a size,  that  it  can  no  longer  be  covered 
by  the  eyelids.  In  such  circumstances,  the 
continual  exposure  of  the  eyeball  to  the 
contact  of  the  air,  and  particles  of  matter 
suspended  in  it;  the  friction  of  the  eye- 
lashes ; the  incessant  flux  of  tears  down  the 
subjacent  cheek  render  the  eye  painful 


and  inflamed  ; the  sound  one  is  affected  by 
sympathy,  and  the  diseased  one  at  length 
ulcerates,  together  with  the  lower  eyelid 
and  cheek,  on  which  it  presses. 

According  to  Richter  (Obs.  Chir.  Fasc.  2.) 
staphyloma  is  generally  formed,  without  the 
swelling  of  the  cornea  being  preceded  by 
any  of  those  morbific  dispositions  which  are 
generally  considered  capable  of  weakening 
the  texture  and  elasticity  of  the  cornea; 
which,  in  fact,  acquires  a much  greater 
thickness,  than  what  it  has  in  its  natural 
state,  and  consequently,  staphyloma,  far 
from  being  concave  within,  is  every  where 
compact  and  solid  ; though  it  ought  to  be 
quite  the  contrary,  if  the  tumour  were  oc- 
casioned, as  Beer  yet  appears  to  believe,  by 
an  immoderate  distention,  operating  on  the 
cornea  from  within  outward,  with  absorp- 
tion of  its  natural  texture. 

Scarpa  thinks,  that  Richter  has  general- 
ized his  doctrine  too  much,  by  not  drawing 
any  line  of  distinction  between  the  staphy- 
loma of  recent  occurrence  in  infants,  and 
that  ot  adult  subjects,  in  whom  the  disease 
has  acquired  so  large  a volume,  as  to  pro- 
trude considerably  beyond  the  eyelids.  He 
agrees  with  Richter,  >hat  the  recent  staphy- 
loma in  infants  is  quite  compact  and  solid, 
on  account  of  the  augmented  thickness  of 
the  cornea  ; but  he  is  convinced  by  repeated 
observation,  that,  in  this  very  same  staphy- 
loma, originally  quite  solid  and  compact, 
the  cornea  becomes  thinner,  or, at  all  events, 
is  not  thicker  than  natural,  after  the  disease 
has  existed  a series  of  years  in  adult  sub- 
jects, and  in  whom  the  swelling  of  the  cor- 
nea has  attained  such  a size  as  to  protrude 
beyond  the  eyelids.  The  tumour,  he  ob- 
serves, is  not  solid  throughout,  except  in 
regard  to  its  containing,  in  its  amplified 
state,  the  iris,  the  crystalline,  and  very 
often,  also,  a portion  of  the  vitreous  hu- 
mour. 

The  cornea  of  infants,  in  its  natural  state, 
is  at  least  twice  as  thick  and  pulpy  as  that 
of  adults,  and,  consequently,  the  anterior 
chamber  of  the  aqueous  humour,  in  the 
former,  is  comparatively  so  contracted,  to 
what  it  is  in  the  latter,  that,  in  infants  at  the 
breast,  the  cornea  may  be  considered  as  in 
contact  with  the  iris. 

To  such  qualities  of  the  cornea,  in  child- 
ren of  tender  years,  and  to  the  natural  nar- 
rowness of  the  anterior  chamber  of  the 
aqueous  humour,  Scarpa  imputes  the  cause 
why  ophthalmies  in  infants  so  often  pro- 
duce opacity  and  thickening  of  this  mem- 
brane. The  cornea  swells,  becomes  preter- 
naturally  thickened,  and  is  very  soon  con- 
verted into  a pointed,  whitish,  or  pearl-co- 
loured tumour,  without  any  cavity  inter- 
nally, and  either  in  perfect  contact  with,  or 
adherent  to,  the  iris.  In  the  course  of  years, 
however,  Scarpa  remarks  that  this  disease 
undergoes  new  modifications.  For,  as  the 
whole  eye  enlarges  with  age,  the  iris  and 
crystalline,  from  causes  not  sufficiently  un- 
derstood, abandon  their  natural  situation, 
and  are  propelled  forward,  nearer  and 
nearer  to  the  cornea;  which  they  in  time 


STAPHYLOMA 


■distend  in  all  its  dimensions,  so  as  to  make 
it  project  beyond  the  eyelids,  at  the  same 
time  rendering  it  thinner  in  a ratio  to  its 
bulk  and  magnitude.  Scarpa  has  never  met 
with  a voluminous  staphyloma,  projecting 
beyond  the  eyelids  in  adult  persons,  which 
had  not  originally  made  its  first  appearance 
in  infancy  ; and  he  has  invariably  found, 
that  the  thickness  and  density  of  the  cornea, 
both  in  the  living  and  dead  bodies  ot  those 
who  have  been  affected  with  this  disease, 
were  in  an  inverse  ratio  to  the  eye.  Jn  in- 
veterate cases  of  staphyloma,  forming  a 
large  protuberance  beyond  the  eyelids,  the 
iris  may  here  and  there  be  clearly  discerned 
through  the  diseased  cornea,  and  if  it  be 
not  equally  manifest  at  all  points  of  the  tu- 
mour, it  is  because  the  conjunctiva  exter- 
nally spread  over  the  cornea  forms,  in  con- 
junction with  its  varicose  vessels  on  the 
surface  of  the  tumour,  a stratum  of  matter, 
not  every  where  equally  dense  and  opaque. 
This  dense  stratum  of  the  conjunctiva, 
spread  over  the  cornea,  easily  causes  decep- 
tion in  a staphyloma  of  considerable  bulk. 
The  more  the  tumour  increases,  the  more 
the  substance  of  the  cornea  seems  to  be- 
come dense  and  thickened  ; while  in  reality 
the  contrary  happens  ; for  the  augmentation 
in  the  density  of  the  layer  of  the  conjunc- 
tiva, covering  the  cornea,  only  partly  sup- 
plies the  diminution  in  the  thickness  of  the 
latter  membrane.  In  staphyloma,  as  Mr. 
Wardrop  observes,  “ the  pupil  is  hid  accord- 
ing to  the  situation  and  degree  of  the  opa- 
city of  the  cornea ; but,  in  most  cases  it  is 
altogether  obliterated,  and  even  in  those, 
where  a transparent  portion  of  the  cornea 
is  opposite  to  it,  the  vision  is  much  impair- 
ed ; for,  as  the  eye  has  lost  its  form  as  an  op- 
tical instrument,  the  change  in  its  refractive 
power  must  render  objects  very  indistinct .” 
{Morbid  Anat.  of  the  Eye,  Vol.  1 ,p.  101.) 

The  sclerotica  is  also  subject  to  staphy- 
loma, that  is,  to  a partial  distention  and  pro- 
minence ?of  its  anterior  hemisphere  in  the 
white  of  the  eye.  Scarpa  never  met  with 
any  tumour  or  prominence  on  the  front  sur- 
face of  the  sclerotica,  corresponding  to  the 
white  of  the  eye  ; but  in  the  dead  subject  he 
has  met  with  two  examples  of  staphyloma 
in  the  posterior  hemisphere  of  the  sclerotica. 
According  to  Mr.  Travers,  in  the  spheroidal 
staphyloma  of  the  cornea,  the  sclerotica 
sometimes  yields  so  much  as  greatly  to  in- 
crease the  deformity.  “This  happens  in 
hydropic  and  other  degenerations  of  the 
humours.  It  also  frequently  becomes  ex- 
tenuated, or  bulged  near  its  junction  with 
the  cornea  in  the  amaurosis,  which  follows 
inflammation  of  the  choroid.  This  protru- 
sion, larger  or  smaller,  is  sometimes  cir- 
cumscribed, and  in  other  instances  diffused 
over  a large  portion  of  the  ball.  It  is  often 
seen  encircling  the  cornea,  and  presenting 
a sacculated  or  pouched  appearance.  It 
has  a bluish  gray  tint,  &-c.‘’  ( Synopsis  of 

the  Diseases  of  the  Eye,  p.  130.) 

When  in  the  staphyloma  of  the  cornea, 
this  part  is  affected  with  irremediable  opa- 
city, Scarpa  thinks  that  if  the  disease  be  re- 
cent. and  in  a child,  the  only  object  must  be 


to  hinder  the  increase  Of  the  swelling  of  the 
cornea,  the  organization  of  which  is  already 
destroyed.  The  tumour  must  be  levelled, 
and  flattened  as  much  as  possible  ; and 
when  the  swelling  of  the  cornea  is  invete- 
rate, very  large,  and  prominent  beyond  the 
eyelids,  it  is  to  be  diminished  by  surgical 
means,  so  as  to  return  within  the  orbit,  suf- 
ficiently to  permit  the  deformity  of  the  face 
to  be  amended  by  the  application  of  an  ar- 
tificial eye. 

In  cases  of  recent  staphyloma,  Richter 
used  to  make  at  the  bottom  of  the  tumour 
of  the  cornea  an  artificial  ulcer,  by  repeat- 
edly applying  the  argentum  nitratum,  or  the 
oxygenated  muriate  of  antimony  (butter  of 
antimony,)  and  to  keep  the  little  sore  open 
by  the  continued  use  of  the  same  caustic, 
with  the  view  of  effecting  a diminution  of 
the  swelling  of  the  cornea.  In  this  way 
Richter  frequently  succeeded  in  lessening 
staphyloma,  and  be  one  particular  case  he 
even  restored  the  transparency  of  the  cor- 
nea. Ter  repetitd  operalione,  quarto  scilicet , 
septimo  et  decimo  die,  ne  vestigium  quidem 
morbi  die  decimo-quarto  superabat.  Obs. 
Chir.  Fasciculus  2. 

Though  Scarpa  has  frequently  attempted 
to  cure  the  recent  staphyloma  of  infants'  by 
the  above  method,  he  has  never  yet  met 
with  such  success,  as  can  be  at  ail  compared 
with  Richter’s,  either  in  restoring  the  trans- 
parency of  the  cornea,  or  accomplishing  a 
diminution  of  the  volume  of  the  staphyloma. 
Having  formed  with  the  argentum  nitratum 
a small  ulcer,  at  the  bottom  of  the  cornea, 
arid  kept  the  sore  open  thirty  days  and 
more,  he  failed  in  obtaining  any  benefit,  in 
respect  to.  the  diminution,  much  less  the 
opacity  of  the  cornea,  in  three  infants,  one 
a year  and  a half  old,  and  the  two  others 
somewhat  more  than  three,  all  which  sub- 
jects had  been  recently  attacked  with  sta- 
phyloma in  one  eye,  in  consequence  of  the 
small-pox.  A violent  chemosis,  in  a very 
short  time  produced  a staphyloma  in  the 
eye  of  a child  five  years  old.  Scarpa  made 
an  ulcer  at  the  bottom  of  the  cornea,  in  the 
unorganized  swollen  substance  of  which  he 
introduced,  for  a little  depth,  the  flat  part 
of  a lancet.  Scarpa  kept  the  sore  open  for 
five  weeks,  with  a solution  of  the  argentum, 
nitratum,  and  he  remarked  that  the  staphy- 
loma became  somewhat  flatter,  so  as  to 
lose  the  acute  prominence  which  it  had  at 
its  centre  ; but  the  cornea  continued,  as  be- 
fore, every  where  opaque.-  Though  Scarpa 
employed  the  same  method  in  two  otjier 
subjects,  of  about  the  same  age,  and  in  the 
same  circumstances ; though  he  kept  the 
ulcer  open  fifty  days,  he  was  never  able  to 
effect  any  depression  or  diminution  cf  the 
staphyloma;  and,  consequently,  the  point- 
ed, pearl-coloured  projecting  part  of  the 
tumour  continue’d  in  the  same  state  as  it  was 
before.  The  conical  shape  which  the  cor- 
nea assumes  in  this  disease,  he  observes,  is 
a characteristic  symptom  by  which  a sta- 
phyloma may  be  distinguished  from  a leu- 
coma,  with  total  opacity  of  the  cornea. 

If,  also,  in  the  course  of  further  trials, 
partial  benefit  be  found  to  accrue  from  thic' 


STAFHYtOMA 


42k 


plan,  adopted  not  tor  the  purpose  of  re- 
establishing the  transparency  of  the  cornea, 
but  for  that  of  merely  checking  and  dimi- 
nishing the  recent  staphyloma  in  infants, 
still  Scarpa  is  of  opinion,  that  no  one  will 
be  easily  persuaded  that  the  same  treatment 
can  ever  prove  of  the  least  service  in  dimi- 
nishing the  size  of  the  large,  inveterate 
staphyloma  in  adults ; in  other  words,  of 
that  which  projects  beyond  the  eyelids,  and 
rests  on  the  cheek.  Under  these  circum- 
stances, he  believes,  that  there  is  no  effect- 
ual means  of  restraining  the  progress  of  the 
complaint,  and  removing  the  deformity,  but 
cutting  away  the  staphyloma,  and  when  the 
place  is  healed,  an  artificial  eye  may  be  ap- 
plied. 

Celsus  thus  expresses  himself  on  the  sub- 
ject of  this  operation  : — Curalio  duplex  est. 
Altera  ad  ipsas  radices  per  medium  transuere 
acu,  duo  lina  ducente , deinde  atlerius  Uni  duo 
capita  ex  superiore  parte , alterius  ex  inferiore 
adslringere  inter  se  quce  paulatim  secando  id 
excidant.  Altera  insumma  parti  ejus  ad  len - 
iiculcB  magnitudinem  exscindere  ; dtinue  spo- 
dium , nut  cadmiam  inf  Heart.  Utrolioet  au- 
tern  facto , album  ovi  lana  excipiendum,  et  im- 
ponendum ; posleaque  vapore  aquee  ealidee 
fovendus  o cuius,  et  ienibus  medicamentis  un - 
guendus  est.  De  Medicina,  lib.  7,  cap.  6. 

Though,  says  Scarpa,  the  first  plan,  or  that 
of  the  ligature,  is  at  present  abandoned,  the 
majority  of  surgeons  still  persevere  in  pass- 
ing a needle  and  ligature  through  the  lower 
part  of  the  staphyloma,  not  for  the  purpose 
of  tying  or  constricting  the  tumour,  it  is  true, 
but  of  making  a noose,  in  order  to  fix  the 
eye  conveniently,  when  the  staphyloma  is  to 
be  cut  off  in  a circular  manner.  This  use  of 
a needle  and  ligature,  which  1 observe  is 
sanctioned  by  Mr.  Travers,  (Synopsis,  fyc.  p. 
285,) i is  strongly  disapproved  of  by  Scarpa. 

With  regard  to  the  second  method  of  re- 
moving the  staphyloma,  or  that  of  excision, 
Scarpa  thinks  that  sufficient  attention  has  not 
hitherto  been  paid  to  what  Celsus  has  written 
on  this  subject.  In  fact,  Celsus  does  not  for- 
bid cutting  away  the  staphyloma,  by  a circu- 
lar incision  at  its  base,  as  is  practised  at  the 
present  day,  but  says  that  this  operation  is  to 
be  done  in  the  centre,  or  conical  point  of  the 
tumour,  and  that  as  much  of  this  part  of  the 
staphyloma  is  to  be  cut  away  as  will  equal  a 
iontil  in  size  : In  summd  parte  ejus  ad  lenticu- 
he  magnitudinem  exscindere.  Scarpa  remarks, 
that  the  great  importance  of  this  precept  of 
Celsus,  in  regard  to  the  successful  treatment 
of  the  staphyloma,  can  only  be  duly  appre- 
ciated by  surgeons  who  have  often  had  oc- 
casion to  compare  the  advantages  of  Celsus’s 
doctrine,  with  the  serious  inconveniences 
which  result  from  the  common  practice  of 
cutting  away  the  staphyloma  circularly  at  its 
base  ; and  with  the  evils  produced  by  a se- 
micircular sectioii,  comprehending  the  scle- 
rotica, in  Woolhouse’s  manner,  always  fol- 
lowed by  acute  inflammation  of  the  eyeball 
and  eyelids,  violent  pains  in  the  head,  rest- 
lessness, spasms,  copious,  and  somotimes  gan- 
grenous, suppurations  of  the  eye  and  eyelids. 

The  patient  being  seated,  Scarpa  directs 
an  assistant  to  support  his  head  properly  ; 


then  taking  in  his  hand  a knife,  similar  to 
what  is  used  in  the  extraction  of  the  cata- 
ract, he  passes  the  instrument  completely 
across  the  staphyloma,  at  the  distance  of  one 
line  and  a half,  or  two  lines,  from  the  centre 
or  apex  of  the  tumour,  from  the  external  to- 
wards the  internal  angle  of  the  eye,  and  by 
passing  the  knife  forward  in  the  same  direc- 
tion, just  as  is  done  in  the  extraction  of  the 
cataract,  he  makes  a semicircular  incision 
downwards,  in  the  most  prominent  part  of 
the  tumour.  Having  done  this,  be  takes 
hold  of  the  segment  of  the  staphyloma  with 
the  forceps,  and  turning  the  edge  of  tl\e 
knife  upward,  he  completes  the  circular  re- 
cision  of  the  apex  of  the  tumour,  in  such  a 
way  that  the  detached  portion  is  one,  two, 
three,  or  four  lines  in  diameter,  according  to 
the  size  of  the  staphyloma.  As  a portion  of 
the  iris  adhering  to  the  cornea,  from  the  very 
commencement  of  the  disease,  is  commonly 
included  in  this  section  of  the  pointed  part 
of  the  tumour,  no  sooner  is  the  circular  di- 
vision of  the  apex  of  the  staphyloma  made, 
than  the  crystalline,  or  its  nucleus,  issues 
from  the  eye,  followed  by  a portion  of  the 
vitreous  humour.  In  consequence  of  this 
evacuation,  the  eyeball  often  diminishes  in 
such  a degree,  that  it  can  be  covered  by  the 
eyelids,  to  which  Scarpa  immediately  ap- 
plies a pledget  of  dry  lint,  supported  by  a 
retentive  bandage. 

When  the  eye  and  eyelids  begin  to  be  pain- 
ful, inflame,  and  swell,  as  they  generally  do 
on  the  fourth  day,  the  eye  is  to  be  covered 
with  a bread  and  milk  poultice.  When 
things  proceed  in  a regular  manner, the  swell- 
ing of  the  eyelids  subsides  about  the  seventh 
or  ninth  day,  and  purulent  matter  is  seen  on 
the  poultice,  blended  with  the  vitreous  hu- 
mour. The  matter  afterward  becomes  thick 
and  whitish,  the  patient  feels  great  relief,  and 
the  eyeball  shrinks  and  sinks  into  the  orbit. 

At  this  period,  on  gently  separating  the 
eyelids,  the  conjunctiva  is  found  swelled, 
and  reddish,  and  the  margin  of  the  wound 
seems  like  a whitish  circle.  This  is  usually 
detached  on  the  twelfth  or  fourteenth  day  af- 
ter the  operation,  when  the  edge  of  the  sur- 
face, from  which  the  staphyloma  was  cut, 
becomes  red,  contracts,  and  daily  diminishes, 
so  that  at  last  the  wound  is  entirely  closed. 
There  only  remains  in  the  centre  of  the  cor- 
nea, for  a few'  days,  a small  fleshy  promi- 
nence, resembling  a little  reddish  papilla, 
which,  after  being  touched  a few  times  with 
the  argentum  nitraturn,  contracts,  and  heals. 

So  far,  says  Scarpa,  are  alarming  symp- 
toms from  following  this  operation,  that  in 
a great  number  of  cases  the  surgeon  is  even 
obliged,  several  days  afterward,  to  stimulate 
the  eye  on  which  it  has  been  performed,  in 
order  to  make  it  inflame,  partly  by  leaving  it 
a long  while  uncovered,  and  exposed  to  the 
air,  partly  by  enlarging  the  circular  recision, 
made  in  the  centre  of  the  staphyloma,  of 
which  another  circular  portion,  half  a line 
broad,  is  removed,  in  order  to  facilitate  the 
more  abundant  discharge  of  the  humours, 
and  the  ingress  of  air  into  the  cavities  ot  the 
eye,  which  are  so  backward  to  inflame.  An 
soon  as  inflammation  has  invaded  tho  infe 


STL 


SUL  429 


tior  of  the  eye,  and  suppuration  has  taken 
place,  the  rest  of  the  cure  regularly  follows 
under  the  use  of  topical  emollients,  and  is 
soon  completed  with  all  possible  mildness. 

It  should  be  particularly  recollected,  that 
Scarpa  means  the  foregoing  practice  for  in- 
veterate cases  of  staphyloma,  where  the  eye- 
sight is  totally  lost,  and  (he  projection  of  the 
diseased  coruea  produces  serious  annoyance. 
Under  other  circumstances,  the  method 
can  hardiy  be  admissible.  Among  others, 
Dr.  Vetch  particularly  objects  to  the  remo- 
val of  the  apex  of  the  tumour,  as  destructive 
of  all  chance  of  the  recovery  of  a degree  of 
vision  ; a consideration,  however,  which 
would  not  exist  in  the  hopeless  cases  spoken 
of  by  Scarpa.  Dr.  Vetch  also  disapproves 
of  letting  out  the  aqueous  humour  in  cases 
of  staphyloma  as  art  endless  operation,  from 
which  no  permanent  effect  takes  place,  the 
humour  collecting  again  in  a few  hours;  a 
sentiment  which  is  likewise  expressed  by 
Mr.  Travers.  (See  Vetch  on  the  Diseases  of 
the  Eye,  p.  63  ; and  B.  Travers , Synopsis , fyc. 
p.  286.)  For  the  purpose  of  accomplishing 
the  gradual  diminution  of  the  tumour,  and 
bringing  the  eye  into  a stale  in  which  an  arti- 
ficial pupil  may  be  made , Dr.  Vetch  has  em- 
ployed caustic  (the  method  commended  both 
by  Richter  and  Beer)  and  the  introduction  of 
a seton  through  the  tumour.  Beer  confirms 
the  statement  of  Scarpa,  concerning  the  im- 
possibility of  restoring  the  transparency  of 
any  part  of  the  cornea  affected  with  staphy- 
loma. For  the  relief  of  a partial  staphylo- 
ma, he  prefers  the  cautious  application  of 
the  oxygenated  muriate  of  antimony,  by 
means  of  the  point  of  a camel-hair  brush, 
while  the  eyelids  are  held  asunder.  The  dis- 
eased part  of  the  cornea  is  to  be  smeared 
with  it  until  a small  white  superficial  slough 
is  formed,  when  every  particle  of  the  caus- 
tic must  be  immediately  washed  out  of  the 
eye  with  another  larger  camel-hair  brush, 
dipped  in  water,  or  milk.  The  application 
is  not  to  be  repeated  until  the  subsequent  in- 
flammation has  quite  subsided,  and  the  slough 
been  thrown  off.  Beer  condemns  all  escha- 
rotic  salves,  because  the  iraction  extends  to 
pcrts  which  should  be  left  uuirritated.  ( Lehre 
■von  den  Augenkr.  B.  2,  p.  74.) 

Wenzel,  and  numerous  other  writers,  im- 
ply  by  staphyloma,  a protrusion  of  a piece 
of  the  iris  through  a wound  or  ulcer  of  the 
eye.  (See  Iris,  Prolapsus  of.) 

R.  Fr.  B.  Ho  elder.  De  Staphylomale,  Tu- 
bing#, 1748.  Scarpa  Suite  Malatlie  Degli 
Occhi,  Ed.  5.  G J.  Beer's  Ansicht  der  Sta- 
phylomatosen  Melamorphosen  des  Auges , tyc. 
IVien.  1805.  jYachtrag  zur  Ansicht , $-c. 
1806;  and  Lehre  von  den  Augenkr.  B.  2 ,p. 
69,8 vo.  Wien.  1817.  Richter,  Anfangsgrunde 
der  Wundarz n eykunst , B.  3.  p.  153.  fyc.  Gotl. 
1795.  Sabatier,  Mddecine  Operaloire.  T.  2, 
p.  191,  Ed.  2,  1810.  James  Wardrop . Essays 
on  the  Morbid  Anatomy  of  the  Human  Eye, 
Vol.  1,  p.  99,  8 vo.  Edinb.  1808.  £.  Travers , 
Synopsis  of  the  Diseases  of  the  Eye,  8 vo.  Load. 
1820.  J.  Vetch , A Practical  Treatise  on  the 
Diseases  of  the  Eye,  8 vo.  Lond.  1821. 

•STEATOMA.  (from  <r]e*e,  fat.)  A wen. 


or  encysted  tumour,  containing  fat.  See  Tu- 
mours, Encysted. 

STELLA,  or  STELLATED  BANDAGE. 
A bandage  so  named  because  it  makes  a 
cross,  or  star,  on  the  back.  It  is  a roller,  ap- 
plied in  the  manner  of  a figure  8,  so  as  to 
keep  back  the  shoulders.  It  is  often  em- 
ployed in  cases  of  fractures  and  dislocations 
of  the  clavicle. 

STRAMONIUM.  A series  of  interesting 
experiments  were  detailed  in  illustration  of 
the  properties  of  stramonium,  in  a Disserta- 
tion, which  was  read  to  the  Medical  Facul- 
ty of  the  University  of  Pennsylvania,  on 
the  12th  of  May,  1797,  by  Dr.  Samuel 
Cooper  The  experiments  No.  15  and  16, 
merit  particular  notice  in  this  Dictionary,  as 
being,  perhaps,  the  earliest  discovery  of  the 
effect  of  the  local  application  of  powerful 
narcotics  in  dilating  the  pupil.  A drop  cf 
an  infusion  of  the  powder  of  stramonium 
was  let  fall  into  the  left  eye.  In  half  an  hour 
the  pupil  began  to  enlarge,  and  attained  its 
greatest  dimensions  about  twelve  hours  after 
the  experiment,  at  which  time  it  was  viewed 
in  a considerable  light,  and  seemed  thrice  as 
large  as  the  other.  It  continued  dilated  two 
days.  In  a strong  light,  objects  were  seen 
more  distinctly  with  the  right  eye;  but  in  a 
weak  light,  with  the  left.  Some  other  gen- 
tlemen, however,  on  whom  the  experiment 
was  tried,  experienced  no  increased  power 
of  seeing  in  the  -dark.  A drop  of  the  ex- 
pressed juice,  dropped  into  the  eye  of  a cat, 
soon  converted  the  whole  of  the  coloured 
part  of  the  eye  into  pupil.  (See  Caldwell's 
Medical  Theses,  p.  173,  8ro.  Philadelphia, 
1805)  Stramonium,  then,  resembles  bella- 
donna and  hyosciamus  in  its  action  upon  the 
iris.  It  has  been  exhibited  internally,  in  epi- 
lepsy, tic  douleureux,  and  severe  chronic 
pains,  and  used  in  poultices  for  dispersing  in- 
durations of  the  breast,  and  in  ointments  for 
allaying  the  pain  of  piles.  The  doses  should 
at  first  be  only  gr.  ss.  of  (lie  extract  twice  a 
day,  but  they  may  be  gradually  increased  to 
five  grains. 

STRICTURE,  (from  stringo,  to  bind.) 
A diminution,  or  contracted  state  of  some 
tube,  or  duct,  in  the  body.  See  Urethra , 
Strictures  of;  (Esophagus , 4'c-  Rectum , fyc. 
Stricture  also  means,  in  cases  of  strangula- 
ted hernia,  the  narrowest  part  of  the  open- 
ing, or  passage  through  w hich  the  bowels 
protrude,  which  narrowest  part  makes  on  the 
viscera  the  pressure  causing  all  the  bad  symp- 
toms. See  Hernia. 

SI  RUMA.  (from  slrno,  to  heap  up.)  Scro- 
fula, or  Scrophula.  The  King’s  Evil.  See 
Scrofula, 

STYE  A little  inflammatory  tumour  on 
the  eyelid.  See  Hordeolum. 

SULPHURIC  ACID.  The  strong  sulphu- 
ric acid  is  not  much  used  in  the  practice  of 
surgery,  except  as  a means  of  extricating 
from  the  nitrate  ot  potash,  or  muriate  of 
soda,  certain  gases  for  the  purpose  of  purify- 
ing the  air  of  sick  rooms,  or  infected  places. 
A few'  practitioners  have  also  sometimes 
employed  it,  blended  with  sixteen  times  its 
weight  of  lard,  aa  a local  application  for  the 


48>i) 


SUFPU  RATION 


cure  of  scabies.  Asa  caustic,  it  is  not  gene- 
rally eligible,  because  it  is  difficult  to  limit 
its  operation  exactly  to  the  parts  which  are 
intended  to  be  destroyed.  A few  years  ago, 
a proposal  was  made  to  apply  this  acid  along 
the  outside  of  the  eyelid,  in  cases  of  trichia- 
sis, so  as  to  produce  a slough,  and  subsequent 
ulcer,  the  cicatrization  of  which  draws  out 
the  inverted  tursus.  Nay,  it  is  alleged  that 
the  application  sometimes  produces  an  in- 
stantaneous amendment  of  the  position  of 
the  eyelid.  I have  seen  one  example,  in 
which  the  experiment  was  tried  ; but  whe- 
ther it  was  owing  to  the  acid  not  having 
been  sufficiently  applied,  or  other  causes,  the 
method  did  not  answer  so  well  as  the  usual 
plan  of  removing  a part  of  the  integuments 
with  a cutting  instrument. 

Diluted  sulphuric  acid  is  frequently  em- 
ployed as  an  ingredient  in  gargles.  It  is  also 
commonly  exhibited  with  a view  of  check- 
ing passive  hemorrhages,  and  profuse  noctur- 
nal sweats  in  hectic  fever.  The  dose  is  from 
ten  to  thirty  drops. 

This  acid,  in  the  diluted  form,  has  been 
tried  in  venereal  cases.  According  to  Mr. 
Pearson,  when  a bad  state  of  health  prohi- 
bits the  introduction  of  mercury,  the  case 
has  not  yet  put  on  an  unequivocal  appear- 
ance, or  dyspeptic  symptoms,  attended  with 
profuse  perspirations,  harass  the  patient,  it 
is  an  useful  remedy,  capable  of  giving  a 
temporary  check  to  the  progress  of  the  dis- 
ease. He  says,  that  he  has  often  seen  it 
arrest  the  progress  of  venereal  ulcers  of  the 
tonsils,  and  make  venereal  eruptions  fade 
and  nearly  disappear  ; but  that  these  bene- 
ficial effects  were  never  permanent.  At 
the  same  time  he  acknowledges  that  the 
medicine  will  confer  actual  and  durable  be- 
nefit in  ulcers  of  the  penis,  groin,  and  throat, 
sometimes  remaining  stationary  after  a mer- 
curial course.  He  has  likewise  found  this 
acid  very  efficient,  when  mercury  acts  too 
violently  upon  the  mouth.  (See  Pearson's 
Obs.  on  the  Effects  of  various  Art  hies  in  the 
Cure  of  Lues  Venerea,  p.  189 — 191,  Ed.  2.) 

In  cases  of  poison  by  sulphuric  acid,  the 
most  successful  treatment  consists  in  ma- 
king the  patient  drink  large  quantities  of 
water,  in  which  calcined  magnesia  is  sus- 
pended. Should  this  last  medicine,  how- 
ever, not  be  at  hand,  soap,  blended  with 
water,  is  the  best  substitute.  While  these 
remedies  are  preparing,  copious  draughts  of 
some  mucilaginous  beverage,  milk,  or  even 
of  common  water,  should  be  administered 
without  delay  ; for  the  practitioner  should 
ever  be  mindful,  that  so  rapidly  does  sulphu- 
ric acid  operate  upon  the  texture  of  the  parts 
with  which  it  comes  into  contact,  that  all 
chance  of  saving  the  patient  must  depend 
upon  the  quickness  with  which  the  means 
to  counteract  the  poison  are  applied.  After 
the  acid  has  been  diluted  and  neutralized, 
local  and  general  bleeding,  emollient  clys- 
ters, and  mucilaginous  drinks,  constitute  the 
best  remedies.  ( Orfila , Traitt  des  Poisons , 
fyc.  Vol.  1.  p.  434,  Ed.  2.) 

SUPPRESSION  OF  URINE.  See  Urine , 
Retention  of. 


SUPPURATION.  A process,  by  which  a 
peculiar  fluid,  termed  pus,  is  formed  in  the 
substance,  or  from  the  surface  of  parts  of 
the  body.  From  the  observations  made  in 
the  article  inflammation , it  appears,  that 
when  this  last  affection  is  above  a certain 
pitch,  it  sometimes  terminates  in  suppura- 
tion. 

When  purulent  matter  accumulates  in  the 
part  affected,  it  is  termed  an  abscess , which 
is  distinguished  into  several  kinds,  the  ccw/e, 
chronic,  venereal,  scrofulous , &c. 

It  is  observed  by  Professor  Thomson,  that 
the  texture,  in  which  suppuration  seems  to 
be  most  readily  produced,  by  a certain  de- 
gree of  inflammation,  is  mucous  membrane, 
whether  this  lines  excretory  ducts,  or  canals, 
or  covers  the  inner  surfaces  of  the  respira- 
tory, or  urinary  organs.  In  a few  hours, 
after  an  irritating  cause  has  been  applied  to 
these  surfaces,  the  physical  and  cbymical 
qualities  of  the  fluid  which  they  secrete  in 
their  natural  state,  are  changed.  From 
being  a tough  viscid  substance,  not  easily 
miscible  with  water,  the  mucus  of  the  nose 
and  bronchia  becomes,  during  an  attack  of 
inflammation,  very  readily  miscible  with 
water,  of  a yellowish  white  colour,  and  fluid 
consistence.  If,  in  this  state,  the  secretion 
from  these  membranes  be  examined  with 
the  microscope,  it  will  be  found  to  contain 
small  globules,  similar  to  those  which  are 
seen  in  the  blood  ; and  these  globules  are 
found  to  increase  in  number  in  proportion 
to  the  degree  and  continuance  of  the  inflam- 
mation. We  have  examples  of  the  produc- 
tion of  this  pus,  or  at  least  of  a puriform 
fluid,  in  the  respiratory  organs  of  persons 
affected  with  catarrh,  and  in  the  urinary 
organs  of  those  who  labour  under  gonor- 
rhoea. In  the  progress  of  these  diseases, 
we  can  generally  trace  the  changes,  which 
take  place  by  slow,  but  sensible  degrees, 
in  the  nature  of  the  secretion,  from  mucus 
to  pus,  and  from  pus  back  again  to  the  state 
of  mucus.  This  puriform  discharge  from 
mucous  membranes,  in  a state  of  inflamma- 
tion, may  be  kept  up  for  months  without 
these  membranes  appearing  to  undergo  auy 
other  morbid  changes  than  a slight  degree 
of  redness  and  swelling.  A loss  of  substance, 
or  ulceration,  is  found  not  to  happen  of- 
tener  than  in  one  case  out  of  ten  examples 
of  suppuration  from  mucous  membranes. 

( Thomson's  Lectures  on  Inflammation, p.  305, 
306.) 

The  same  well-informed  writer  afterward 
proceeds  to  explain,  that  suppuration  may 
be  readily  produced  in  the  skin,  or  cutane- 
ous texture,  by  whatever  excites  inflamma- 
tion in  that  texture,  and  causes  a separation 
of  the  cuticle.  We  have  examples  of  this 
fact  in  blisters  from  cantharides,  and  in  ve- 
sications  of  the  cuticle  from  superficial 
burns.  If  the  cuticle  covering  a recent 
blister,  or  burn  be  removed,  and  the  cutis 
exposed  to  the  irritation  of  stimulating  sub- 
stances, pus  will  soon  be  discharged  from 
the  abraded  surface.  Suppuration  can  be 
kept  up  in  cutaneous  texture,  for  an  indefi- 
nite length  of  time,  as  we  see  done  every 


SXJPPURATIOX 


uay  iu  the  management  ot  perpetual  blis- 
ters. Ulceration  is  seldom  observed  in  these 
cases,  and  consequently,  in  cutaneous  tex- 
ture, loss  of  substance  is  by  no  means  ne- 
cessary for  the  production  of  pus. 

If  the  cutis  be  divided,  as  in  a wound,  or 
a portion  of  it  remov  ed,  as  in  the  extirpation 
of  tumours,  and  either  the  air,  or  any  other 
external  body,  be  permitted  to  remain  in 
contact  with  the  divided  surfaces,  the  pro- 
cess of  suppuration  is  speedily  induced  in 
the  cellular  texture  subjacent  to  the  skin. 
After  the  hemorrhage,  which  takes  place 
from  the  small  vessels,  has  ceased,  an  oozing 
of  a fluid,  at  first  resembling  serum,  occurs, 
which  is  gradually  changed  into  pus.  But 
in  this  case,  as  Dr.  Thomson  has  correctly 
observed,  the  surface  of  the  wound  is  pre- 
viously covered  with  a layer  of  coagulable 
lymph,  which  is  penetrated  with  blood-ves- 
sels, and  gradually  raised  into  the  little  red 
eminences,  termed  granulations. 

Appearances  similar,  though  slighter  in 
degree,  says  Dr.  Thomson,  are  observed  in 
cutaneous  suppuration,  giving  probability  to 
the  opinion  of  Sir  E.  Home,  that  in  inflam- 
mation, a vascular  surface  is  produced  pre- 
viously to  the  formation  of  pus  in  a cellular 
membrane,  and  perhaps  also  in  cutaneous 
texture.  Dr.  Thomson  is  inclined  to  be- 
lieve, however,  that  no  new  vascular  sur- 
face is  generated  in  the  inflammation  of 
mucous  membrane.  Thus,  we  see,  that  in 
the  formation  of  pus  in  raucous  membrane, 
cutaneous  texture,  and  exposed  cellular  sub- 
stance, no  ulceration,  no  breach  of  sub- 
stance occurs : but  that,  on  the  contrary, 
in  two  of  these  textures,  the  cutaneous  and 
cellular,  there  is  an  addition  made  to  the 
parts  by  the  exudation  of  coagulable  lymph, 
which  becomes  organized.  ( Thomson , p. 
305—308.) 

SYMPTOMS  OF  SUPPURATION. 

When  matter  is  fully  formed  in  a tumour, 
there  is  a remission  of  all  the  symptoms. 
The  throbbing  pain,  which  was  before  fre- 
quent, now  goes  off,  and  the  patient  com 
plains  of  a more  dull,  constant,  heavy  pain 
A conical  eminence,  or  pointing , as  it  is 
termed,  takes  place  at  some  particular  part 
of  the  tumour,  generally  near  its  middle. 
In  this  situation,  a whitish,  or  yellowish  ap- 
pearance is  general  observable,  instead  of 
a deep  red,  which  was  previously  apparent, 
and  a fluctuation  of  a fluid  underneath  may 
be  discovered,  on  a careful  examination 
with  the  fingers.  Sometimes,  indeed,  when 
an  abscess  is  thickly  covered  with  muscles 
and  other  parts, the  fluctuation  cannot  be  ea- 
sily distinguished,  though, from  other  concur- 
ring circumstances,  there  can  hardly  be  the 
least  doubt  of  there  being  even  a very  con- 
siderable collection  of  matter.  An  oedema- 
tous  swelling  over  the  situation  of  deeply- 
situated  abscesses  is  a symptom  which  of- 
ten occurs,  and  is  well  worthy  the  attention 
of  every  practical  surgeon. 

The  discovery  of  the  existence  of  deep 
abscesses  is  a circumstance  of  the  highest 
importance  in  practice,  and  one  which 


greatly  involves  the  practitioner's  reputa- 
tion. In  no  part  of  the  surgeon’s  employ- 
ment is  experience  in  former  similar  cases 
of  greater  use  to  him  than  in  the  present ; 
and  however  simple  it  may  appear,  yet  no- 
thing, it  is  certain,  more  readily  distinguishes 
a man  of  observation  and  extensive  prac- 
tice, than  his  being  able  easily  to  detect 
collections  of  deep-seated  matter.  On  the 
contrary,  nothing  so  materially  injures  the 
character  and  professional  credit  of  a sur- 
geon, as  his  having  in  such  cases  given  aa 
inaccurate  or  unjust  prognosis ; for,  in  dis- 
orders of  this  kind,  the  nature  and  event  of 
the  case  are  generally  at  last  clearly  demon- 
strated to  all  concerned. 

Together  with  the  several  local  symptoms 
of  the  presence  of  pus,  already  enumerated, 
may  be  mentioned  the  frequent  shiverings , 
to  which  patients  are  liable  on  its  first  for- 
mation. However,  these  rigours  seldom  oc- 
cur so  as  to  be  distinctly  observed,  unless 
the  collection  of  matter  is  considerable,  or 
situated  internally  in  some  of  the  viscera. 

In  the  progress  of  the  fever,  accompa- 
nying acute  inflammation,  (says  Professor 
Thomson)  rigours,  or  cold  shiverings  not 
un frequently  take  place,  which  recur  at  ir- 
regular intervals,  and  are  in  general  follow- 
ed by  a hot  fit,  and  slight  increase  of  the 
febrile  symptoms.  These  rigours,  or  cold 
shiverings,  in  general  indicate,  when  they 
occur  in  the  progress  of  inflammatory  dis- 
eases, that  pus  either  is  formed,  or  is  about 
to  be  so.  In  inflammation,  succeeding  to 
injuries  of  the  head,  these  rigours  are  often 
the  first  constitutional  symptoms  which  give 
alarm  to  the  well-informed  practitioner : 
for  they  are  generally,  though  not  always' 
an  indication  that  inflammation  has  already 
made  a dangerous,  if  not  fatal  progress. 
These  rigours  also  accompany  the  forma- 
tion of  pus  in  the  viscera  contained  within 
the  cavities  of  the  chest  and  belly,  and  are 
often  the  first  symptoms  which  inform  the 
practitioner,  that  his  endeavours  to  procure 
resolution  have  not  been  successful.”  (See 
Thomson's  Lectures  on  Inflammation,  p.  321.) 

Rigours,  as  Mr.  Hunter  remarked,  are 
more  common  at  the  commencement  of 
spontoneous  inflammations,  than  in  inflam- 
mations from  external  injury.  They  seldom 
occur  in  the  suppurations  which  follow- 
operations. 

The  constitutional  symptoms  which  attend 
the  formation  of  pus  in  the  progress  of  chro- 
niesuppurations,  are  generally  comprehend- 
ed under  the  name  of  hectic  fever.  (See 
Fevers.) 

The  pain  attending  what  Mr.  Hunter 
termed  the  suppurative  inflammation,  is  in 
creased  at  the  time  when  the  arteries  are 
dilated,  and  this  gives  the  sensation  called 
throbbing,  in  which  every  one  can  count 
his  own  pulse,  by  merely  paying  attention 
to  the  inflamed  part.  Perhaps,  this  last 
symptom  is  one  of  the  best  characteristics  of 
this  species  of  inflammation.  When  the  in- 
flammation is  moving  from  the  adhesive 
state  to  the  suppurative,  the  pain  is  conside- 
rably increased  ; but  when  suppuration  has 


sUPPUKATICtt 


*6-1 


taken  place,  the  pain  m some  degree  sub- 
sides. (Hunter.) 

The  redness  that  took  place  in  the  adhe- 
sive stage  is  now  increased,  and  is  of  a pale 
scarlet  colour.  The  part  which  was  firm, 
hard,  and  swelled,  in  the  previous  stage  of 
the  inflammation,  now  becomes  still  more 
swelled,  in  consequence  of  the  greater  dila- 
tation of  the  vessels,  and  the  greater  quan- 
tity of  coagulating  lymph  thrown  out. 
(Hunter.) 

THEORY  OF  SUPPURATION. 

The  dissolution  of  the  living  solids  of  an 
animat  bod)7  into  pus,  and  the  power  of  this 
fluid  to  continue  the  dissolution,  are  opinions 
which  are  no  longer  entertained . by  any 
well-informed  surgeons  of  the  present  day  ; 
and  the  use  of  such  phrases  as  a pus  corrodes,” 
:l  it  is  acrid,”  &c c.  expressions  vrbich  imply 
an  erroneous  way  of  thinking,  is  very  pro- 
perly almost  entirely  discontinued  in  the 
language  of  every  sinsible  medical  man.  If 
these  notions  were  true,  no  sore  which  dis- 
charges matter,  could  be  exempted  from  a 
continual  dissolution.  Such  ideas  probably 
arose  from  the  circumstance  of  an  abscess 
being  a hollow  cavity  in  the  solids,  and 
from  the  supposition,  that  the  whole  of  the 
original  substance  of  that  cavity  was  now 
the  matter,  which  was  found  in  it.  This 
was  a very  natural  way  of  accounting  for 
the  formation  of  pus  by  one  entirely  igno- 
rant of  the  moving  juices,  the  powers  of  the 
arteries,  and  what  takes  place  in  an  abscess 
after  it  is  opened.  The  knowledge  of  these 
three  subjects,  abstracted  from  the  know- 
ledge of  the  abscess  before  its  being  opened, 
should  have  led  surgeons  to  account  for  the 
formation  of  pus  from  the  blood  by  the  pow- 
ers of  the  arteries  alone.  According  to  the 
above  erroneous  principle,  abscesses  would 
continue  to  increase  after  being  opened,  as 
fast  as  before.  Upon  the  principle  of  the 
solids  being  dissolved  into  pus,  was  founded 
the  practice  of  bringing  ail  indurated  parts 
to  suppuration  if  possible,  and  not  making 
an  early  opening.  This  was  done  for  the 
purpose  of  giving  time  for  the  solids  to  melt 
down  into  pus ; but  it  was  apparently  for- 
gotten, tiiat  abscesses  formed  matter  after 
they  were  opened,  and  therefore  the  parts 
stood  the  same  chance  of  dissolution  into 
pus  as  before.  Blinded  with  the  idea  that 
?he  solids  entered  into  the  composition  of 
pus,  the  partisans  of  this  doctrine  could  never 
see  pus  flowing  from  any  internal  canal,  as 
from  the  urethra,  in  cases  of  gonorrhoea, 
without  supposing  the  existence  of  an  ulcer 
. the  passage.  Such  sentiments  might  be 
forgiven  before  it  was  known  that  those  sur- 
faces could,  and  generally  did,  form  pu3 
without  a breach  of  the  solids  ; but  the  con- 
tinuance of  this  way  of  thinking  now  is  not 
mere  ignorance,  but  stupidity.  The  forma- 
tion of  pints  of  matter  in  the  cavities  of  the 
chest  and  abdomen,  without  any  breach  in 
the  solids,  could  not  have  been  overlooked 
by  the  most  zealous  advocates  for  the  doc- 
trine of  dissolution.  (Hunter.) 

The  moderns  have  been  still  more  ridicu- 
lous; for  knowing  that  it  was  denied,  that 


the  solids  were  ever  dissolved  into  pus,  acd 
that  there  was  not  n single  proof  of  it,  they 
have  been  busy  in  producing  what  to  them 
seemed  a proof.  They  have  been  putting 
dead  animal  matter  into  abscesses,  and  find- 
ing that  it  was  either  wholly  or  in  part  dis- 
solved, they  therefore  attributed  the  loss 
to  its  being  formed  into  pus.  This,  howe- 
ver, was  putting  living  and  dead  animal 
matter  upon  the  same  footing,  which  is  a 
contradiction  in  itself;  for  if  the  result  of 
this  experiment  were  really  what  they  sup- 
posed it  to  be,  the  idea  of  living  parts  being 
dissolved  into  pus  must  be  abandoned,  be» 
cause  living  and  dead  animal  matter  can 
never  be  considered  in  the  same  light- 
(Hunter.) 

It  might  have  been  remarked,  that  even 
extraneous  animal  matter  w ould  lie  in  ab- 
scesses for  a considerable  time  without  be- 
ing dissolved,  and  that  in  abscesses  arising 
either  from  violence,  or  from  a species  of 
erysipelatous  inflammation,  there  were  often 
sloughs  of  the  eeiluiar  membrane,  which 
sloughs  would  come  away  like  wet  tow,  and 
therefore  were  not  dissolved  into  pus.  (Hun- 
ter.) 

It  might  also  have  been  noticed,  that  in 
abscesses  in  tendinous  parts,  as  about  the 
ankle,  a tendon  often  mortified  and  sloughed 
away,  and  that  the  sores  would  not  heal  til! 
such  sloughs  were  detached  ; but  though  this 
separation  was  sometimes  not  completed  be- 
fore the  expiration  of  months,  yet  the  sloughs 
at  last  were  thrown  off,  and  consequently 
could  not  be  converted  into  pus.  Pieces  of 
dead  bone  often  lie  soaking  in  matter  for  many 
months,  without  being  changed  into  pus; 
and  although  bones,  so  circumstanced,  may 
lose  a considerable  deal  of  their  substance, 
a loss  which  some  might  impute  to  the  dis- 
solution of  the  bone  into  pus,  yet  that 
waste  can  be  accounted  for  and  proved  on 
the  principle  of  absorption.  The  loss  is 
always  upon  that  surface,  upon  which  the 
continuity  is  broken  off,  and  it  is  a part  of 
the  process  by  which  exfoliation  of  a dead 
piece  of  bone  is  accomplished.  The  forma- 
tion of  pus  has  been  attributed  to  a kind  of 
fermentation,  in  which  both  the  solids  and 
fluids  were  concerned.  This  doctrine  is 
easily  retuted  by  stating  what  happens  in 
internal  canals,  which  naturally  secrete  mu- 
cus, but  frequently  form  pus,  without  any 
loss  of  substance,  or  any  previous  ferment- 
ing process.  Were  we  to  suppose  a fer- 
mentation of  the  solids  and  fluids,  the  imme- 
diate cause  of  the  production  of  pus,  whence 
could  the  solids  come,  which  enter  into  the 
composition  of  discharges  from  the  urethra  ? 
for  the  whole  penis  could  not  afford  matter 
enough  to  form  the  pus,  which  is  discharged 
in  a common  gonorrhoea.  How  also  could 
the  fermentation  of  the  solids  ever  cease  ? 
for  there  is  the  same  surface  secreting  its 
mucus,  whenever  the  formation  of  pus  is 
discontinued.  It  may  be  asked  likeivise,  by 
w hat  power  the  first  particle  of  pus  in  an 
abscess,  or  on  a sore,  is  formed,  before  there 
is  any  particle  existing,  which  is  capable  of 
dissolving  the  solids?  An  abscess  may  be 


SUPPURATION. 


433 


* 


stationary  for  months,  and  at  last  be  absorb- 
ed ; what  becomes  of  the  fermentation  all 
the  while  the  collection  of  matter  continues 
stationary  ? 

Extravasated  blood  has  been  supposed  to 
be  capable  of  being  converted  into  pus.  We 
find,  however,  that  blood,  when  exiravasa- 
ted,  either  from  violence,  or  a rupture  of  a 
vessel,  as  in  aneurism,  neverof  itself  becomes 
pus  ; nor  was  pus  ever  formed  in  these  cases, 
without  being  preceded  by  inflammation. 
Both  the  blood  and  matter  are  also  found 
together  in  the  same  cavity,  under  such  cir- 
cumstances. If  the  blood  had  coagulated, 
which  it  seldom  does  in  cases  of  violence, 
it  would  be  found  still  coagulated  ; and  if  it 
bad  not  coagulated,  the  pus  would  be  bloody. 
(Hunter.) 

The  modern  theory  of  suppuration  is,  that 
tbe  matter  is  separated  from  the  bjood  by 
the  secreting  power  of  the  vessels  of  the 
inflamed  part,  which  acquire  a new  mode  of 
action. 

That  pus  is  formed  in  the-vessels  from 
which  it  exudes,  by  an  action  of  these  ves- 
sels analogous  to  secretion,  was,  so  far  as  I 
know,  (says  Professor  Thomson)  first  dis- 
tinctly suggested  by  Dr  Simpson  of  St  An- 
drew’s, in  his  *•  Dissertationes  de  Re  Medico,,’ 
published  in  tbe  year  1722.  An  opinion 
similar  to  that  of  Dr.  Simpson’s  suggested 
itself,  about  the  year  1756,  to  De  Haen,  from 
the  consideration  of  what  takes  place  in 
some  cases  of  phthisis  pulmonalis.  This 
author  observes,  that  pus  was  often  expecto- 
rated, for  a great  length  of  time,  by  patients 
affected  with  phthisis,  in  whom,  after  death, 
no  mark  of  ulceration  could  be  perceived, 
not  even  the  place  in  which  the  pus  had 
been  formed.  The  hypothesis  of  pus  being 
a secretion  was  afterward  more  fully  con- 
sidered by  Dr.  Morgan  of  Philadelphia,  in 
his  inaugural  thesis  printed  at  Edinburgh  in 
1763,  entitled  “ Puopoioses,  sive  Tentamen 
Medicum  de  Puris  Confectione.”  The  belief 
that  pus  is  a secretion,  or  formed  at  least  by 
an  action  of  the  vessels  analogous  to  secre- 
tion, was  adopted  by  Mr.  Hunter.  Indeed, 
the  merit  of  the  original  suggestion  of  this 
hypothesis  has  been  ascribed  to  him,  though 
improperly.  Bruggraan,  professor  of  botany 
at  Leyden,  has  maintained  the  same  doc- 
trine in  an  excellent  thesis  11  De  Puogenia ,” 
published  in  1785;  and  it  is  that  which  is 
now  very  gen  rally  taught  ail  over  Europe. 
(See  Thomson’s  Lectures  on  Inflammation,  p. 
316,  317.)  With  respect  to  suppuration 
from  exposed  surfaces,  however,  it  is  more 
proper  to  say,  that  the  vessels  secrete  a fluid, 
which  becomes  pus;  for  Sir  Everard  Home 
has  proved,  that  this  fluid  has  not  the  puru- 
lent appearance,  when  first  secreted,  but 
acquires  it  while  it  remains  on  the  inflamed 
surface,  and  does  not  acquire  it  the  less 
readily,  when  removed  from  that  surface  in 
a colourless  state,  provided  its  proper  tem- 
perature be  preserved,  and  it  be  kept  ex- 
posed to  the  air,  which  promotes  the  change. 

The  opinion  that  suppuration  is  a process 
analogous  to  glandular  secretion,  was  at 
first  hastily  rejected  by  many  who  were 
Vox,.  II  55 


swayed  by  tbe  fact,  that  no  pus  is  ever  found 
blended  with  the  blood  in  the  circulating 
system.  By  this  mode  of  reasoning,  howe 
ver,  such  thinkers  must  be  led  to  deny  the 
universally  received  and  undoubted  doctrine, 
that  the  bile  is  a secretion  ; and  yet  it  is  well 
known,  that  nothing  like  this  fluid  can  be 
detected  in  an  analysis  of  the  blood,  and,  in- 
deed, a very  small  quantity  would  be  suffi- 
cient to  tinge  the  whole  mass  of  circulating 
blood  with  a yellow7  colour,  the  same  as  we 
see  in  cases  of  jaundice-  No  one  would 
wish  to  defend  the  idea  of  there  being 
either  pus,  or  bile,  actually  in  the  circula- 
tion; but  only  the  matter,  or  modifications 
of  the  matter,  w hich,  by  tbe  combinations, 
or  whatever  changes  we  may  choose  to 
term  them,  taking  place  in  the  secreting 
vessels,  and  by  their  operations  are  com 
verfed  into  one  of  the  particular  fluids  in 
question. 

Violence  done  to  parts  is  one  of  the  great 
causes  of  suppuration  ; but  simply,  violence 
does  not  always  occasion  it.  The  violence 
must  be  followed  by  a prevention  of  a cure 
in  a more  simple  way,  viz.  by  a restoration 
of  the  structure,  so  as  to  carry  on  the  animal 
functions  of  the  part.  The  parts  must  be 
kept  long  enough  in  that  state  into  which 
they  were  put  by  the  violence.  Or  what  is 
somewhat  similar  to  this,  the  violence  must 
be  attended  with  death  in  a part,  as,  in  many 
bruises,  all  mortifications  and  all  sloughs,  in 
consequence  of  the  application  of  caustic, 
which,  when  the  dead  pnrls  separate,  leave 
internal  surfaces  exposed.  (Hunter.) 

As  every  injury  or  effect  of  outward  vio* 
lence,  under  the  above  circumstances,  is 
more  or  less  exposed  to  the  surrounding  air, 
the  application  of  air  to  internal  surfaces  has 
been  assigned  as  a cause  of  suppuration  ; 
but  certainly  the  air  has  not  the  least  effect  on 
parts,  circumstanced  as  above,  for  a stimulus 
would  arise  from  a wound,  were  it  even 
contained  in  a vacuum.  In  circumscribed 
abscesses,  the  air  cannot  possibly  get  to  the 
parts,  so  as  to  have  any  share  in  making  them 
suppurate 

In  cases  of  emphysema,  when  the  air  is  dif- 
fused over  tbe  whole  body,  no  suppuration 
is  tbe  consequence,  unless  an  exposure  or 
imperfection  of  some  internal  surface  should 
be  made,  for  the  purpose  of  allowing  the  air 
to  escape.  A stronger  proof,  that  it  is  not 
tbe  admission  of  air,  which  makes  parts  in- 
flame, is,  that  the  cells  in  the  soft  parts  of 
birds,  and  many  of  the  cells  and  canals  of 
their  bones,  communicating  with  the  lungs, 
and  always  containing  air,  never  inflame 
but  if  these  cells  are  exposed  in  an  unnatural 
way,  then  the  stimulus  of  imperfection  is 
given,  these  cavities  then  inflame,  and  their 
surfaces  either  form  adhesions  together,  or 
produce  pus.  (Hunter.) 

When  the  interior  of  an  abscess  is  exa- 
mined, the  cavity  which  contained  the  mat- 
ter is  observed  to  be  lined  w ith  a smooth, 
raeinbranous-looking  substance,  which  is  of 
a whitish  ash-colour,  and  has  a strong  re- 
semblance to  coagulating  lymph.  This 
membrane-like  substance  has  been  termed 


43'4 


SUPPUKATlOps 


the  sac  or  cyst  of  the  abscess.  This  sac  or 
cyst  seems  in  general  to  adhere  by  a vascu- 
lar union  to  the  surrounding  cellular  mem- 
brane, which  is  itself  likewise  denser  in  tex- 
ture, and  more  vascular  than  in  the  natural 
state,  {Thomson' s Lectures , p.  310.)  its  cells 
being  closed  by  coagulating  lytnph,  effused 
in  consequence  of  that  species  of  inflamma- 
tion which  Mr.  Hunter  termed  the  adhesive. 
Thus  by  the  formation  of  a cyst,  and  the 
etfusion  of  coagulating  lymph  in  the  cellular 
substance  around  the  abscess,  the  collection 
of  matter  is  bounded,  and  cannot  become 
diffused,  as  it  otherwise  would  do,  in  the 
communicating  cavities  of  the  cellular  mem- 
brane, like  the  water  in  oedema. 

Something  like  this  diffusion  of  pus  seems 
to  occur  in  erysipelas  phlegmonoides.  “ But 
in  this  case,  (says  Professor  Thomson)  the 
vitality  of  greater  or  less  portions  of  the 
cellular  substance  is  destroyed,  the  deadened 
portions  are  converted  into  dirty,  whitish, 
ash-coloured  sloughs,  and  it  becomes  ex- 
tremely difficult  to  say,  whether  any  part  of 
the  pus  contained  in  the  deadened  cellular 
membrane  has  been  formed  in  the  cells,  in 
which  itis  contained,  or  has  been  absorbed 
into  these  cells,  after  being  separated  from 
the  parietes  of  the  cavities  containing  the 
sloughs  themselves.”  ( Lectures , p.  310.) 

There  can  be  no  doubt,  that  after  an  ab- 
scess has  received  a membranous  lining  or 
cyst,  the  secretion  of  pus  is  continued  from 
the  surface  of  the  latter  part  entirely,  as  well 
as  whatever  degree  of  absorption  of  the 
same  fluid  happens  to  be  going  on.  In  fact, 
the  cysts  must  be  both  secreting  and  absorb- 
ing surfaces.  The  circumstances  which 
leave  no  doubt  of  this  point,  are  the  frequent, 
sudden,  or  gradual  removal  of  very  large 
manifest  collections  of  matter ; the  continu- 
al changes  occurring  in  the  quantity  and  con- 
sistence of  the  pus ; and  the  speedy  filling  of 
the  cavity  with  purulent  matter  again  after 
the  first  contents  of  the  abscess  have  been 
discharged. 

Another  thing  which  is  yet  a subject  of 
controversy  is,  whether  suppuration  ever 
happens  unpreceded  by  inflammation  ? Pro- 
fessor Thomson,  of  Edinburgh,  believes  that 
the  affirmative  opinion  on  this  point  was 
first  suggested  by  De  Haen  of  Vienna  ; but 
lie  thinks  that  much  of  the  difference  of  sen- 
timent in  this  matter  has  proceeded  from 
the  vague  “ notions  entertained  with  regard 
to  the  symptoms  which  necessarily  charac- 
terize the  state  of  inflammation,  and  also 
with  regard  to  the  properties  by  which  pus 
is  to  be  distinguished  from  other  animal 
fluids.  Accordingly,  in  almost  ail  the  exam- 
ples which  De  Haen  has  adduced  to  prove 
the  formation  of  pus,  without  the  previous 
existence  of  inflammation,  he  has  himself 
occasion  to  remark  the  exudation  of  coagu- 
lating lymph,  and  the  existence  of  preterna- 
tural adhesions;  phenomena  which  we  know 
are  produced  by  that  state,  which  Mr.  Hun- 
ter denominated  adhesive  inflammation.” 
But  De  Haen  uses  the  term  inflammation 
to  express  that  state,  which  we  deuorni- 
eatc  ulceration,  or  ulcerative  absorption ; 


for  in  speaking  of  the  cases  of  suppuration, 
which  he  has  adduced,  he  observes,  that 
“ in  many  of  them  no  previous  loss,  or  con- 
sumption of  substance  could  be  perceived.” 
An  observation  similar  to  this  was  made 
about  the  same  time,  or  perhaps  a little 
earlier,  by  Dr.  William  Hunter,  and  an 
account  given  of  it  in  the  second  volume 
of  the  London  Medical  Observations  and 
Inquiries. 

Mr.  Hunter,  though  he  endeavours  to 
establish  it  as  an  invariable  fact,  that  no 
suppuration  takes  place,  which  is  not  pre- 
ceded by  inflammation,  is  of  opinion,  that 
collections  of  what  he  terms  extraneous 
matter,  something  like  pus,  may  form  in 
various  parts  of  the  body,  without  the  pre- 
vious existence  of  inflammation  in  the  parts 
in  which  it  is  formed ’;  and  accordingly  you 
will  find,  at  page  300  of  his  Treatise  on  In- 
flammation, a chapter  entitled,  ‘ Of  Collec- 
tions of  Matter  without  Inflammation.’  ” 
Professor  Thomson  doubts,  however, 

“ whether  these  collections  of  matter,  said 
to  be  formed  without  inflammation,  would 
not  have  been  more  properly  denominated 
scrotulous  abscesses,  or  chronic  suppurations. 

I am  disposed  to  believe  (says  he,)  that,  in 
whatever  texture  or  organ  of  the  body 
scrofula  manifests  itself,  there  inflammation 
will  be  found  to  exist.  The  phenomena,  it 
is  true,  of  inflammation,  both  local  and  con- 
stitutional, are  modified  by  the  existence  of 
the  scrofulous  diathesis  ; but  they  are,  I be- 
lieve, always  present  in  such  a degree  as  to 
justify  us  in  giving  to  them  the  name  of  in- 
flammation* and  in  classing  most,  if  not  all, 
local  scrofulous  affections,  among  inflamma- 
tory diseases.  When  the  indolent  swellings, 
of  which  Mr.  Hunter  speaks,  occur  near  to 
the  surface  of  the  body,  that  part  feels 
warmer  than  usual,  as  may  be  felt  in  white 
swellings  of  the  joints.  The  swelling  also 
is  either  preceded  or  accompanied  with 
some  degree  of  pain,  though,  when  the 
afl'ection  is  internal,  the  patient  may  not 
always  be  very  accurate  with  regard  to  the 
precise  seat  of  this  pain.  .When  cut  into, 
the  parts  also  affected  with  scrofulous  swel- 
lings are  always  found  more  vascular  than 
usual  ; in  short,  all  the  symptoms  occur  by 
which  the  state  of  inflammation  is  charac- 
terized.” (See  Thomson's  Lectures  on  In- 
flammation, p.  313,  314.)  In  another  place, 
this  author  admits  that  the  matter,  which  is 
formed  in  chronic  suppurations,  does  not 
always  accurately  resemble  that  which  is 
formed  in  acute  abscesses;  but  yet  he  con- 
tends that  it  is  so  analogous  both  in  its 
physical  and  chymical.characters,  as  well  as 
in  the  circumstances  in  which  it  is  produced, 
that  he  can  see  no  reason  why  it  should  not 
be  called  pus,  or  a puriforra  fluid,  (fl.  315.) 

q.UAUTIES  OF  PUS. 

True  pus  has  certain  properties,  which, 
when  taken  singly,  may  belong  to  other  se- 
cretions, but  which,  conjointly,  form  the 
peculiar  character  of  this  fluid,  viz.  globules 
swimming  in  a fluid,  which  is  coagulabte 


SUPPURATION. 


435 


by  a solution  of  the  muriate  of  ammonia, 
which  no  other  animal  secretion  is,  and  at 
the  same  time  a consequence  of  inflamma- 
tion. 

The  colour  and  the  consistence  of  pus  are 
the  two  qualities,  which  first  attract  the 
notice  of  every,  the  most  superficial  obser- 
ver. The  colour  arises  from  the  largest 
portion  of  this  fluid  being  composed  of  very 
: mall  round  bodies,  very  much  like  the 
globules  of  cream.  The  fluid  in  which  the 
globules  of  pus  swim,  might  at  first  be 
supposed  to  be  the  serum  of  the  blood,  for 
it  coagulates  with  heat  like  the  latter  fluid. 
Pus  is  also  probably  mixed  with  a small 
quantity  of  coagulating  iytnph  ; as  it  partly 
coagulates  after  it  is  secreted.  However, 
the  fluid  part  of  pus  is  found  to  have  pro- 
perties which  serum  has  not.  There  being 
a similarity  between  pus  and  milk,  experi- 
ments have  been  made  to  ascertain  whether 
the  fluid  of  pus  could  be  coagulated  with 
the  gastric  juice  of  animals:  but  no  coagu- 
lation could  be  effected  in  this  manner  ; a 
solution  of  muriate  of  ammonia  made  the 
fluid  part  of  pus  coagulate  ; but  not  any 
other  secretion  or  natural  fluid ; and  hence 
it  was  concluded,  that  whenever  globules 
were  found  swimming  in  a fluid,  coagulable 
by  muriate  of  ammonia,  the  matter  was  to 
be  considered  as  pus.  (Hunter.) 

The  proportion  which  the  white  globules 
bear  to  the  other  parts  of  pus,  depends  on 
the  health  of  the  parts  producing  the  dis- 
charge. When  the  globules  are  very  abun- 
dant, the  matter  i3  thicker  and  whiter,  and 
is  called  healthy  pus  ; the  meaning  of  which 
is,  that  the  solids  which  produced  it  are  in 
good  health;  for  these  appearances  in  the 
matter  are  no  more  than  the  result  of  certain 
salutary  processes  going  on  in  the  solids, 
the  effect  of  which  processes  is  to  produce 
the  disposition,'  on  wfaieh  both  suppuration 
and  granulation  depend  (Hunter.) 

Pus  is  specifically  heavier  than  water,  and 
is  probably  about  as  heavy  as  blood. . 

Besides  the  above  properties,  pus  has  a 
sweetish  mawkish  taste,  very  diflereut  from 
that  of  most  other  secretions,  and  the  same 
taste  takes  {dace,  whether  it  is  pus  from  a 
sore,  or  an  irritated  inflamed  surface. 

Pus  has  a smell  in  some  degree  peculiar 
to  itself ; but  this  differs  in  different  cases. 
Some  diseases,  it  is  said,  may  be  known  by 
the  smell,  as  for  instance,  a gonorrhoea. 

Pus  sinks  in  water ; mucus  floats.  Pus 
communicates  to  water  an  uniformly  trou- 
bled white  colour;  mucus  gives  the  appear- 
ance of  stringy  portions  floating  in  it. 
Mucus  is  said  to  be  more  readily  dissolved 
by  sulphuric  acid  than  pus  is.  It  has  also 
been  asserted,  that  if  water  be  added  to 
such  solutions,  the  pus  is  precipitated  to  the 
bottom  of  the  vessel ; while  the  mucus, 
instead  of  being  completely  precipitated, 
forms  swimming  flakes.  A solution  of  caus- 
tic alkali  dissolves  both  pus  and  mucus  ; 
but  when  water  is  added,  the  pus  is  said  to 
become  separated,  but  not  the  mucus. 

Though  solutions  in  chymical  menstrua 
and  precipitations,  have  been  thought  a 


test  of  the  distinction  between  these  two 
fluids,  yet  the  method  has  been  thought 
absurd  and  unphilosophical.  It  has  been 
conceived,  that  all  animal  substances  what- 
ever, when  in  solution,  either  in  acids  or 
alkalies,  would  be  in  the  same  state,  and 
therefore,  that  the  precipitation  would  be 
the  same  in  all.  Calcareous  earth,  when 
dissolved  in  muriatic  acid,  is  in  that  acid  in 
the  same  state,  whether  it  has'been  dissolved 
from  chalk,  limestone,  marble,  or  calcareous 
spar,  and  precipitations  from  all  are  the  same. 
Hence,  experiments  were  made  on  organic 
animal  matter,  such  as  muscles,  tendon,  car- 
tilage, liver,  and  brain  ; and  on  inorganic, 
such  as  pus  and  the  white  of  an  egg.  Ail 
these  substances  were  dissolved  in  sulphuric 
acid,  and  precipitated  with  potassa.  Each 
precipitation  was  examined  with  such  mag- 
nifiers, as  plainly  showed  the  forms  of  the 
precipitates,  all  which  appeared  to  be  flaky 
substances.  The  precipitate  by  ammonia 
had  exactly  the  same  appearance.  The  same 
appearances  were  seen,  when  the  above 
kinds  of  animal  matter  were  dissolved  by 
caustic  potassa,  and  precipitated  with  the 
muriatic  acid.  A flaky  substance,  void  of 
any  regular  form,  composed  each  precipi- 
tate. (Hunter.)  For  additional  observations 
on  the  tests  of  pus,  and  an  account  of  those 
suggested  by  Dr.  Young  and  Grasmeyer,  see 
the  First  Lines  of  the  Practice  of  Surgery ) 
Vol.  l,p.  32,  Ed.  4. 

Pus  does  not  irritate  the  particular  surface 
which  secretes  it,  though  it  may  be  very  ir- 
ritating to  any  other.  Hence,  no  suppura- 
ting surface  of  any  specific  kind,  can  be 
kept  up  by  its  own  matter;  if  this  had  not 
been  the  case,  no  sore  of  a specific  quality, 
or  producing  matter  of  an  irritating  kind, 
could  ever  have  been  healed.  This  is  simi- 
lar to  every  other  secretion  of  stimulating 
fluids,  as  the  bile,  tears,  &c.  which  fluids  do 
not  stimulate  their  own  glands,  or  ducts,  but 
are  capable  of  stimulating  any  other  part  of 
the  body.  (Hunter.) 

Whenever  a real  disease  attacks,  either 
the  suppurating  surface,  or  the  constitution, 
the  production  of  true  pus  ceases,  anti 
the  fluid  becomes  changed  in  some  measure, 
in  proportion  to  these  morbid  alterations. 
In  general  it  becomes  thinner  and  more 
transparent,  and  it  partakes  more  of  the  na- 
ture of  the  blood,  as  is  the  case  in  most 
othersecretions  under  similar  circumstances. 
Sanies  is  the  term  usually  applied  by  surge- 
ons to  pus,  in  this  degenerated  state.  This 
unhealthy  sort  of  matter  has  more  of  the  se- 
rum, and  frequently  more  of  the  coagula- 
ting lymph  in  it,  and  less  of  the  combination 
which  renders  it  coagulable  by  a solution  of 
muriate  of  ammonia.  It  has  also  a greater 
proportion  of  the  extraneous  parts  of  the 
blood,  which  are  soluble  in  water,  such  as 
salts  ; and  it  has  a greater  tendency,  than 
true  pus,  to  become  putrid.  Such  unheal- 
thy matter  may  even  be  irritating  to  the 
surface  which  produces  it. 

The  discharge,  when  of  an  irritating  sort, 
is  more  stimulating  to  the  adjoining  parts 
with  which  it  comes  in  contact,  than  to  its 


SUPPURATION. 


'136 

own  secreting  surface.  In  this  manner  it  cns  silver  probes,  and  preparations  of  lead, 
frequently  produces  excoriation  of  the  skin  This  effect  is  imputed  by  Dr.  Crawford  to 
smd  ulceration.  Thus  the  tears  excoriate  the  sulphurated  hydrogen  gas,  generated  in 
the  skin  of  the  cheek,  in  consequence  of  the  the  matter.  (Phil.  Trans,  vol.  80,  Fear  17903 
quantity  of  salts  which  they  contain.  From  p.  385.)  Further  interesting  observations 
this  effect,  matter  has  been  called  corrosive,  on  the  nature  of  pus  may  be  found  in  an 
a quality  which  it  has  not ; the  only  proper-  Essay  on  the  Differences  between  Pus  and 
ty  which  it  possesses  being  that  of  irritating  Mucus,  by  Dr.  Darwin,  junior  ; also  in  Dr. 
parts  which  it  touches,  so  as  to  cause  their  G.  Pearson’s  Paper  in  Philos.  Trans.  1811. 
absorption.  (Hunter.) 

When  the  vessels  thus  lose  the  power  of  use  of  pus. 

producing  good  pus,  they  also  lose  more  or 

less  the  power  of  forming  granulations.  By  some  it  is  supposed  to  carry  off  hu- 
This  may  depend  on  some  deviation  from  mours  from  the  constitution.  Suppuration 
the  due  structure  and  action,  which  such  is  sometimes  regarded  as  a constitutional 
vessels  should  possess,  in  order  to  be  qua-  disease,  changed  into  a local  one,  which  con- 
lifted  for  the  performance  of  these  two  ope-  stitutional  malady  is  discharged,  or  thrown 
rations.  out  of  the  body,  either  in  the  form  of  pus. 

Pus,  from  several  circumstances,  would  or  together  with  this  fluid.  Critical  abscess- 
appear  in  general  to  have  a greater  tenderly  es  have  been  thought  to  be  cases  of  this 
cy  to  putrefaction  than  the  natural  juices  sort.  Suppuration  has  also  been  imagined 
have;  but,  perhaps,  this  is  not  the  case  with  to  carry  off  local  complaints  from  other 
pure  pus,  which,  when  first  discharged  from  parts  of  the  body,  on  the  old  principle  of 
an  abscess,  is  commonly  perfectly  sweet,  derivation  or  revulsion.  For  this  reason, 
There  are, however,  some  exceptions  to  this,  sores  or  issues  are  made  in  sound  parts  be- 
but  these  depend  on  circumstances  entirely  fore  allowing  other  sores  to  be  dried  up. 
foreign  to  the  nature  of  pus  itself.  Thus,  if  Suppuration  is  sometimes  excited  uTith  a 
the  abscess  had  any  communication  with  the  view  of  making  parts,  such  as  indurated 
air,  while  the  matter  was  confined  in  it ; or  swellings,  dissolve  into  pus  ; but  I have  en- 
if  the  collection  has  been  so  near  the  colon  deavoured  to  show,  that  no  dissolution  of 
or  rectum  as  to  have  been  infected  by  the  the  solids  is  concerned  in  the  production  of 
feces,  then  we  cannot  wonder  that  the  mat  pus.  ) 

ter  should  become  putrid.  When  blood  is  A secretion  of  pus  is  looked  upon  as  a ge* 
blended  with  pus;  when  sloughs  are  mixed  neral  prevention  of  many,  or  of  all  the  cau- 
with  it ; when  the  parts  forming  the  seat  of  ses  of  disease.  Hence,  issues  are  made  to 
the  abscess  are  in  a gangrenous  state  from  an  keep  off  both  universal  as  well  as  local  dis- 
erysipelatous  affection  ; the  matter  has  a eases.  However,  the  use  of  pus  is  perhaps 
greater  tendency  to  putrify  than  the  pure  unknown  ; for  it  is  formed  most  perfectly 
pus  discharged  from  sound  abscesses  or  heal-  from  healthy  sores,  and  in  healthy  constru- 
ing sores.  Pure  matter,  though  easily  ren-  tions ; and  large  discharges  from  parts  not 
dered  susceptible  of  change,  by  extraneous  very  essential  to  life,  produce  very  little 
additions,  is  in  its  own  nature  tolerably  uni-  change  in  the  constitution,  and  as  little  upon 
form  and  immutable.  It  appears  so  un-  being  healed  up,  whatever  some  may  sup- 
changeable,  that  we  find  it  retained  in  an  pose  to  the  contrary.  (Hunter.) 
abscess  for weeks,  without  having  undergone  This  is  certainly  the  case  with  many  old 
any  alteration.  These  qualities,  however,  ulcers,  the  suppuration  from  which  seems 
only  belong  to  perfect  pus.  If  a healthy  to  have  little  or  no  effect  in  impairing  the 
sore  inflames,  the  matter  now  produced  from  health.  Nor  is  there  any  real  reason  to  be 
it,  though  unmixed  with  extravasated  blood,  afraid  of  healing  such  ulcers,  when  possible, 
or  dead  solids,  becomes  much  sooner  putrid,  lest  a worse  disease  should  follow  from  the 
and  much  more  irritating,  than  the  discharge  stoppage  of  a discharge  to  which  the  system 
formed  before  this  alteration  of  the  ulcer,  is  supposed  to  be  so  habituated  that  the 
(Hunter.)  continuance  of  it  must  be  essential  to 

In  the  preceding  paragraph  it  is  stated,  health 
that  matter  remains  very  often  unchanged  Every  one  know  s,  that  when  there  is  no 
in  abscesses  for  weeks.  This  expression  of  interference  of  art,  that  is.  when  the  surface 
Hunter’s  is  not  strictly  correct ; for  it  is  w ell  of  a sore  is  left  uncovered,  the  thin  part  of 
known,  that  the  surfaces  of  the  cavities  of  the  matter  evaporates,  and  the  thick  part 
abscesses  are  always  absorbing,  as  well  as  dries  and  forms  a scab.  Nature,  therefore, 
secreting  ones  ; consequently,  there  must  seems  to  have  designed  that  one  use  of  pus 
be  a continual  mutation  going  on  in  the  con-  should  be  to  make  a cover,  or  protection 
tained  matter.  for  ulcerated  surfaces.  But  I cannot  agree 

When  there  are  diseased  bones,  or  other  writh  what  has  been  asserted,  (Hunter)  that 
extraneous  bodies,  exciting  irritation,  some-  the  natural  healing  of  a sore  under  a scab 
times  even  in  so  great  a degree  as  to  make\  takes  place  more  quickly  than  when  surgi- 
the  vessels  bleed,  and  often  wounding  the  cal  dressings  are  employed, 
vessels  of  the  part,  the  matter  is  always  On  ulcers,  as  would  appear  from  modem 
found  to  be  very  offensive.  This  state  of  microscopical  observations,  u the  coagula- 
the  discharge  is  one  mark  of  a diseased  ted  pus  is  rendered  tubular  by  the  extrica- 
fcone.  tion  of  its  carbonic  acid  gas,  and  that  these 

The  discharge  of  an  unhealthy  sore  black-  tubes,  or  canals,  are  immediately  filled  with 


SUPPURATION 


red  blood,  and  thus  connected  with  the  cir- 
culation.” If  this  point  be  established,  Sir 
Everard  Home  conceives  that  there  will 
then  be  little  difficulty  in  making  out  the 
succeeding  changes,  by  means  of  which 
the  coagulated  pus  afterward  becomes  or- 
ganized. (On  the  conversion  of  Pus  into 
Granulations  or  new  Flesh , in  Phil.  Trans. 
Vol.  109,  p.  109,  Lond.  1819)  These  state- 
ments are  curious,  and  ought  to  have  been 
noticed  in  the  article  Granulations,  to  which 
they  more  immediately  relate. 

Among  the  secondary  uses  of  suppura- 
tion, maybe  mentioned,  opening  a commu- 
nication between  a disease  and  the  external 
surface  of  the  body  ; forming  a passage  for 
the  exit  of  extraneous  bodies,  be. 

TREATMENT  WHEN  SUPPURATION  MUST  TAKE 
PLACE. 

In  cases  of  inflammation,  arising  from 
accident,  but  so  circumstanced,  that  wre 
know  suppuration  cannot  be  prevented,  the 
indication  is  to  moderate  the  inflammation, 
which,  if  the  powers  are  great,  and  the  in- 
jury done  considerable,  will  probably  be 
very  violent.  If  the  constitution  should  also 
be  much  affected,  certain  general  means  are 
proper,  such  as  bleeding,  purging,  and  nau- 
seating medicines.  While  the  constitution 
continues  to  be  disturbed,  suppuration  can- 
not take  place  in  the  most  favourable  man- 
ner. In  these  cases,  also,  such  medicines 
as  produce  a gentle  perspiration  greatly  re- 
lieve the  patient,  for  instance,  the  pulv. 
ipecac,  comp.;  antimonials;  aq.  ammon. 
acet.;  saline  draughts,  fee.  Opiates  may 
produce  a temporary  diminution  of  action; 
but  it  is  not  always  the  consequence  of  this 
medicine,  as  there  are  constitutions  which 
it  renders  more  irritable,  and  of  course 
where  it  aggravates  the  inflammatory  ac- 
tion. 

The  applications  to  inflammations,  which 
are  to  suppurate  and  form  an  abscess,  com- 
monly used  are  poultices  and  fomentations. 
These,  however,  appear  to  be  applied  with- 
out much  critical  exactness  or  discrimina- 
tion ; for  they  are  applied  before  suppura- 
tion has  taken  place,  and  when  this  event 
is  not  desired  ; and  they  are  also  applied 
after  suppuration  has  taken  place.  With 
respect  to  suppuration  itself,  abstracted  from 
all  other  considerations,  the  indication 
cannot  be  the  same  in  every  state  . but  if 
poultices  and  fomentations  are  found  to  be 
of  real  service  in  the  two  stages  of  the  dis 
ease,  there  must  be  something  common  to 
both,  for  which  they  are  of  service,  inde- 
pendently of  simple  suppuration.  Poultices 
are  useful  when  the  inflammation  attacks 
therskin,  either  in  the  first  instance  or  after 
an  abscess  has  approached  so  near  the  skin 
that  this  becomes  secondarily  affected.  This 
benefit  appears  to  arise  from  the  skin  being 
kept  soft  and  moist.  Such  is  the  use  of  a 
poultice  in  inflammation,  either  before  or 
after  suppuration,  until  the  abscess  is  open- 
ed. But,  when  poultices  and  fomentations 
are  applied  to  inflamed  parts,  in  which  we 


wish  to  avoid  suppuration,  reason  and  prin- 
ciple will  not  justify  the  practice,  though 
such  applications  may  be  proclaimed  by 
experience  to  be  very  proper.  (Hunter.) 

TREATMENT' AFTER  SUPPURATION  HAS  TAKEI7 
PLACE. 

When  suppuration  cannot  be  stopped,  or 
resolved  it  is  in  general  to  be  promoted. 

How  far  suppuration  can  be  usefully  pro- 
moted by  medicines  or  applications,  is 
questionable;  but  attempts  are  generally 
made,  and,  for  Ibis  purpose,  suppurating 
cataplasms  and  plasters,  composed  of  the 
warm  gums,  seed's,  kc.  were  formerly  much 
recommended.  Mr.  Hunter  doubted,  whe- 
ther such  applications  had  any  considerable 
effect  in  the  way  intended  ; for,  if  they  were 
put  on  a sore,  they  would  hardly  increase 
the  discharge  from  it,  and  perhaps  even  di- 
minish it.  However,  in  many  cases  in  which 
the  parts  are  indolent,  and  hardly  admit  of 
true  inflammation,  in  consequence  of  which 
a perfect  suppuration  cannot  take  place, 
stimulating  the  skin  brings  on  a more  salu- 
tary, and  of  course  a quicker  inflammation. 
Thus  the  antimonial  ointment,  and  blister  - 
ing the  skin,  over  chronic  swellings  and 
abscesses,  are  sometimes  indicated. 

These  applications  have  been  found,  how- 
ever, to  bring  the  matter  more  quickly  to 
the  skin,  even  in  the  most  rapid  suppura- 
tions. This  effect  has  been  mistaken  fox3 
an  increased  formation  of  pus  ; but  this 
consequence  can  only  follow  in  cases  in 
whi>  h the  inner  surface  of  the  abscess  is 
within  the  influence  of  the  skin.  The  ac- 
celerated progress  of  the  matter  to  the  sur- 
face of  the  body  arises  from  another  cause, 
viz.  the  promotion  of  ulceration  in  the  parts, 
between  the  collection  of  matter  and  the  cu- 
ticle. 

Emollient  poultices  are  commonly  ap- 
plied to  inflamed  parts,  when  suppuration 
is  known  to  have  taken  place.  These  can 
have  no  effect  upon  suppuration,  except 
that  of  lessening  the  inflammation,  or  ra- 
ther making  the  skin. more  easy.  The  in- 
flammation must  have  reached  the  skin 
before  poultices  can  have  much  effect,  for 
they  can  only  affect  that  part.  The  ease  of, 
the  patient,  however,  should  be  considered, 
and  We  find  that  fomentations  and  poultices 
are  often  beneficial  in  this  way.  By  keep- 
ing the  cuticle  moist  and  warm,  the  sensi- 
tive operations  of  the  nerves  of  the  parts 
are  soothed.  On  the  contrary,  if  the  infla- 
med skin  is  allowed  to  dry,  the  inflamma- 
tion is  increased,  and  as  suppuration  is  pro- 
bably not  checked  by  the  above  treatment, 
it  ought  to  be  put  in  practice.  As  warmth 
excites  action,  the  fomentation  should  be 
as  warm  as  the  patient  can  bear  without  in- 
convenience. (Hunter.) 

“ The  local  treatment  in  phlegmonous 
abscesses  (as  professor  Thomson  observes) 
is  still  more  simple  than  that  by  which  we 
endeavour  to  procure  resolution.  It  con- 
sists almost  solely  in  the  application  of  a 
moderate  degree  of  warmth  and  moisture 


Suppuration. 


4.3s 


to  the  inflamed  pari,  either  by  means  of 
fomentations  or  poulticed.  The  manner  in 
which  these  means  act  in  promoting  sup- 
puration is  unknown,  independently  of 
their  temperature,  it  seems  very  doubtful 
whether  fomentations  and  poultices  have 
any  power  of  promoting  suppuration  in  the 
parts  to  which  they  are  applied.  They  keep 
the  cuticle  moist  and  warm,  they  promote 
perspiration,  they  sooth  and  allay  pain  in 
many  inflammations,  and  these  are  probably 
the  only  immediate  effects  which  they  pro- 
duce. The  rest  is  the  work  of  nature.  In 
suppurations,  attended  by  very  sevefe  pain, 
the  use  of  w arm  fomentations  is  often  found 
to  atford  singular  relief,  not  only  by  their 
effect  in  easing  pain,  but  also  by  their  seem- 
ing to  shorten  the  duration  of  the  suppura- 
tive stage.  In  the  cases  of  suppuration,  in 
which  they  give  relief,  they  should  be  re- 
peated every  four  or  six  diours.  The  most 
common  way  of  employing  them  is  by 
wringing  linen,  or  woollen  cloths,  out  of 
warm  water,  and  applying  these  to  the  in- 
flamed part,  of  as  high  a temperature  as  the 
feelings  of  the  patient  can  bear.  Decoc- 
tions of  herbs  were  formerly  much  employ- 
ed in  the  way  of  embrocation,  and  were 
then,  and  are  still,  by  many  practitioners, 
supposed  to  possess  peculiar  virtues  in  pro- 
moting suppuration.  Whether  embroca- 
tions with  the  narcotic  herbs  might  not  in 
some  cases  be  beneficial,  by  producing  a 
sedative  effect  in  allaying  pain,  I arn  una- 
ble to  say,  though  1 am  inclined  to  believe 
that  even  they  act  chiefly  by  their  warmth 
and  moisture.  In  cases  where  you  find  it 
necessary  to  use  an  embrocation  with  herbs, 
the  flowers  of  chamomile  may  in  general  be 
substituted  in  place  of  the  leaves  or  flowers 
of  almost  every  other  plant.  These  flow- 
ers readily  imbibe  and  retain  moisture. 
They  are,  when  moist,  of  a soft  consistence, 
and  can  be  easily  moulded  to  the  figure  of 
the  parts  to  which  they  are  applied.” 
(Thomson’s  Lectures , p.  333.)  Oatmeal, 
crumb  of  bread,  and  especially  linseed 
meal,  are  the  ingredients  mostly  preferred 
in  this  country  for  emollient  poultices. 
When  bread  is  used,  it  is  generally  boded 
in  milk.  The  observations,  however,  Which 
have  been  offered  on  poultices  in  another 
place,  are  here  equally  applicable.  (See 
Inflammation.) 

OF  THE  TIME  WHEN  ABSCESSES  SHOULD  BE 
OPENED. 

As  abscesses,  wherever  formed,  must  in- 
crease that  part  of  their  cavity  which  is 
next  to  the  skin,  more  quickly  than  the 
bottom,  they  must  become,  in  some  degree, 
tapering  towards  the  latter  part,  with  their 
greatest  breadth  immediately  under  the 
skin.  This  shape  of  an  abscess,  when  allow- 
ed to  take  place  is  favourable  to  its  healing, 
for  it  puts  the  bottom,  which  is  the  scat  of 
the  disease,  more  upon  a footing  with  the 
mouth  of  the  abscess  than  it  otherwise  could 
be.  As  the  bottom,  or  part  where  the  ab- 
scess began,  is  more  or  less  in  a diseased 


state  ; and  as  the  parts  between  the  seat  of 
the  abscess  and  the  external  surface  are 
sound  parts,  having  only  allowed  a passage 
for  the  pus,  they,  of  course,  have  a stronger 
disposition  to  heal  than-the  bottom  has. 

To  keep  the  mouth  of  an  abscess  from 
healing  before  its  bottom,  the  collection  of 
matter  should  be  allowed  to  break  of  itself; 
for  although  abscesses  in  general  only  open 
by  a small  orifice,  more  especially  when 
sound,  yet,  in  such  cases,  the  skin  over  the 
general  cavily  of  the  matter  is  so  thinned, 
thatit  has  very  little  tendency  to  heal,  and 
often  ulcerates  and  makes  a free  opening. 
If  the  latter  event  should  not  spontaneously 
occur,  it  may  now  be  more  easily  obtained 
by  the  interference  of  the  surgeon. 

Abscesses  w hich  are  the  most  disposed  to 
heal  favourably,  are  the  quickest  in  their 
progress  to  the  skin,  and  the  matter  comes 
to  the  surface  almost  at  a point ; the  swell- 
ing is  not  so  conical  as  in  other  cases,  and 
when  it  bursts  the  orifice  is  exceedingly 
small.  On  the  other  hand,  when  there  is 
an  indolence  in  the  progress  of  the  abscess, 
the  collection  spreads  more,  or  distends  the 
surrounding  parts  in  a greater  degree,  in 
consequence  of  their  not  being  so  finely 
united  by  inflammation  in  the  one  as  they 
are  in  the  other  instance  ; nor  will  ulcera- 
tion so  readily  take  the  lead,  and  the  matter 
will  come  to  the  skin  by  a broad  surface, 
so  as  to  thin  a large  portion  of  the  cutis. 
(Hunter.) 

It  may  be  set  down  as  a general  axiom, 
that  alf  phlegmonous  abscesses  should  be 
allowed  to  break,  and  not  be  opened  by  the 
surgeon.  When  punctured  unnecessarily, 
or  prematurely,  they  never  heal  so  favoura- 
bly as  when  left  to  themselves. 

Particular  cases,  however,  should  be 
opened  as  soon  as  the  existence  of  matter 
is  ascertained.  Abscesses  should  only  be 
allowed  to  burst  of  themselves,  when  the 
confinement  of  the  matter  can  do  no  mis 
chief.  Abscesses  in  tbe  abdomen  or  tho- 
rax, under  the  cranium,  near  the  eye,  or  in 
joints,  should  be  mostly  opened  very  soon. 
When  suppuration  takes  place  beneath  liga- 
mentous expansions,  or  aponeuroses,  which 
invariably  retard  the  progress  of  the  matter 
to  the  surface  of  the  body,  an  early  opening 
should  be  made.  It  this  be  not  done,  the 
matter  spreads  to  a great  extent,  separating 
such  ligamentous  expansions  from  the  mus- 
cles, and  the  muscles  from  each  other,  and, 
as  the  pus  cannot  get  to  the  surface  of  the 
body;  the  length  of  the  disorder  is  of  course 
increased.  When  matter  is  so  situated  as 
to  be  liable  to  insinuate  itself  into  the  chest 
or  abdomen,  or  into  the  capsular  ligaments 
of  the  joints,  it  is  highly  proper  to  prevent 
this  extension  of  mischief,  by  making  a 
timely  opening  into  the  abscess. 

u Those  abscesses  ought  to  be  opened 
early,  (says  Professor  Thomson)  that  are 
situated  in  parts  through  which  the  matter 
is  liable  to  become  widely  diffused.  This 
is  particularly  the  case  with  abscesses  that 
are  situated  on  the  forepart  of  the  neck,  or 
in  the  cavity  of  the  axilla,  or  by  the  side  of 


SUPPURATION. 


433 


iii e rectum.  When  matter  is  formed  In  the 
cavity  of  the  axilla,  if  it  does  not  speedily 
obtain  an  external  outlet,  it  is  very  liable  to 
pass  up  towards  the  clavicle  in  the  course 
of  the  axillary  plexus  of  nerves  and  vessels, 
or  forwards  under  the  pectoral  muscle.  I 
have  repeatedly  seen  axillary  abscess  take 
both  of  these  directions  at  the  same  time, 
forming  one  of  the  most  painful  and  diffi- 
cult cases  to  treat  which  occurs  in  the  ma- 
nagement of  abscesses.”  Dr.  Thomson  also 
considers  an  early  opening  proper  and  ne- 
cessary, where  the  matter  is  lodged,  as  in 
some  cases  of  whitloe,  in  the  sheaths  of  the 
tendons;  where  matter  is  formed  under  the 
periosteum  ; where  it  collects  under  fas- 
ciae, or  in  the  vicinity  of  large  arteries, 
joints,  or  the  greater  cavities  of  the  body: 
also  when  the  abscess  is  deep-seated.  (See 
Thomson’s  Lectures  on  Inflammation , p. 
336—338.) 

With  respect  to  making  an  early  opening 
into  abscesses,  situated  near  large  arteries, 

I am  not  aware,  that  any  danger  of  the  ar- 
tery ulcerating  in  consequence  of  the  near- 
ness of  the  pus,  really  exists.  Therefore, 
some  doubts  may  reasonably  be  entertained 
of  Professor  Thomson’s  advice  in  this  par- 
ticular case,  as  the  general  rule  of  opening 
abscesses  nearHarge  blood-vessels,  in  an 
early  stage  of  the  disease,  would  be  objec- 
tionable on  the  ground  of  the  practice  ex- 
posing the  vessels  themselves  to  injury. 
Indeed,  this  well-informed  writer  distinctly 
mentions,  in  considering  the  subject  in 
question,  that  the  arteries  are  not  very 
susceptible  of  ulcerating  absorption.  (P. 
337.) 

OF  THE  PLACE  WHERE  THE  OPENING  SHOULD 
BE  MADE. 

If  a free  opening  is  not  required,  or  ma- 
king one  is  not  practicable,  it  is  at  least  pro- 
per to  make  whatever  opening  can  be  made 
in  a depending  situation.  By  this  means 
the  matter  will  more  readily  escape,  and  all 
pressure  arising  from  the  confinement  or 
lodgment  of  pus,  will  be  prevented.  Avery 
small  degree  of  pressure  on  that  side  of  the 
abscess  which  is  next  to  the  skin,  may  pro- 
duce ulceration  there  ; and  although  such 
pressure  might  not,  in  many  cases,  be  so 
great  as  to  produce  ulceration  at  the  bottom 
of  the  abscess  ; yet  it  might  be  sufficiently 
great  to  prevent  granulations  from  forming 
on  that  side,  and  thereby  retard  the  cure, 
as  no  union  can  take  place,  but  by  means 
of  granulations.  The  pressure  is  always 
most,  and  retards  the  formation  of  granula- 
tions in  the  greatest  degree,  at  the  most  de- 
pending part  of  the  abscess.  Hence,  if  no 
opening  be  made  in  this  situation,  tbw  upper 
part  of  the  abscess  readily  heals  to  a small 
point,  which  becomes  a fistula. 

When  circumstances  forbid  making  an 
opening  at  the  most  depending  part  of  an 
abscess,  perhaps  nothing  more  can  be  done, 
than  to  evacuate  the  matter  as  often  as  ne- 
cessary, and  gently^to  compress  fixe  sides  of 


the  abscess  together,  when  the  situation  of 
the  case  admits  of  the  practice. 

But  abscesses  are  not  always  to  be  open- 
ed at  the  most  depending  part.  The  distance 
between  the  matter  and-  the  skin  at  this  part 
is  the  common  reason  against  the  method. 
If  an  abscess  is  rather  deeply  situated,  and 
points  in  a place  which  is  higher  than  where 
the  collection  lies,  it  is  proper  to  make  the 
opening  where  the  conical  eminence,  or  as 
it  is  terme.d,  the  pointing,  appears.  Thus,  if 
an  abscess  should  form  in  the  centre  of  the 
breast,  and  point  at  the  uppermost  part, 
which  is  often  the  case,  jt  would  be  impro- 
per to  cut  through  the  lower  half  of  the 
mamma,  in  order  to  make  a passage  for  the 
matter  in  that  direction.  If  an  abscess 
should  form  on  the  upper  part  of  the  foot, 
it  would  be  wrong  to  make  an  opening 
through  the  sole  of  the  foot  to  get  at  the 
most  depending  part  of  the  abscess  ; (or, 
besides  cutting  such  a depth  of  sound 
parts,  a great  many  useful  ones  would  be 
destroyed. 

When  the  abscess  does  not  point  in  a de- 
pending situation,  as  in  the  instances  just 
cited,  since  the  place  where  the  matter 
threatens  to  open  a passage  is  likely  to  be 
the  future  opening,  and  this  situation  is  dis- 
advantageous to  the  healing  of  the  deep 
part  of  the  abscess,  it  is  generally  best  to 
let  tbe  collection  of  matter  first  burst  of 
itself,  and  then  dilate  the  opening  as  freely 
as  necessary.  By  allowing  abscesses  to 
burst  spontaneously,  the  opening  is  not  so 
apt  to  heal  as  if  made  by  art,  and  therefore, 
is  better  in  such  situations.  (Hunter.) 

In  most  cases,  it  is  more  advantageous 
erven  to  cut  through  a certain  thickness  of 
parts,  for  the  sake  of  obtaining  a depending 
opening,  than  to  make  an  opening,  where 
the  pointing  appears,  that  is,  where  the  parts 
are  thinnest,  and  the  matter  nearest  the  sur- 
face. This  remark  is  highly  worthy  of  re- 
membrance, when  there  is  no  doubt  of  the 
existence  of  matter  at  the  depending  place, 
and  when  the  parts  to  be  divided  are  not  im- 
portant ones.  Collections  of  matter  be- 
neath the  fasciae  of  the  fore-arm  and  thigh 
particularly  demand  attention  to  this  direc 
tion,  as  they  commonly  point  where  thgsc 
ligamentous  expansions  are  thinnest,  not 
where  the  matter  can  most  readily  escape. 

Abscesses  in  the  sheath  of  the  rectus  ab- 
dominis should  also  be  opened  in  a low  situ- 
ation. 

DIFFERENT  METHODS  OF  OPENING  AB 1 
SCESSES. 

All  abscesses  will  naturally  burst  of  them- 
selves, unless  the  matter  be  absorbed,  and, 
in  general,  they  ought  to  be  allowed  to 
take  this  course.  There  are,  however,  as  I 
have  already  explained,  particular  circum 
stances  which  require  an  early  opening ; 
but,  when  the  skin  over  the  abscess  is  very 
thin,  it  is  not  (ff  so  much  consequence, 
whether  the  case  be  permitted  to  burst  of 
itself,  or  it  be  opened  by  the  surgeon. 

When  abscesses  are  large,  it  is  generally 


SUPPURATION, 


m 


necessary  to  open  them  by  art,  whether  they 
have  hurst  of  themselves  or  not;  for,  the 
natural  opening  will  seldom  be  sufficient 
for  the  completion  of  a cure  ; and,  although 
it  may  be  sufficient  for  the  free  discharge  of 
the  matter,  yet  these  abscesses  will  heal 
much  more  readily  when  a free  opening  is 
made  ; for,  the  thin  skin  over  the  cavity 
granulates  but  indifferently,  and  therefore 
unites  but  slowly  with  the  parts  underneath. 
(Hunter.) 

Abscesses  may  be  opened  either  by  an 
incision  or  by  making  an  eschar  with  caus- 
tic. To  the  latter  pjan,  however,  many  urge 
strong  objections  : the  use  of  caustic  is  not 
usually  attended  with  any  advantage  which 
may  not  be  obtained  by  a simple  incision  ; 
upon  a tender  inflamed  part  it  gives  much 
more  pain  ; it  is  more  slow  in  its  effects  ; 
and  the  surgeon  can  never  direct  the  ope- 
ration of  the  caustic  so  accurately  as  to  de- 
stroy exactly  the  parts  which  he  wishes,  and 
no  more.  If  the  eschar  be  not  made  deep- 
ly enough,  the  lancet  must,  after  all,  be 
used  Caustic  also  leaves,  after  its  applica- 
tion, a disagreeable  scar,  a consideration  of 
some  importance  in  opening  abscesses  about 
the  female  neck  or  face.  To  these  nume- 
rous objections  we  have  to  add,  that  the 
eschar  is,  very  frequently,  ten  or  twelve  te- 
dious days  in  becoming  detached. 

When  there  is  a redundance  of  skin,  or 
when  there  is  a good  deal  of  it  thinned, 
however,  an  opening  made  with  caustic 
will  answrer,  perhaps,  as  well  as  an  incision. 
The  application  of  a caustic  may  also  some- 
times be  advantageously  resored  fo  when 
there  is  a good  deal  of  indolent  hardness 
around  a small  abscess. 

The  calx  cum  polassa,  or  the  potassa  alone, 
is  the  best  caustic  for  opening  abscesses. 
The  part  is  first  to  be  covered  with  a piece 
of  adhesive  plaster,  which  has  a portion 
cut  out  exactly  of  the  same  figure  and  size 
as  the  opening  intended  to  be  made  in  the 
abscess.  The  best  way  of  making  the  eschar 
is  to  dip  the  end  of  the  caustic  in  water,  and 
to  rub  it  on  the  part  till  the  skin  becomes 
brown.  The  active  substance  is  then  vo  be 
immediately  washed  off  with  some  wet  tow, 
the  plaster  is  to  be  removed,  and  an  emol- 
lient poultice  applied. 

In  almost  all  cases,  it  is  better  to  use  the 
lancet,  or  double-e  iged  bistoury.  Either 
of  these  instruments  opens  the  abscess  at 
once,  and  with  less  pain,  than  results  from 
the  use  of  caustic;  it  occasions  no  loss  of 
substance,  consequently  a smaller  cicatrix  ; 
and,  by  using  it,  the  opening  may  be  made 
in  the  most  advantageous  direction,  and  of 
the  exact  size  required. 

DRESSINGS  AFTER  OPENING  ABSCESSES. 

When  an  abscess  has  burst  of  itself,  and 
it  is  unnecessary  to  enlarge  the  opening,  the 
only  thing  requisite  is  to  l^ep  the  surround- 
ing parts  clean.  The  continuation  of  the 
same  kind  of  poultice,  which  was  before 
used,  is,  perhaps,  ns  good  a practice  as  any  ; 
and  when  the  tenderness,  arising  from  the 


inflammation,  is  over,  lint  and  a pledged 
may  be  made  use  of,  instead  of  the  poul- 
tice. 

But,  an  abscess,  opened  by  a cutting  in- 
strument, is  both  a wround  and  a sore,  and 
partakes  more  of  the  nature  of  a fresh 
wound  in  proportion  to  the  thickness  of  the 
parts  cut.  Hence,  it  is  necessary  that  some- 
thing should  be  put  into  the  opening  to  keep 
it  from  healing  by  the  first  intention.  If  it 
is  lint,  it  should  be  dipped  in  some  salve, 
which  will  answer  better  than  lint  alone,  as 
it  will  allow  of  being  taken  out  sooner. 
This  is  advantageous,  because  such  sores 
should  be  dressed  the  next  day.  or  at  latest 
on  the  second  day,  in  order  that  the  pus  may 
be  discharged  again.  When  the  cut  edges  of 
the  opening  have  suppurated,  which  will  be 
in  a few  days,  the  future  dressings  may  be  as 
simple  as  possible,  for  nature  will,  in  gene- 
ral, complete  the  cure. 

If  the  abscess  has  been  opened  with  caus- 
tic, and  the  slough  has  either  been  cut  out: 
or  separated  of  itself,  the  case  is  to  be  re- 
garded altogether  as  a suppurating  sore,  and 
dressed  accordingly. 

Perhaps,  dry  lint  is  as  good  a dressing  as 
any,  till  the  nature  of  the  sore  is  known. 
If  it  should  be  of  a good  kind,  the  same 
dressing  may  be  continued*;  but,  if  not, 
then  it  must  be  dressed  accordingly.  Parts, 
which  at  first  appear  to  be  sound,  some- 
times assume  every  species  of  disease, 
whether  from  indolence,  from  irritability, 
from  scrofulous,  and  other  dispositions. 
This  tendency  to  disease  arises,  in  some  ca- 
ses, from  the  nature  of  the  parts  affected, 
as,  for  instance,  bone,  ligament,  &o.  (Hun- 
ter.) 

Consult  particularly  John  Hunter's  Trea- 
tise on.the  Blood , Inflammation,  nnd  Gunshot 
Wounds , a work,  in  which  more  interesting 
knowledge  respecting  Abscesses  and  Suppura- 
tion is  contained,  than  in  any  other  ever  pub- 
lished. See  also  Traite  de  la  Suppuration 
de  F Ouesnay,  1749.  J Grashuis,  A Diss. 
on  Suppuration,  8 vo.  Load.  1752.  Various 
parts  of  the  Memoir es  de  1' Academic  de  Chi- 
r /rgie.  J B Boyer , De  Suppuratione  et  Cu- 
ratione  Inflammatvmis  per  Suppuralionem  ter- 
minandee.  Monsp.  1766.  U Encyclopedic  Me 
thodique.  Partie  Chirurgicale,  article  Abces. 
Dissertations  on  Inflammation  by  John  Burns, 
1800.  Sir  E Home's  Dissertation  on  the 
Properties  of  Pus , 1788  ; and  his  Pract.  Obs. 
on  Ulcers,  2d  Edit.  1S01  James  Hendy, 
Essay  on  Glandular  Secretion,  containing  an 
experimental  Inquiry  into  the  Formation  of 
Pus,  fyc.8vo.  Loud.  1775.  JY.  Romayne,  De 
Puris  Generatione,8vo.  Edinb.  1780.  C.  Dar- 
wins Experiments,  establishing  a criterion  be- 
tween mucilaginous  and  purulent  matter,  fyc. 
Litchfield,  1780.  P.  Clare,  Essay  on  Abscesses. 
Loud.  1781.  Several  parts  of  Poll's  Chirurgi- 
cal  Works,  but  especially  his  Treatise  on  the 
Fistula  in  Ano.  T.  Brand , Strictures  in  Vin- 
dication of  some  of  the  Doctrinesmisreprcsented 
by  Mr.  Foot  in  his  two  pamphlets,  entitled  “Ob- 
servations upon  the  new  opinions  of  J.  Hunter , 
in  his  Treatise  on  the  Venereal,  including  Mr. 
Pott'  Plagiarisms,  and  misinfomal'bv  p*r. 


SURGERY. 


4.41 


Pus,"  fyc.  4 to.  Load.  1787.  Richter,  Anfangs- 
griinde  der  Wundarzneykunst,  B.  1,  Kap.  2. 
Dr.  J.  Thomson's  Lectures  on  Inflammation, 
p.  305.  tyc.  Edinb  1813  ; a work,  in  which  a 
profound  knowledge  of  medical  science,  and 
of  surgery  in  particular , is  every  where  con- 
spicuous. J.  F.  Crevecwur,  De  Diagnosi 
Puris  ; Longchamps,  1793.  Pearson's  Prin- 
ciples of  Surgery,  p.  34,  §'C.  Edit.  2.  Lassus 
Pathologic  Cfururgicale.  T 1 , p.  21,  fyc.  fyc. 
Edit,  of  1809.  Stb.J.  Brugmans,  De  Puo- 
genia,  sive  mediis  quihus  naturautitur  in  cre- 
au do  pure,  8vo.  Groningce,  1785.  Dr.  G. 
Pearson  s ' ibs . and  Experiments  on  Pus  in  the 
Philosophical  Trans,  for  1811.  C.  J.  M. 
Langenbeck,  Von  der  Behandiung  der  Fistel- 
gttnge,  der  Schusscanale , und  grosser  Eiter 
absonderndtr  Holden,  in  Neue  Bibl.  far  die 
Chirurgie,  12mo.  Hanover,  1817. 

SURGERY,  or  C 111 RURGERY,  (derived 
from  chirurgeon,  from  the  hand,  and 

s e,yov,  work,)  has  been  by  many  considered 
to  be  that  branch  of  medicine,  which  prin- 
cipally effects  the  cure  of  diseases  by  the 
application  of  the  hand  alone,  the  employ- 
ment of  instruments,  or  the  use  of  topical 
remedies.  (Encyclopedic  Mcthodique,  Padie 
Chir.  Tom.  I,  Art.  Cliirurgie.)  But,  although 
this  definition  certainly  conveys  to  us  some 
idea  of  the  nature  of  this  most  useful  pro- 
fession, it  is  not  entirely  accurate  as  applied 
to  the  present  state  of  practice.  It  might, 
indeed,  be  correct  during  that  short  unfa- 
voured period  of  surgery  upon  the  conti- 
nent, some  centuries  ago,  when  its  practice 
was  denounced  by  the  Council  of  Tours, 
as  unfit  for  the  hands  of  priests  and  men  of 
literature,  and  when  the  surgeon  became 
little  better  than  a sort  of  professional  ser- 
vant to  the  physician,  the  latter  alone  not 
only  having  the  sole  privilege  of  prescribing 
internal  medicines,  but  even  that  of  judging 
and  directing  when  surgical  operations 
should  be  performed.  Then  the  subordi- 
nate surgeon  was  only  called  upon  to  exe- 
cute with  his  knife,  or  his  hand,  duties 
which  the  more  exalted  physician  did  not 
choose  to  undertake  ;.and,  in  fact  he  visit- 
ed'the  patient,  did  what  was  required  to  be 
done,  and  took  his  leave  of  the  case  alto- 
gether under  the  orders  of  his  master.  In 
modern  times,  however,  the  good  sense  of 
mankind  has  discovered  that  surgery  is  de- 
serving of  an  eminent  rank  among  such 
arts  as  ought  to  be  cultivated  for  the  gene- 
ral benefit  of  society  ; that  the  man  who  is 
not  himself  accustomed  to  the  performance 
of  operations,  cannot  be  the  best  judge  of 
their  safety  and  necessity  j and  that,  in 
every  point  of  viewy  the  surgical  practition- 
er merits  as  much  favour  and  independence 
in  the  exercise  of  his  profession,  as  he 
whose  avocation  is  confined  to  physic. 
Hence,  the  surgeon  is  now  exclusively  con- 
sulted about  many  of  the  most  important 
diseases  to  which  the  human  body  is  liable. 
Being  no  longer  under  the  yoke  of  the  phy- 
sician, he  follows  the  dictates  of  his  own 
judgment  and  knowledge ; he  prescribes 
whatever  medicines  the  case  may  demand, 
internal  as  well  as  external ; and  under  the 
Vor,,  11 


encouragement  of  an  enlightened  age,  he 
sees  his  profession  daily  becoming  more 
scientific,  more  respected,  and  more  exten- 
sively useful. 

By  some  writers,  physic  is  said  to  have 
for  its  object  the  treatment  of  internal, 
surgery  that  of  external  diseases.  This 
definition,  however  good  and  plausible  it 
may  at  first  appear,  can  only  be  received 
with  numerous  exceptions  in  regard  to 
modern  surgery : for  instance,  the  psoas 
abscess,  stone  in  the  bladder,  an  extravasa- 
tion of  blood  withiritheskullin  consequence 
of  accidental  violence, are  universally  allow- 
ed to  be  strictly  chirurgical  cases  ; yet  no 
man  in  his  senses  would  call  these  disorders 
external. 

Others  have  defined  surgery  to  be  the  me- 
chanical part  of  physic,  “ quod  in  therapeia 
mechanicum  but,  although  this  has  obtain- 
ed the  assent  of  so  eminent  a modern  sur- 
geon as  Professor  Richerand,  of  Paris,  (Did. 
des  Sciences  Medicates,  Tom.  5,  p.  85.)  I 
believe  few  on  this  side  of  the  water  will  be 
of  his  opinion.  As  Mr  John  Pearson  has 
observed,  “ Many  people  have  imagined 
that  when  a man  has  learnt  the  art  of  dress- 
ing sores,  of  applying  bandages,  and  per- 
forming operations  with  a little  dexterity, 
he  must  necessarily  be  an  accomplished 
surgeon.  If  a conclusion  so  gross  and  falla- 
cious had  been  confined  to  the  vulgar  and 
illiterate,  the  progress  of  scientific  surgery 
would  have  suffered  little  interruption  ; but 
if  young  minds  are  directed  to  these  objects, 
as  the  only  important  matters  upon  which, 
their  faculties  are  to  be  exercised  ; if  the 
gross  informations  of  sense  constitute  the 
sum  of  their  knowledge,  little  more  can  be 
expected  from  such  a mode  of  study,  than 
servile  imitation,  or  daring  empiricism.  In- 
deed, some  people  have  affected  to  oppose 
surgery  as  an  art,  to  medicine  as  a science  ; 
and  if  their  pretensions  wTere  justly  founded, 
the  former  would  certainly  be  degraded  to 
a mere  mechanical  occupation.  But  it  is 
not  very  easy  to  comprehend  the  grounds 
of  such  a distinction.  The  internal  and 
external  parts  of  the  body  are  governed  by 
the  same  general  laws  during  a state  of 
health  ; and,  if  an  internal  part  be  attacked 
with  inflammation,  the  appearances  and 
effects  will  bear  a great  similarity  to  the 
same  disease  situated  externally  ; nor  are 
the  indications  of  cure,  in  general,  materi- 
ally different.  If  by  science,  therefore,  be 
meant  ‘ a knowledge  of  the  laws  of  nature,* 
he  who  knows  what  is  known  of  the  order 
and  method  of  nature,  in  the  production, 
progress,  and  termination  of  surgical  dis- 
eases, merits  as  justly  the  title  of  a scienti- 
fical  practitioner  as  the  well-educated  phy- 
sician. The  practical  parts  of  physic  and 
surgery  are  very  frequently  disunited  ; but 
their  theory  and  principles  are  indivisible, 
since  they  truly  constitute  one  and  the  same 
science.”  (Pearson's  Principles  of  Surgery , 
Preface.) 

But,  though  we  can  object  on  good  grounds 
to  the  above-mentioned  definitions  of  surge- 
ry. it  seems  impossible  to  offer  any  other. 


SURGERY 


•142 


against  „which  equal  objections  could  not 
be  brought.  Tn  fact,  how  is  it  possible  to 
define  surgery  with  any  degree  of  accuracy, 
until  the  boundaries  between  it  and  physic 
can  be  determined  ? Richerand  talks  indeed 
of  the  Medical  School  of  Paris  having  now 
successfully  established  the  limits  and  'ob- 
jects of  surgery,  and  he  boasts  of  this  as  an 
original  improvement  reflecting  credit  on 
his  countrymen.  (See  Did.  des  Sciences 
Med.  T.  5,  p.  88.)  Yet,  what  are  we  to 
think,  when  we  remember,  not  only  that 
he  has,  in  the  commencement  of  the  very 
same  article,  defined  surgery  to  be  u quod 
in  therapeia  mechanicum  ” but  that  by  way 
of  illustrating  what  the  Parisian  School  has 
accomplished,  he  says,  that  surgery  was  first 
demonstrated  by  it  to  be  only  a means  of 
physic,  and  not  a separate  and  distinct 
science  ? (See  also  Dicl.  des  Sciences  Med. 
article  Chirurgicales , Maladies.) 

As  a learned  Professor  notices,  the  limits 
between  physic  and  surgery  are  not  very 
precisely  marked,  and  the  respective  func- 
tions of  the  physician  and  surgeon,  long  as 
those  names  have  existed,  are  still  but  very 
* ^accurately  defined.  “The  most  superfi- 
cial acquaintance  with  the  symptoms,  pro- 
gress, and  termination  of  the  various  mor- 
bid affections  to  which  the  human  body  is 
liable,  must  be  sufficient  to  convince  every 
unprejudiced  inquirer,  that  there  is  but  a 
slight  foundation,  if  indeed  there  be  any, 
for  this  distinction,  in  the  nature  of  the  dis- 
eases, which  these  practitioners  are  required 
to  treat,  or  in  the  modes  of  treatment,  by 
which  the  diseases  themselves  may  be  cured 
or  relieved.  Experience  has  long  shown, 
that  the  use  of  internal  remedies  is  not  only 
required  in  a large  proportion  of  the  diseases, 
which  are  regarded  as  strictly  chirurgical,  but 
also,  that  there  are  few  diseases,  which  come 
under  the  care  of  the  physician,  in  which 
morbid  affections,  requiring  the  manual  aid, 
or  practical  skill  of  the  surgeon,  do  not  fre- 
quently occur. 

“ The  treatment  of  febrile  and  internal 
inflammatory  diseases,  it  will  be  allowed, 
belongs  exclusively  to  the  province  of  the 
physician,  w herever  the  distinction  between 
physician  and  surgeon  has  been  introduced, 
and  is  rigidly  observed  ; yet,  in  some  species 
of  fevers,  and  in  all  internal  inflammatory 
diseases,  blood-letting  is  often  the  principal, 
if  not  the  only  remedy  that  is  required. 
But  this  is  an  operation,  however  urgent  the 
necessity  for  it  be,  which  from  engagement 
the  physician  cannot,  and,  from  the  fear  of 
degrading  his  province  of  the  profession, 
will  not  perform.  Retention  of  urine  not 
unfrequently  takes  place  in  symptomatic 
febrile  diseases,  and  this  is  an  affection 
which  does  not  always  yield  to  the  use  of 
internal  remedies;  but  it  is  an  affection 
also,  from  the  painful  uneasiness,  which  it 
immediately  excites,  as  well  as  from  the  dan- 
ger which  it  threatens,  that  will  not  admit 
of  delay.  When  internal  remedies, therefore, 
fail  in  relieving  the  patient,  the  urine  must 
be  speedily  drawn  off  by  means  of  a chirur- 


gical  operation  ; otherwise  inflammation, 
mortification,  and  rupture  of  the  bladder, 
must  necessarily  ensue.  Febrile  and  in- 
ternal inflammatory  affections  terminate  not 
unfrequently  in  the  formation  of  fluids, 
w hich  it  is  necessary  to  let  out  by  a chirur- 
gical  operation  ; and  abscesses,  fistulous 
openings,  and  ulcers  are  formed,  which  re- 
quire the  aid  of  the  surgeon.  In  patients, 
also,  affected  with  severe  febrile  diseases, 
from  being  long  fixed  down  to  their  beds  in 
one  position,  some  of  the  parts  of  the  body, 
upon  which  they  rest,  occasionally  acquire  a 
disposition  to  mortify,  larger  or  smaller 
portions  of  the  skin  and  subjacent  cellular 
membrane  becoming  dead,  separate  from 
the  living  parts,  and  sores  are  formed,  wffiich 
are  but  too  often  the  subject  of  unavailing 
chirurgical  practice.  To  employ,  in  the 
different  stages  of  this  species  of  mortifica- 
tion, from  its  first  commencement  to  the 
complete  separation  of  the  dead  parts,  and 
the  formation  of  a newr  skin,  the  appropri- 
ate external  and  internal  remedies,  requires 
a greater  share  of  chirurgical  skill  than  can 
reasonably  be  expected  in  those  who  make 
a profession  solely  of  physic.  Unhappy, 
therefore,  must  be  the  lot  of  that  patient, 
who  in  circumstances  similar  to  those  w'hich 
I have  described,  has  the  misfortune  to  have 
for  his  sole  medical  attendant,  a physician 
ignorant  of  surgery. 

“ Bui  (continues  Professor  Thomson, ) if 
a knowledge  of  surgery  be  necessary  to  the 
student  who  intends  to  practise  physic,  the 
knowledge  of  physic,  on  the  other  hand, 
is  no  less  necessary  to  him  wrho  intends  to> 
devote  his  attention  exclusively  to  the  pro- 
fession ot  surgery;  for,  indeed,  there  are 
few  chirurgical  diseases,  which  are  not  in 
some  period  or  another  of  their  existence, 
accompanied  by  mobid  affections  of  the 
same  nature  with  those  which  fall  properly, 
and  most  frequently  under  the  care  of  the 
physician.  It  will  only  be  necessary  to  men- 
tion, as  examples  of  these  affections,  the 
symtomatic  fever,  which  attends  inflamma- 
tion, whetherthis  affection  has  been  induced 
by  external  injury,  or  has  occurred  spontane- 
ously in  the  body  from  internal  disease  ; the 
hectic  fever,  supervening  to  long-continued 
processes  of  suppuration  ; the  febrile  state 
and  other  morbid  affections,  which  are  some- 
times brought  on  by  the  too  sudden  and  in- 
judicious use  of  mercury  ; bilious  fevers, 
and  the  various  derangements  of  the  di- 
gestive organs,  which  are  sometimes  the 
cause,  and  at  other  times  the  consequence, 
of  local  diseases ; the  nervous  affections, 
such  as  apoplexy,  convulsions,  paralysis, 
and  mania,  which  arise  not  unfrequently 
from  injuries  of  the  head  ; and  locked  jaur, 
or  tetanus,  which,  in  warm  climates  parti- 
cularly, is  so  very  liable  to  be  induced  by 
punctured  wounds.  These  are  morbid  af- 
fections, the  proper  study  and  treatment  of 
which,  when  they  occur  without  local  inju- 
ry, are  supposed  to  belong  to  the  physiciu.% 
rather  than  the  surgeon  ; but  occuring  very 
frequently  as  they  do  in  chirurgical  diseases, 
and  always  modifying,  or  aggravating,  the 


SUHGEKi 


«tfects  oi  these  diseases,  ignorance  of  their 
nature,  relations,  and  modes  of  cure,  is  not 
only  inexcusable,  but  highly  criminal  in  the 
practitioner,  who  ventures  to  undertake 
their  treatment.”  ( Thomson's  Lectures  on 
Inflammation , Introduction.  Also  J.  R.  C. 
Bollman,  Tentamen,  ostendens  Chirurgiam  a 
Medicina  hand  impune  separari,  12 mo.  Rintel , 
1803.) 

From  what  has  been  stated,  I think  it 
very  certain,  that  there  never  can  be  a com- 
plete scientific  division  of  the  healing  art 
into  physic  and  surgery ; and  that  all  at- 
tempts to  distinguish  the  numerous  diseases 
and  injuries  of  the  human  body  into  medi- 
cal and  surgical  cases,  must  in  a great  mea- 
sure be  decided  by  custom,  and  the  mutual 
agreement  of  practitioners,  rather  than  by 
any  rules,  or  principles,  which  are  at  all 
consistent. 

In  the  earliest  periods,  the  same  men 
cultivated  the  whole  field  of  medicine.  The 
writings  of  Hippocrates,  Galen,  Celsus,  Pau- 
ius  (Egineta,  Albucasis,  &c.  prove  that  the 
Greeks,  Romans,  and  Arabians  never  had  an 
idea  of  the  human  body  being  susceptible  of 
only  two  classes  of  diseases,  one  of  which 
formed  the  province  of  physic,  while  the 
other  constituted  a separate  and  distinct 
science  called  surgery.  All  these  ancient 
authors  treat  successively  of  fevers,  frac- 
tures, wounds,  and  nervous  diseases,  and 
none  of  them  appear  to  have  supposed,  that 
there  could  be  any  disorders  which  really 
deserved  to  be  called  external , and  others 
internal.  Nor  was  it  until  the  middle  of  the 
twelfth  century,  that  the  ecclesiastics  were 
restrained  from  undertaking  any  bloody  ope- 
ration. Surgery  was  then  rejected  from  the 
universities,  under  the  empty  pretext,  “ Ec 
clesia  abhorret  a sanguine ,”  often  expressed 
in  its  decrees,  as  Professor  Thomson  well 
observes,  but  never  acted  upon,  except  in 
this  instance,  by  the  church  of  Rome.  It  is 
to  this  epoch  that  we  must  refer  the  true 
separation  of  physic  from  surgery,  the  latter 
being  abandoned  to  the  laity,  who,  in  those 
ages  of  barbarism,  were  totally  illiterate. 

It  is  an  observation  made  by  the  celebra- 
ted Bichat,  that  two  things  are  essentially 
necessary  to  form  a great  surgeon,  viz.  genius 
and  experience.  One  traces  for  him  the 
way,  the  other  rectifies  it ; both  recipro- 
cally assist  in  forming  him.  Without  expe- 
rience, genius  would  be  unprofitably  fertile  ; 
without  genius,  experience  would  only  be 
a barren  advantage  to  him.  ( CEuvres  Chir. 
de  Desault , par  Bichat,  T.  1,  Discours  Prelim.) 
Out  of  the  large  number  of  hospital  surgeons, 
who  are  to  be  met  with  in  every  country  of 
Europe,  and  who  enjoy  ample  opportunities 
of  profiting  by  the  lessonsof  experience,  bow 
few  distinguish  themselves,  or  ever  contri- 
bute a mite  to  the  improvement  of  their 
profession.  Opportunity,  without  talents 
and  an  aptness  to  take  advantage  of  it,  is 
not  of  more  use  than  light  to  a blind  man. 
On  the  other  hand,  splendid  abilities,  with- 
out experience,  can  never  be  enough  to 
make  a consummate  surgeon,  any  more 


than  a man  with  the  greatest  genius  for 
painting  can  excel  in  his  particular  art  with- 
out having  examined  and  studied  the  real 
objects  which  he  wishes  to  delineate.  In 
short,  as  a sensible  writer  has  remarked, 

“ Les  grands  chirurgiens  sont  aussi  rares,  que 
le  gdnie,  le  savoir,  et  les  talens.”  (Mem.  de 
V Acad,  de  Chir.  T.  1,  Pref.  p.  41,  Edit. 
12  mo.) 

The  description  of  the  qualities  which  a 
surgeon  ought  to  possess,  as  given  by  Celsus, 
is  excellent  as  far  as  it  goes.  A surgeon^ 
says  he,  should  be  young,  or,  at  any  rale, 
not  very  old;  his  hand  should  be  firm  and 
steady,  and  never  shake ; he  should  be  able 
to  use  his  left  hand  with  as  much  dexterity 
as  his  right ; his  sight  should  be  acute  and 
clear;  his  mind  intrepid  and  pitiless,  so  that 
when  he  is  engaged  in  doing  any  thing  to  a 
patient,  he  may  not  hurry,  nor  cut  less  than 
he  ought,  but  finish  the  operation,  just  as  if 
the  cries  of  the  patient  made  no  impression 
upon  him.  Ul.  C.  Celsi  Med.  Prcef.  ad 
lib.  7.) 

By  the  word  “ immisericors ,”  as  Richerand 
has  observed,  ( JYoscgr . Chir.  Tom.  1,  p.  42,  v 
Edit.  2,)  Celsus  did  not  mean  that  a surgeon 
ought  to  be  quite  insensible  to  pity;  but 
that  during  the  performance  of  an  operation, 
this  passion  should  not  influence  him,  as  all 
emotion  would  then  be  mere  weakness. 
This  undisturbed  coolness,  which  is  still  more 
rare  than  skill,  is  the  most  valuable  quality 
in  the  practice  of  surgery.  Dexterity  may 
be  acquired  by  exercise  ; but  firmness  ot 
mind  is  a gift  of  nature.  Haller,  to  whom 
nature  was  so  bountiful,  in  other  respects, 
was  denied  this  quality,  as  he  candidly  con- 
fesses. “ Although  (says  he)  I have  taught 
surgery  seventeen  years,  and  exhibited  the 
most  difficult  operations  upon  the  dead  body, 

I have  never  ventured  to  apply  a cutting  in- 
strument to  a living  subject,  through  a fear 
of  giving  too  much  pain.”  (Bibl.  Chir.  1775;, 
Vol.  2.) 

Surgery  may  boast  of  having  had  an  ori- 
gin, that  well  deserves  to  be  called  noble, 
for  the  earliest  practice  of  it  arose  from  the 
most  generous  sentiment  which  nature  has 
implanted  in  the  heart  of  man,  viz.  from  that 
sympathetic  benevolence,  which  leads  us  to> 
pity  the  misfortunes  wThich  we  behold,  and 
inspires  us  with  an  anxious  desire  toalleviate 
them.  He  who  first  saw  his  fellow-creature 
suffer  could  not  fail  to  participate  in  the  pain, 
and  endeavour  to  find  out  the  means  of 
affording  relief.  Opportunities  of  exercising 
this  useful  inclination  were  never  wanting. 
In  the  first  ages  of  the  world,  man  in  his  des- 
titute state  was  under  the  necessity  of  earn- 
ing by  force  or  stratagem,  a subsistence 
which  was  always  uncertain,  and  in  the 
combats  into  which  this  sort  of  life  drew 
him,  he  frequently  met  with  wounds  and 
other  injuries.  Wherever  the  chace  was  in 
vogue  as  a means  of  livelihood  or  amuse- 
ment ; wherever  broils  and  contests  occa- 
sionally arose  ; and  man  was  the  same  ani- 
mal he  now  is,  liable  to  various  diseases 
and  accidental  hurts ; there  must  have  ex- 
isted a necessity  for  curgery ; nor  can  there 


SURGERY 


444 


be  a doubt,  that  the  origin  of  this  valuable 
practice  is  as  ancient,  as  the  exposure  of 
mankind  to  several  of  the  same  kinds  of  in- 
juries, as  befall  the  human  race  at  the  pre- 
sent day.  At  length  wars  became  more 
frequent  and  extensive;  wounds  were  conse- 
quently multiplied;  and  the  necessity  for 
surgical  assistance  was  increased,  and  its 
value  enhanced. 

In  fact,  among  the  ancients,  the  profes- 
sion of  medicine  and  surgery  constituted  a 
sacred  kind  of  occupation,  and  the  practice 
of  it  belonged  only  to  privileged  persons. 
JEsculapius  was  the  son  of  Apollo.  In  the 
armies,  the  highest  princes  gloried  in  dress- 
ing the  wounds  of  those  who  had  fought  the 
battles  of  their  country.  Among  the  Gre- 
cians, Podalirius,  Chiron,  and  Machaon, 
were  not  only  distinguished  for  their  valour, 
but  also  for  their  skill  in  surgery,  as  we 
learn  from  the  poem  of  the  immortal  Homer. 
The  value  which  was  placed  upon  the  ser- 
vices of  Machaon  by  the  Grecian  army  may 
well  be  conceived  from  the  anxiety  which 
they  evinced  to  have  him  properly  taken 
care  of  when  he  was  wounded  in  the  shoul- 
der with  a dart.  “ O Nestor,  pride  of  Greece, 
(cries  ldomeneus)  mount,  mount  upon  thy 
chariot!  and  let  Machaon  mount  with  thee! 
Hasten  with  him  to  our  ships  ; for  a warrior, 
who  knows,  as  he  does,  how  to  relieve  pain, 
and  cure  wounds,  is  himself  worth  a thou- 
sand other  heroes.”  (See  Iliad , lib.  xi.)  Hip- 
pocrates was  one  of  the  first  citizens  of 
Greece ; he  nobly  refused  all  the  rich  offers 
of  several  kings,  enemies  of  his  country,  to 
entice  him  into  their  service  ; and,  in  parti- 
cular, he  disdained  to  accept  those  of  Xerxes, 
whom  he  regarded  as  a barbarian. 

It  is  in  the  immortal  poems  of  the  Iliad 
and  Odyssey,  that  we  find  the  only  certain 
traditions  respecting  the  state  of  the  art  be- 
fore the  establishment  of  the  republics  of 
Greece,  and  even  until  the  time  of  the  Pelo- 
ponnesian war.  There  it  appears  that  sur- 
gery was  almost  entirely  confined  to  the 
treatment  of  wounds,  and  that  the  imaginary 
power  of  enchantment  was  joined  with  the 
use  of  topical  applications. 

In  the  cures  recorded  in  the  sacred  wri- 
tings of  the  Christian  religion,  the  interven- 
tion of  a supernatural  power  is  always  com- 
bined with  what  is  within  the  scope  of  hu- 
man possibility.  The  same  character  evinces 
itself  in  the  infancy  of  the  art  in  every  na- 
tion. The  priests  of  India,  the  physicians 
of  China  and  Japan,  and  the  jugglers  of  the 
savage  or  half-civilized  tribes  of  the  old  and 
new  continents,  constantly  associate  with 
drugs  and  manual  operations  certain  myste- 
rious practices,  upon  which  they  especially 
rely  for  the  cure  of  their  patients.  Such 
was  also,  no  doubt,  the  character  of  the 
medicine  of  the  Egyptians,  in  the  remote 
times,  previous  to  the  invention  of  the  alpha- 
bet, and  upon  which  so  very  little  light  is 
now  thrown. 

It  is  curious,  however,  to  find,  from  some 
late  observations  made  by  the  men  of 
science,  who  accompanied  the  French  ex- 
pedition to  Egypt,  in  1798,  that,  among  the 


ruins  of  ancient  Thebes  there  are  documemB, 
which  fully  prove  that  surgery,  in  the  early 
limes  of  the  Egyptians,  had  made  a degree 
of  progress,  of  which  few  of  the  moderns 
have  any  conception.  It  is  noticed  by  Lar- 
rey,that  when  the  celebrated  French  Gene- 
ral Desaix  had  driven  the  Mamelukes  beyond 
the  cataracts  of  the  Mile,  the  Commission 
of  Arts  had  an  opportunity  of  visiting  the 
monuments  of  the  famous  Thebes,  and  the  re- 
nowned temples  of  Tentyra,  Karnack,Medy- 
net,  Abou,  and  Luxor,  the  remains  of  which 
still  display  their  ancient  magnificence.  It  is 
upon  the  ceilings  and  walls  of  these  tem- 
ples that  basso-relievos  are  seen . representing 
limbs  that  had  been  cut  off  with  instruments 
very  analogous  to  those  which  are  employed 
at  the  present  day  for  amputations.  The 
same  instruments  are  again  observed  in  the 
hieroglyphics,  and  vestiges  of  other  surgical 
operations  may  be  traced,  proving  that,  in 
these  remote  periods,  surgery  kept  pace  with 
the  other  arts,  which  had  already  attained  a 
high  degree  of  perfection.  ( Larrey , Me- 
moir es  de  Chir.  Militaire,  T.  1,  p.  233  ; T.  2, 
p.  223.) 

We  next  come  to  the  epoch  when,  by  the 
union  and  arrangement  of  scattered  facts, 
the  science  truly  arose.  Hippocrates,  born 
in  the  island  of  Cos,  four  hundred  and  sixty 
years  before  the  common  era,  collected  the 
observations  of  his  predecessors,  added  the 
results  of  his  own  experience,  and  composed 
his  first  treatises.  In  the  hands  of  this  great 
genius,  medicine  and  surgery  did  not  make 
equal  progress.  The  former  reached  the 
highest  degree  of  glory.  Hippocrates  drew 
up  the  history  of  acute  diseases  in  so  mas- 
terly a style,  that  twenty  past  centuries  have 
hardly  found  occasion  to  add  any  thing  to 
the  performance.  But  surgery  was  far  from 
attaining  the  same  degree  of  perfection. 
The  religious  veneration  for  the  asylums  of 
the  dead,  and  the  impossibility  of  dissecting 
the  human  body,  formed  an  insurmountable 
obstacle  to  the  study  of  anatomy.  An  im- 
perfect acquaintance  with  the  structure  of 
animals,  reputed  to  bear  the  greatest  resem- 
blance to  man,  could  only  furnish  venture- 
some conjectures,  or  false  inferences.  These 
circumscribed  notions  sufficed  for  the  study 
of  acute  diseases.  In  these  cases,  the  atten- 
tive observation  of  strongly-marked  symp- 
toms, and  the  idea  of  the  operation  of  a sa- 
lutary principle,  derived  from  remarking  the 
regular  succession  of  such  symptoms,  and 
their  frequently  beneficial  termination,  en- 
lightened the  physician  in  the  employment 
of  curative  means  ; while  surgery,  deprived 
of  the  assistance  of  anatomy,  was  too  long 
kept  back  in  an  infant  state.  Whatever 
praises  may  have  been  bestowed  on  those 
parts  of  the  works  of  Hippocrates  particu 
larly  relating  to  surgery,  and  which  amount 
to  six  in  number  (de  ojirina  medici  ; de  frac- 
turis ; de  capitis  vulneribvs;  de  articulis  vel 
luxatis ; de  ulceribus;  de  Jistulis;)  when  com- 
pared with  his  other  acknowledged  legiti- 
mate writings,  they  appear  only  as  the  rough 
sketches  of  a picture  by  a great  master. 

Excepting  the  fragments,  collected  or 


sURGERY 


M6 


cited  by  Galen,  we  possess  no  work  written 
by  any  of  the  successors  of  Hippocrates  un- 
til the  period  of  Celsus  ; which  leaves  a bar- 
ren interval  of  almost  four  centuries.  In 
this  space  lived  Erasistratus,  as  well  as  He- 
rophilus,  celebrated  for  the  sects  which  they 
established,  and  particularly  for  having  been 
the  first  who  studied  anatomy  upon  the  hu- 
man body. 

Celsus  lived  at  Rome  in  the  reigns  of  Au- 
gustus, Tiberius,  and  Caligula.  He  appears 
never  to  have  practised  the  healing  art,  on 
which,  however,  he  has  written  with  much 
precision,  elegance,  and  perspicuity.  His 
work  is  the  more  precious,  inasmuch  as  it  is 
the  only  one,  which  gives  us  information, 
with  regard  to  the  progress  of  surgery  in  the 
long  interval  between  Hippocrates  and  him- 
self. The  four  last  books,  and  especially 
the  seventh  and  eighth,  are  exclusively  al- 
lotted to  surgical  matter.  I he  style  of 
Celsus  is  so  elegant,  that  he  has  generally 
been  regarded  quite  as  the  Cicero  of  medi- 
cal writers,  and  long  enjoyed  high  reputation 
in  the  schools.  His  surgery  was  entirely 
that  of  the  Greeks,  notwithstanding  he  wrote 
at  Rome : for,  in  that  capital  of  the  world, 
physic  was  then  professed  only  by  persons 
who  had  either  come  from  Greece,  or  had 
received  instruction  in  the  celebrated  schools 
of  this  native  soil  of  all  the  arts  and  sciences. 

Let  us  pass  over  the  interval  which  sepa- 
rates Celsus  and  Galen  This  latter  was 
born  at  Pergamus  in  Asia  Minor,  and  came 
to  Rome  in  the  reign  of  the  emperor  Marcus 
Aurelius.  He  practised  surgery  and  physic 
there  about  the  year  165  of  the  Christian  era. 
( Galeni  Opera  Omnia , 1521,  Edit.  Aldi , 5 
Vols.  in  fol .)  These  two  sciences  were  at 
that  time  still  united,  and  though  some  wri 
ters  of  much  earlier  date  speak  of  the  divi- 
sion of  physic  into  dietetical,  chirurgical, 
and  pharmaceutical,  no  such  distinction  w as 
followed  in  practice.  As  Galen  had  been  a 
surgeon  at  Pergamus,  he  continued  the  same 
profession  at  Rome  ; but,  being  soon  attract- 
ed by  the  predominating  taste  of  the  age  in 
which  he  lived,  for  a science  which  more 
easily  yields  to  the  systems  and  dazzling 
speculations  of  philosophical  sects,  he  after- 
ward neglected  surgery  which  strictly  re- 
jects them.  His  writings  prove,  however, 
that  he  did  not  abandon  it  entirely.  His 
commentaries  on  the  treatise  of  Hippocrates, 
De  Officina  Medici , and  his  essay  on  banda- 
ges, and  the  manner  of  applying  them,  show 
that  he  was  well  versed  even  in  the  minor 
details  of  the  art.  Besides  it  is  known.  that 
he  paid  great  attention  to  pharmacy,  and  in 
his  work  upon  antidotes,  chap  13*  he  tells 
us  himself,  that  he  had  a drug  shop  in  the 
Via  Sacra,  which  fell  a sacrifice  to  the 
flames  that  destroyed,  in  the  reign  of  Corn- 
modus,  the  Temple  of  Peace,  and  several 
other  edifices. 

To  Galen  succeeded  the  compiler  Oriba- 
sius,  (Etius  of  Amida,  a physician,  who  lived 
towards  the  close  of  the  fifth  century,  Alex- 
ander of  Tralles,  and  Paulus  (Egineta,  so 
called  from  the  place  of  his  birth,  though  he 
practised  at  Rome  and  Alexandria.  Paulus 


collected  into  one  work,  still  justly  esteem- 
ed, all  the  improvements,  which  had  been 
made  in  surgery  up  to  his  own  time.  He 
concludes  the  series  of  Greek  and  Roman 
physicians,  and  may  be  looked  upon  as  the 
last  of  the  ancients,  unless  it  be  wished  to 
let  the  Arabians  have  a share  in  the  honours 
of  antiquity.  “He  appears,  says  Portal,  to 
be  one  of  those  unfortunate  writers,  to  whom 
posterity  has  not  done  justice.  It  seems  as 
if  he  had  been  decried  without  having  been 
read  ; for  if  pains  had  been  taken  to  examine 
his  works,  he  would  neither  have  been  re- 
garded as  a mere  copyist,  nor  been  called 
the  “ape  of  Galen,”  with  whom  he  does  not 
always  coincide.  Nay,  in  some  places,  he 
ventures  to  oppose  the  doctrines  of  Hippo- 
crates. He  was  perfectly  acquainted  with 
the  practice  of  the  ancients,  and  when  he 
agrees  with,  or  differs  from  them,  it  is  not 
from  a spirit  of  contradiction,  but  because 
the  reasons,  which  led  him  to  take  one  side, 
or  the  other,  appeared  to  him  well  founded.” 
{Portal,  Hist,  de  VAnat.  fyc.  T.  1,  p.  123.) 
All  now  agree,  that  surgery  is  much  indebted 
to  him.  (See  R.  A.  I’ogtl , De  Pauli  (Egineta , 
Meritisin Medicinam imprimisque  Chirurgiam, 
4 to  Golt.  1768.)  Afterward  the  downfall 
of  surgery  followed  tbatof  all  the  other  scien- 
ces,and  from  thecaptureof  the  Alexandria  by 
the  Saracens  under  Amrou,  viceroy  of  Egypt, 
1641,  until  the  end  of  the  tenth  century, 
nothing  prevailed  but  the  dark  clouds  of  ig- 
norance and  barbarism.  The  Arabians,  who 
became  masters  of  a great  part  of  the  Ro- 
man empire,  dug  up  the  Greek  manuscripts, 
which  lay  buried  under  the  ruins  of  the  li- 
braries ; translated  them  ; appropriated  to 
themselves  the  doctrines  which  they  con- 
tained; impoverished  them  with  additions  ; 
and  transmitted  1o  posterity  only  enormous 
compilations  In  a word,  such  are  the  trea- 
tises of  Rhazes,  Hali- Abbas,  Avicenna,  Aver- 
rhoes,  and  Albucasis,  the  most  celebrated  of 
the  Arabian  authors.  Inventors  of  a prodi- 
gious number  of  instruments  and  machines, 
they  appear  to  have  calculated  the  efficacy 
of  surgery  by  the  richness  of  its  arsenals, 
and  to  have  been  more  anxious  to  inspire 
terror,  than  confidence.  As  an  instance  of 
the  cruelty  of  their  methods,  I shall  merely 
notice,  that,  in  order  to  stop  the  bleeding 
after  amputation  of  a limb,  they  plunged 
the  stump  in  boiling  pitch. 

The  fate  of  medicine  was  not  more  for- 
tunate. In  vain  the  school  of  Salernum, 
founded  about  the  middle  of  the  seventh 
century,  made  some  attempts  to  revive  its 
splendour.  As  a modern  writer  observes, 
medical  science,  seated  on  the  same  benches 
where  the  doctrine  of  Aristotle,  accommo- 
dated to  religious  opinions,  was  the  subject 
of  endless  controversies,  imbibed,  as  it  were 
by  contagion,  the  argumentative  and  so- 
phistical mania,  and  became  enveloped  in 
the  dark  hypotheses  of  scholastic  absurdity. 
{Richer and,  Nosogr.  Chir.  T.  1,  Ed.  2.) 

The  universal  ignorance  (continues  this 
author  ;)  the  pretended  horror  of  blood  ; the 
dogma  of  a religion  which  shed  it  in  tor- 
rents for  useless  quarrels;  an  exclusive  re 


SURGERY. 


iish  for  the  subtleties  of  the  school,  and 
speculative  theories ; are  circumstances  fur- 
ther explaining  the  profound  darkness  which 
followed  these  empty  labours.  About  the 
middle  of  the  twelfth  century,  (1163,)  the 
Council  of  Tours  prohibited  the  ecclesias- 
tics, who  then  shared  with  the  Jews  the 
practice  of  medicine  in  Christian  Europe, 
from  undertaking  any  bloody  operation. 
It  is  to  this  epoch  that  the  true  separation 
of  medicine  from  surgery  must  be  referred. 
The  latter  was  abandoned  to  the  laity,  the 
generality  of  whom,  in  those  ages  of  barba- 
rism, were  entirely  destitute  of  education. 
The  priests,  however,  still  retained  that 
portion  of  the  art  which  abstained  from  the 
effusion  of  blood.  Roger  Rolandus,  Bruno, 
Gulielmus  de  Salicetus,  Lanfranc,  Gordon, 
and  Guy  de  Chauliac,  confined  themselves 
to  commentaries  on  the  Arabians,  and  if 
the  latter  author  be  excepted,  they  all  dis- 
graced surgery  by  reducing  it  nearly  to  the 
mere  business  of  applying  ointments  and 
plasters.  Guy  de  Chauliac,  however,  the 
last  of  the  Arabians,  is  to  be  honourably  ex- 
cluded from  such  animadversion.  His  work 
written  at  Avignon,  in  1363,  in  the  pontifi- 
cate of  Urban  the  fifth,  to  whom  he  was 
physician,  continued  to  be,  for  a long  while', 
the  only  classical  book  in  the  schools.  It 
may  be  observed,  that  as  he  imitated  in 
eveiy  respect  the  other  Arabian  physicians, 
and  like  them  thought  that  it  did  not  be- 
come an  ecclesiastic  to  deviate  from  the 
austerity  of  his  profession,  he  passed  over 
In  silence  the  diseases  of  women. 

Atlength  Antonio  Beneveni,  a physician 
of  Florence,  began  to  insist  upon  a truth, 
of  the  highest  importance  to  the  extension 
of  surgical  knowledge,  viz.  that  the  compi- 
lations of  the  ancients  and  Arabians  ought 
to  be  relinquished  for  the  observation  of 
nature.  ( De  abditis  rerum  causis,  Florent. 
1507,  4to.)  A new  era  now  began.  The 
moderns  were  convinced,  that  by  treading 
servilely  in  the  footsteps  of  their  predeces- 
sors, they  should  never  even  equal,  much 
less  surpass  them.  The  labours  of  Vesalius 
also  gave  birth  to  anatomy,  illuminated  by 
which  science,  surgery  put  on  quite  a dif- 
ferent appearance  in  the  hands  of  Ambroise 
Fare,  the  first  and  most  eminent  of  the 
French  surgeons.  For  the  credit  of  Italy, 
however,  it  should  be  recorded,  that  the 
sensible  writings  published  in  that  country 
prior  to  the  time  of  Par6,  had  the  greatest 
influence  in  creating  a due  sense  of  the 
value  and  importance  of  surgery,  and  in 
disposing  men  of  talents  and  education  to 
cultivate  it  as  a liberal  profession. 

Obeying  the  dictates  of  his  genius,  Par6 
made  authority  yield  to  observation,  or 
sought  to  reconcile  them.  However,  his 
superior  merit  soon  excited  the  ignorant, 
the  jealous,  and  the  malignant  against  him  ; 
he  became  the  object  of  a bitter  persecution, 
and  his  discoveries  were  represented  as  a 
crime.  Although  he  was  the  restorer,  if 
not  the  inventor,  of  the  art  of  tying  the 
blood-vessels,  the  power  of  his  persecutors 
compel! ed  bint  to  make  imperfect  extracts 


from  Galen,  and  alter  his  text,  in  order  to 
rob  himself,  in  favour  of  the  ancients,  of  the 
glory  which  this  distinguished  improvement 
deserved. 

Surgeon  of  King  Henry  the  second,  Fran- 
cis the  second,  Charles  the  ninth,  and  Henry 
the  third,  of  France,  Pare  practised  his  pro- 
fession in  various  places,  followed  the 
French  armies  into  Italy,  and  acquired  such 
esteem,  that  his  mere  presence  in  a besieged 
town  was  enough  to  reanimate  the  troops 
employed  for  its  defence.  In  the  execrable 
night  of  Saint  Bartholomew,  his  reputation 
saved  his  life.  As  he  was  of  the  reformed 
religion,  he  would  not  have  escaped  the 
massacre,  had  not  Charles  the  ninth  himself 
undertaken  to  protect  him.  The  historians 
of  those  days  < Mem  de  Sully ) have  pre- 
served the  remembrance  of  this  exception, 
so  honourable  to  him  who  was  tile  object  of 
it;  but  which  should  not  diminish  the  just 
horror  which  the  memory  of  the  most  weak 
and  cruel  tyrant  must  ever  inspire.  u II 
n’en  voulut  jamais  sauver  aucun  (says  Bran- 
tome)  siuon  maistre  Ambroise  Pare,  son 
premier  chirurgien,  et  le  premier  de  la  chr6- 
tiennetfi  ; et  l’envoya  querir  et  venir  le  soir 
dans  sa  chambre  et  garderobe,  lui  comman- 
dant de  n’en  bouger  ; et  disait  qu’il  n’etait 
raisonnable  qn’un  qui  pouvait  servir  h tout 
un  petit  monde,  feust  ainsi  massacre.” 

Ambroise  Pare  was  not  content,  like  his 
predecessors,  with  exercising  his  art  with 
reputation  ; he  did  not  follow  the  example 
of  the  Quatre-Maitres  of  Pitard,  so  justly 
celebrated  for  having  composed  the  first 
statutes  of  the  College  of  Surgeons  at  Paris, 
-in  the  reign  of  St.  Lewis,  whom  he  had  at- 
tended in  his  excursions  to  the  Holy  Land  ; 
and  of  several  other  surgeons,  the  fruits  of 
whose  experience  were  lost  to  their  suc- 
cessors. Par6  transmitted  the  result  of  his 
own  experience  in  a work  that  will  remain 
immortal.  (See  (Euvres  d'  Ambroise  Par£y 
Conseiller  et  premier  Chirurgien  du  Roi , di - 
visees  in  28  livres , in  folio , Edit.  4 to.  Paris, 
1535.) 

His  writings,  so  remarkable  for  the  vari- 
ety and  number  of  facts  in  them,  are  emi- 
nently distinguished  from  all  those  of  his 
time,  inasmuch  as  the  ancients  are  not 
looked  up  to  in  them  with  superstitious 
blindness.  Freed  from  the  yoke  of  autho- 
rity, he  submitted  every  thing  to  the  test  of 
observation,  and  acknowledged  experience 
alone  as  his  guide.  The  French  writers  are 
with  reason  proud  of  their  countryman 
Pai6  to  this  day  : they  allege,  that  he  must 
ever  hold  among  surgeons  the  same  place 
that  Hippocrates  occupies  among  physi- 
cians. Nay,  they  add,  that  perhaps  there 
are  none,  either  of  the  ancients  or  moderns, 
who  are  worthy  of  being  compared  with 
him.  (Richerand  JVosogr.  Chirurg.  T.  1.) 

After  the  death  of  this  great  man,  surgery, 
which  owed  its  advancement  to  him,  con- 
tinued stationary,  and  even  took  a retro- 
grade course.  This  circumstance  is  alto- 
gether ascribable  to  the  contemptible  state 
into  which  those  who  professed  the  art  fell 


SURGERY.  447 

alter  being  united  to  the  barbers  by  the  to  the  grave  the  secret  of  hi's  admirable  in- 
most disgraceful  association.  jections.  (See  also  his  Thesaur.  Anat.  x.  in 

Pigrai,  the  successor  of  Ambroise  Part%  4 to.  Adversariorum  anatomicorum  medico - 
was  far  from  being  an  adequate  substitute  chirurgicorum  Decad.  3,  in  4 to.  Amstelodam .) 
for  him.  A spiritless  copyer  of  his  master,  Roonhuysen  also  made  a secret  of  his  lever, 
he  abridged  his  surgery  in  a latin  work,  which,  before  the  invention  of  the  forceps, 
where  the  unaffected  graces  of  the  original,  was  the  only  resource  in  difficult  labours, 
the  sincerity,  and  the  ineffable  charm  inse-  Raw,  who  successfully  cut  fifteen  hundred 
parable  from  all  productions  of  genius,  en-  patients  for  the  stone  took  such  pains  to 
tirely  disappeared.  He  received,  however,  conceal  his  manner  of  operating,  that  Heis- 
equal  praise  from  his  contemporaries  ; ter  and  Albinus,  his  two  most  distinguished 
doubtless,  because,  he  filled  a high  situation  ; pupils,  have  each  given  a different  explana- 
but,  as  Richerand  remarks,  his  name,  which  tion  of  it.  Such  a disposition,  which  was 
is  to-day  almost  forgotten,  proves  sufficient-  extremely  hurtful  to  the  advancement  of 
ly,  that  dignities  do  not  constitute  glory.  surgical  knowledge,  would  materialy  have 
Rousset  and  Guillemeau  distinguished  retarded  the  progress  of  surgery  in  Holland, 
themselves,  however,  in  the  art  of  mid-  had  not  Camper,  in  the  following  century, 
wifery,  while  Covillard,  Cabrol,  and  Habi-  effaced  this  imputation  by  the  great  number 
cot  enriched  surgery  writh  a great  number  of  his  discoveries,  and  his  zealous  desire  to 
of  curious  observations,  (~ee  Obs.  Chir.  make  them  public. 

pleines  de  remarques  curieuses,  Lyon,  1639,  While  great  improvements  were  going  on 
in  8 vo.  Alphabet  Anatomique,  Gen&ve,  1602,  in  Italy,  England,  and  Holland,  surgery  fan 
in  4 to.  Semaine  Anatomique;  Question  guished  in  a humiliated  state  in  France 
Chir.  sur  la  Bronchotomie,  Paris,  1620,  The  accoucheur  Mauriceau  ( Trait6  des  Ma- 
in 8v o.)  ladies  des  Femmes  grosses , Paris,  1668,  in 

In  the  next  or  seventeenth  century,  a 4/o.)  Dionis,  (Cours  d’ Operations  de  Chi- 
fresh  impulse  produced  additional  improve-  rurgie,  Paris,  1707,  8vo.)  Saviard, 
inents.  Then  appeared  in  Italy,  Ca?sar  veau  Recueil  d'Obs.  Chir.  Paris,  1702,  in 
Magatus,  who  simplified  the  treatment  of  12mo.)  and  Belloste  ( Chirurgien  d’Hopital, 
wounds,  (de  rarct  vulnerum  medicalione,  Paris,  1696,  in  8vo.)  were  the  only  French 
libri  2,  Venet.  1616,  in  folio ;)  Fabriciusab  surgeons  of  note  who  could  be  contrasted 
Aquapendente,  even  less  praise-worthy  as  a with  so  many  distinguished  men  of  other 
surgeon  than  as  a physiologist,  ( Opera  nations.  Richerand  observes,  that  the  splen- 
Chir.  Paris,  1613  in  fol. ;)  and  Marcus  Au-  did  days  of  Louis  the  Fourteenth  were  an 
relius  Severinus,  that  restorer  of  active  sur-  iron  age  for  discouraged  surgery.  And  yet 
gery.  Dt  ejfficac)  Medicina , libri  3,  Franco - this  monarch  seems  to  have  been  personally 
furt,  1613,  in  folio.  De  recondita  abscessu-  interested  in  the  melioration  of  this  irapor- 
um  natura  libri  7,  Koapoli,  1632,  in  4 to  taut  art ; for  he  was  very  nearly  falling  a 
and  Trimembris  ( hirurgia . ^c.  Franco  fur  t.  victim  to  a surgical  disease,  a fistula  in  ano, 
2653,  in4to.)  Among  the  English  surgeons  and  was  not  cured  till  after  a great  number 
flourished  Wiseman,  w ho  was  the  Pare  of  of  blundering  operations  and  useless  experi- 
England  (See  Several  Chinirgical  Treatises,  ments. 

Lond.  1676,  in  fol.;)  and  William  Harvey,  Chronology  teaches  simply  the  history  of 
whose  discovery  of  the  circulation  of  the  dates.  In  the  study  of  the  sciences,  the 
blood  had  such  an  influence  over  the  ad-  only  method  of  impressing  the  memory 
vancement  of  surgery,  that  he  must  be  class-  with  facts,  consists  in  connecting  the  epoch 
cd  among  the  principal  improvers  of  this  °f  them  with  the  learned  men  by  whom 
science.  (See  Exercitatio  Anatomica  de  they  have  been  illustrated.  But  the  great- 
motu  cordis  et  sanguinis  in  animalibus,  F>an - est  surgeons  of  the  eighteenth  century  have 
cofurti,  1653,  in  4to.)  In  Germany,  Fabri-  not  altered  the  face  of  their  profession, 
eius  Hildanus,  (Obs.  et  Curationum,  Cen  although  they  have  powerfully  contributed 
turitzG,  2 Vol.in4to.  1641)  who  was  far  to  its  advancement.  In  surgery,  as  an  au- 
superior,  as  a surgeon,  to  the  Italian  Fabri-  thor  has  remarked,  some  feeble  rays  always 
cius  Scultetus,  so  well  known  for  his  work,  precede  brilliant  lights,  and  it  approaches 
entitled  Armamentarium  Chirurgicwn  ; Ul-  perfection  in  a very  gradual  way.  In  the 
mce,  1653,  in  folio.  Purmann  and  Solingen,  last  century,  however,  among  the  distin- 
whohad  the  fault  of  being  too  partial  to  the  guished  surgeons  of  France,  there  are  two 
use  of  numerous  complicated  instruments,  of  extraordinary  genius,  round  whom,  as  it 
(See  Cursre  Obs.  Chir.  Lipsice,  1710,  in  4 to.  were,  all  the  others  might  be  grouped  and 
Mqnuale  Obs.  der  Ckirurgie,  Amsterdam,  arranged,  and  whose  names  deserve  to  be 
1684,  in  4to.)  affixed  to  the  two  most  brilliant  epochs  of 

Holland,  restored  to  liberty  by  the  gene-  French  surgery.  These  are,  first,  J.  L. 
rous  exertions  of  its  inhabitants,  did  not  Petit,  whose  glory  was  shared  by  the  Aca- 
remain  a stranger  to  4the  improvement  of  demy  of  Surgery;  and,  secondly,  the  cele- 
surgery.  This  nation,  so  singular  in  many  brated  Desault. 

respects,  presents  us  with  one  particularity  It  is  not  with  surgery,  as  with  physic, 
which  claims  the  notice  of  a medical  bisto-  strictly  so  called  ; the  epochs  of  the  latter 
nan,  Ruysch,  who  was  an  eminent  ana-  are  distinguished  by  hypotheses  ; while  those 
tomist,  and  merits  equal  celebrity  for  his  of  surgery  are  marked  by  discoveries.  The 
Obs.  Anatomico- Chirurgicorum  Centuriae,  eminent  men  in  this  last  branch  of  the  pro 
Amstelodam.  1691,  in  4to . carried  with  him  fession  have  not?  like  the  most  renowmed 


SURGERY. 


**48 


physicians,  created  sects,  built  systems,  de- 
stroyed those  of  their  predecessors,  and  con- 
structed a new  edifice,  which  in  its  turn  has 
been  demolished  by  other  hands.  All  of 
them  have  been  satisfied  with  combating  an- 
cient errors,  discovering  new  facts,  and  con- 
tinuing their  art,  the  sphere  of  which  they 
have  enlarged  by  their  discoveries,  without 
making  it  bend  under  the  yoke  of  systems, 
which  it  would  have  ill  supported.  To  this 
steady  and  uniform  course,  (says  Richerand,) 
which  is  a striking  proof  of  the  superiority 
of  surgery,  and  of  the  certainty  and  invaria- 
bleness of  its  principles,  shall  we  oppose  the 
numerous  revolutions  of  physic  ? The  Chris- 
tian religion,  which  abounds  in  sects,  has  not 
a greater  number  of  them  than  physic.  fs'a- 
turi-tes,  solidistes,  humoristes,  vitalistes,  ani- 
misies,  semi-animistes,  mecaniciens,  chi- 
roistes;  le  plus  grand  nombre  des  medecins 
honore  Hippocrate  d’un  culte  presque  super- 
stitieux  ; ceux-ci  marchent  sous  les  ban- 
nieres  de  Staahl ; ceux-las’*ppuient  du  grand 
nom  de  Boerhaave  ; tels  autres  invoquenl 
Sydenham,  Hoffmann,  Stoll,  absolument 
comcne  les  iheologiens  combattent  pour  Lu- 
ther, Zuiugle,  Calvin,  ou  Jansen.”  ( Nosogr 
Chir.  T.  1.) 

The  elogy  on  J.  L.  Petit,  delivered  in  the 
midst  of  the  Royal  Academy  of  Surgery,  of 
which  he  was  one  of  the  first  and  most  dis- 
tinguished members, represents  him  as  blend- 
ing the  study  of  anatomy  with  his  amuse- 
ments when  a boy  ; and  ardently  seeking 
ever,  opporl unity  to  increase  his  knowledge 
by  observaiion.  He  had  had  experience 
enough  to  publish  at  an  early  period  of  his 
life  his  Traitd  sur  les  Maladies  des  Os,  Paris, 
17o5,  in  l'2mo. ; a work  which  for  a centu- 
ry was  esteemed  the  best  upon  the  subject. 
His  success  was  most  virulently  opposed  by 
the  envious  critics;  and  it  was  uot  till  after 
more  than  thirty  years  of  academical  labours 
an  t extensive  practice,  that  he  was  unani- 
mously chosen  the  head  of  hisassociates.  This 
acknowledged  superiorly,  however,  was  the 
more  flattering,  as  the  honour  was  obtained 
at  a period  when  surgery  was  in  a flourishing 
state  in  France,  and  when  Petit  held  no  of- 
fice, from  which  he  could  derive  an  influence 
foreign  to  his  peisonat  merit.  While  Mares- 
chal.  La  Peyronie, and  La  Martiniere  assured 
him  of  the  royal  favour,  Quesriay,  Morand, 
and  Louis,  who  corrected  his  writings,  made 
him  speak  a language  which  does  honour  to 
that  famous  collection,  to  which  he  contribu- 
ted his  observations,  (>ee  Mimoires  et  Prix 
de  l' Academic  Royale  de  Chirurgie,  10  Pols, 
in  4 to.)  and  in  which,  it  some  theoretical  ex- 
planations be  put  out  of  consideration,  no- 
thing lias  lost  its  value  by  age.  J.  L.  Petit 
was  al  o the  author  of  a “ Traile  des  Mala- 
dies Chirurgicaies  et  des  Operations  qui  leur 
conviennent.  Outrage  Podhume  ;"  a pro- 
duction that  will  always  sl  *nd  high  in  the 
estimation  of  the  judicious  surgeon. 

The  history  of  this  epoch,  so  glorious  for 
the  profession  of  surgery,  is  completely  de- 
tailed in  the  Me  moires  and  Prix  of  the  Royal 
Academy  of  Surgery  ; a work  which  is  ab- 
solutely indispensable,  and  the  various  parts 


of  which  cannot  be  too  often  considered. 
In  it  are  preserved  the  labours  of  Mareschal, 
Quesnay,  La  Peyronie,  Morand,  Petit,  De  la 
Martiniere,  Le  Dran,  Garengeot,  De  la  Faye, 
Louis,  Verdier,  Foub>  rt,  Hevin,  Pibrac,  Fa- 
bre,  Le  Cat,  Bordenave,  Snbatier,  Puzos, 
Levret,  and  several  other  practitioners,  who, 
though  less  famous,  contributed  by  their  ex- 
ertions and  know  ledge  to  form  this  useful 
body  of  surgical  facts.  Many  of  the  prece- 
ding surgeons  also  distinguished  themselves 
by  other  productions,  which,  however,  I 
shall  not  here  enumerate,  as  they  are  quoted 
in  many  other  parts  of  this  work. 

To  the  foregoing  list  of  eminent  French 
surgeons,  must  be  added  the  names  of  La 
Motte,  Maim-Jean,  Goulard,  Daviel,  Rava- 
ton,  Mejean,  Pouteau,  David,  and  Frere 
Cosme. 

While  surgery  was  thus  advancing  in 
France,  other  nations  were  not  neglectful  of 
it.  At  this  period  flourished  in  England, 
White,  Cheselden,  Douglas,  the  two  Monros, 
Sharp,  Covvper,  Warner,  Alanson,  Percival 
Pott,  Hawkins,  Suiellie,  and  the  two  Hun- 
ters. 

White’s  Cases  in  Surgery,  1770:  Chesel- 
den’s  Treatise  on  the  High  Operation  for  the 
Stone,  London,  1723  in  Hvo.  ano  his  Treatise 
on  the  Anatomy  of  the  Human  Body ; Dou- 
glas’s Tract,  entitled.  Lithotomia  Douglass - 
iana;"  Sharp’s  Treatise  of  the  Operations ; 
and  his  “ Critical  Inquiry  into  the  present 
State  of  Surgery Monro's  Works  by  his 
son;  Warner's  Cases  in  Surgery,  1754,  and 
his  Description  of  the  Eye  and  its  Diseases, 
1775;  Alanson' s Treatise  on  Amputation; 
Pott’s  Chirurgical  Works  ; Smellie's  Midwife- 
ry ; and  John  Hunter  on  the  Blood,  Inflam- 
mation, fyc. ; his  Treatise  on  the  Venereal 
Disease  ; Animal  Economy , the  Teeth,  and 
all  the  papers  written  by  himself  and  his 
brother,  in  the  Phil.  Trans.  Med.  Obs.  and 
Inquiries , and  Trans,  of  a Society  for  the  Im- 
provement of  Med.  and  Chir.  Knowledge ; 
are  productions  which  reflect  the  highest 
credit  on  the  state  of  surgery  in  England. 

But  of  all  these  eminent  men,  none  con- 
tributed more  powerfully  than  Mr.  Percival 
Pott,  to  the  improvement  ot  the  practice  of 
surgery  in  England.  His  life,  indeed,  forms 
a sort  of  epoch  in  the  history  of  the  profes- 
sion. Before  his  inculcations  and  example 
had  produced  a desirable  change,  the  maxim 
of  “ dolor  medicina  doloris ,”  as  we  learn 
from  Sir  James  Earle,  remained  unrefuted. 
The  severe  treatment  of  the  old  school,  in 
the  operative  part  and  in  the  applications, 
continued  in  force.  The  first  principles  ot* 
surgery,  the  natural  process  and  powers  of 
healing,  were  either  not  understood,  or  not 
attended  to  ; painful  and  escharoiic  dress- 
ings were  continually  employed;  and  the 
actual  cautery  was  iiLsuch  frequent  use,  that 
at  the  times  wuen  Ine  surgeons  visitej  the 
hospiial,  it  was  regularly  heated,  and  prepa- 
red as  a necessary  part  of  the  apparatus. 
Where  shall  we  find  more  sensible,  or  more 
truly  practical  observations  on  the  treatment 
of  abscesses,  than  in  his  excellent  treatise  ou 
the  fistula  in  nuo  ? Where  shall  we  meet  with 


&LRGERY  '449 


belter  remarks  on  the  local  treatment  of  gan- 
grenous parts,  than  in  his  valuable  tract  on 
tthe  mortification  of  the  toes  and  feet  ? What 
author  abounds  with  so  many  just  observa 
tions  on  the  injuries  of  the  head,  blended,  it 
is  true,  with  rather  too  great  a partiality  to 
the  trepan,  the  so  frequent  necessity  for  which 
is  now  less  generally  acknowledged  ? His 
description  of  the  inflammation  and  suppu- 
ration of  the  dura  mater,  and  of  the  treat- 
ment, is  matchless.  The  account  which  he 
has  left  us  of  the  disease  of  the  vertebra?,  at- 
tended with  paralysis  of  the  limbs,  is  per- 
haps his  most  original  production.  His  ce- 
lebrated essay  on  fractures,  was  also  very 
original,  and  has  had  in  this  country  consi- 
derable influence  over  the  treatment  of  these 
injuries  ; but  there  can  now  be  no  doubt, 
that  the  effects  of  position  were  exaggerated 
5n  this  part  of  bis  writings,  and  that  surgeons 
ought  still  to  make  every  possible  exertion 
to  render  their  apparatus  for  broken  bones 
more  effectual.  (See  Fractures.)  A more 
peally  valuable  production  of  this  eminent 
surgeon  is  his  remarks  on  amputation.  The 
necessity  for  that  operation  in  certain  cases 
is  there  convincingly  detailed  ; and  the  most 
advantageous  period  for  its  performance 
clearly  indicated.  The  urgency  for  its  prompt 
execution,  after  particular  injuries,  he  has 
indeed  so  perfectly  explained,  that  the  late 
inculcations  on  the  subject  by  Larrey,  and 
several  other  modern  surgeons,  appear  to  be 
in  a great  measure  anticipated  ; the  only  dif- 
ference being,  that  Pott’s  remarks  applied 
principally  to  compound  fractures,  while 
Larrey’s  refer  to  gunshot  wounds.  All  these, 
however,  are  cases  of  accidental  violence, 
and  of  course  should  be  treated  upon  the 
same  general  principles 

A longer  comment  on  the  writings  and 
improvements  of  Percival  Pott  would  here 
be  requisite  to  do  him  every  degree  of  jus- 
tice; but  his  name,  advice,  and  opinions  are 
so  conspicuous  throughout  this  volume,  that 
1 shall  be  excused  for  not  saying  any  thing 
more  in  the  present  place,  than  that  he  was 
in  his  time,  the  best  practical  surgeon,  the 
best  lecturer,  the  best  writer  on  surgery,  the 
best  operator,  of  which  this  large  metropo- 
lis could  boast. 

Another  character  of  still  greater  genius 
and  originality,  though  of  inferior  education, 
was  the  ever  memorable  John  Hunter,  sur- 
geon to  St.  George’s  Hospital,  who  was  at 
once  eminent  as  a surgeon,  an  anatomist,  a 
physiologist,  a naturalist,  and  philosopher. 
If  Pott  materially  improved  many  parts  of 
the  practice  of  surgery  in  England,  and 
evinced  himself  to  be  the  most  skilful  ope- 
rator of  his  time,  John  Hunter  was  also  not 
less  importantly  employed  in  extending  the 
boundaries  of  physiological  knowledge,  and 
in  the  investigation  of  human,  and  particu- 
larly comparative  anatomy.  The  knowledge 
which  he  derived  from  his  favourite  studies, 
fie-oonstantly  applied  to  the  improvement  of 
the  art  of  surgery,  and  he  omitted  no  oppor- 
tunity of  examining  morbid  bodies,  whereby 
he  collected  facts  which  are  invaluable,  as 
Vol.  II  57 


they  tend  lo  explain  the  real  causes  of  (he 
symptoms  of  numerous  diseases. 

In  the  practice  of  surgery,  whenever  ope 
rations  proved  inadequate  to  their  intention, 
Mr.  Hunter  always  investigated  with  uncotn 
rnon  zeal  the  causes  of  ill  success,  and  in 
this  way  he  detected  many  fallacies,  as  well 
as  made  some  important  discoveries  in  the 
healing  art.  He  ascertained  the  cause  of 
failure,  common  to  all  the  operations  in  use 
for  the  radical  cure  of  the  hydrocele,  and 
was  enabled  to  propose  a mode  of  operating 
attended  with  invariable  success.  He  ascer 
tained,  by  experiments  and  observations, 
that  exposure  to  atmospherical  air,  simply, 
can  neither  produce  nor  increase  inflamma- 
tion. He  discovered  in  the  blood  so  many 
phenomena  connected  with  life,  and  not  to 
be  referred  to  any  other  cause,  that  he  con- 
sidered it  alive  in  its  fluid  state.  He  impro- 
ved the  operation  for  the  fistula  lachrymalis, 
by  removing  a circular  piece  of  the  os  un- 
guis, instead  of  breaking  it  down  with  the 
point  of  a trocar.  He  explained  better  than 
any  of  bis  predecessors,  all  the  highly  inte- 
resting modern  doctrines  relative  to  inflame 
(nation,  union  by  the  first  intention,  suppura- 
tion, ulceration,  and  mortification.  His 
writings  also  throw  considerable  light  on  the 
growth,  structure,  and  diseases  of  the  teeth 
As  instances  of  his  operative  skill,  it  deserves 
to  be  mentioned,  that  he  removed  a tumour 
from  the  side  of  the  head  and  neck  of  a pa- 
tient at  St.  George’s  Hospital,  as  large  as  the 
head  to  which  it  was  attached  ; and  by  bring- 
ing the  cut  edges  of  the  skin  together,  the 
whole  wound  was  nearly  healed  by  the  first 
intention.  He  likewise  dissected  out  of  the 
neck  a tumour,  which  one  of  the  best  opera- 
tors in  (his  country  had  declared,  rather  too 
strongly,  that  no  one  but  a fool  or  a mad- 
man would  meddle  with  ; and  the  patient 
got  perfectly  well.  But  perhaps  the  greatest 
improvement  which  he  made  in  the  practice 
of  surgery,  was  his  invention  of  a new  mode 
of  performing  the  operation  for  the  popliteal 
aneurism,  by  taking  up  the  femoral  artery  on 
the  anterior  part  of  the  thigh,  without  open 
ing  the  tumour  in  the  ham.  (See  Trans,  of 
a Society  for  the  Improvement  of  Med ^ and 
Chir.  Knowledge.)  The  safety  and  efficacy 
of  this  method  of  operating  have  now  been 
fully  established,  and  the  plan  has  been  ex 
tended  to  all  operations  for  the  cure  of  this 
formidable  disease.  (See  Aneurism.) 

According  to  Sir  Everard  Home,  Mr. 
Hunter  was  also  one  of  the  first  who  taught, 
that  cutting  out  the  bitten  part  was  the  only 
sure  mode  of  preventing  hydrophobia  ; and 
he  lengthened  the  time  in  which  this  pro- 
ceeding might  be  reasonably  adopted,  be- 
yond the  period  which  had  been  generally 
specified. 

His  researches  into  the  nature  of  the  ve- 
nereal disease,  and  his  observations  on  the 
treatment,  will  for  ever  be  a lasting  monu 
raent  of  his  wonderful  powers  of  reasoning 
and  investigation.  If  he  left  some  points  of 
the  subject  doubtful  and  unsettled,  he  has 
admirably  succeeded  in  the  elucidation  of 
others  : and  his  work  on  this  interesting  di- 


SURGERY . 


order,  is,  with  ail  its  defects,  the  best  which 
is  jet  extant. 

Even  (he  language  and  mode  of  expression 
of  this  great  man  were  his  own  ; for  so  ori- 
ginal were  his  sentiments,  that  they  could 
hardly  be  delineated  by  any  ordinary  arrange- 
ment of  words.  His  phrases  are  still  adopt- 
ed in  all  the  medical  schools  of  this  country, 
and  continue  to  modify  the  style  of  almost 
every  professional  book.  Great  as  Mr.  Hun- 
ter’s merit  as  a surgeon  was,  it  was  stdl  great- 
er as  a comparative  anatomist  and  physiolo- 
gist. The  museum  of  the  Royal  College  of 
Surgeons,  and  his  papers  in  the  Phil.  Trans, 
will  for  ever  attest  hts  greatness  in  these  cha- 
racters. 

At  the  period,  when  the  preceding  distin- 
guished men  upheld  the  character  of  their 
profession  in  Great  Britain,  Lancisi,  Mor- 
gagni, Molinelli,  Bertrandi,  Guattani,  Mas- 
cagni, Matani,  Troja.  and  Moscati,  were 
doing  the  same  thing  in  Italy.  Bertrandi’s 
Treatise  on  the  Operations  of  Surgery,  and 
Troja’s  Work  on  the  Regeneration  of  Bones, 
are  even  at  this  day  works  of  the  highest 
repute.  Of  late  years,  the  credit  of  the  Ita- 
lian surgeons  has  been  honourably  main- 
tained by  Monteggia,  Scarpa,  Paletta,  Qua- 
dri,  Assalini,  Morigi,  and  others.  In  Hol- 
land flourished  Albinus,  Deventer,  Sandi- 
fort,  and  Camper;  and  in  Germany,  and 
the  north  of  Europe,  the  immortal  Haller, 
Heister,  well  known  for  his  “ Institutiones 
ChirurgicB  Piatner;  Rcederer  ( Elemtnla 
Artis  Obstetricicc.  Goeit.  1752.  Obs.  de  Partu 
Laborioso.  Decad.  11,  1756.)  stein,  Bilguer, 
Acrell,  Callisen,  {System a Chirurgice  Hodi- 
crnce , 2 Vol.  8 vo.)  Brambilla,  Thecien,  ( Pro - 
gres  ulterieurs  de  la  Chirurgie.}  Sch mucker, 
( V crmischte  Chvrurgische  Sckriften,  B.  3,  and 
Chir.  Wahrnchmungf,n.)  Richter,  ( Traite  des 
Hernies,  2 Vol.&vo.  Bibl.  fur  die  Chirurgie  ; 
Ansfangsgr.  der  Wundarsn.  7 B.  and  Obs. 
ChirurgicaruniFa.sc.)  Also  Arnemann,  Weid- 
niaun,  Beer,  Soemmering,  Creutzenfeldt, 
Hesselbach,  Idufeland,  Graefe,  Klein,  Him- 
iy,  Langenbeck,  Walther,  J A.  Schmidt,  G. 
J.  Beer,  &c.  should  not  be  forgotten,  seve- 
ral of  whom  are  still  pursuing  their  useful 
and  honourable  career.  Be  it  also  record- 
ed as  a part  of  the  great  merit  of  the  Ger- 
mans, that  they  now  rank  among  the  best 
and  most  minute  anatomists ; that  they  are 
zealous  cultivators  of  comparative  anato- 
my ; that  their  industry  allow  s no  improve- 
ment in  medical  science,  wherever  made, 
to  escape  their  notice ; and  that  surgery  is 
greatly  indebted  to  them  for  the  best  descrip- 
tions of  the  diseases  of  the  eye. 

On  the  continent,  the  Academy  of  Surge- 
ry at  Paris  was  long  considered  quite  as  the 
solar  light  of  this  branch  of  science.  The 
French  Revolution,  which,  by  a fatal  abuse, 
involved  in  the  same  prohibition  both  use- 
ful and  pernicious  societies,  did  not  spare 
even  this  beneficial  establishment.  Al- 
though the  Academy  was  deprived  of  the 
talents  of  Louis,  who  died  a short  time  be- 
fore its  suppression,  it  yet  had  at  this  period 
several  members,  worthy  of  continuing  its 
labours,  and  supporting  its  reputation  : Sa- 


batier, Desault,  who  may  be  regarded  ay 
the  Pott  of  France,  Chopart,  Lassus,  Pey- 
rilhe,  Dubois,  Percy,  Baudeloque,  Pelletan, 

Sue,  &c. 

The  Academy  of  Surgery  in  France  was 
succeeded  by  what  is  named  the  Ecole  de 
Medecine.  Desault,  who  was  almost  a stran- 
ger in  the  former,  became  quite  the  leading 
character  in  the  latter.  Several  things  re- 
commended him  strongly  to  the  remem- 
brance and  admiration  of  posterity  ; the  ex- 
actness and  method  which  he  introduced 
into  the  study  of  anatomy  ; the  ingenious 
kinds  of  apparatus  which  he  invented  for 
the  treatment  of  fractures,.;  a noble  ardour 
in  his  profession,  which  he  knew  how  to 
impart  to  all  his  pupils  ; his  clinical  lectures 
upon  surgery, "which  were  the  first  ever  de- 
livered ; and  the  boldness  and  simplicity  of 
bis  modes  of  operating.  Indeed,  such  was 
his  genius,  that  even  when  he  practised  only 
methods  already  understood,  he  did  them 
with  so  much  adroitness,  that  he  rather  ap- 
peared to  be  the  inventor  of  them.  From 
the  Ecole  de  Medecine  have  issued  Dupuy- 
tren,  Boyer,  Richerand,  Dubois,  Lheritier. 
Manoury,  Lallemant,  Petid  de  Lyon,  Bi- 
chat, &c. 

The  researches  of  Bichat,  who  quitted 
surgery,  powerfully  contributed  to  the  ad- 
vancement of  physiological  science.  His 
mind,  richly  stored  with  the  positive  facts 
which  he  had  learned  in  the  study  of  surge- 
ry, conceived  no  less' a project  than  that  of 
rebuilding  the  whole  edifice  of  medicine. 
Some  courses  of  lectures  upon  the  materia 
medica,  internal  clinical  medicine  and  mor- 
bid anatomy,  announced  this' vast  design, 
which  was  frustrated  by  a premature  death. 

Bichat,  as  a physiologist,  and  man  of  very 
original  genius,  may  be  consideral  as  the 
John  Hunter  of  France;  but  his  qualities 
were  of  a different  cast,  and  hardly  admit 
of  comparison  with  those  of  Hunter,  whose 
investigations  were  not  limited  to  man,  but 
extended  to  the  whole  chain  of  animated 
beings.  Bichat  died  in  the  midst  of  his  la- 
bours, and  in  dying  his  greatest  regret  was 
that  of  not  having  completed  them.  His 
example,  says  Richerand,  proves  most  con- 
vincingly what  Boerhaave  always  inculcu 
ted,  how  indispensable  the  study  and  even 
the  practice  of  surgery  are  to  him,  who 
would  wish  to  be  a distinguished  and  sue 
cessful  physician.  (Nosogr.  Chir.  Tom.  1, 
p.  25.) 

Perhaps  nothing  contributed  so  materially 
to  the  improvement  of  surgical  knowledge, 
as  the  establishmentof  the  Royal  Academy  of 
Surgery  in  France;  anomie  institution,  which, 
fora  long  while,  gave  our  neighbours  infinite 
advantage  over  us,  in  the  cultivation  of  this 
most  useful  profession.  Indeed,  every  one 
truly  interested  in  the  improvement  of  sur- 
gery, cannot  fail  to  regret  the  discontinu- 
ance of  a society,  in  which  emulation  and 
talents  were  so  long  united  for  the  benefit 
of  mankind.  The  various  dissertations  pub- 
lished by  the  illustrious  members  of  the  aca- 
demy, will  serve  as  a perpetual  memorial 
of  the  spirit,  ability,  and  success,  with  which 


SURGER\ 


the  objects  of  the  institution  were  pursued  ; 
and  centuries  hence,  practitioners  will  reap 
from  the  pages  of  its  memoirs  the  most  va- 
luable kind  of  surgical  information.  Unfor- 
tunately, this  establishment,  which  was 
overthrown  by  ihe  agitation  of  the  French 
Revolution,  has  had  only  a very  inferior 
substitute  in  the  Ecole  de  Mfidecine 

Were  l to  name  any  one  thing,  which,  in 
my  opioion,  would  have  the  greatest  influ- 
ence in  giving  life  to  the  study  and  cultiva- 
tion of  surgery  in  this  country,  I should 
without  hesitation  assign  such  importance 
to  the  establi-hment  of  an  institution  in  the 
metropolis,  on  the  same  grand,  liberal,  and 
encouraged  plan,  as  the  late  Royal  Acade- 
my of  Surgery  in  France. 

At  the  same  time,  1 am  conscious  that  the 
present  Medical  and  Chirurgical  Society  of 
London  have  every  claim  to  the  encourage- 
ment and  gratitute  of  the  profession.  No 
other  institution  of  the  kind  has  ever  done 
so  much  in  so  short  a space  of  time.  Many 
of  the  facts  which  they  have  collected  and 
published,  are  of  considerable  importance, 
especially  those  relating  to  the  subj'ects  of 
aneurism  and  hemorrhage.  Their  library  is 
already  the  most  select,  valuable,  and  com- 
plete collection  of  medical  literature  in 
Great  Britain  ; and  it  is  daily  receiving  ad- 
ditions both  by  large  purchases  at  borne  and 
abroad,  and  by  the  liberal  donations  of  its 
members.  The  intercourse  and  correspond- 
ence ^hich  such  a society  continually  main- 
tain among  the  innumerable  scattered  mem- 
bers of  tbe  profession,  cSnnot  fail  to  be  at- 
tendedwith  the  most  beneficialconsequences. 
A generous  and  useful  sort  of  emulation  is 
thus  kept  alive  ; the  spirit  of  inquiry  is  pre- 
vented from  slumbering  ; and  every  indivi- 
dual vrho  ascertains  a new  fact,  has  now 
the  means  of  making  it  known  to  the  world, 
with  all  the  expedition  which  its  import- 
ance may  demand. 

Within  the  last  twenty  or  thirty  years, 
most  important  improvements  have  certain- 
ly been  made  in  almost  every  branch  of 
surgery;  and  it  must  gratify  every  English- 
man to  find,  that  his  own  countrymen  have 
acted  a very  leading  part  in  effecting  an 
object,  in  which  the  interests  of  mankind 
are  so  deeply  concerned. 

Before  the  time  of  Mr.  John  Hunter,  onr 
ideas  of  the  venereal  disease  were  surround- 
ed with  absurdities  ; and  it  is  to  this  lumi- 
nary that  we  are  in  an  eminent  degree 
indebted  for  the  increased  discrimination 
and  reason,  which  now  prevail,  both  in  the 
doctrines  and  treatment  of  the  complaint. 
It  must  be  confessed,  however,  that  much 
yet  remains  to  be  made  out.  respecting  the 
nature  and  treatment  of  syphilitic  disorders. 
Need  1 mention  a greater  proof  of  the  truth 
of  this  remark,  than  the  sudden  change  of 
practice  in  some  of  the  principal  hospitals 
in  London,  mercury  being  now  not  exhibited 
in  more  than  one  out  of  ten  cases,  for  which 
this  medicine  a few  years  ago  was  always 
deemed  indispensable  ? Numerous  cases, 
having  all  the  characters  of  primary' vene- 
real sores,  seem  now  to  be  curable  by  sim- 


401 

pie  dressings  and  cleanliness.  In  short,  so 
different  is  every  thing  from  what  it  used  to 
be,  that  many  surgeons  are  tempted  to  sup- 
pose the  nature  of  the  venereal  disease  to 
tally  (altered.  Some  observations  on  this 
important  topic  are  offered  in  another  place. 
See  Venereal  Disease. 

Strictures  in  the  urethra,  an  equally  com- 
mon and  distressing  disease,  were  not  well 
treated  of  before  Mr.  Hunter  published  on 
the  venereal  disease  ; at*d  the  advantage  of 
armed  bougies  in  the  treatment  of  certain 
cases  has  been  subsequently  pointed  out 
by  Sir  Everard  Home. 

In  modern  times,  hernial  diseases,  those 
common  afflictions  in  every  country,  have 
received  highly  interesting  elucidations 
from  the  labours  of  Pott,  Camper,  Richter, 
Sir  Astley  Cooper,  Hey,  Gimbernat,  Hes- 
selbach,  Scarpa,  Lawrence,  he. 

The  treatment  of  injuries  of  the  head 
has  been  materially  improved  by  Quesnay, 
Le  Dran,  Pott,  Hill,  Desault,  and  Aber- 
nethy. 

I he  disease  of  the  vertebra?,  which  oc- 
casion* paralysis  of  the  limbs,  formerly  al- 
ways baffled  the  practitioner;  but  the  me- 
thod  proposed  by  Air.  Pott  is  now  frequently 
productive  of  considerable  relief,  and  some- 
times of  a perfect  cure.  The  diseases  of  the 
joints  in  general  may  also  be  said  to  be  at 
present  viewed  with  much  more  discrimina- 
tion than  *hey  were  a veryfewr  years  ago;  and 
this  great  step  to  better  and  more  successful 
practice  reflects  great  honour  on  Mr.  Brodie, 
while  it  keeps  up  a well-founded  hope,  that 
morbid  anatomy,  the  study  which  has  of  late 
banished  so  much  confusion  from  this  part 
of  surgery,  will  yet  be  the  means  of  bring- 
ing to  light  other  useful  fact^  and  observa- 
tions, relative  to  the  diseases  of  the  joints  in 
general. 

The  mode  of  treating  lumbar  abscesses  has 
been  rendered  much  more  successful  than 
formerly,  and  for  this  change  the  world  is  in- 
debted to  Mr/  Abernethy. 

The  almost  infallible  plan  of  curing  hy- 
droceles by  an  injection,  as  described  by  Sir 
James  Earle,  may  also  be  enumerated  among 
modern  improvements. 

The  increasing  aversion  to  the  employment 
of  the  gorget  in  lithotomy,  and  the  many  dis- 
tinguished advocates  for  the  use  of  better  in- 
struments in  this  operation,  may  be  hailed 
as  propitious  omens  of  beneficial  changes  in 
this  part  of  practice. 

The  diseases  of  the  eyes,  to  which  affec- 
tions English  surgeons  seemed  to  pay  much 
less  attention  than  was  bestowed  by  foreign 
practitioners,  now  obtain  due  attention  in 
this  country.  Although  we  have  generally 
had  some  distinguished  oculists,  our  regular 
surgeons  have  generally  been  wonderfully 
ignorant  of  this  part  of  their  profession,  and 
uninformed  on  the  subject,  they  have  given 
up  to  professed  oculists  and  quacks  one  of 
the  most  lucrative  and  agreeable  branches 
of  practice.  However,  the  able  writings  of 
Daviel,  Wenzel,  and  Ware,  begin  now  to  be 
familiarly  known  to  practitioners:  and  the 
observations  of  Scarpa,  Richter,  Beer, 


SURGERY 


Wardrop,  Travers,  and  Saunders,  will  soon 
have  immense  effect  in  diffusing  in  the  pro- 
fession a due  knowledge  of  the  numerous 
diseases,  to  which  the  organs  of  vision  are 
liable.  As  likewise  the  generality  of  the 
hospital  surgeons  of  London,  have,  during 
the  last  thirty  years,  grossly  neglected  the 
study  of  the  diseases  of  the  eye,  and  consci- 
entiously refused  to  have  any  thing  to  do 
with  these  cases,  the  public  at  length  saw 
the  necessity  of  establishing  Eye  Infirma- 
ries, where  such  afflictions  might  be  more 
attentively  observed  and  relieved.  Some 
of  these  have  now  become  excellent  schools, 
in  which  the  rising  generation  of  surgeons 
have  abundant  opportunities  of  studying  the 
nature  of  all  the  diseases  of  the  eyes,  and 
the  most  approved  methods  of  treatment. 

While,  however,  1 am  thus  commending 
separate  institutions  for  disorders  of  the  eye, 
it  becomes  me  to  express  my  regret  for  the 
long-continued  neglect,  and  the  ignorance 
of  these  diseases,  manifested  by  several 
hospital  surgeons,  which  were  in  fact  the 
original  causes  of  those  distinct  establish- 
ments. For,  according  to  my  conceptions, 
it  would  have  been  far  better  to  have  had 
the  practice  in  eye-cases  exhibited  in  the 
common  great  schools  of  surgery,  the  large 
hospitals  of  London.  1 am  of  this  opinion, 
not  only  because  I think  these  diseases 
would  then  have  met  with  more  general 
and  public  observation ; but  also  because  I 
have  always  considered  all  unnecessary  sub- 
divisions of  practice,  in  short  all  measures 
which  tend  to  throw  particular  cases  into 
the  hands  of  a few  individuals,  hurtful  to  the 
best  interests,  and  degrading  to  the  charac- 
ter of  the  profession. 

In  the  treatment  of  aneurisrnal  diseases, 
English  surgeons  have  much  to  be  proud  of. 
All  the  boldest  operations  in  this  branch  of 
surgery  have  been  devised  by  the  genius, 
and  executed  by  the  spirit  and  skill  of  British 
surgeons.  Even  M.  Roux  himself  is  here 
obliged  to  confess  our  superiority.  ( Paral - 
lele  de  la  Chirurgie  Angloise , fyc.  p.  249.) 
The  carotid  artery,  the  external  and  internal 
iliac,  and  the  subclavian,  have  all  been  suc- 
cessfully tied  by  surgeons  of  this  country. 
The  first  operation,  in  which  the  external 
iliac  was  tied,  I was  a spectator  of : it  was 
performed  by  Mr.  Abernethy  in  Bartholo- 
mew’s hospital,  and  it  has  subsequent!)  been 
repeated  in  many  examples,  both  iri  this 
country  and  others,  with  considerable  suc- 
cess. I bad  also  the  honour  of  seeing  the 
same  gentleman  likewise  tie  the  carotid,  in 
the  first  instance  of  that  operation  in  Eng- 
land. This  important  measure  has  also  now 
been  frequently  practised  with  success,  and 
it  constitutes  one  of  the  great  improvements 
in  the  operative  part  of  modern  surgery. 

In  the  article  Aneurisoi,  I have  cited 
many  examples,  in  which  the  carotid  artery 
has  been  successfully  tied ; and  the  safety 
and  propriety  of  the  operation  are  now  ge- 
nerally known  and  acknowledged.  Indeed, 
so  little  are  surgeons  now  afraid  of  the  ill 
effects  upon  the  brain,  that  the  carotid  arte- 
ry has  lately  been  tied  merely  for  the  purpose 


of  enabling  the  operator  (o  fake  away  a large 
tumour,  including  the  whole  of  the  parotid 
gland,  from  the  side  of  the  neck,  without  risk 
of  hemorrhage ; a mode  of  proceeding, 
however,  which  ought  not  to  be  encouraged 
into  a common  practice.  (See  Medico-Chir . 
Trans.  Vol.  7,  p.  112.)  Before  1 quit  this 
subject,  my  feelings  call  upon  me  to  express 
tbe  high  opinion  which  I entertain  of  Mr 
Hodgson’s  Treatise  on  the  Diseases  of  Arte- 
ries and  Veins,  published  in  1815,  a work 
which  reflects  great  credit  on  English  sur- 
gery, and  contains  practical  precepts  far  su 
perior  to  those  of  Scarpa. 

In  the  modern  practice  of  surgery,  a 
variety  of  old  prejudices  are  gradually  va- 
nishing. Peruvian  bark  not  many  years 
ago,  was  regarded  as  a sovereign  remedy 
and  specific  for  nearly  all  cases  of  gangrene  „ 
and  in  these  and  many  other  instances,  it 
was  prescribed  without  any  discrimination, 
and  in  doses  beyond  all  moderation.  But 
the  false  idea,  that  this  medicine  has  any 
specific  effect  in  checking  mortification,  no 
longer  blinds  the  senses  of  the  most  superfi- 
cial practitioner.  He  neither  believes  this 
doctrine,  nor  tbe  still  more  absurd  opinion, 
that  strength  can  be  mysteriously  ex- 
tracted from  this  vegetable  substance,  and 
communicated  to  the  human  constitution,  in 
proportion  to  the  quantity  which  can  be 
made  to  remain  in  the  stomach.  This  sub 
ject,  however,  has  been  duly  discussed  in  the 
articles  Cinchona  and  Mortification. 

The  removal  of  this  deeply-rooted  pre- 
judice, concerning  the  virtues  of  bark,  in 
stopping  mortification,  will  pave  the  way  to 
better  and  more  successful  practice. 

But  upon  the  subject  of  mortification,  the 
present  day  opens  to  us  the  investigation  of 
a point,  which  is  of  the  first-rate  conse- 
quence. Every  surgeon  is  aware,  that  when 
a limb  is  affected  with  mortification,  ampu 
tation  is  absolutely  necessary  to  effect  a 
cure.  This  is  generally  acknowledged;  but 
the  performance  of  the  operation  has,  since 
the  time  of  Mr.  Pott,  only  been  sanctioned 
when  the  mortification  has  manifestly  ceased 
to  spread,  and  a line  of  separation  is  formed 
between  the  dead  and  living  parts.  All 
other  instances,  in  which  the  disorder  was 
in  a spreading  state,  were  left  to  their  fate 
It  is  true,  some  of  tbe  old  surgeons  occasion  - 
ally  ventured  to  deviate  from  this  precept  , 
but  as  they  did  so  without  any  discrimina- 
tion, or  knowledge  of  the  particular  exam- 
ples which  ought  to  form  an  exception  to 
the  general  rule,  their  ill  success  cannot  con- 
stitute a just  argument  against  the  plan  of 
amputating  earlier  in  a certain  description  of 
cases. 

Now  if  modern  experience  can  prove, 
that  many  lives  may  be  saved  by  a timely 
performance  of  amputation,  under  circum- 
stances in  which  it  has  until  lately  been  ge 
nerally  condemned,  it  must  be  allowed  that 
the  established  innovation  will  be  one  of  the 
greatest  improvements  in  the  practice  of  the 
present  time. 

For  reviving  the  consideration  of  this 
question,  and  venturing  to  deviate  from  the 


SURGERY 


beaten  path,  the  world  is  much  indebted  to 
that  eminent  military  surgeon,  Baron  Lar- 
rey.  How  different  his  doctrines  and  prac- 
tice are  from  those  usually  taught  in  the 
schools,  the  article  Mortification  will  suffi- 
ciently prove. 

In  the  treatment  of  ununited  fractures,  the 
simple  and  ingenious  practice  proposed  by 
Dr.  Physick  of  Philadelphia,  merits  particu- 
lar notice,  not  only  on  account  of  the  seve- 
ral successful  trials  which  have  been  made 
of  it  in  this  country  and  France;  (See  Me- 
dico- Chir.  Trans.  Vols.  5 7,  and  Buyer's 

Trait6  des  Maladies  Chir.)  hut  also  because 
it  is  perhaps  the  first  improvement  of  con- 
sequence, that  has  hitherto  been  made  in 
the  practice  of  surgery  by  our  transatlantic 
brethren. 

The  inestimable  treatise  of  Dr.  Jones  on 
Hemorrhage,  has  now  produced  quite  a re- 
volution in  all  the  principles,  by  which  the 
surgeon  is  guided  in  the  employment  of  the 
ligature  for  the  stoppage  of  bleeding  and  the 
cure  of  aneurisms.  Instead  of  thick  clumpy 
cords,  small  firm  silks  or  threads,  are  now 
generally  used;  and  so  far  is  the  practitioner 
I from  being  fearful  of  tyjng  arteries  too  tight- 
f ly,  lest  the  ligature  cut  through  them,  that  it 
is  now  a particular  object  with  him  to  apply 
the  silk  or  thread,  with  a certain  degree  of 
force,  in  order  that  the  inner  coat  of  the  ves- 
i sel  may  be  divided.  If  this  be  not  done,  the 
effusion  of  coagulating  lymph  within  the  ar- 
tery, an  important  part  of  the  process  of  ob- 
literation, cannot  be  expected  as  a matter  of 
certainly,  and  secondary  hemorrhage  is 
more  likely  to  occur-  But  in  order  to  con- 
vey an  adequate  idea  of  the  beneficial 
changes  which  Dr.  Jones’s  observations  are 
tending  to  produce  in  practice,  we  have 
been  careful  in  the  article  Hemorrhage,  to 
give  a tolerably  full  account  of  the  results  of 
all  his  interesting  experiments. 

Besides  using  very  small,  firm,  round 
threads,  instead  of  large  fiat  tapes  or  cords, 
t as  was  the  custom  a few  years  ago,  modern 
surgeons  begin  to  suspect,  that  much  benefit 
may  also  arise  from  cutting  off  both  portions 
of  the  ligature  close  to  the  knot,  after  am- 
putation, the  removal  of  the  breast,  &c.  ]\o 

one  has  insisted  so  much  as  Mr.  Lawrence 
upon  the  propriety  of  examining  further  the 
merits  of  this  innovation.  If  no  bad  effects 
result  from  leaving  so  small  a particle  of  ex- 
traneous substance  in  the  flesh,  as  the-  little 
bit  of  silk  composing  the  knot  and  noose  on 
1 the  artery,  the  practice  will  form  a consider- 
able improvement.  The  wound  may  then 
be  brought  together  at  every  point  ; the 
quantity  of  extraneous  matter  in  the  wound 
i will  be  lessened  to  almost  nothing  ; the  dan- 
1 ger  of  convulsive  affections  w ill  bp  reduced 

i in  proportion  as  a serious  cause  of  pain  or 

irritation  is  diminished  ; and  the  chance  of 
accomplishing  perfect  union  by  the  first  in- 
tention will  be  materially  increased.  Mr. 
Lawrence  has  tried  the  plan  in  many  instan- 
ces, and  hitherto  his  experience  has  not 
found  any  ill  consequences  follow,  while  it 
lias  proved,  that  many  advantages  are  un- 
i doubtedly  the  result  of  it.  In  amputations, 


453 

the  method  has  been  practised  by  several  of 
our  military  surgeons ; and  although  they 
have  probably  not  employed  exuctly  such 
ligatures  as  this  mode  absolutely  requires, 
the  greater  part  of  them  have  met  with  hard- 
ly any  instances  of  future  trouble  from  the 
bits  of  ligature  enclosed  in  the  wound. 
However,  if  larae  ligatures  be  used,  the  prac- 
tice is  not  lairly  tried,  or  rather  the  practice 
is  not  tried  at  all;  because  the  great  princi- 
ple, on  which  it  answers,  is  the  very  small 
atom  of  silk  composing  the  extraneous  sub- 
stance left  in  the  wound,  when  such  liga- 
tures as  Mr.  L .vvrence  particularly  recom- 
mends are  employed.  Delpech  and  Rous 
have  also  sometimes  adopted  the  plan  of  re- 
moving the  ends  of  the  ligature  close  to  the 
knot.  (See  Parldlble  de  la  Chir.  Angloise 
avec  la  Chir.  Fanqoise,  p.  131.)  See  Ampu- 
tation, Aneurism , Hemorrhage , and  Liga- 
ture. 

Among  other  real  improvements  in  mo- 
dern practice,  I must  not  forget  the  present 
more  rational  method  of  dressing  the  wound, 
alter  the  majority  of  capital  operations, 
with  light,  cooling  applications,  instead  of 
laying  on  the  part  a farrago  of  irritating’ 
pledgets  and  piasters,  and  a cumbersome 
mass  of  lint,  tow,  flannel,  and  other  banda- 
ges, woollen  caps,  &c.  The  fewer  the  adhe- 
sive strips  are  the  better,  if  they  bold  the 
lips  of  the  wound  together.  This  is  all  they 
are  intended  to  do.  Whereas,  if  you  apply 
more  than  are  necessary  for  this  purpose, 
they  do  harm  by  heating  the  part,  and  co- 
vering the  wound  so  entirely  as  to  prevent 
the  issue  of  the  discharge.  Over  the  adhe- 
sive plasters,  let  the  surgeon  be  content  with, 
placing  a simple  pledget  of  spermaceti 
cerate,  and  some  linen  wet  with  cold  wa- 
ter, which  will  often  avert  hurtful  degrees  of 
pain  and  inflammation,  by  keeping  the  parts 
cool. 

Wars,  which  are  unfavourable  to  most 
other  sciences,  are  rather  conducive  to  ad- 
vances in  surgery.  The  many  new  and  in 
teresting  observations  which  Baron  Larrev 
has  made  in  the  course  of  his  long  and  ex 
tensive  military  experience,  are  a proof  of 
the  foregoing  remark.  Pitard,  almost  the 
founder  of  surgery  in  France,  was  a milita 
ry  surgeon.  Ambrose  Paieand  Wiseman  also 
collected  their  most  valuable  knowledge 
principally  in  the  service  of  the  army.  Mr. 
Hunter  himself  gained  much  of  bis  practical 
information  in  the  same  line  of  life.  To 
Baron  Larrey  surgeons  are  indebted  for  many 
highly  important  observations,  relating  to 
amputation  in  cases  of  gunshot  wounds.  In 
particular  he  has  adduced  a larger  and  more 
convincing  body  of  evidence,  than  was  ever 
before  collected  to  prove,  that  in  gunshot 
injuries,  the  operation  of  amputation  should 
always  be  performed  without  the  least  delay, 
in  every  instance  in  which  such  operation  is 
judged  to  be  unavoidable,  and  the  ullimate 
preservation  of  the  limb  either  impossible, 
or  beyond  the  scope  of  all  rational  probabi 
lity.  He  has  established  the  truth  of  this 
most  important  precept  in  military  surgery 
by  innumerable  facts,  drawn  chiefly  from 


454 


SU3 


his  own  ample  experience,  and  partly  from 
the  practice  of  many  able  colleagues.  The 
great  operations  of  the  shoulder-joint,  and 
hip-joint  amputations,  he  has  executed  w ith 
success.  The  necessity  for  the  former, 
however,  he  proves  may  sometimes  be  su- 
perseded, and  the  limb  be  saved,  by  making  a 
suitable  incision  for  the  extraction  of  the 
splintered  portions  of  the  upper  part  of  the 
humerus.  This  method,  which  was  in  many 
instances  done  with  success  in  the  peninsu- 
lar war  was,  1 believe,  originally  proposed 
and  practised  by  Boucher.  (See  Mem.  de 
I'Acad.  de  Chir.  T.  2,  Ato.)  However,  it 
was  more  particularly  described  and  even 
practised  by  Mr,  C.  White,  of  Manchester. 
(See  his  Cases  in  Surgery.)  It  has  been  re- 
peated wiib  success  by  Mr.  Morell  in  the 
York  Hospital.  (See  Med.  Chir.  Trans.  Vol. 
7.)  See  Amputation. 

Amputation  at  the  hip-joint,  performed 
only  in  the  most  dreadful  cases,  because 
itself  the  most  dreadful  operation  in  surgery, 
Bar  m Larrey  has  performed  five  limes,  and 
twice  (I  believe)  with  success.  This  pro- 
ceeding has  also  been  adopted  by  Mr 
Brownrigg  and  Mr.  Guthrie,  and  their  pa- 
tients ^recovered.  As  must  be  the  case, 
however,  on  account  of  the  desperate  cir- 
cumstances under  which  the  operation  is 
performed,  and  the  severity  of  the  operation 
itself,  the  examples  of  recovery  bear  only  a 
small  proportion  to  the  large  number  of 
deaths,  known  to  have  followed  amputation 
at  the  hip  in  the  many  cases,  in  which  it  has 
now  been  undertaken.  However,  the  un- 
fortunate truth  should  not  be  exaggerated 
into  a reason  for  a general  condemnation  of  the 
practice,  which  is  adopted  as  the  only  means 
affording  a chance  of  life.  But  as  there  may 
he  diffic  dty  in  deciding  whether  the  patient 
will  have  the  best  chance  with  or  w ithout 
the  operation,  it  is  to  be  hoped  that  no  sur- 
geons will  perform  it,  except  under  the 
authority  of  ;be  united  opinion  of  a board,  or 
consultation  of  the  best-informed  practition- 
ers, whom  circumstances  will  allow  to  assem- 
ble. See  Amputation. 

In  military  surgery,  the  useful  innovation 
of  ambulances,  or  light  caravans,  furnished 
with  a proper  number  of  surgeons,  assist- 
ants, and  orderlies,  and  capable  of  keeping 
up  with  the  vanguard,  if  requisite,  is  un- 
doubtedly the  best  means  of  affording  speedy 
surgical  assistance  to  the  w'ounded  on  the 
field  of  battle,  and  ought  to  be  enumerated 
as  one  of  the  greatest  modern  improvements 
Barons  Percy  and  Larrey  deserve  the  chief 
praise  for  their  successful  exertions  in  organi- 
zing and  bringing  to  perfection  so  indispensa- 
ble mi  establishment.  The  account  of  this 
subject  well  deserves  perusal  ; and  ii  may 
be  s en  eiiher  in  Larrey' s Mtmoires  de  Chi- 
rurgie  Militaire,  or  in  tht  Diet,  des  Sciences 
Mi  icales,  T.  5 

SUSPENSORY.  A bandage  for  support- 
ing the  scrotum  ; a bag-truss.  Bandages  of 
this  kind  are  now  usually  sold  at  the  shops, 
and  seldom  made  by  surgeons  themselves ; 
therefore  a particular  description  of  them  is 
not.  essential  in  this  work.  In  cases  of  her- 


Sti’l 

nia  humoralis,  varicocele,  cirsoceie,  some, 
particular  ruptures,  and  several  other  affec- 
tions of  the  testicle,  and  spermatic  chord,  a 
suspensory  bandage  is  of  infinite  service. 

SUTURES,  (from  suo,  to  sew.)  A suture, 
in  surgery,  means  a mode  of  uniting  the 
edges  of  a wound,  by  keeping  them  in  con- 
tact with  stitches. 

Mr.  Sharp  remarks,  that  “ when  a wound 
is  recent,  and  the  parts  of  it  are  divided  by 
a sharp  instrument,  without  any  further  vi- 
olence. and.  in  such  manner,  that  they  may 
be  made  to  approach  each  other,  by  being 
returned  with  the  hands,  they  will,  if  held 
in  close  contact  for  some  time,  reunite  by 
inosculation  and  cement,  like  one  branch 
of  a tree  ingrafted  on  another.  To  maintain 
them  in  this  situation,  several  sorts  of  su- 
tures have  been  invented,  and  formerly 
practised,  but  the  number  of  them  has,  of 
late,  been  very  much  reduced.  Those  mow 
chiefly  described  are  the  interrupted , the 
glover's,  the  quilled,  the  hoisted,  and  the  dry , 
sutures : but  the  interrupted  and  twisted  are 
almost  the  only  useful  ones,  for  the  quilled 
suture  is  never  preferable  to  the  interrupted  ; 
the  dry  suture  is  ridiculous  in  terms,  since  it 
is  only  a piece  of  plaster,  applied  in  many 
different  ways,  to  reunite  the  lips  of  the 
wound  ; and  the  glover’s,  or  uninterrupted 
stitch,  which  is  recommended  in  superficial 
wounds,  to  prevent  the  deformity  of  a scar, 
does  rather,  by  the  frequency  of  the  stitches, 
occasion  it,  and  is  therefore  to  be  rejected, 
in  favour  of  a compress  and  sticking  plaster. 5 
( Oper . of  Surgery.)  The  twisted  suture  is 
described  in  speaking  of  the  harelip ; and 
gaslroraphe,  w hich  also  properly  belongs  to 
the  present  subject,  forms  a distinct  article 
in  this  Dictionary. 

Interrupted  Suture. — The  wound  being 
cleansed  from  all  clots  of  blood,  and  its 
lips  being  brought  evenly  into  contact,  the 
needle,  armed  with  a ligature,  is  to  be  care- 
fully carried  from  without  inwards  to  the 
bottom,  and  so  on  from  within  outwards 
G’are  must  be  taken  to  make  the  puncture 
far  enough  from  the  edge  of  the  wound,  lest 
the  ligature  should  tear  quite  through  the 
skin  and  flesh.  This  distance,  according  to 
Mr.  Sharp,  may  be  three,  or  four-tenths  of 
an  inch.  The  other  stitches  required  are 
only  repetitions  of  the  same  process.  The 
threads  having  beeu  all  passed,  “ you  are 
in  general  to  begin  tying  them  in  the  middle 
of  the  wound  ; though,  if  the  lips  be  held 
carefully  together,  (says  Mr.  Sharp,)  it  will 
not  be  of  great  consequence,  which  stitch  is 
tied  first.”  ( Operations , Chap.  1.) 

Surgical  writers  in  general  state,  that  the 
number  of  stitches  must,  in  a great  measure, 
depend  upon  the  extent  of  the  wound.  The 
common  rule  is,  that  one  suture  is  sufficient 
for  every  inch  of  the  wound  ; but  that  in 
some  instances,  a stitch  must  be  more  fre- 
quently made,  particularly  when  a wound 
gapes,  very  much,  in  consequence  of  a trans- 
verse division  of  muscles.  As  w'e  have  al- 
ready explained,  it  is  necessary  to  pierce  the 
skin,  at  a sufficient  distance  from  the  sides 
of  the  wound,  lest  the  thread  should  cut 


SUTURES.  Too* 


through  the  flesh  in  a short  time  : but,  though 
Mr.  Sharp  lays  down  the  necessary  distance, 
in  general  as  three,  or  four-tenths  of  an  inch, 
and  others  advise  the  needle  to  be  always 
carried  through  the  deepest  part  of  the 
wound,  we  must  receive  these  directions, 
particularly  the  last,  as  subject  to  numerous 
exceptions.  When  a wound  is  very  deep, 
it  would  be  conspicuously  absurd,  and  even, 
in  many  instances,  dangerous,  to  drive  the 
needle  through  a vast  thickness  of  parts. 
Other  wounds,  of  considerable  length,  might 
not  be,  in  some  places,  four-tenths  of  an 
inch  deep ; though  it  is  true,  sutures  could 
never  be  requisite  at  such  points. 

The  needles  for  making  the  interrupted 
suture  will  pass  with  the  greatest  facility, 
when  their  shape  corresponds  exactly  with 
the  segment  of  a circle,  and  they  should  al- 
ways form  a track  of  sufficient  size  to  allow 
the  ligatures,  which  they  draw  after  them, 
to  pass  through  the  flesh  with  the  utmost 
ease. 

The  interrupted  suture  obviously  receives 
its  name  from  the  interspaces  between  the 
stitches  ; and  it  is  the  one  most  frequently 
employed.  Its  action  is  alwTays  to  be  assisted 
and  supported,  either  with  the  uniting  ban- 
dage, (see  Bandage ) or  with  strips  of  adhe- 
sive plaster,  compresses,  &e. 

Quilled  Suture. — As  Mr.  John  Bell  has 
observed,  “ when  the  wound  was  deep 
among  the  muscular  flesh,  the  old  surgeons 
imagined,  that  so  large  a wound  could  not 
be  commanded  by  the  common  interrupted 
suture,  howrever  deep  the  stitches  might  be 
driven  among  the  flesh  ; they  were  besides 
' fearful  of  using  the  continued  (glover’s)  su- 
ture in  deep  gashes,  lest  the  wound  should 
be  made  to  adhere  superficially,  w'hile  it  w as 
still  open  within,  forming  perhaps  a suppu 
ration,  or  deep  collection  of  matter  They 
believed,  that  a deep  muscular  wound  could 
not  be  safely  healed,  without  a degree  of 
suppuration  ; while  they  wished  to  bring  it 
together  at  the  bottom,  they  were  afraid  to 
close  it  very  exactly  at  the  mouth,  lest  the 
matter  should  be  collected  in  the  deeper 
parts  of  the  wound  ; it  was  for  this  purpose 
(says  Mr.  John  Bell)  that  they  used  what 
they  called  the  compound , or  quilled  suture. 
It  is  merely  the  interrupted  suture,  writh  this 
difference,  that  the  ligatures  are  not  tied 
over  the  face  of  the  wound,  but  over  two 
quills,  or  rolls  of  plaster,  or  bougies,  which 
are  laid  along  the  sides  of  the  wound.  In 
performing  this  suture,  we  make  first  two, 
three,  or  four  stitches,  of  the  interrupted 
suture  very  deep,  and  then,  all  the  ligatures 
being  put  in,  we  lay  two  bougies  along  the 
sides  of  the  wound,  then  slip  one  bougie 
into  the  loop  of  the  ligatures  on  one  side, 
drawing  all  the  ligatures  from  the  other  side, 
(Mr.  Bell  should  rather  have  said  towards 
the  other  side,)  till  that  bougie  is  firmly  bra- 
ced down.  Next  we  lay  the  other  bougie, 
and  make  the  knots  of  each  ligature  over 
it,  and  draw'  it  also  pretty  firm  ; and  thus  the 
ligatures,  in  form  of  an  arch,  go  deep  into 
the  bottom  of  the  wound,  and  hold  it  close, 
while  the  bougies,  or  quills,  keep  the  mid- 


dle of  the  wound,  and  lips  of  it  pressed  to- 
gether with  moderate  closeness,  and  prevent 
any  strain  upon  the  threads,  or  any  coarse 
and  painful  tying  across  the  face  of  the 
wound.’’  In  a note  Mr.  J.  Bell  says,  that 
Dionis  violently  reprobates  the  quilled  su- 
ture; but,  that  De  la  Faye  (the  annotator  on 
Dionis)  says,  it  is  good  for  deep  muscular 
wounds.  The  quilled  suture  is  now  scarcely 
ever  employed  ; nor  has  it  any  advantages, 
except,  perhaps,  in  some  wounds  in  the 
belly.  (See  Principles  of  Surgery,  Vol.  \,p. 
50.) 

I think  the  reader  will  more  easily  com- 
prehend the  manner  of  making  the  quilled 
suture,  from  the  following  simple  directions. 
Take  as  many  needles,  as  stitches  intended 
to  be  made  ; arm  them  with  a double  liga- 
ture, or  one  capable  of  being  readily  split 
into  two  ; introduce  the  ligatures  through 
the  wound  ; cut  off  the  needles  : lay  a piece 
of  bougie  along  one  side  of  the  wound,  and 
tie  the  ends  of  the  ligatures  over  it.  Next 
draw  the  other  extremities  of  the  ligatures, 
so  as  to  bring  the  first  piece  of  bougie  into 
close  contact  with  the  flesh  ; lay  the  second 
piece  of  bougie  along  the  opposite  side  of 
the  wound,  and  tie  the  other  ends  of  the  li- 
gatures over  it  with  sufficient  tightness. 

Glover's  Suture.  This  had  also  the  name  of 
the  continued  suture.  It  was  executed  by 
introducing  the  needle  first  into  one  lip  of 
the  wound,  from  within  outw  ards,  then  into 
the  other  in  the  same  w ay  ; and,  in  this 
manner  the  whole  track  of  the  wound  was 
sewed  up. 

The  glover’s  suture  has  long  been  rejected 
by  all  good  surgeons,  as  improper  to  be  em- 
ployed in  cases  of  common  wounds.  It 
was  not,  however,  till  very  lately,  that  this 
suture  was  totally  abandoned;  for JVJr.  Sharp, 
and  several  eminent  writers  since  his  time, 
have  advised  its  adoption  in  wounds  of  the 
stomach  and  intestines.  From  what  has 
been  said  in  the  articles  Wounds  of  the  Abdo- 
men and  Hernia,  the  reader  will  perceive, 
that  even  in  such  particular  instances,  the 
glover’s  suture  would  not  be  adviseable  ; so 
that  it  may,  in  every  point  of  view,  be  now 
considered  as  totally  disused  in  every  case 
of  surgery  which  can  possibly  present  itself. 
When  we  remember,  in  making  this  suture, 
how  many  stitches  are  unavoidable ; how 
unevenly,  and  in  w hat  a puckered  state  the 
suture  drags  the  edges  of  the  skin  together, 
and  what  irritation  it  must'  produce,  we  can 
no  longer  be  surprised  at  its  now  being  ne- 
ver practised  on  the  living  subject.  It  is 
commonly  employed  for  sewing  up  dead 
bodies;  a purpose  for  which  it  is  well  fitted, 
but  for  the  honour  of  surgery,  and  the  sake 
of  mankind,  it  is  to  be  hoped  that  it  will 
never  again  be  adopted  in  practice. 

False,  or  Dry  Suture. — Modern  surgeons 
commonly  understand  by  this  expression 
nothing  more,  than  the  plan  of  bringing 
the  sides  of  a wound  together,  by  means  of 
adhesive  plaster  ; nor  did  Mr  Samuel  Sharp 
attach  any  other  meaning  to  the  phrase, 
wTjich  he  sets  dowm  as  highly  ridiculous, 
as  there  is  no  sewing  employed.  For  the 


456  • SUTURES 


following  remarks,  i am  indebted  to  Mr. 
Carwardine,  of  Earls  Colne  Priory,  near 
Halsted,  Essex.  Alluding  to  what  was  sta- 
ted in  the  last  edition  of  this  Dictionary, 
concerning  the  dry  suture,  he  observes, 
e(  you  do  not  appear  to  be  aware  any  more 
than  Mr.  Sharp,  of  the  precise  mode  of  its 
application,  or  why  it  was  so  called.  In- 
deed, it  is  a curious  circumstance,  how  this 
method  of  dry  suture  should  have  been  so 
lost,  as  not  to  be  described  by  any  modern 
surgeons,  who  laugh  at  the  very  term,  speak- 
ing of  it  as  a mere  application  of  a strip  of 
adhesive  plaster.  In  the  sulura  sicca,  so  call- 
ed in  opposition  to  the  sulura  crumta, 
where  blood  followed  the  needle,  some  ad- 
hesive plaster  was  spread  on  linen,  having 
a selvage.  A piece  of  this  was  applied 
along  each  side  of  the  wound  (the  selvages 
being  opposed  to  each  other,)  and  then 
drawn  together  by  sewing  them  with  a com- 
mon needle,  without  bloodshed.  Hence 
the  term  sulura  sicca.  The  dry  suture  was 
used  in  all  wounds  of  the  face  to  avoid 
scars.  You  will  find  it  thus  described 
by  our  countryman  Thomas  Gale  in  his 
Enceiridion,  1563 ; and  also  by  A.  Pa- 
rey,  who  gives  a figure  of  it  in  his  folio 
work,  1579.”  I feel  much  obliged  to  my 
friend  Mr.  Carwardine  for  this  explanation, 
without  which  the  expression  dry  suture  is 
undoubtedly  absurd.  As  the  common  way 
of  dressing  wounds  with  sticking  plaster 
will  come  under  consideration  in  a future 
part  of  this  work,  (see  Wounds,)  I shall  not 
here  detain  the  reader  upon  that  topic. 

Sutures,  by  which  I mean  such  as  were 
made  in  the  flesh  with  a needle  and  ligature, 
were  much  more  frequently  employed  by  the 
old  surgeons,  than  they  are  by  the  moderns. 
The  best  practitioners  of  the  present  day 
never  resort  to  this  method  of  holding  the 
sides  of  a wound  in  contact,  except  in  cases 
in  which  there  is  a real  necessity  for  it,  and 
other  modes  will  not  suffice. 

There  were,  indeed,  certain  instances,  in 
which  the  employment  of  sutures  was  long 
ago  forbidden.  Of  this  kind  were  enve- 
nomed wounds,  in  which  accidents  the  des- 
truction of  the  poison  always  :ormed  a prin- 
cipal indication  in  the  treatment. — Wounds, 
accompanied  with  considerable  inflamma- 
tion, were  not  deemed  proper  tor  the  use  of 
sutures,  as  the  stitches  had  a tendency  to  in- 
crease the  inflammatory  symptoms.  Also, 
as  contused  wounds  necessarily  suppurated, 
and,  consequently,  could  not  be  united,  su- 
tures were  not  recommended  for  them  ; nor 
were  they  judged  expedient  for  wounds  at- 
tended with  such  a loss  of  substance  as  pre- 
vented their  lips  from  being  placed  in  con- 
tact. Formerly,  wounds  penetrating  the 
chest,  were  not  united  by  sutures  ; nor  were 
those  in  which  large  blood-vessels  were  in- 
jured ; at  least,  until  all  danger  of  hemor- 
rhage was  obviated  by  the  vessels  being 
tied. 

Dionisbelieved,  with  several  otherautliors, 
that  wounds  should  not  he  united,  when 
bones  were  exposed,  on  account  of  the  ex- 
foliations which  might  he  expected,  '.rids 


precept  is  no  longer  valid  ; lor  when  bones 
are  neither  altered  nor  diseased,  and  are 
only  simply  denuded,  or  divided  with  a cut- 
ting instrument,  no  exfoliations  will  com- 
monly follow,  if  the  surgeon  take  care  to 
replace  the  fresh-cut  soft  parts  so  as  to  cover 
the  exposed  portion  of  the  bone.  The 
practicable  ness  of  uniting  wounds,  attended 
with  the  division  of  a bone,  is  confirmed 
by  numerous  facts.  De  la  Peyronie  com- 
municated to  the  French  Academy  of  Sur- 
gery, a case  conclusive  on  this  point.  A 
man  was  wounded  with  a cutting  instru- 
ment, in  an  oblique  direction,  on  the  exter- 
nal and  middle  part  of  the  arm.  The  bone 
was  completely  cut  through,  together  with 
the  integuments  and  muscles,  in  such  a 
manner  that  the  arm  only  hung  by  an  un- 
divided pox’tion  of  the  skin,  about  an  inch 
wide,  under  which  were  the  large  vessels. 
De  la  Peyronie  tried  to  unite  the  parts,  be- 
ing convinced  that  it  would  be  time*  enough 
to  amputate  afterward,  if  the  case  should 
require  it.  He  placed  the  two  extremities 
of  the  divided  bone  in  their  natural  situa- 
tion ; made  several  sutures  for  promo- 
ting the  union  of  the  soft  parts,  and  ap- 
plied a bandage  to  the  fracture.  In  this  ban- 
dage there  were  slits,  or  apertures,  over  the 
wound,  to  allow  the  dressings  to  be  applied. 
Spirit  of  wine,  containing  a little  muriate  of 
ammonia,  was  used  as  a topical  application, 
and  the  forearm  and  hand,  which  were  cold, 
livid,  and  insensible,  were  also  fomented 
with  the  same.  By  these  means  the  natural 
warmth  was  restored,  and  the  wound  was 
dressed  in  a week  the  dressings  were  re- 
moved, through  the  opening  in  the  bandage ; 
in  a fortnight  they  were  changed  a second 
time,  and  the  wound  seemed  disposed  to 
heal.  On  the  eighteenth  day,  the  healing 
had  made  considerable  progress ; the  part 
had  a natural  appearance  ; and  the  beating 
of  the  pulse  was  very  perceptible.  De  la 
Peyronie  now  substituted  a common  roller 
for  the  preceding  bandage,  and  care  was  ta- 
ken to  change  the  dressings  every  ten  days. 
In  about  seven  weeks  all  applications  were, 
left  off,  and  at  the  end  of  two  months  the 
patient  was  quite  well,  with  the  exception  of 
a little  numbness  in  the  part.  This  case  is 
one  of  the  most  important  in  all  the  records 
of  surgery  , for  it  displays,  in  a most  stri- 
king manner,  what  very  had  wounds  it  is  the 
duty  of  the  surgeon  to  attempt  to  unite  ; 
and  above  all,  it  exemplifies  the  propriety 
of  attempting  to  save  many  compound  frac 
tures,  which,  judged  of  only  from  first  ap- 
pearances, would  lead  almost  any  one  to 
resort  to  amputation.  In  such  cases,  when 
the  divided  parts  are  put  in  contact,  the  ap 
pearances  are  quite  altered. 

From  what  has  been  already  stated,  it  ap- 
pears that  surgeons,  a considerable  time 
back,  did  not  at  once  sew  up  every  sort  of 
wound  ; though  the  considerations,  which 
led  them  not  to  close  the  wound,  were 
erroneous,  as  may,  perhaps,  he  said  with  re- 
spect to  the  apprehension  of  bleeding  and 
exfoliations.  The  best  modern  practitioners 
employ  sutures  much  less  frequently  than 


SUTi 

Ikeir  predecessors.  Pibrac  ?s  dissertation  on 
the  abuse  of  sutures,  inserted  in  the  third 
volume  of  the  Memoirs  of  the  Academy  of 
Surgery,  has  had  considerable  effect  in  pro- 
ducing this  change,  and  I may  safely  add, 
this  improvement  in  practice.  This  judi- 
cious and  enlightened  practitioner  opposed 
the  method  of  uniting  wounds  by  means  of 
sutures,  which,  he  contended,  ought  never  to 
be  adopted  in  practice,  except  in  certain 
cases  in  which  it  vsas  absolutely  impossible 
to  keep  the  sides  of  the  wound  in  contact, 
by  means  of  a suitable  posture,  and  the  aid 
of  a methodical  bandage.  Such  circum- 
stances Pibrac  represents  as  exceedingly  rare, 
if  they  ever  occur  at  all.  He  speaks  of 
sutures  as  seldom  fulfilling  the  intention  of 
the  surgeon,  who,  in  the  majority  of  cases 
in  which  he  employs  them,  finds  himself  ne- 
cessitated to  remove  them,  before  they  have 
accomplished  the  wished-for  end.  Pibrac 
believes  that  sutures  are  generally  more 
hurtful  than  conducive  to  the  union  of 
wounds ; and  that  when  they  succeed,  they 
do  not  effect  a cure  more  speedily  than  apro- 
per  bandage.  He  cites  numerous  cases  of 
very  extensive  wounds  of  the  abdomen, 
neck,  fee.  for  the  cure  of  which  a bandage 
proved  effectual,  and  this  even  in  many  in- 
stances in  which  sutures  had  previously 
failed,  and  cut  their  way  through  the  flesh. 
Louis,  who  adopted  the  opinions  of  Pibrac, 
published  in  the  fourth  volume  of  Mem.  de 
V Acad  de  Chirurgie,  a valuable  dissertation, 
in  which  he  endeavours  to  provd;  that  even 
the  harelip  can  be  better  united,  by  means 
of  the  uniting  bandage  than  sutures  ; a case, 
however,  which  the  best  modern  surgeons 
very  rightly  agree  to  consider,  for  particular 
reasons  elsewhere  noticed,  (see  Harelip ,)  as 
an  example,  in  which  a suture  is  adviseable. 

As  far  as  1 can  judge,  the  fair  statement 
of  the  matter  is,  that  sutures  are  by  no 
means  requisite  in  the  generality  of  wounds; 
but  that  there  are  particular  cases,  in  which 
either  their  greater  convenience,  or  superior 
efficacy,  still  makes  them  approved,  and 
employed  by  all  the  most  eminent  practi- 
tioners of  the  present  day.  Since  sutures 
cannot  be  practised,  without  additional 
wounds  being  made,  and  pain  occasioned, 
and  since  the  threads  always  act  as  extrane- 
ous bodies  in  the  parts,  exciting  more  or  less 
inflammation  and  suppuration  round  them  ; 
there  can  be  no  doubt  that  their  employ- 
ment is  invariably  wrong,  whenever  the 
sides  of  a wound  can  be  maintained  in  con- 
tact by  less  irritating  means,  with  equal 
steadiness  and  security.  For,  what  is  it 
which  generally  counteracts  the  wishes  of 
the  surgeon,  and  renders  his  attempts  to 
make  the  opposite  surfaces  of  wounds  grow 
together  unavailing?  Is  not  the  general  cause 
too  high  a degree  of  inflammation,  which 
necessarily  ends  in  suppuration  ? Are  not 
sutures  likely  to  augment  inflammation,  both 
by  the  additional  wounds  of  the  needles,  and 
the  still  more  pernicious  irritation  of  the 
threads  which  always  act  as  foreign  bodies, 
sometimes  producing  not  merely  an  increase 
"f  inflammation  and  suppuration  in  their 
voL.n  58 


JilES.  4*7 

track  ; but  frequently  such  ulceration  as  en- 
ables them  to  cut  their  way  out,  or  else 
sloughing  of  the  parts  ; or,  in  particular  con- 
stitutions, a very  extensive  erysipelatous 
redness. 

In  consequence  of  the  ulcerative  process, 
sutures  very  often  cease  to  have  the  power 
of  any  longer  keeping  the  edges  of  wounds 
in  contact ; as  the  observations  of  Pibrac,  and, 
indeed,  what  every  man  may  daily  remark 
in  practice,  fully  testify  ; and  the  violent 
inflammaiory  symptoms  which  are  excited, 
frequently  oblige  the  surgeon  to  cut  the 
threads,  and  withdraw  them  altogether. 

But,  even  admitting,  that  by  the  general 
adoption  of  sutures  some  wounds  would  be 
united,  which  could  not  be  so  were  this 
means  of  accomplishing  the  union  aban- 
doned, still  it  must  be  allowed,  on  the  other 
hand,  that  the  cause  of  some  wounds  not 
uniting  is  entirely  ascribable  to  the  irritation 
occasioned  by  the  sutures  themselves.  Hence, 
if  it  be  only  computed,  that  as  many  wounds 
are  prevented  from  uniting  by  the  irritation 
of  sutures,  as  other  wounds  which  are  united 
by  their  means,  and  could  be  united  by  no 
other  methods,  we  must  still  perceive,  that 
mankind  would  be  no  sufferers,  and  surgery 
undergo  no  deterioration,  were  sutures  alto- 
gether rejected  from  practice.  1 believe, 
however,  that  every  man,  who  has  had  op- 
portunities of  observation,  and  has  made  use 
of  them  with  an  unprejudiced  mind,  will 
feel  persuaded  that  more  wounds  are  hin- 
dered from  uniting  by  sutures,  than  such  as 
are  healed  by  them,  and  could  not  be  united 
by  other  means. 

But  prudent  practitioners  are  not  obliged, 
either  to  condemn  or  praise  the  use  of  su- 
tures, in  every  instance,  without  exception 
Men  of  independent  principles  will  always 
adopt  the  line  of  conduct  which  truth  points 
out  to  them  as  that  which  is  right ; nor  will 
they  obstinately  join  Pibrac  and  Louis,  in 
contending  that  sutures  are  always  improper 
and  disadvantageous,  nor  with  other  bigoted 
persons,  who  may  use  sutures  in  every  kind 
of  wound  whatever.  Perhaps,  sutures  arc 
still  rather  too  much  employed,  and,  in  all 
probability,  will  long  be  so.  It  will  be 
difficult  entirely  to  eradicate  the  prejudices, 
ou  which  their  too  frequent  use  is  founded, 
as  long  as,  what  may  be  called,  the  teachers 
of  surgery  are  seen  holding  up  the  practice 
for  imitation  in  every  principal  hospital  in 
the  kingdom.  Such  surgeons,  however,  as 
are  ready  to  imbibe  fair  and  candid  senti 
ments  on  the  subject,  and  to  qualify  them  - 
selves for  practising  this  part  of  surgery  with 
judgment,  should  by  no  means  neglect  to 
read  both  what  Pibrac  and  Louis  have  writ- 
ten on  the  subject.  I know  that  the  latter 
authors  are  a little  too  sanguine  in  their  re- 
presentations ; but,  as  I have  already  re- 
marked, sutures  are  still  rather  too  much 
used,  and  something  is  yet  necessary  to  do 
away  a certain  unwarranted  habit  of  having 
recourse  to  them  without  real  necessity. 
Nothing  will  tend  to  produce  this  desirable 
change  so  much,  as  the  perusal  of  every  ar- 
gument against  their  employment. 


T BANDAGE 


m 


I am  decidedly  of  opinion,  not  from  what 
I have  read,  but  what  1 have  actually  seen, 
that  the  sides  of  the  generality  Gf  wounds 
are  capable  of  being  effectually  kept  in  con- 
tact, by  means  of  a proper  position  of  the 
part,  and  the  aid  of  strips  of  adhesive  plaster, 
compresses,  and  a bandage.  I believe  that 
such  success  can  be  obtained  with  every  ad- 
vantage which  can  be  urged  in  favour  of 
sutures,  and  without  their  disadvantages ; 
such  as  greater  pain,  inflammation,  &x  I 
even  think,  with  Louis,  that  the  harelip 
might  in  general  be  united  very  well  by 
means  of  a bandage  ; but  still  I am  of  opi- 
nion, that  the  twisted  suture  is  attended  with 
least  trouble,  is  most  suited  for  universal 
practice,  and  that,  unless  such  pains  were 
taken  as  many  practitioners  would  not,  and 
others  could  never  take,  the  method  by  ban- 
dage would  frequently  fail. 

I find  it  exceedingly  difficult  to  lay  down 
any  fixed  principles  for  the  guidance  of  the 
surgeon,  in  respect  to  when  he  ought,  and 
when  he  ought  not,  to  use  sutures. 

Perhaps,  sutures  should  be  made  use  of 
for  all  cuts  and  wounds,  which  occur  in 
parts  which  are  subject  to  an  unusual  degree 
of  motion,  such  as  would  be  apt  to  derange 
the  operation  of  bandages,  sticking  plaster, 
and  compresses.  Hence  the  propriety  of 
using  the  twisted  suture  for  the  harelip. 

Sutures  are  probably,  for  the  most  part, 
advantageous  in  all  wounds  of  the  abdomen, 
of  a certain  length,  and  attended  with  ha- 
zard of  the  viscera  making  a protrusion.  In 
this  situation,  the  continual  motion  and  ac- 
tion of  the  abdominal  muscles,  in  respiration, 
besides  the  tendency  of  the  viscera  to  pro- 
trude, may  be  a reason  in  favour  of  the  use 
of  sutures. 

When  tw'o  fresh-cut  surfaces  positively 
cannot  be  brought  into  contact  by  sticking 
plaster,  bandages,  the  observance  of  a pro- 
per posture,  &e.  there  can  be  no  doubt  of 
the  advantage  of  using  sutures,  if  they  will 
answer  the  purpose.  Some  wounds  of  the 
trachea ; some  wounds  made  for  the  cure  of 
certain  fistulous  communications  between 
the  vagina  and  bladder,  or  others  for  the  cure 
of  similar  affections  in  the  perinaeum,  afford 
instances  of  cases  to  which  I allude. 

1 observe,  that  many  surgeons  in  this  me- 
tropolis use  sutures  for  bringing  the  sides  of 
the  wound  together  alter  several  operations  ; 
as  that  of  removing  a diseased  breast,  castra- 
tion, and  operations  for  strangulated  hernia. 

The  reason  for  using  sutures  in  the  scro- 
tum, I suppose,  arises  from  the  difficulty  of 
keeping  the  edges  of  the  wound  in  contact, 
owing  to  the  great  quantity  and  looseness 
of  the  part.  In  this  case,  I cannot  deter- 
mine whether  sutures  are  really  necessary 


or  not  ; but,  alter  the  amputation  of  the 
breast,  I have  no  hesitation  in  pronouncing 
their  employment  wrong  and  injudicious. 

I shall  conclude  with  referring  to  what  PL 
brae  and  Louis  have  written  on  the  above 
subjects,  in  Mini.  de  l’ Acad,  de  Chir.  Tom.  3 
and  4,  Sharp,  Dionis , Gooch , Le  Dran , Btr 
trandi , Sabatier  B . Beil , and  J.  Bell , have  all 
treated  of  sutures.  See  also  C.  E.  Boeder 3 
Sutures  Vulnerum  ; Upsnl , 1772. 

SYMPA  THETIC  BUBO.  See  Bubo. 

SY  ACHYSIS.  (from  a-vyyyu*.  to  confound.;' 
The  term  synchysis  sometimes  denotes  the 
confusion  of  the  humours  of  the  eye  occa- 
sioned by  blows,  and  attended  with  a rup- 
ture of  the  internal  membranes  and  capsules 
Beer  understands  by  the  expression,  a 
dissolution  of  the  vitreous  humour,  or  the 
state  of  it  in  which  its  consistence  is  en  - 
tirely destroyed.  (See  Lthre  von  den  An - 
genkr.  B.  2,  p.  257.) 

SYNECHIA.  The  case  in  which  the  iris 
adheres  to  the  cornea  is  termed  synechia 
anterior;  that  in  which  the  uvea  adheres  to 
the  capsule  of  the  lens,  synechia  posterior.. 
Beer  has  delivered  two  valuable  chapters 
on  these  subjects.  The  synechia  posterior, 
on  account  of  the  frequent  delicacy  of  the 
adhesions,  is  apt  not  to  be  detected  unless 
the  eye  be  examined  with  particular  care. 
A magnifying  glass  should  be  used,  and 
the  pupil  be  first  dilated  with  hyoscia- 
mus,  or  belladonna.  The  treatment,  as  far 
as  the  prevention  and  removal  of  such  ad- 
hesions are  practicable,  strictly  belongs  to 
the  subject  of  iritis.  (See  Ophthalmy.)  With 
the  view  of  dispersing  them,  Beer  praises 
the  good  effects  of  applying  to  the  eye  itself 
ointments  containing  preparations  of  mer- 
cury, or  a collyrium  hydrarg.  oxymuriatis, 
to  which  some  of  the  thebaic  tincture  is 
added.  As  an  inward  medicine,  he  says, 
calomel  is  the  most  effectual.  When 
eye-salves  are  used.  Beer  recommends  a 
little  of  the  extract  of  hyosciamus  to  be 
mixed  with  them,  so  that  they  may  dilate 
the  pupil,  and  thus  suddenly  break  any 
slight  threads  of  lymph.  ( B . 2,  p.  58.)  For 
additional  information  on  the  synechia  pos- 
terior and  anterior,  see  Lehre  von  den  Au~ 
genkr.  B.  2,  p.  54  and  p.  263.  Also  Begert 
De  Synechia  seu  prelernaturali  adhesione  cor - 
nnc  cum  iride.  Haller , Disp.  Chir.  T.  1,  p. 
435. 

SYNTHESIS,  (from  <rvvt  together,  and 
6e<r/c,  position,  situation.)  A generic  term, 
formerly  much  used  in  the  schools  of  surge 
ry,and  comprehending  every  operation,  by 
which  parts,  which  had  been  divided,  were 
reunited. 

SYPHILIS.  Lues  Venerea.  The  veno 
real  disease.  (See  Venereal  Disease.) 


T. 

F#1  BANDAGE.  A bandage,  so  named  tion  for  the  cure  of  fistula  in  ano,  in  disease- 
A from  its  figure.  I(  is  principally  used  of  the  perinamm,  and  those  of  the  groin' 
for  supporting  the  dressings  after  the  opera-  anus,  &<*.  It  is  composed  of  two  lougUmU 


TENDONS. 


»al  pieces  of  cloth,  of  greater  or  lesser 
breadth,  according  as  occasion  requires. 
The  transverse  piece  of  doth  serves  to  go 
round  the  body  above  the  hips : the  per- 
pendicular piece  is  sewed  at  one  of  its  ends 
to  the  middle  of  the  latter;  and  in  general, 
its  other  extremity  is  slit  into  two  portions, 
or  tails,  about  six  or  eight  inches  long.  The 
perpendicular  piece  of  the  T bandage  applies 
itself  between  the  glutaii  muscles,  and  to  the 
perinaeum  : while  its  two  ends,  j jst  descri-' 
bed,  are  to  he  carried  betwfeen  the  thighs  and 
the  pudenda  to  the  right  and  left,  and  fasten- 
ed to  the  transverse  piece  surrounding  the 
body.  Besides  the  common  T bandage, 
there  is  another  one  named  double,  which 
has  two  perpendicular  pieces,  sewed  to  the 
transverse  one,  about  four  inches  apart. 
The  double  T bandage  is  said  to  be  more 
particularly  applicable  after  lithotomy,  and 
tor  the  diseases  of  the  perinaeum  ; because 
one  may  make  the  two  perpendicular  pieces 
cross  each  other  on  the  part  affected,  and 
leave  the  anus  uncovered ; an  advantage 
which  the  simple  T bandage  certainly  has 
not.  The  T bandage  may  be  used  in  some 
other  ways,  which  have  been  noticed  in 
the  article  Bandage. 

TALPA.  (a  mole.)  A tumour  which 
creeps  under  the  skin  as  a mole  under  the 
surface  of  the  ground.  Such  is  the  etymo- 
logy. It  is  often  applied  to  an  encysted  tu- 
mour, which  forms  on  the  head,  and  contains 
a paplike  matter.  (See  atheroma,  and  TV 
mours,  Encysted.) 

TAPPING.  See  Paracentesis. 

TARAXIS.  (from  r&gaao-a),  to  disturb.)  A 
slight  ophthalmy.or  inflammation  of  the  eye. 

Taxis,  (from  'mcrcra,  to  put  in  order.) 
The  operation  of  reducing  a hernia  with 
the  hand.  (See  Hernia.) 

TENDONS,  RUPTURE  OF.  The  tendons 
liable  to  be  broken  by  the  violent  action  of 
the  muscles  with  which  they  are  connected, 
are  the  tendo  Achillis,  that  of  the  extensor 
muscles  of  the  leg,  and  the  tendon  of  the 
triceps  extensor  cubiti.  The  ancient  sur- 
geons seem  not  to  have  been  well  acquaint- 
ed with  the  rupture  of  the  tendo  Achillis, 
which  they  probably  might  mistake  for  a 
sprain,  or  some  other  complaint.  In  cases 
in  which  this  part  had  been  cut,  they  re- 
commended approximating  the  separated 
portions,  and  maintaining  them  in  contact 
by  means  of  a suture. 

When  the  ruptured  tendo  Achillis  was 
afterward  better  understood,  the  plan  just 
mentioned  was  even  adopted  in  this  case, 
the  integuments  having  been  previously 
divided,  for  the  purpose  of  bringing  the 
tendon  into  view.  But  there  is  no  necessity 
fot  having  recourse  to  this  painful  proceed- 
ing. (Encyclopedic  Mtthodiqw , Par  tit  Chir. 
T.  1.  p.  55.) 

The  superficial  situation  of  the  tendo 
Achillis  always  renders  the  diagnosis  of  its 
rupture  exceedingly  obvious,  and  the  acci- 
dent can  only  become  at  all  difficult  to 
detect,  when  there  is  a considerable  de- 
gree of  swelling,  which  is  very  rare.  When 
the  tendon  has  been  cut.  the  division  of  the 


skin  even  allows  the  accident  to  be  seen. 
When  the  tendon  tias  been  ruptured,  the 
patient  hears  a sound,  like  that  of  the  smack 
of  a whip,  at  the  moment  of  the  occurrence. 
In  whatever  way  the  tendon  has  been  di- 
vided, there  is  a sudden  incapacity,  or  at 
least,  an  extreme  difficulty  eilhei  of  standing 
or  walking.  Hence,  the  patient  falls  down, 
and  cannot  get  up  again.  Besides  these 
symptoms,  there  is  a very  palpable  depres- 
sion between  the  ends  of  the  tendon,  which 
depression  is  increased  when  the  foot  is 
bent  and  diminished,  or  even  quite  removed 
when  the  foot  is  extended. 

The  patient  can  spontaneously  bend  his 
foot,  none  of  the  flexor  muscles  being  in- 
terested. The  power  of  extending  the  foot 
also  is  still  possible,  as  the  peronaei  muscles, 
the  tibialis  posticus,  and  long  flexors  of  the 
toes  (see  a cast  recorded  by  J.  L.  Petit)  re- 
main perfect,  and  may  perform  this  motion. 
(( Euvrcs  Chir.de  Desault,  par  Bichat,  T.  1.) 

I he  indications  are  to  bring  the  ends  of 
the  divided  part  together,  and  to  keep  them 
so,  until  they  have  become  firmly  united. 
The  first  object  is  easily  fulfilled,  by  putting 
the  foot  in  a state  of  complete  extension  , 
the  second,  namely,  that  of  keeping  the 
ends  of  the  tendon  in  contact,  is  more  dif- 
ficult. 

In  order  to  have  a right  comprehension  ol 
the  indications,  we  should  consider  what 
keeps  the  ends  of  the  tendon  from  being  in 
contact.  The  flexion  of  the  foot  b.-s  this 
effect  on  the  lower  portion  ; the  contraction 
of  the  gastrocnemius,  and  solaeus,  on  the 
upper  one.  The  indications  then  are  to  put 
the  foot  in  an  unalterable  state  of  extension, 
and  to  counteract  the  action  of  the  above 
muscles. 

The  action  of  the  muscles  may  be  oppo- 
sed : — 1.  By  keeping  these  powers  in  a 
continual  state  of  relaxation.  For  this 
purpose  the  leg  must  be  kept  half  bent  upon 
the  thigh.  2.  By  apply  ing  methodical  pres- 
sure to  the  muscles;  methodical,  because 
it  is  to  operate  on  the  fleshy  portion  of  the^ 
muscles,  and  not  on  the  tendon,  the  ends  oi 
which,  being  depressed  by  it,  would  be 
separated  from  each  other,  and,  instead  of 
growing  together,  would  unite  to  the  adja- 
cent parts.  The  pressure  should  also  operate, 
so  as  to  prevent  the  ends  of  the.  tendon  from 
inclining  either  to  the  right  or  left. 

J.  L.  Petit  seems  entitled  to  the  honour  of 
having  first  devised  the  plan  of  treating  the 
ruptured  or  divided  tendo  Achillis,  by  keep- 
ing the  leg  and  foot  in  a particular  posture, 
with  the  aid  of  an  apparatus.  Seeing  that 
the  extension  of  the  foot  brought  the  ends 
of  the  tendon  into  contact,  it  occurred  to 
him,  that  such  extension  should  be  main- 
tained during  the  whole  of  the  treatment, 
in  order  to  bring  about  a permanent  union 
This  aim  is,  in  fact,  the  common  basis  ot  alt 
the  numerous  methods  of  cure,  which  have 
been  since  recommended. 

Dr.  Alexander  Monro, primus, happened  to 
rupture  his  tendo  Achillis.  When  the  acci- 
dent took  place,  he  heard  a loud  crack,  as 
if  he  had  suddenly  broken  a nut  with  his 


TEN 


heel,  am]  he  experienced  a sensation  as  it 
the  heel  of  bis  shoe  had  made  a hole  in  the 
iloor.  This  sensation,  he  says,  has  also 
been  observed  by  others,  though  some  have 
complained  of  a smart  stroke,  like  what 
would  be  produced  by  a stone  or  cane. 
Immediately  suspecting  what  had  happened, 
the  doctor  extended  his  left  fool,  in  which 
the  occurrence  had  taken  place,  as  strongly 
as  he  could  with  his  right  hand,  while  with  ^ 
the  left  he  pressed  the  muscles  of  the  calf 
downward,  so  as  to  bring  the  ends  of  the 
broken  tendon  as  near  together  as  possible. 
In  this  position  he  sat,  until  two  surgeons 
came  to  his  assistance.  They  applied  com 
presses,  and  a bent  board  to  the  upper  part 
of  the  foot  and  forepart  of  the  leg,  both 
which  they  kept,  as  nearly  as  possible,  in  a 
straight  line,  by  a tight  bandage  made  with 
a long  roller.  But  as  this  mode  of  dressing 
soon  became  very  uneasy,  it  was  changed 
for  the  following  one.  A foot-sock,  or  slip- 
per, was  made  of  double  quilted  ticking, 
from  the  heel  of  which  a belt  or  strap  pro- 
jected, of  sufficient  length  to  come  up  over 
the  calf  of  the  leg.  A strong  piece  ot  the 
same  materials  was  prepared  of  sufficient 
breadth  to  surround  the  calf,  and  this  was 
fastened  with  lacings.  On  the  back  part  of 
this  was  a buckle,  through  which  the  strap 
of  the  foot-sock  was  passed,  so  that  the 
foot  could  be  extended,  and  the  calf  brought 
down  at  pleasure.  The  leg  and  foot  were 
wrapt  up  in  soft  flannel,  fumigated  with 
benzoin,  and  the  bandage  was  kept  on  day 
and  night,  the  belt  being  made  tighter  when 
the  doctor  was  about  to  go  to  sleep,  and 
loosened  when  he  was  awake,  and  on  his 
guard.  For  a fortnight  he  did  not  move 
bis  foot  and  leg  at  all,  but  was  conveyed  in 
a chair  on  castors  from  one  part  of  the 
room  to  another.  After  this,  he  began  to 
move  the  ankle-joint,  but  in  such  a gentle 
manner  as  not  to  give  any  pain.  The  de- 
gree of  motion  wras  gradually  increased  as 
the  tendon  became  capable  of  bearing  it. 
care  being  taken  to  stop  when  the  motion 
began  to  create  uneasiness.  The  affected 
limb  was  moved  in  this  way  for  half  an 
hour  at  a time.  In  a few  days  the  hollow, 
between  the  separated  ends  of  the  tendon 
became  imperceptible,  though  the  part  con- 
tinued soft  much  longer.  It  became,  how- 
ever, gradually  thicker  and  harder,  until  a 
knot  was  at  last  formed  in  it,  apparently  of  a 
cartilaginous  nature.  Though  this  was  at 
first  as  large  as  a middling  plum,  and  gra- 
dually became  softer  and  smaller,  yet  it  did 
not  disappear  entirely.  Having  occasion  to 
go  out  six  weeks  after  the  accident,  the 
doctor  put  on  a pair  of  shoes,  with  heels 
two  inches  high,  and  contrived  a steel  ma- 
chine to  keep  his  foot  in  the  proper  position. 
This  machine, however,  lie  afterward  changed 
for  another,  made  of  the  same  materials  as 
the  former.  It  was  not  till  five  months  after 
the  accident,  that  he  thought  proper  to  lay 
aside  all  assistance,  and  to  put  the  strength  of 
the  tendon  to  a trial.  (See  Monro’s  Works , 
p.  661.) 

Both  in  a wouad  and  rupture  in  the  tendo 


TE8f 

Aehillis,  the  ancient  method  of  using  a 
suture  for  keeping  the  ends  of  the  tendon 
in  contact,  is  at  present  quite  exploded,  and 
position  of  the  limb  is  the  grand  agent,  by 
which  the  cure  is  now  universally  accom- 
plished. Thefollowing  was  Desault’s  method, 
which,  though  it  was  expressly  designed  to 
fill  all  the  above-mentioned  indications,  may 
not  be  a more  valuable  practical  plan  than 
what  was  adopted  by  Dr.  Monro.  After 
the  ends  of  the  tendon  had  been  brought 
into  contact  by  moderate  flexion  of  the 
knee,  and  complete  extension  of  the  foot, 
Desault  used  to  fill  up  the  hollows  on  each 
side  of  the  tendon,  with  soft  lint  and  com- 
presses. The  roller,  applied  to  the  limb, 
made  as  much  pressure  on  these  compresses 
as  on  the  tendon  ; and  hence,  this  part  could 
not  be  depressed  too  much  against  the  sub- 
jacent parts.  Desault  next  took  a compress 
about  two  inches  broad,  and  long  enough  to 
reach  from  the  toes  to  the  middle  of  the 
thigh,  and  placed  it  under  the  foot,  over  the 
back  of  the  leg  and  lower  part  of  the  thigh. 
He  then  began  to  apply  a few  circles  of  a 
roller  round  the  end  of  the  foot,  so  as  to 
fix  the  lower  extremity  of  the  longitudinal 
compress.  After  covering  the  whole  foot 
with  the  roller,  he  used  to  make  the  bandage 
describe  the  figure  of  8,  passing  it  under  the 
foot,  and  across  the  place  where  the  tendon 
was  ruptured  ; and  the  method  was  finished 
by  encircling  the  limb  upward  with  the 
roller,  as  far  as  the  upper  end  of  the  longi- 
tudinal compress.  (See  Monro’s  Works. 
Encyclopedic  Methodique , article  Achilla,  ten- 
don de,  and  Memoirs  sur  la  Division  du 
Tendon  d'Achille,  in  (Euvres  Chirurgicales 
de  Desault,  par  Bichat,  T.  1 ,p.  806.) 

A rupture  of  the  tendon  of  the  extensor 
muscles  of  the  leg,  would  require  nearly  the 
same  kind  of  treatment  as  a fracture  of  the 
patella.  However,  pressure  exactly  on  the 
broken  part  of  the  tendon  should  be  avoid  - 
ed, the  limb  should  be  kept  extended,  and 
somewhat  raised;  a bandage  might  be  put 
round  the  thigh,  and  antiphlogistic  treatment; 
be  at  first  adopted.  In  the  course  of  two 
or  three  weeks,  the  surgeon  should  cause 
the  joint  to  be  very  gently  moved,  without 
any  muscular  exertion  on  the  part  of  the 
patient  himself.  When  the  tendon  of  the 
triceps  extensor  cubiti  is  ruptured,  the  limb 
is  to  be  kept  straight  ; cold  applications  are 
to  be  used  for  a few  days,  and  if  necessary, 
strict  antiphlogistic  treatment  pursued. 

TENT.  A roll  of  lint  for  dilating  open- 
ings, sinuses,  &lc. 

TEREBELLA.  (dim.  of  terebra,  a perfo 
rating  instrument.)  A trepan,  or  instrument 
for  sawing  out  circular  portions  of  the  skull, 
A trephine. 

TEREBRA.  (from  to  bore.)  A tre- 
pan, or  trephine.  Also  an  instrument  called 
a perforator. 

TESTICLE,  DISEASES  OF.  For  au 
account  of  many  of  these  affections,  I must 
refer  to  distinct  articles  in  this  Dictionary  ; 
for  instance,  Cirsocele,  Fungus  Haniatodes, 
Hernia  Humoralis,  Hccmalocele , Hydrocele , 
fyc. 


TESTICLE. 


jNIr.  Pott  defines  sarcoc.de  to  be  a disease 
of  the  body  of  the  testicle,  and,  as  the  term 
implies,  it  consists,  in  general,  in  such  an 
alteration,  made  in  the  structure  of  that  or- 
gan, as  produces  a resemblance  to  a hard, 
fleshy  substance,  instead  of  that  fine,  soft, 
vascular  texture,  which  it  naturally  presents. 
u Sarcocele  (says  Call isen)  is  a name  applied 
to  every  chronic  swelling  of  the  testicle, 
attended  with  a total,  or  partial,  conversion 
of  the  part  into  an  heterogeneous  sub 
stance.”  ( Systema  Chirurgice  Hodiernce, 
Pars  2,  p.  144.)  According  to  these  defini- 
tions, sarcocele  becomes  a term  admitting 
of  almost  general  application  to  the  mor- 
bid affections  of  the  testicle,  since  most  of 
them  are  attended  with  induration  and 
swelling  of  the  part.  In  fact,  we  find  that 
the  old  writers,  and  a great  many  of  the 
moderns,  call  all  diseased  indurations  and 
enlargements  of  the  testicle  sarcoceles , whe- 
ther the  disorder  be  a simple,  chronic,  in- 
dolent tumour,  unaccompanied  with  any 
symptoms  of  specific  disease,  or  malignan- 
cy, or  whether  it  be  a scrofulous,  or,  what 
is  still  more  different  and  more  serious,  a 
truly  scirrhous  disorder  of  the  organ.  Even 
the  fungus  heematodes  of  the  testicle  was, 
until  lately,  often  termed  sarcocele. 

That  this  vague  method  of  employing  the 
word  sarcocele  can  be  attended  with  no 
advantage,  but,  on  the  contrary,  must  have 
a tendency  to  destroy  all  useful  discrimina- 
tion, is  a proposition,  the  truth  of  which  is 
-self-evident.  I am  well  aware,  that  Mr. 
Pott,  and  many  late  writers,  set  out  with  an 
idea  that  every  sarcocele  has  a propensity 
to  change  into  scirrhus,  and  actual  carcino- 
ma, and,  therefore,  the  latter  states  are  con- 
sidered by  these  authors  only  as  stages  of 
the  same  disease.  Indeed,  it  is  universally 
admitted  by  the  best  and  most  experienced 
observers,  that  a common  indolent  sarco- 
cele, a simple  fleshy  enlargement  of  the 
testicle,  may  change  into  the  peculiar  ma- 
lignant disease,  called  scirrhus,  or  cancer. 
But  yet  it  is  by  no  means  proved,  that  all 
the  diseases  which  are  comprehended  under 
the  name  of  sarcocele,  are  accompanied 
with  a risk  of  their  assuming  the  nature  of 
scirrhus  and  cancer ; for  nothing  can  be 
more  certain,  than  that  the  enlargement  of 
the  testicle,  produced  by  fungus  ha?matodes, 
is,  from  the  first  to  the  last,  always  of  one 
character,  and  can  never  change  into  ordi- 
nary scirrhus,  or  carcinoma.  Neither  do 
indolent  scrofulous  swellings  of  this  organ 
ever  undergo  such  an  alteration  as  to  de- 
serve the  epithets  of  scirrhous  and  cancerous. 
In  opposition  to  the  belief  of  Mr.  Hunter, 
(see  his  Treatise  on  ihe  Venereal  Disease,  p. 
59,;  some  surgeons  still  imagine,  that  there 
is  really  one  kind  of  chronic  enlargement 
of  the  testicle,  arising  from  a venereal  cause. 
(Roux,  Parallele  de  la  Chirurgie  Angloise, 
fyc.p.  305.  Richerand,  Nosographie  Chir.  T. 
4,  p . 300,  Edit.  4.)  Now  this  also  has  usu- 
ally been  called  a sarcocele  ; it  was  so  na- 
med by  Pott  himself,  and  if  there  be  such  a 
ca>e,  no  one  will  suppose  that  it,  or  any 
other  form  of  lues  venerea,  is  capable  of 


■161 

changing  into  a true  scirrhous  or  cancerous 
disease.  Perhaps,  therefore,  it  might  be 
more  consistent  and  advantageous  to  restrict 
the  appellation  of  sarcocele,  to  an  indolent 
fleshy  enlargement  of  the  testicle,  unac- 
companied with  any  present  symptoms  of 
malignancy,  or  any  marks  of  its  being  the 
effect  of  a specific  disease  ; and  as  soon  as 
the  case  evincesanothercharacter,  the  name 
should  correspond  with  the  particular  nature 
of  the  disease. 

We  need  not  here  enter  into  a minute  ac- 
count of  the  various  sarcomatous  diseases, 
to  which  the  testicle  is  subject  ; for,  they 
have  no  peculiarity  in  them,  except  what 
depends  upon  their  situation,,  and  the  gene- 
ral characters  of  the  different  species  of  sar- 
coma will  be  considered  in  a future  article. 
(•See  Tumour.)  -The  testicle  is  especially 
liable  to  three  kinds  of  sarcoma,  which  have 
been  named,  by  Mr.  Abernethy,  the  common 
vascular,  the  cystic , and  the  medullary.  The 
latter  case,  however,  which  is  often  called 
soft  cancer  of  the  testicle,  I shall  describe  in 
the  present  article,  in  order  that  the  reader 
may  judge  whether  there  is  any  material 
difference  between  this  case  and  another 
distemper  to  which  the  testicle  is  subject, 
(See  Fungus  Hcematodes.)  Sometimes  the 
testicle  is  converted  into  a truly  scrofulous 
mass.  It  is  increased  in  size,  and  when  cut 
into,  a whitish,  or  yellowish  coagulated 
matter  is  discovered,  mixed  with  pus.  The 
complaint  is  not  attended  with  so  much 
pain  and  induration  as  a scirrhous  disorder 
of  the  testicle  ; nor  does  it  produce  any  un  - 
favourable state  of  the  health. 

As  Dr.  Buillie  observes,  the  testicle  is  of- 
ten found  converted  into  a hard  mass,  of  a 
brownish  colour,  and  generally  intersected 
with  membranes.  Sometimes,  there  are 
cells  in  the  tumour,  which  are  filled  with  a 
sanious  fluid.  ( Morbid  Anatomy , <^c.  p.  352, 
353,  Edit.  2.)  This  is  the  truly  scirrhous  its 
tide  which  is  attended  with  great  hardness, 
severe  pains  darting  along  the  spermatic 
chord  to  the  loins,  and  an  unequal  knotty 
feel.  In  general  the  health  becomes  impair 
ed  To  use  Mr.  Pott’s  words,  sometimes 
the  fury  of  the  disease  brooks  no  restraint  : 
but,  making  its  way  through  a!!  the  mem 
branes,  which  envelope  the  testicle,  it  either 
produces  a large,  foul,  stinking,  phagedenic 
ulcer,  with  hard  edges,  or  it  thrusts  forth  a 
painful  gleeting  fungus,  subject  to  frequent 
hemorrhage.  (Pott's  Chimrgical  Works , 
Vol.  2,  p.  390,  Edit.  1808.)  These  latter 
states  of  the  disease  are  denominated  cancer 
of  the  testicle. 

Sooner  or  later,  the  scirrhous  induration 
extends  from  the  epididymis  upward  along 
the  spermatic  chord,  even  within  the  abdo- 
minal ring.  In  the  latter  circumstance,  the 
lymphatic  glands  in  the  groin  usually  be- 
come diseased  ; and  this  extension  of  mis 
chief,  together  with  the  impossibility  of  re- 
moving the  whole  of  the  diseased  chord,  too 
frequently  deprives  *the  patient  of  every 
chance  of  getting  well. 

I have  already  stated,  that  some  of  the 
most  simple  sarcomatous  enlargements  of 


TESTICLE. 


462 

the  testicle  are  capable  of  assuming,  in  a 
very  sudden  manner,  a malignant  and  can- 
cerous tendency  ; and  that  sometimes  the 
scirrhous  induration  of  the  chord  makes  a 
rapid  progress  upward.  Hence,  that  sur- 
geon acts  with  prudence,  who  recommends 
the  early  extirpation  of  every, testicle,  which 
is  incurably  diseased,  and  so  deprived  of  its 
original  organization,  as  to  be  totally  unfit 
for  the  secretion  of  the  semen. 

Chronic  enlargements  of  the  testicle  are 
sometimes  attended  with  an  accumulation  of 
limpid  fluid  in  the  tunica  vaginalis,  and  the 
disease  is  then  termed , hydro  arcocele,  an  ap- 
pellation first  employed  by  Fabricius  ab 
Aquapendente. 

The  hardness  and  swelling  of  the  epididy- 
mis, remaining  after  an  acuie  inflammation 
of  the  testicle  (see  Hernia  Humaraii •>,)  do 
not  Constitute  a complaint,  which  surgical 
authors  class  with  sarcocele ; for,  the  dis- 
ease hardly  ever,  increases  so  as  to  give 
trouble. 

I have  stated,  that  sarcoceles,  in  common 
with  the  generality  of  other  sarcomatous  tu- 
mours, may  change  into  dis, tempers,  which, 
in  point  of  malignity,  and  the  manner  in 
which  they  injure  the  health,  are  quite  as 
bad  as  cancer  itself,  ft  is  said,  however, 
that  sarcocele  of  the  epididymis  rarely  be- 
comes malignant,  and  is  much  more  easy 
of  cure,  than  the  same  disease  of  the  glan- 
dular portion  of  the  testicle  ; but  both  parts 
are  often  diseased  together. 

Sarcoceles  sometimes  continue  for  years, 
without  undergoing  any  particular  change  ; 
in  other  instances,  they  increase  with  sur- 
prising rapidity.  t he  inconveniences,  which 
they  excite,  often  proceed  chiefly  from  their 
weight  and  magnitude  : their  weight  occa- 
sions an  uneasy,  and  even  a painful  sensa- 
tion in  the  loins,  especially  when  the  pa- 
tient neglects  to  wear  a suspensory  bandage, 
or  a bag  truss  for  the  support  of  the  part. 
The  danger  of  a sarcocele  arises  from  the 
increase  and  extension  of  the  hardness  up 
the  spermatic  chord,  and  from  the  change 
of  the  tumour  from  its  indolent  state  into  a 
painful,  ulcerated,  and  incurable  disease. 

A sarcocele  sometimes1 'bears  a resemblance 
to  hydrocele  of  the  tunica  vaginalis.  It 
sometimes  has  the  usual  pyramidal  shape 
of  the  latter  disease,  and,  like  it,  is  always 
situated  at  the  lower  end  of  the  spermatic 
chord.  The  chief  difference  between  the 
two  cases  seems  to  be,  that  the  sarcocele  is 
bard,  while  the  hydrocele  has  a soft,  yield- 
ing, elastic  feel.  It  should  be  known,  how- 
ever, that  the  fungus  haematodes  of  the  tes- 
ticle is  remarkable  for  the  deceitful  feel  of 
fluctuation  and  elasticity,  which  it  presents  ; 
and  every  surgeon  ought  to  be  aware,  that  a 
sarcocele  is  not  always  particularly  hard, 
and  that  hydroceles  are  sometimes  exceed 
ingly  indurated.  The  sarcocele,  indeed,  is 
not  transparent;  neither  is  the  hydrocele  in 
certain  instances  ; and,  .these  are  cases,  in 
which  a mistake  may  easily  be  made.  Still, 
with  due  attention,  both  diseases  may  be 
discriminated  with  tolerable  precision,  the 
sarcocele,  when  held  in  the  surgeon’s  hand, 


seems  heavier  than  the  hydrocele.  Every 
part  of  a diseased  te  ticle  is  seldom  equally 
indurated,  so  that  the  sarcocele  is  usually 
much  softer  in  some  places  than  others. 
The  hydrocele  presents  the  same  kind  of 
feel  at  every  point,  except  behind,  where 
the  testicle  is  felt.  When,  in  the  case  of 
hydrocele,  pressure  is  made  in  this  latter 
situation,  the  patient  experiences  a much 
more  acute  sensation,  than  when  the  pres- 
sure is  made  upon  any  other  part  of  the  tu- 
mour ; but,  in  the  example  of  sarcocele, 
the  patient  commonly  has  the  same  kind  of 
feel  let  the  pressure  be  applied  to  any  part 
of  the  -.welling  whatsoever.  When  the  up- 
per portion  of  the  spermatic  chord  can  be 
fell,  and  it  seems  quite  hard  and  thickened, 
the  surgeon  has  reason  for  suspecting  the 
case  to  be  a sarcocele.  Lastly,  though  a 
hydrocele,  wrhen  gently  handled,  may  seem 
very  hard,  yet,  on  being  more  strongly  com- 
pressed, it  will  generally  betray  a soft,  elas- 
tic feel,  which,  excepting  instances  of  fungus 
haematodes,  is  never  the  case  with  an  indu- 
rated sarcocele. 

It  has  been  already  explained,  that  a sar- 
cocele is  sometimes  conjoined  with  a hy- 
drocele, which  case  is  well  known  among 
surgeons  by  tbe  appellation  of  hydro-sarco - 
cele.  As  the  diseased  testicle  is  then  sur- 
rounded with  fluid,  it  cannot  be  felt  and 
examined  by  the  fingers.  However,  when 
an  unusual  degree  of  hardness  is  percepti- 
ble at  the  back  part  of  the  tumour,  where 
the  testicle  is  situated,  or  when  the  upper 
portion  of  the  spermatic  chord  is  found  to 
be  quite  indurated,  there  is  reason  for  sus- 
pecting that  the  testicle  is  diseased.  The 
sarcocele  also  is  commonly  the  original  and 
principal  complaint,  the  hydrocele  not  oc- 
curring till  some  time  after  the  enlargement 
of  the  testicle. 

In  some  unusual  cases,  the  substance  of 
the  scrotum  is  converted  into  an  indurated 
mass,  which  occasionally  attains  a vast  size, 
and  presents  the  appearance  of  an  enormous 
sarcocele.  An  example  in  which  the  tu- 
mour weighed  701b.  has  been  lately  publish- 
ed by  Dr.  Titley  (See  . Med.  Chir  Trans . 
Vol.  6,  p.  73.)  In  one  case,  recorded  by  Dr. 
Cheston,  a swelling  of  this  kind  was  as  large 
as  a child’s  head.  On  dissection  of  the 
parts,  the  testicle  and  tunica  vaginalis  were 
found  to  be  quite  free  from  disease.  The 
tumour  proceeded  entirely  from  an  indura- 
tion of  the  cellular  membrarfe,  which  im- 
mediately covers  the  external  surface  of 
the  vaginal  coat.  This  curious  disease  is 
more  common  in  warm  climates,  and  seve- 
ral instances  of  it  were  met  with  in  Egypt 
by  Baron  Larrev.  (See  Mem.  de  Chir.  Mili- 
laire,  T.  2,  p.  1 10,  et  serp)  Some  interesting 
particulars  relative  to  it  will  be  found  in 
another  part  of  thte  Dictionary.  (See  Scro- 
tum.) 

The  operation  of  castration  -is  the  most 
certain  means  of  relieving  the  patient  from 
sarcocele.  This  measure,  however,  is  not 
invariably  practicable,  nor  is  it  always  ne- 
cessary ; for,  sometimes  the  induration  of 
the  testicle  admits  of  being  dispersed  by  the 


TESTICLE. 


judicious  employment  ot  internal  medicines 
and  external  applications.  The  hope  of  ac- 
complishing this  desirable  object  may  De 
reasonably  entertained,  when  the  swelling 
is  not  very  large,  when  it  has  not  existed  a 
considerable  time,  and  when  it  is  not  at- 
tended w ith  very  great  induration  Expe- 
rience has  proved,  that  some  kinds  of  s-tr- 
cocele  have  yielded  to  the  exhibition  of 
emetics,  ( Warner,  Pringle,  and  Home  i?i 
Chymical  Experiments ;)  to  a decoction  ot 
ono  .isspinos.  ( Bergius  Mai.  Med.  Richter's 
Chir.  Bibl.  7 B.  p 6U5  ;)  to  cicuta  and  bark 
(Warner ;)  to  mercurial  frictions  {Le  bran- 
B.  Bell,  Richer  and,  Detpech  ; to  the  external 
use  of  the  liquor  amnion,  acetatis  (Rich  er's 
Chir.  Bibl.  B.p.  127  ;)  to  poultices  contain- 
ing opium  (Fothergill,  in  Med.  Obs.ty  Inq. 
Vol.  5 ;)  to  a lotion  made  of  a strong  de- 
coction of  hemlock  ( Warner  ,')  to  the  steam 
of  vinegar,  the  repeated  employment  of 
leeches,  and  the  ap  lication  of  cold,  foe. 
The  operation  of  all  these  means  w ill  be  ad- 
vantageously assisted  by  the  continual  use 
of  a bag-truss,  the  observance  as  much 
as  possible  of  an  horizontal  position,  and 
attention  to  a suitable  low  diet. 

"Mr.  Pott  believed  that  the  man  who  has 
the  misfortune  to  be  afflicted  with  a sarco- 
cele,  has  very  little  chance  of  getting  rid 
of  the  disease  by  any  plan  except  extirpa- 
tion ; and  all  the  time  the  operation  is  de- 
ferred, he  carries  about  him  a part,  not  only 
useless  but  burdensome,  and  which  is  every 
day  liable  to  become  worse,  and  unfit  for 
such  an  operation.  JNow,  although  there 
is  a great  deal  of  truth  in  this  opinion,  yet, 
I conceive,  it  is  rather  exaggerated,  and  that 
it  would  tend  to  authorize  the  practice  f 
castration  to  an  extent  beyond  all  necessity. 
I certainly  think,  with  Mr.  Pott,  tha:  there 
never  was  a sarcocele  cured,  w here  the  or- 
ganization of  the  testicle  had  been  destroy- 
ed by  disease,  or  where  its  structure  had 
suffered  so  much  as  to  render  it  incapable 
of  the  office  for  w hich  it  is  destined.  But 
such  state  cannot  always  be  known  by  m 
spection  or  manual  examination,  and  were 
a surgeon  to  condemn  to  the  knife  every 
testicle  which  he  finds  affected  with  indo- 
lent swelling  and  induration,  he  wrould  re- 
move many  wdiich,  under  some  of  the^above 
plans  of  treatment,  might,  be  perfectly  cu- 
red. That  there  are  some  chronic  enlarge- 
ments ot  the  testicle  which  may  be  resolved, 
is  a truth  of  which  experience  must  have 
convinced  the  generality  of  surgeons. 

The  scrofulous  induration,  and  several 
other  swellings  of  this  organ,  which  are 
very  imperfectly  understood,  may  some 
times  be  benefited,  and  even  entirely  cured, 
just  like  some  analogous  affections  of  the 
breast.  What  is  termed  the  venereal  sarco 
cele  (Mr.  Pott  allows)  always  gives  way  to 
a mercurial  course  properly  conducted. 
The  diagnosis  of  this  case,  it  must  be  con- 
fessed, is  not  very  clearly  explained  by  sur- 
gical w riters,  nor  wras  its  reality  acknow- 
ledged by  Mr.  blunter.  According  to  Mr. 
Pott,  it  is  seldom  an  early  symptom,  and 
he  does  not  remember  ever  to  have  seen 


403 

an  instance  in  wdiich  it  was  not  either  im 
mediately  preceded,  or  accompanied  by 
some  other  appearances  plainly  venereal. 
He  adds,  that  it  has  neither  the  inequality 
nor  darting  paii  s of  scirrhus.  But  the 
question,  whether  the  case  is  truly  syphilitic 
or  not,  is  lar  less  interesting  than  the  ques- 
tion, whether  there  are  not  many  sarcoceles 
which  may  be  diminished  and  cured  by 
mercury  P The  affirmative  cannot  be  ques- 
tioind.  I have  seen  many  such  cases  my- 
self, and  there  are  numerous  examples  on 
record.  v statement  of  several  has  been 
lately  published  by  Richerand.  (See  Aroso - 
graphic  Chirurgicale,  T.  4,  p.  300,  et  seq. 
Edit.  4.)  The  authority  of  Delpech  is  also 
on  the  same  side.  Precis  Element  air  e dcs 
Maladies  Reputees , Chir  T.  3 ,p.  564.) 

Indeed  this  last  writer  maintains,  that 
many  common  sarcoceles  and  scirrhi  of 
the'esticle  are  so  much  alike  in  their  symp- 
toms. that  the  difference  of  their  nature 
cannot  always  be  at  once  detected  by  the 
practitioner.  Hence,  although  I am  an 
advocate  tor  the  early  performance  of  cas- 
tration in  cases  of  sarcocele,  w here  there  is 
reason  to  suppose  the  disease  so  far  advan  - 
ced, that  the  organization  of  the  testicle  is 
totally  destroyed;  or  where  internal  and 
external  remedies  have  been  tried  a certain 
time  in  vain  ; yet  these  sentiments  do  not 
incline  me  to  recommend  the  operation  for 
other  examples  in  which  the  disease  is 
quite  recent,  and  no  plan  of  treatment  what- 
soever has  been  fairly  tried,  i have  already 
enumerated  various  plans  of  treatment, 
which  have  been  proved  by  experience  to 
be  sometimes  capable  of  affording  relief. 
The  disease  of  the  testicle,  which  is  usually 
called  the  scrofulous  sarcocele,  like  other 
forms  of  scrofula,  often  gets  well  spontane- 
ously after  a certain  time,  and  it  may  fre  - 
quently be  considerably  benefited  by  admi- 
nistering internally  the  conium  maculatum, 
and  small  doses  of  the  submuriate  of  mer- 
cury ; lotions  of  sea-water,  or  poultices  of 
sea-w eetis,  being  applied  to  tne  scrotum. 
Several  other  indolent  enlargements  of  the 
testicle  yield  to  frictions  with  ca  . phorated 
mercurial  ointment  on  the  scrotum.  The 
late  Mr.  Ramsden  thought  that  some  sarco- 
celes might  be  relieved  by  removing  with 
bougies  a supposed  morbid  irritability  of  the 
urethra,  with  which  bis  theories  led  him  to 
connect  the  origin  of  the  complaint.  (See 
Pracl.  Obs.  on  Sdemceie,  fyc.)  The  novelty 
of  this  suggestion  for  a time  attracted  con- 
siderable notice  ; but  the  interest  which  it 
once  excited  has  now  died  away;  a suffi- 
cient proof  to  my  mind,  that  the  practice 
inculcated  was  not  of  much  value. 

From  the  preceding  observations,  it  may 
be  inferred,  that  all  chronic  enlargements 
of  the  testicles  are  not  incurable  ; but  that 
w e ought  at  the  same  time  to  be  duly  im- 
pressed with  the  expediency  of  not  wasting 
too  much  time  in  the  trial  of  means  which 
are  not  (6  be  depended  upon,  and  which 
if  continued  immoderately  long,  might 
allow  the  disease  to  advance  too  far  to  be 
capable  of  beipg  afterward  effectually  extiv 


TESTICLE. 


464 

pated.  According  to  Mr.  Foil,  the  circum- 
stances in  which  the  operation  of  castration 
is  adviseable,  or  not,  are  of  two  kinds,  and 
relate  either  to  the  general  habit  of  the  pa- 
tient, and  the  disorders  and  indispositions 
of  some  of  the  viscera,  or  to  the  state  of  the 
testicle  and  spermatic  chord 

A pale,  sallow  complexion,  in  those  who 
used  to  look  otherwise  ; a wan  counte- 
nance, and  loss  of  appetite  and  ilesh,  with- 
out any  acute  disorder  ; a fever  of  the  hec- 
tic kind;  and  frequent  pain  in  the  back 
and  bowels  are,  in  those  who  are  afflicted 
with  a scirrhous  testicle,  such  circumstances 
as  would  induce  a suspicion  of  some  latent 
mischief  in  some  of  the  viscera;  in  which 
case,  as  Mr.  Fott  truly  observes,  success 
from  the  mere  removal  of  the  testicle  is  not 
to  be  expected.  They  whose  constitutions 
are  spoiled  by  intemperance,  previous  to 
their  being  attacked  with  this  disease;  who 
have  hard  livers,  arid  anasarcous  limbs;  be 
says,  are  not  proper  subjects  for  such  an 
operation.  Hard  tumours  within  the  abdo- 
men, in  the  regions  of  the  liver,  spleen, 
kidneys,  or  mesentery,  implying  a diseased 
state  of  the  said  viscera,  are  very  material 
objections  to  the  removal  of  the  local  evil 
in  the  scrotum,  in  short,  whenever  there 
are  manifest  appearances,  or  symptoms  of 
a truly  diseased  state  of  any  of  the  principal 
viscera,  the  success  of  the  operation  be- 
comes very  doubtful. 

“ The  state  of  the  mere  testis  can  hardly 
ever  be  any  objection  to  the  operation  ; the 
sole  consideration  is  the  spermatic  chord  : 
if  this  be  in  a natural  state,  and  free  from 
disease,  the  operation  not  only  may,  but. 
ought  to  be  performed,  let  the  condition  of 
the  testicle  be  what  it  may  ; if  the  sperma- 
tic chord  be  really  diseased,  the  operation 
ought  not  to  be  attempted.  And  Mr.  Pott 
afterward  remarks,  “ when  the  spermatic 
vessels  are  not  only  turgid  and  full,  but  firm 
and  hard;  when  the  membrane  which  in- 
vests and  connects  them  has  lost  its  natural 
softness  and  cellular  texture,  and  has  con- 
tracted such  a state,  and  such  adhesions 
as  not  only  greatly  to  exceed  its  natural 
size,  but  to  become  unequal,  knotty,  and 
painful,  upon  being  handled,  and  this  state 
has  possessed  all  that  part  of  the  chord 
which  is  between  the  opening  in  the  oblique 
muscle  and  the  testicle,  no  prudent,  judi- 
cious, or  humane  man,  will  attempt  the 
operation;  because  he  will,  most  certainly, 
not  only  do  no  good  to  his  patient,  but  will 
bring  on  such  symptoms  as  w ill  most  ra- 
pidly, as  well  as  painfully  destroy  him.” 

“ On  the  other  hand,”  says  Pott,  “ every 
enlargement  of  the  spermatic  chord  is  not 
of  this  kind,  nor  by  any  means  sufficient  to 
prohibit  or  prevent  the  operation. 

“These  alterations  or  enlargements  arise 
from  two  causes,  viz.  a varicose  dilatation 
of  the  spermatic  vein,  and  a collection,  or 
collections,  of  fluid  in  the  membrane  in- 
vesting and  enveloping  the  said  vessels.” 
Shortly  afterward  the  same  practical  writer 
continues: — “ The  diseased  state  of  a truly 
r-cirrhous  testicle,  its  weight,  and  the  altera- 


tion that  must  be  made  in  the  due  and  pro- 
per circulation  of  the  blood,  through  both 
it  and  the  vessels  from  which  it  is  depend- 
ent, may  and  do  concur  in  inducing  a vari- 
cose dilatation  of  the  spermatic  vein,  with- 
out producing  that  knotty,  morbid  altera- 
tion and  hardness,  which  forbid  our  at- 
tempts. Between  these,  a judicious  and 
experienced  examiner  will  generally  be  able 
to  distinguish. 

“ In  the  former,  (the  truly  diseased  state) 
the  chord  is  not  only  enlarged,  but  feels 
unequally  hard  and  knotty  ; the  parts  of 
which  it  is  composed  are  undistinguishably 
blended  together;  it  is  either  immediately 
painful  to  the -touch,  or  becomes  so  soon 
after  being  examined ; the  patient  com- 
plains of  frequent  pains  shooting  up  through 
his  groin  into  his  back ; and  from  the  dis- 
eased state  of  the  membrane  composing 
the  tunica  communis,  such  adhesions  and 
connexions  are  sometimes  contracted,  as 
either  fix  the  process  in  the  groin,  or  render 
it  difficult  to  get  the  finger  and  thumb  quite 
round  it. 

“ In  the  other  (the  mere-varicose  disten- 
tion) the  vessels,  though  considerably  en- 
larged and  dilated,  are  nevertheless  smooth, 
soft,  and  compressible  ; the  whole  process 
is  loose  and  free,  and  will  easily  permit  the 
fingers  of  an  examiner  to  go  quite  round  it, 
and  to  distinguish  the  parts  of  wrhich  it  is 
composed  ; it  is  not  painful  to  the  touch  ; 
nor  does  the  examination  of  it  produce  or 
occasion  those  darting  pains  which  almost 
always  attend  handling  a process  malig- 
nantly indurated.” 

Mr.  Pott  next  explains  that,  “ in  the 
cellular  membrane,  leading  to  a diseased 
testicle,  it  is  no  very  uncommon  thing  to 
find  collectionsof  extravasated  fluid.  These, 
as  they  add  considerably  to  the  bulk  and 
apparent  size  of  the  process,  make  the  com 
plaint  appear  more  terrible;  and,  as  I have 
just  said,  less  likely  to  admit  relief. 

“ When  the  extravasation  is  general, 
through  all  the  cells  of  the  investing  mem- 
brane. and  the  spermatic  vessels  themselves 
are  hardened,  knotty,  and  diseased,  the 
case  is  without  remedy  ; for,  although  a 
puncture,  or  an  incision,  will  undoubtedly 
give  discharge  to  some,  or  even  the  greatest, 
part  of  the  fluid;  yet  this  extravasation  is 
so  small  and  so  insignificant  a circumstance 
of  the  disease,  and  the  parts,  in  this  state, 
are  so  little  capable  of  bearing  irritation, 
that  an  attempt  of  this  kind  must  be  inef- 
fectual, and  may  prove  mischievous. 

“But,  on /the  other  hand,  collections  of 
water  are  sometimes  made  in  the  same 
membrane,  from  an  obstruction  to  the  pro- 
per circulation  through  the  numerous  lym- 
phatics in  the  spermatic  process,  while  the 
vessels  themselves  are  really  not  diseased, 
and  therefore  very  capable  of  permitting  the 
operation.  In  this  case,  the  fluid  is  generally 
in  one  cyst,  or  bag,  like  to  an  encysted 
hydrocele,  and  the  spermatic  chord,  cyst 
and  all,  are  easily  moveable  from  side  to 
side  ; contrary  to  the  preceding  ,state  in 
which  the  general  lead  in  the  membrane 


TESTICLE. 


465 


fixes  the  whole  process,  and  renders  it 
almost  in  moveable. 

“ A discharge  of  the  fluid  will,  in  this 
case,  enable  the  operator  to  examine  the 
true  state  of  the  process,  and,  as  I have 
t wice  or  thrice  seen,  put  it  into  his  power  to 
free  his  patient  from  one  of  the  most  terri- 
ble calamities  which  can  befall  a man.” 
(See  Pott  on  Hydrocele,  tyc.) 

The  testicle  is  subject  to  a disease  often 
called  soft  cancer , which,  though  of  a 
very  malignant  and  incurable  nature,  is 
different  from  the  true  cancer,  already  de- 
scribed. It  has  been  particularly  noticed 
by  Mr.  Abernethy.  under  the  name  of  Me- 
dullary Sarcoma.  In  most  of  the  instances 
which  this  gentleman  has  seen,  the  tumour, 
when  examined  after  removal,  appeared  to 
be  of  a whitish  colour,  resembling  on  a 
general  and  distant  inspection,  the  appear- 
ance of  the  brain,  and  having  a pulpy  con- 
sistence. He  has  also  often  seen  it  of  a 
brownish  red  appearance.  The  following 
case  is  related,  to  illustrate  the  nature  and 
progress  of  the  disease. 

“ A tall,  thin,  healthy-looking  man,  of 
about  forty  years  of  age,  had,  about  fifteen 
years  before,  a swelled  testicle  from  a go- 
norrhoea ; the  epididymis  remained  indura- 
ted. Six  years  afterward  it  became  enlar- 
ged, and  a hydrocele  at  the  same  time 
formed.  Half  a pint  of  water  vvas  dischar- 
ged by  a puncture,  but  inflammation  suc- 
ceeded the  operation,  and  this  testis  became 
very  large.  An  abscess  formed,  and  burst 
in  the  front  of  the  scrotum,  and  the  testis 
subsided  in  some  degree.  Mercury  was 
employed  to  reduce  it,  but  without  effect. 
The  part,  however,  was  indolent,  and  gave 
the  patient  no  trouble  but  from  its  bulk. 

“ About  a year  afterward,  a gland  enlar- 
ged in  the  left  groin,  (ihe  same  side  as  the 
testis.)  another  then  became  swoln  in  the 
right  groin,  and  in  the  course  of  two  years, 
several,  glands  in  each  groin  had  attained  a 
very  considerable  magnitude.  At  this  peri- 
od, he  was  admitted  into  St.  Bartholoon  w’s 
Hospital,  under  the  care  of  Mr.  Long.  j.he 
testis  was,  at  this  time,  between  four  and 
five  inches  in  length,  and  about  three  in 
breadth:  it  resembled  its  natural  foim, 

and  wa-  indolent  in  its  disposition.  The 
spermatic  chord  was  thickened,  but  not 
much  indurated.  Four  or  five  glands  were 
enlarged  in  the  groin  on  both  sides  ; each 
of  which  was  of  the  size  of  a very  large 
orange  ; and  when  observed  together,  they 
formed  a tumour  of  very  uncommon  shape 
and  magnitude. 

“ They  gradually  increased  in  size  for 
several  months,  till  at  last  the  skin  appeared 
as  if  unable  to  contain  them  any  longer.  It 
became  thin,  inflamed,  and  ulcerated,  Tlrst 
in  the  left  groin,  and  thus  exposed  one  of 
the  most  prominent  tumours.  The  exposed 
tumour  inflamed  and  sloughed  progressive- 
ly, till  it  entirely  came  away.  As  the 
sloughing  exposed  its  vessels,  which  were 
large,  they  bled  profusely,  insomuch  that 
the  students  endeavoured,  but  in  vain,  to 
secure  them  by  ligatures  : for  the  substance 
Pox>  IF,  59 


of  the  tumour  was  cut  through,  and  tom 
away  in  the  attempt.  Pressure  by  the  fin- 
ger, eoniinued  for  some  time,  was  the  only 
effectual  mode  of  restraining  this  hemor- 
rhage. 

“ The  loss  of  one  gland  relieved  the  dis- 
tended skin,  which  had  only  ulcerated  on 
the  most  prominent  part  of  the  tumour,  and 
had  not  become  diseased.  It  now  lost  its 
inflamed  aspect:  granulations  formed,  and 
a cicatrix  took  place.  In  the  opposite  groin 
a similar  occurrence  happened.  One  gland, 
exposed  by  the  ulceration  of  the  skin,  slough- 
ed out,  being  attended  by  the  circumstances 
just  recited.  However,  htTorethe  skin  was 
cicatrized,  ulceration  had  agaUntken  place 
in  the  right  groin,  in  conseqlwice  of  the 
great  distention  of  the  skin  from  the  growth 
of  the  tumour;  and  sloughing  had  begun  in 
the  tumour,  when  the  patient,  whose  vital 
powers  had  long  been  greatly  exhausted, 
died.”  (See  Mlrnethys  Surgical  Observa- 
tions, 8fc°.  1S04.) 

The  preceding  kind  of  disease  is  now  ge- 
nerally considered  to  be  fungus  haematodes 
If  there  are  any  differences,  they  consist  in 
the  parts  sloughing  out,  and  then  healing, 
instead  of  a fungus  shooting  out,  and  con- 
tinually increasing  in  size.  (See  Fungus 
Haematodes.) 

JDi.  Bail  lie  has  noticed  some  affections,  in. 
which  the  testicle  becomes  bony,  cartilagin 
ous,  &o. ; but  on  these  it  is  not  necessary 
for  us  to  dwell  in  this  Dictiouary.  The 
preceding  observations  may  be  considered  as 
relating  expressly  to  the  diseases  for  which 
castration  is  generally  pertormed.  (See  Cas- 
tration.) 

Besides  the  fungus,  which  arises  from  the 
testicle  in  the  advanced  stage  of  carcinoma, 
arid  the  bieeding  fungous  growth,  which 
arises  from  tliis  organ  in  the  ulcerated  state 
of  fungus  hajmatodes,  there  is  another su 
perficial  fungous  excrescence,  to  which  the 
testicle  is  subject,  and  which  is  entirely  free 
from  all  malignancy.  The  disease  to  which 
I refer,  has  been  noticed  by  Callisen,  under 
the  name  of  lipoma  of  the  testicle.  “ Si  ex 
superlicie  albugineas  vel  ipsa  tunica  vaginali 
excrescentiae  surgunt,  totum  demum  testem 
involventes,  et  scirrhum  seu  fungum,  men- 
tientes,  ipsius  tamen  testis  substantia  parum 
aut  vix  de  statu  naturali  aberrante ; malum 
naturam  lipomatis  sequitur,  vix  unquamm 
scirrhum  et  carcinoma  abiens.”  (See  Sys- 
tema  Chirurgice  Hodi&rnce , Vol.  2,  p.  145, 
Edit.  i800.)  The  superficial  fungus,  or  lipo- 
ma of  the  testicle,  was  noticed  in  an  early 
edition  of  another  publication,  and  described 
as  “ a particular  affection  of  the  testicle,  iii 
which  a fungus  grow's  from  the  glandular 
substance  of  this  body,  and  in  some  instances, 
from  the  surface  of  the  tuniea  albuginea. 
This  excrescence  is  usually  preceded  by^tu 
enlargement  of  the  testicle,  in  consequence 
of  a bruise,  or  some  species  of  external  vio- 
lence, A small  abscess  takes  place  and 
bursts,  and  from  the  ulcerated  opening  the 
fungus  gradually  protrudes.”  I then  proceed- 
ed to  represent  how  unnecessary  and  impro- 
per it  was  to  extirpate  the  testicle,  on  account* 


1ES 


'i'ET 


406 

of  this  affection,  if  after  the  subsidence  of 
tiie  inflammation,  the  part  should  not  seem 
much  enlarged  and  indurated.  I recom- 
mended the  fungus  to  be  cut  off,  or  else  de- 
stroyed with  caustic;  and  1 founded  my  ad- 
vice on  a successful  attempt  of  the  first  kind, 
which  was  made  in  St.  Bartholomew’s  H os- 
pital,  by  Sir  Janies  Earle,  a little  while  before 
my  book  was  published.  (See  First  Lines  of 
the  Practice  of  Surgery , p.  399.) 

An  interesting  little  paper  has  also  been 
written  on  the  subject,  by  my  friend  Mr. 
Lawrence,  who  has  favoured  the  public  with 
a more  particular  account,  and  nine  cases 
iliustrativigtf  the  causes,  symptoms,  and 
progress  tlWe  disorder.  According  to  Mr. 
Lawrence,  the  patient  generally  assigns  some 
blow’,  or  other  injury,  as  the  cause  of  the 
complaint  ; in  other  instances,  it  originates 
in  consequence  of  the  hernia  humoralis 
from  gonorrluea,  and  sometimes  appears 
spontaneously.  A painful  swelling  of  the 
gland,  particularly  characterized  by  its  hard- 
ness, is  the  first  appearance  of  the  disease. 
After  a certain  length  of  time,  the  scrotum, 
growing  gradually  thinner,  ulcerates;  but 
the  opening  which  is  thus  formed,  instead  of 
discharging  matter,  gives  issue  to  a firm,  and 
generally  insensible  fungus.  The  surround- 
ing integuments  and  cellular  substance  are 
thickened  and  indurated  by  the  complaint, 
so  that  there  appears  to  be  altogether  a con- 
siderable mass  of  disease.  The  pain  abates, 
and  the  swelling  subsides  considerably,  when 
t he  scrotum  has  given  way.  In  this  state, 
the  disorder  appears  very  indolent ; hut  if 
the  fungus  be  destroyed  by  any  means,  the 
integuments  come  together,  and  a cicatrix 
ensues,  which  is  inseparably  connected  with 
the  testicle.  Mr.  Law  rence  next  informs  us, 
that  if  the  part  be  examined  while  the  fun- 
gus si  ill  remains,  the  excrescence  is  found  to 
have  its  origin  in  the  glandular  substance  of 
the  testicle  itself ; that  the  coats  of  the  part 
are  destroyed  to  a certain  exteut ; and  that 
a protrusion  of  the  tubuli  seminiferi  takes 
place  through  the  aperture  thus  formed. 
Mr.  Lawrence  says,  he  has  often  ascertained 
the  continuity  of  the  excrescences  with  the 
pulpy  substance  of  the  testicle,  of  which 
more  or  less  remains,  according  to  the  differ- 
ence in  the  period  of  the  disorder.  The 
same  gentleman  thinks,  that  the  glandular 
part  ot  the  testicle  experiences  an  inflamma- 
tory affection  in  the  first  instance,  in  conse- 
quence of  the  violence  inflicted  on  it ; and 
that  the  confinement  of  the  swollen  sub- 
stance, by  the  dense  and  unyielding  tunica 
albuginea,  sufficiently  explains  the  peculiar 
hardness  of  the  tumour,  and  the  pain  w hich 
is  always  attendant  on  this  stage  of  the  dis- 
order. The  absorption  of  the  coats  of  the 
toslis,  and  of  the  scrotum,  obviates  the  ten- 
sion of  the  parts,  and  (hereby  restores  ease  to 
the  patient,  at  the  same  time  that  the  fungus 
makes  its  appearance  externally. 

With  regard  to  the, treatment,  Mr.  Law- 
rence is  of  opinion,  that  if  thecomplaint  were 
entirely  left  to  itself,  the  swelling  would  pro- 
!'  bably  subside,  the  fungus  shrink,  and  a com- 
plete cure  ensue,  without  any  professional 


assistance  ; but  lie  adds,  that  the  disorder  is 
so  indolent  in  this  stage,  that  a spontaneous 
cure  would  not  be  accomplished  till  after 
much  time.  He  says  that  the  excrescence 
may  be  removed  wiih  a knife,  or  if  the  na- 
ture of  its  attachment  permit,  with  a ligature, 
or  that  it  may  be  destroyed  with  escbarotic 
applications.  Mr  Lawrence  very  judicious- 
ly gives  die  preference  to  removing  the 
tumour  to  a level  with  the  scrotum,  by  means 
of  the  knife,  as  the  most  expeditious  and  ef- 
fectual mode  of  treatment.  He  can  discern 
no  ground  whatever  for  proposing  castration 
in  this  malady,  since  in  no  part  of  its  progress, 
nor  in  any  of  its  possible  consequences  and 
effects,  can  it  expose  the  patient  to  the  slight- 
est risk. 

Mr.  Lawrence  also  mentions  the  possibili- 
ty of  there  being  other  kinds  of  tungi,  which 
may  be  met  with,  growing  from  the  testicle, 
and  quotes  an  distance,  in  which  Dr.  Ma 
cartney  found  a fungus,  of  a firm  and  dense 
Structure,  growing  from  the  tunica  albugi- 
nea, while  all  the  substance  of  the  testicle 
it  self  was  sound.  Dr.  Macartney  was  so  kind 
as  to  show  me  the  preparation,  affording  a 
clear  specimen  of  the  second  kind  of  fungus. 
The  cases  drawn  up  by  Mr.  Lawrence  are^ 
in  my  opinion,  highly  interesting,  and  may 
be  read  in  The  Edinb.  Med.  and  Surg.  Jour 
nal,for  July , 1808. 

I have  already  noticed,  that  Cailisen  repre 
seats  the  lipoma,  as  sometimes  originating 
from  the  surface  of  the  tunica  vaginalis,  a 
kind  of  case  which  has  not  yei  fallen  under 
my  observation. 

In  the  preface  to  the  last  edition  of  this 
Dietionai y,  p.  10,  I quoted  a case,  published 
by  Dr.  H.  Weinhold,  in  which  the  operation 
for  bubonocele  was  performed,  and^is  the 
testicle  wTas  diseased,  the  surgeon  ftade  a 
complete  division  of  (he  spermatic  chord,  tied 
the  spermatic  arteries,  and  then  left  the  tes- 
ticle in  its  natural  situation.  After  a 
time,  the  absorbents  had  diminished  the  part 
to  a very  inconsiderable  little  tumour.  (See 
Journ.  der  Pracl.  Heilkunde  von  C.  IV.  Hufe- 
land  and  K.  Himly , 1812,  Zehntes,  Stack, 
p.  112.)  This  case  merits  attention,  and 
ought  to  have  been  cited  in  the  article  Cas- 
tration, because  it  is  the  first  instance,  l be- 
lieve, m which  such  practice  was  tried 
Subsequently,  the  following  work  has  been 
published,  (hough  I have  not  yet  met  with 
it.  u JYouvelle  Methode  de  trailer  le  Sarcocele. 
sans  avoir  rccours  a V extirpation  du  Testicule , 
par  C.  Th.  Maunoir , 8i>o.  Geneve,  1820 
The  new  plan  consists  in  dividing  and 
tying  the  spermatic  arteries,  and  leaving 
the  rest  of  the  chord  and  the  testis  undis- 
turbed. 

TETANUS.  (from  <rziva>,  to  stretch.) 
Tetanus  is  defined  by  all  authors  to  be  a 
more  or  less  violent,  and  extensive  controc 
tipn  of  the  muscles  of  voluntary  motion,  at- 
tended with  tension  and  rigidity  of  the  parts 
affected. 

The  excessive  contraction  of  the  muscles 
is  kept  up  without  any  intervals  of  complete 
relaxation,  in  which  respect  the  disorder  dif- 
fers from  ordinary  spasms  and  convulsions. 


TETANUS'. 


467 


where  the  contractions  and  relaxations  alter- 
nate in  rapid  succession.  In  tetanus,  the 
powers  of  sensation  and  intellect  also  re- 
main unimpaired,  in  which  particularity  it 
forms  a contrast  to  epilepsy.  ( Rees's  Cyclo- 
pedia, art.  Tetanus.) 

When  its  effects  are  confined  to  the  mus- 
cles of  the  jaw  or  throat,  it  is  called  trismus 
or  locked  jaw  ; when  all  the  body  is  affected 
and  becomes  rigid,  but  retains  its  ordinary 
straightness,  the  case  is  named  tetanus. 
When  the  body  is  bent  forwards,  the  di-ease 
is  termed  emprosihotonos  : and  opisthotonos , 
when  the  muscles  of  the  back  are  principally 
affected. 

To  these  four  forms,  some  writers  have 
added  a fifih,  which  they  denominate  pltu- 
rosthotonos,  and  w hich  is  characterized  by 
the  body  being  drawn  to  one  side.  It  is  the 
tetanus  lateralis  of  Sauvages. 

The  different  terms  which  are  applied  to 
tetanic  affections,  do  not  imply  so  many 
particular  diseases;  but  only  the  seat  and 
various  degrees  of  one  and  the  same  com- 
plaint. 

A far  more  important  division  of  tetanus, 
is  into  the  acute  and  chronic , according  to  its 
greater  or  lesser  intensity.  The  first  is  ex- 
ceedingly dangerous, and  usually  fatal ; whiie 
the  latter,  on  account  of  the  more  gradual 
progress  of  the  symptoms,  affords  more  op- 
portunity of  being  successfully  treated.  ( Lar - 
rey,  in  Mem.  de  Cliirurgie.  Militairc,  T.  1,  p. 
235,  236.; 

Tetanus  may  also  be  distinguished  into 
the  traumatic , or  that  arising  from  wounds, 
being  the  case  with  which  surgeons  have 
principally  to  deal;  and  into  the  idiopathic, 
or  that  proceeding  from  a variety  of  other 
causes. 

atraumatic  tetanus  sometimes  comes  or.  in 
a surprisingly  sudden  manner,  and  quickly 
attains  its  most  violent  degree.  The  most 
rapidly  fatal  case  that  has  ever  been  record- 
ed, is  one  that  we  have  on  the  authority  of 
the  late  Professor  Robison  of  Edinburgh.  It 
occurred  in  a negro,  who  scratched  his 
thumb  with  a broken  china  plate,  and  died 
of  tetanus  a quarter  of  an  hour  after  this 
slight  injury.  (See  Rees's  Cyclopaedia , art. 
Tetanus.)  But  commonly,  the  approaches 
of  the  disorder  are  more  gradual,  and  it 
- slowly  advances  to  its  worst  6tage.  In  this 
sort  of  case,  the  commencement  of  the  dis- 
order is  announced  by  a sensation  of  stiff- 
ness about  the  neck,  a symptom,  which  in- 
creasing by  degrees,  renders  the  motion  of 
the  head  difficult  and  painful.  In  propor- 
tion as  the  rigidity  of  the  neck  becomes 
greater,  the  patient  experiences  about  the 
root  of  tbe  tongue,  an  uneasiness  which 
soon  changes  into  a difficulty  of  mastication 
and  swallowing,  which  after  a time  became 
totally  impossible.  The  attempt  at  degluti- 
tion is  abended  with  convulsive  efforts,  es- 
pecially when  an  endeavour  is  made  to 
swallow*  liquids  ; and  so  great  is  the  distress 
which  accompanies  these  convulsions,  that 
the  patient  becomes  very  reluctant  to  renew 
the  trials,  an*  refuses  all  nourishment. 
Sometimes  it  even  inspires  him  with  a dread 


of  the  sight  ot  water, and  a great  resemblance 
to  hydrophobia  is  produced. 

One  of  the  next  remarkable  symptoms  is 
a very  severe  pain  at  the  bottom  of  the  ster- 
num, darting  from  this  point  backward  to 
tbe  spine,  in  the  direction  of  the  diaphragm. 
As  soon  as  this  pain  commences,  the  spasms 
of  all  the  muscles  about  the  neck  become 
exceedingly  violent,  and  tbe  head  is  drawn 
backwards  or  forwards,  according  as  the 
contraction  of  the  extensor  or  flexor  mus- 
scles  happens  to  be  strongest  ; but  in  the 
majority  of  cases,  the  hea  I and  trunk  are 
curved  backwards,  (Royer,  Traite  dts  Mai. 
Chir.  T.  1 ,p.  288.)  and  the  contractions  in- 
creasing in  force,  the  body  is  frequently 
raised  in  the  form  of  a bow,  resting  upon 
the  head  and  feet  alone  ; a state  which  is 
more  particularly  denominated  opisthotonos. 
(Rees's  Cyclopaedia,  art.  Tetanus.)  At  the 
same  time,  the  muscles  wrhich  close  the 
lower  jaw,  and  which  were  affected  with 
spasm  and  rigidity  in  the  very  beginning  of 
the  disorder,  now  contract  with  great  pow- 
er, so  as  to  maintain  tbe  lower  jaw-bone  in- 
separably applied  to  the  upper  one.  The 
last  state,  which  has  been  considered  as  a 
particular  affection  under  the  name  of  tris- 
mus or  the  locked-jaw,  Boyer  conceives  may 
be  regarded  as  tbe  pathognomonic  symptom 
of  tetanus,  which  in  many  instances  is  limit- 
ed to  such  an  affection  of  the  jaw. 

The  muscles  affected  in  tetanic  cases  are 
never  altogether  relaxed,  as  long  as  the  dis- 
ease continues  ; but  still  they  become  more 
violently  contracted  in  the  frequent  parox- 
ysms of  spasm,  which  always  attend  the 
complaint,  and  increase  as  it  advances. 

The  continuance  of  the  disease  is  marked 
by  the  increasing  spasm  of  the  diaphragm, 
which  now  returns  every  ten  or  fifteen  mi- 
nutes, and  is  instantly  succeeded  by  a 
stronger  retraction  of  the  head  and  rigidity' 
of  the  muscles  of  the  back,  and  even  of  those 
of  the  lower  extremities.  The  abdominal 
muscles  are  also  strongly  contracted,  so  that 
the  belly  feels  as  hard  and  tense  as  a board. 
By  the  violence  of  the  contractions,  indeed, 
tbe  recti  muscles  have  been  known  to  be 
lacerated,  as  l shall  relate  an  example  of 
hereafter.  Sometimes  the  spasm  and  ten- 
sion extend  only  to  the  muscles  on  one  par- 
ticular side  of  the  body  : the  tetanus  lateralis 
of  Sauvages,  and  the  pleuroslholonos  of  other 
nosologists. 

When  the  disease  reaches  its  most  violent 
stage,  the  flexor  muscles  of  the  head  and 
trunk  contract  so  powerfully,  that  they 
counterbalance  tbe  force  of  tbe  extensors, 
and  hold  tiiose  parts  in  a straight,  fixed,  im- 
moveable position.  This  is  the  condition  to 
which  the  appellation  of  tetanus  more  par 
ticularly  belongs.  The  muscles  of  the  lower 
extremities  become  rigid  ; and  even  the 
arms,  which  till  now  were  little  affected, 
also  partake  of  the  general  spasm  and  stiff- 
ness, with  the  exception  of  the  fingers, 
which  often  retain  their  moveableness  to 
tbe  last.  The  tongue  likewise  continues  a 
long  while  endued  with  the  power  of  volun- 
tary motion  ; but.  at  length,  the  viol  err 


T ETA  IN  OS. 


-HiS 


spasms  do  not  leave  it  unaffected,  and  it  is 
then  liable  to  be  forcibly  propelled  between 
the  teeth,  where  it  is  sometimes  dreadfully 
lacerated. 

In  the  extreme  period  of  the  disorder,  all 
the  muscles  destined  for  voluntary  motion, 
are  affected  ; among  others,  those  of  the 
face  ; the  forehead  is  drawn  up  into  fur- 
rows ; the  eyes,  sometimes  distorted,  are 
generally  fixed  and  motionless  in  their  sock 
ets  ; the  nose  is  drawn  up,  and  the  cheeks 
are  retracted  towards  the  ears  ; so  thai  the 
features  undergo  a most  extraordinary 
change  When  tetanus  arrives  at  this  stage, 
and  the  spasms  arc  universal,  a violent  con- 
vulsion usually  puts  an  end  to  the  patient’s 
misery. 

Wherever  the  muscular  contractions  are 
situated  in  cases  of  tetanus,  they  are  always 
accompanied  with  the  most , excruciating 
pain.  They  sometimes  last,  without  any 
manifest  remission,  to  the  end  of  the  disor- 
der ; but  in  almost  all  cases,  their  violence, 
and  the  sufferings  excited  by  them,  undergo 
periodical  diminutions  every  minute  or  ttto. 
The  relaxation,  however,  is  never  such  as  to 
let  the  muscles,  which  experience  it  yield 
to  the  action  of  their  antagonists  ; and  it  is 
in  nearly  all  cases  followed,  in  ten  or  twelve 
minutes,  by  a renewal  of  the  previous  con- 
tractions and  suffering.  The  recurrence  of 
these  aggravated  spasms  frequently  happens, 
without  any  evident  cause;  but  it  is  often 
determined  by  efforts  which  the  patient 
makes  to  change  his  posture,  swallow, 
speak,  &c. 

As  Dr.  Cullen  observes,  the  attacks  of 
this  disease  are  seldom  attended  with  any 
fever.  When  the  spasms  are  general  and 
violent,  the  pulse  is  contracted,  hurrie1.  and 
irregular,  and  the  respiration  is  affected  in 
tike  manner;  but  during  the  remission,  both 
the  pulse  and  respiration  usually  return  to 
their  natural  state.  The  heat  of  the  body  is 
commonly  not  increased  ; frequently  the 
face  is  pale,  with  a cold  sweat  upon  it ; and 
very  often  the  extremities  are  cold,  with  a 
cold  sweat  over  the  whole  body.  When, 
however,  the  spasms  are  frequent  and  vio- 
lent, the  pulse  is  sometimes  more  full  and 
frequent,  than  natural ; the  face  is  flushed, 
and  a warm  sweat  is  forced  out  over  the_ 
whole  body. 

“ Although  fever  be  not  a constant  attend- 
ant of  this  disease,  especially  when  arising 
from  a lesion  of  nerves  ; yet  in  those  cases 
proceeding  from  cold,  a fever  sometimes 
.has  supervened,  and  is  said  to  have  been 
attended  with  inflammatory  symptoms. 
Blood  lias  often  been  drawn  in  this  disease, 
but  it  neve?  exhibits  any  inflammatory  crust ; 
and  all  accounts  seem  to  agree,  that  the 
blood  drawn  seems  to  be  of  a looser  texture 
than  ordinary,  and  that  it  does  not  coagu- 
late in  the  usual  manner. 

“In  this  disease  the  head  is  seldom  af- 
fected with  delirium,  or  even  confusion  of 
thought,  till  the  last  stage  of  it  ; when  by 
the  repeated  shocks  of  a violent  distemper, 
every  function  of  the  system  is  greatly  dis- 
ordered /tfk 


“ It  is  no  less  extraordinary,’  that  in  tin. 
violent  disease  the  natural  functions  are  not 
either  immediately  or  considerably  affected. 
Vomitings  sometimes  appear  early  in  the 
disease  but  commonly  they  are  not  conti- 
nued ; and  it  is  usual  enough  for  the  appe- 
tite of  hunger  to  remain  through  the  whole 
course  of  the  disease  ; and  what  food  hap- 
pens to  be  taken  down  seems  to  be  regularly 
enough  digested.  The  excretions  are  some- 
times affected,  but  not  always.  The  urine, 
is  sometimes  suppressed,  or  is  voided  with 
difficulty  and  pain.  The  belly  is  costive; 
but  as  we  have  hardly  any  accounts,  ex- 
cepting of  those  cases  in  which  opiates  have 
been  largely  employed,  it  is  uncertain  whe- 
ther the  costiveness  has  been  the  effect  of 
the  opiates  or  of  the  disease.  In  several 
instances  of  this  disease  a miliary  eruption 
, has  appeared  upon  the  skin,  but  whether 
this  be  a symptom  of  the  disease,  or  the  ef- 
fect of  a certain  treatment  of  it,  is  undeter- 
mined. In  the  mean  while,  it  has  not  been 
observed  to  denote  either  safety  or  danger, 
or  to  have  any  effect  in  changing  the  course 
of  the  distemper. ’’ — ( First  Lines  of  the  Prac- 
tice of  Physic , Vol.  3.) 

According  to  Baron  Larrey,  the  opistho- 
tonos is  not  so  often  observed  in  Egypt  as 
the  einprostbotonos,  and  the  experience  of 
this  gentleman  taught  him  that  the  former 
was  the  most  rapidly  fatal.  We  must  not 
adopt,  however,  his  curious  opinion,  that 
the  violent  extension  of  the  vertebra?  of  the 
neck,  and  the  manner  in  which  the  head  is 
thrown  back,  cause  strong  compression  of 
the  spinal  marrow,  and  a permanent  con- 
traction of  the  larynx  and  pharynx,  (Mem. 
dc  Chirurgie  Militaire,  T.  1,  p.  240.)  since 
this  sort  of  compression,  if  it  did  not  at  ^ice 
destroy  the  patient,  would  at  any  rate  jroru 
lize  most  of  the  muscles,  and  instantly  stop 
their  extraordinary  contraction. 

This  experienced  writer  notices  how 
much  the  nerves  of  the  neck  and  throat 
seetn  generally  to  be  affected  on  the  inva- 
sion of  this  disease.  The  consequent  con- 
traction of  the  muscles  of  these  parts,  he 
says,  is  soon  attended  with  difficulty  of  de- 
glutition and  respiration.  The  patients  then 
experience,  if  not  a dread  of  liquids,  at  least 
a great  aversion  to  them,  which  often  pre- 
vents the  administration  of  internal  reme- 
dies; and  if  the  wound  is  out  of  reach  of 
the  interference  of  art,  (he  patient  is  doom- 
ed to  undergo  the  train  of  sufferings  attend- 
ant on  this  cruel  and  terrible  disorder.  No- 
thing can  surmount  the  obstacles  which 
present  themselves  in  the  (esophagus.  The 
introduction  of  an  elastic  gum-catheter  into 
this  canal,  through  the  nostrils,  is  followed 
hy  convulsions  and  suffocation.  “ I have 
tried  this  means  (says  Larrey)  on  the  per 
son  of  M.  Navailh,  a surgeon  of  the  second 
class,  who  died  of  a locked-javV,  brought  on 
by  a wound  of  the  face,  accompanied  with 
a comminuted  fracture  of  the  bones  of  the 
nose,' and  part  of  the  left  orbit. 

“ In  the  examination  of£fe  bodies  of  pri- 
son's dead  of  tetanus,  I have  found  the  pha 
rynx  and  oesophagus  much  contracted,  and 


TETAMj:- 


their  internal  membrane  red,  inflamed,  and 
covered  with  a viscid  reddish  mucus. 

“ Hydrophobia,  hysteria,  and  several 
other  nervous  diseases,  likewise  produce 
their  chief  effects  upon  these  organs,  and 
the  result  appears  to  be  the  same.  So,  I 
have  just  remarked,  when  tetanus  is  ar 
rived  at  its  worst  degree,  the  patients  have 
a great  aversion  to  liquids,  and  if  they  are 
forced  to  swallow  them,  immediate  convul- 
sions are  excited.  This  circumstance  was 
particularly  observed  in  M.  Navailh.” — 
(Mm.  da  Chirurgie  Mi  lit  air  e,  T.  1,  p.  247, 
248.) 

Sometimes  tetanic  affections  deviate  from 
their  ordinary  course  and  nature.  The  most 
singular  of  these  anomalies  is  recorded  by  Sir 
Gilbert  Blane  ; it  is  a case  in  which  tetanus 
prevailed  to  a very  considerable  extent, 
without  any  degree  of  pain.  The  spasms 
were  accompanied  with  a tingling  sensation, 
which  was  even  rather  agreeable  than  dis- 
tressing. The  case,  however,  terminated 
fatally  ; but,  to  the  last,  no  pain  was  expe- 
rienced. In  two  examples,  mentioned  by 
the  same  author,  the  spasms  affected  only 
the  side  of  the  body  in  which  the  wound 
was  situated. 

The  dissection  of  patients  who  have  died 
of  tetanus,  has  thrown  no  light  upon  the 
nature  of  this  fatal  disorder.  Sometimes 
slight  effusions  are  found  within  the  cra- 
nium ; but,  in  general,  no  morbid  appear- 
ance whatever  can  be  detected  in  the  head. 
There  is  always  more  or  less  of  an  inflam- 
matory appearance  in  the  oesophagus  and 
in  the  villous  coat  of  the  stomach  about  the 
cardia.  But  those  who  are  conversant  a ith 
dissections  must  be  well  aware,  that  these 
appearances  are  common  to  a great  num- 
ber of  diseases,  and  are  uniformly  met  with 
in  every  case  of  rapid  or  violent  death. 
Besides  the  redness  and  increased  vascula- 
rity of  these  parts,  Baron  Larrey,  as  I have, 
already  stated,  found  the  pharynx  and  oeso- 
phagus much  contracted,  and  covered  with 
a viscid  reddish  mucus.  He  also  found  nu- 
merous lumbrici  in  the  bowels  of  the- seve- 
ral patients  who  died. — (See  Mem.  de  Chir. 
Mililaire,  T.  3 ,p.  2S7.)  This,  however,  could 
only  be  an  accidental  complication,  and 
not  a cause.  In  several  cases,  Dr.  M’Arthur 
found  the  intestines  much  inflamed,  and  in 
two  of  them  a yellow,  waxy  fluid,  of  a pe- 
culiar offensive  smell,  covered  their  internal 
surface  : but  whether  the  inflammation  was 
primary,  or  only  a consequence  of  the  pres- 
sure erf  the  abdominal  muscles,  which  con- 
tract so  violently  in  this  disease,  he  is  una- 
ble to  decide, — (See  Med.  Chir.  Trans.  Col. 
7,  p.  475,  and  Rees's  Cyclopaedia , art.  Teta- 
nus.) 

Dr.  Lionel  Chalmers,  of  Charleston, 
South-Carolina,  states,  that  when  the  disease 
forms  very  quickly,  and  invades  the  unfor- 
tunate persons  with  the  whole  train  of  its 
mischievous  symptoms,  in  a few  hours,  the 
danger  is  proportioned  to  the  rapidity  of  the 
attack,  and  that  the  patients  thus  seized, 
generally  die  in  24,  3o,  or  48  hours,  and 
very  rarely  survive  the  third  day.  Rut 


469 

when  the. disease  is  less  acute,  few  arc  lost 
after  the  ninth  or  eleventh.  (See  Mid.  Ob s. 
and  Imp  Vol.  1 , p.  92, 93.) 

From  the  valuable  report  of  Sir  Jamc 
Macgrigor,  it  appears,  that  several  hundreds 
of  cases  of  tetanus  occurred  in  our  army, 
during  tiie  late  campaigns  in  Spain  and  Por- 
tugal. The  disease  was  observed  to  come 
on  at  uncertain  periods  after  the  receipt  of 
the  local  injury  ; but  it  terminated  on  the 
second,  third,  and  fourth  days,  and  even  as 
late  as  the  seventeenth  and  twentieth  day  ; 
though  it  was  usually  not  protracted  beyond 
the  eighth.  (Med.  Chir.  Trans.  Vol.  6,  p. 
353.) — 1 had  a patient,  however,  who  lin- 
gered in  the  military  hospital  at  Oudenbosch 
five  weeks,  with  chronic  tetanus,  before  he 
died.  This  happened  in  the  year  1814,  soon 
after  the  assault  on  Bergcn-op-Zoom,  where 
the  patient  had  been  wounded,  and  suffered 
amputation  of  the  thigh. 

Although  tetanus  is  a disease  which  has 
been  observed  in  almost  ail  parts  of  the 
world,  experience  proves  that  its  frequency 
is  much  the  greatest1  in  warm  climates,  and 
especially  in  the  hot  seasons  of  those  cli- 
mates.- It  is  also  more  common  in  marshy 
situations,  and  countries  bordering  upon  the ' 
sea,  than  in  places  which  are  very  dry,  ele- 
vated, and  at  a distance  from  the  sea-coast. 
Every  class  of  individuals  is  exposed  to  its 
attacks  , but  infants,  a few  days  after  their 
birth,  and  middle-aged  persons,  are  said  to 
be  oftener  affected  than  older  subjects,  or 
others  in  the  youthful  period  of  life.  The 
male  sex  more  .frequently  suffer  than  the 
female  ; and  tiie  robust  and  vigorous  more 
frequently  than  the  weaker. 

According  to  Dr.  Cullen  and  other  medi- 
cal writers,  the  causes  of  tetanus  are  cold 
and  moisture  applied  to  the  body  while  it  is 
very  warm,  and  especially  the  sudden  vicis- 
situdes of  heat  and  cold.  Or  the  disease  is 
produced  by  punctures,  lacerations,  or  other 
injuries.  Cullen  admits,  however,  that  there 
are  probably  some  other  causes,  which  are 
not  distinctly  known. 

Baron  Larrey  observed,  that  gunshot 
wounds  in  the  course  of  the  nerves,  and 
injuries  of  the  joints,  often  produced  teta- 
nus in  the  climate  of  Egypt,  particularly 
when  the  weather,  or  temperature,  passed 
from  one  extreme  to  the  other,  in  damp 
situations,  and  in  those— which  were  adja- 
cent to  the  Nile,  or  the  sea.  What  he  terms 
dry  and  irritable  temperaments,  were  the 
most  subject  to  the  disorder,  the  event  of 
which  was  found  to  be  almost  always  fatal 
( Larrey , Op.  et  Loc.  cit.)  ' 

Traumatic  tetanus  is  remarked  to  proceed 
oftener  from  wounds  of  the  extremities, 
than  from  similar  injuries  of  the  trunk,  head, 
and  neck.  Sometimes  it  originates  at  the 
moment  of  the  accident,  as  in  the  instance 
mentioned  by  die  late  Professor  Robison  of 
Edinburgh  ; but  in  general,  it  does  not 
come  on  till  several  days  afterward,  some- 
times not  till  the  wound  is  nearly  or  per- 
fectly healed,  and  free  from  all  pain  and 
uneasiness.  Wounds  of  every  description 
may  give  rise  to  tetanus,  and  in  warm  cli 


TETANUS. 


mates,  very  trivial  injuries  produce  it.  Thus, 
in  Egypt,  Larrey  had  one  case  which  pro- 
ceeded from  the  lodgment  of  a small  piece 
of  fish-bone  in  one  of  the  sinuses  of  the 
fauces.  ( M6m.de  Chir urgie  Militaire,  T.  1, 
p.  254.)  There  can  be  no  doubt,  however, 
that  in  colder  regions,  traumatic  tetanus 
seldom  happens  except  from  contused,  punc- 
tured, or  lacerated  wounds  ; or  wounds  of 
the  ginglimoid  joints,  with  iaceration  of  the 
tendons  and  ligaments ; compound  fractures, 
or  dislocations;  deep  pricks  in  the  sole  of 
the  foot  ; and  especially  lacerations  of  the 
fingers  and  toes.  A partial  division  of  a 
nerve  has  been  suspected  as  a cause  ; but 
as  some  nerves  must  be  imperfectly  cut 
through  in  almost  every  wound,  and  yet 
tetanus  does  not  arise,  the  reajity  of  this 
cause  is  doubtful.  Besides,  if  it  were  true, 
the  cure  would  be  easily  effected  by  making 
the  division  of  the  nerve  complete,  which 
experience  contradicts.  Baron  Larrey,  how- 
ever, has  recorded  a fact,  which  favours  the 
opinion,  as  I shall  presently  notice.  The 
inclusion  of  the  nerves  in  the  ligatures  ap 
plied  to  arteries  is  another  alleged  cause  of 
tetanus;  but  as  this  fault  is  very  "common, 
and  tetanus  rather  rare  in  this  country, 
while  it  may  follow  all  sorts  of  wounds, 
whether  accidents  or  operations,  the  accu- 
racy of  this  opinion  may  also  be  doubled. 
In  support  of  it,  however  there  are  some 
cases  and  observations  adduced  by  Larrey, 
which  will  be  quoted  in  the  sequel  of  this 
article.  (See  T.  3,  of  his  Mem.  de  Chir.  Mil.) 
I do  not  mean  to  hint,  however,  that  the 
nerves  are  not  sometimes  tied  in  tetanic 
cases,  or  that  the  practice  is  not  on  every 
account  blaineable.  Amputation  and  cas- 
tration are  the  only  great  surgical  operations 
to  which  1 have  seen  tetanus  succeed  ; 
though  it  may  follow  the- employment  of 
the  knife  on  less  severe  occasions. 

In  warm  countries,  tetanus  is  an  ordinary 
consequence  of  all  kinds  of  wounds. 

There  cannot  be  a doubt,  that  difference 
of  climate  makes  considerable  difference  in 
the  degree  and  danger  of  tetanus.  Larrey 
found,  that  in  Egypt  the  disease  was  more 
intense,  and  bore  a greater  resemblance  to 
hydrophobia,  than  in  the  colder  climate  of 
Germany.  In  both  these  countries,  he  re- 
marked, tiiat  when  the  wounds  causing  te- 
tanus, injured  nerves  situated  on  the  fore- 
part of  the  body,  emprosthotonos  was  occa- 
sioned ; that  if  the  posterior  nerves  were 
.hurt,  opisthotonos  followed  ; and  that  when 
the  wound  extended  quite  through  a limb, 
so  as  to  injure  equally  both  descriptions  of 
jierves,  complete  tetanus  ensued.  lie  no- 
ticed, also,  that  the  disease  commonly  arose 
from  wounds,  when  the  seasons  and  tempe- 
rature passed  from  one  extreme  to  another. 
Exposure  to  the  cold  damp  nocturnal  air,  he 
found  particularly  conducive  to  it.  (Bee 
jtfthn.  de  Chirurgie  Militaire,  T.  3.  p.  286.) 

In  the  late  campaigns  of  our  armies  iri 
Spain  and  Portugal,  according  to  the  report 
of  Sir  James  Macgrigor,  tetanus  occurred  in 
every  description,  and  in  every  stage  of 
wounds,  from  the  slightest  to  the,  most  for- 


midable : it  followed  the  healthy  and  Jhfe 
sloughing  ; the  incised  and  the  lacerated , 
the  most  simple,  and  the  most  complicated. 
It  occurred  at  uncertain  periods ; but  it 
was  remarked,  that  if  it  did  not  commence 
before  22  days  from  the  date  of  the  wound, 
the  patient  was  sate.  (See  Med.  Chir.  Trans. 
Vcl  6,  j>.  453.)  Li  Egypt,  as  we  learn  from 
Larrey,  the  latest  period  of  the  commence- 
ment of  tetanus  after  a wound,  was  from 
the  filth  to  the  fifteenth  day.  {Mem.  dc 
Chir.  Militaire , T.  l,p.  263.) 

It  is  observed  by  Dr.  Dickson,  that  as  the 
acute  toi  m ot  tetanus  is  so  uniformly  fatal, 
it  is  ot  the  greatest  consequence  to  attend  to 
whatever  may  assist  in  detecting  the  dis- 
ease early,  or  in  warding  it  off.  Ricberand 
states,  that  in  wounds  threatening  convul- 
sions and  tetanus,  a persevering  extension 
of  the  limbs  during  sleep  often  manifests 
itself,  before  any  affection  of  the  lower  jaw 
and  we  should  naturally  pay  more  attention 
to  any  admonition  of  this  kind  in  punctured, 
or  extensive  lacerated  wounds,  particularly 
of  tendinous,  or  ligamentous  parts,  and  es- 
pecially in  injuries  of  the  feet,  hands  knee- 
joint,  back,  &c.  Some  prelusive  indications 
of  danger  may  often  be  derived  from  the 
increase  of  pain,  irritation,  restlesness,  ner- 
vous twitchmgs,  pain  and  difficulty  in  de- 
glution,  or  in  turning  the  head  ; spasms,  or 
partial  rigidity  of  some  of  the  voluntary 
muscles : pain  at  the  scrobiculus  cordis  ; a 
suppressed,  or  vitiated  state  of  the  discharge. 
&c.  which  mark  the  slower  approaches  of 
the  disease.  Larrey  adduces  several  in- 
stances of  telanus,  in  which  the  wound  was 
either  dry,  or  afforded  only  a scanty  serous 
exudation,  and  where  the  symptoms  were 
relieved  on  suppuration  being  re-establish- 
ed ; and  Dr.  Reid,  in  the  Edinburgh  Medical 
and  Surgical  Journal  for  July  1*15,  remarks, 
that  on  removing  the  dressing,  the  wound 
was  covered  with  a darkish  unhealthy-look- 
ing matter,  and  that  he  had  seen  this  change 
the  forerunner  of  tetanus  in  two  other  in- 
stances. A torpor  of  the  intestines  has  ge- 
nerally been  observed  to  precede,  as  well 
as  accompany  the  disease,  and  Boyer,  in 
particular,  enumerates  an  obstinate  cousti 
pation  among  the  predisposing  causes. 
{Traiti  des  Mai.  Chir.  '/’.  I,  p.  287.)  Mr. 
Abernethy  also  informs  us,  that  in  four  cases 
where  he  inquired  into  the  state  of  the  bow- 
els, the  evacuations  were  not  like  feces; 
and  he  proposes  as  a question,  in  investiga- 
ting the  cause,  what  is  the  state  of  the  bow- 
els between  the  infliction  of  the  injury, and 
the  appearance  of  this  dreadful  malady 
{Abernethy' s Surgical  Works.  Vol.  1,  p ■ 1R4.) 
Dr  Parry  thinks  the  velocity  of  the  circula- 
tion an  useful  criterion  of  the  danger  of  the 
disease,  and  observes,  tiiat  if  the  pulse  be 
not  above  1(H),  or  1 10,  by  the  fourth  or  fifth 
day,  the  patient  almost  always  recovers; 
but  that  it  it  be  quickened  early,  the  disease 
mostly  proves  fatal,  and  yet  there  are  a few 
instances  of  recovery,  where  the  pulse  has 
risen  to  120  on  the  first  day.  Baron  Larrev 
remarks,  that  when  the  perspiration,  which 
so  often  attends  the  disease  is  symptomatic 


iKTAiNiJS 


it  begins  upon  the  iiead  ami  extremities;  but 
that  when  it  is  critical,  it  occurs  over  the 
chest  and  the  abdomen.  ( Mtmoires  de  Chir. 
Militaire , T.  1 ,p.  256.)  It  must  be  confess- 
ed, however,  that  in  many  cases,  perspira- 
tion Hows  very  freely,  without  bringing  re- 
lief. ( Rees's  Cyclopaedia,  arl.  Tetanus.) 

I next  proceed  to  consider  the  treatment 
of  tetanus  a subject  of  infinite  difficulty,  be- 
cause the  disease  frequently  baffles  every 
mode  of  practice,  and  in  certain  instances, 
get  well  under  the  employment  of  the  very 
same  remedies,  which  decidedly  fail  in  other 
similar  cases  of  the  disorder.  Every  plan 
has  occasionally  succeeded,  and  every  plan 
lias  still  more  frequently  miscarried.  The 
great  difficulty,  therefore,  is  to  ascertain, 
among  numerous  discordant  accounts,  what 
practice  is  found  on  the  whole  to  be  attend- 
ed with  the  least  ill-success?  For,  in  the  pre- 
sent state  of  our  knowledge,  the  most  cre- 
dulous practitioner  will  not  flatter  himself 
with  the  supposition,  that  any  effectual  re- 
medy for  tetanus  has  yet  been  discovered. 
As,  however,  tetanus  was  regarded  by  Hip- 
pocrates and  the  ancients  as  certainly  mor 
tal,  and  it  does  not  always  prove  so  in  mo- 
dern times,  it  seems  allowable  to  conclude 
that  the  recoveries,  which  now  happen, 
must  be  ascribed  to  improvements  in  prac- 
tice This  reflection  should  lead  us  not  to 
give  up  the  subject  as  hopeless ; but  to  re- 
double our  exertions  for  the  discovery  of  a 
more  successful  method  of  treatment,  and 
if  possible,  of  some  new  medicine,  possess- 
ing more  specific  power  over  the  disorder. 

As  it  is  justly  observed  by  a well-inform- 
ed writer,  w hen  we  reflect  upon  the  obscu- 
rity which  involves  both  the  ratio  sympto- 
matum , and  the  proximate  cause  of  tetanic 
affections,  we  need  not  wonder,  that  the 
practice  in  these  disorders  should  still  be 
entirely  empirical.  The  indication  of  cure, 
which  is  generally  applicable  in  all  diseases, 
namely,  the  removal  of  the  exciting  causes, 
has  but  little  place  in  a morbid  condition, 
which  is  the  consequence  of  causes,  that  in 
general  have  ceased  to  act,  or  which  it  is 
not  in  our  power  either  to  remove  or  con- 
trol. In  those  cases,  where  we  could  sup- 
pose local  irritation  to  be  still  operating,  the 
most  effectual  method  o£  counteracting  its 
effects  on  the  system,  would  obviously  be 
to  intercept  all  communication  between 
the  seat  of  the  irritation  and  the  sensorium. 
If,  however,  the  disease  has  already  esta- 
blished itself,  and  the  severe  symptoms  have 
come  on,  it  does  not  appear  that  this  would 
succeed  iti  arresting  the  course  of  the  disor- 
der. Experience  has  but  too  fully  shown, 
that  the  amputation  of  the  limb,  from  the 
injury  of  which  the  tetanus  has  arisen,  will 
very  seldom  procure  even  a mitigation  of 
the  symptoms,  if  performed  after  a certain 
period  from  their  first  appearance.  ( Rees's 
Cyclopaedia,  art.  Tetanus.)  Baron  Larrey 
has  been  the  greatest  modern  advocate  for 
the  performance  of  amputation  in  cases 
where  tetanus  depends  upon  a wound  of  the 
extremities  ; but  the  facts  which  he  has  ad- 
duced in  its  favour  are  not  numerous,  and 


4U 

he  limits  lus  recommendation  of  ike  measure 
chiefly  to  chronic  cases,  and  extends  it  to  ho 
others,  except  on  the  very  first  accession  of 
the  symptoms. 

“ The  equally  unexpected  and  entire  suc- 
cess (observes  Larrey,)  obtained  by  the  am 
putation  of  the  injured  limb,  in  the  person 
of  an  officer  attacked  with  chronic  tetanus, 
leads  me  to  propose  the  question,  whether , 
in  this  disorder,  occasioned  by  a wound  of 
sme  part  of  the  extremities,  it  would  not  be 
better  to  amputate  the  injured  limb  immedi- 
ately the  symptoms  of  tetanus  commence,  rather 
than  expect  from  the  resources  of  nature,  and 
from  very  uncertain  remedies , a cure  which  so 
seldom  happens  ? 

u If  tetanus  is  chronic,  as  is  sometimes  ob- 
served. amputation  may  be  done  at  every 
period  of  the  disorder,  provided  a choice  be 
made  of  the  time  when  there  is  an  inter- 
mission of  the  symptoms.  The  operation 
would  not  answer  so  well  in  acute  tetanus, 
if  the  disease  were  advanced,  and  the  mus- 
cles to  be  divided  were  strongly  contracted 
and  rigid,  as  l have  observed  at  the  siege  of 
Acre  in  a soldier,  who  was  seized  with  teta- 
nus in  consequence  of  a gun-hot  wound  of 
the  left  elbow.”  ( Mim.deChir . Militaire.  T. 

1 ,p.  262.) 

Larrey  did,  indeed,  try  amputation  in  a few 
instances  of  acute  tetanus.  In  the  case  last 
cited,  the  symptoms  were  already  considera- 
bly advanced,  when  the  experiment  of  am- 
putating the  arm  was  made  ; yet,  says  Lar- 
rey, the  operation  was  followed  by  consider- 
able ease.  The  symptoms  recurred,  how- 
ever, a few  hours  afterward,  and  proved 
fatal  on  the  third  day.  In  another  example, 
this  gentleman  repeated  the  experiment, 
though  acute  tetanus  had  begun,  'the  ope- 
ration is  described  as  having  stopped  all  the 
symptoms,  as  it  were,  by  enchantment  ; the 
patient  even  passed  twelve  hours  in  perfect 
ease  ; but  being  exposed  to  the  damp  cold 
air,  the  disorder  returned,  and  carried  him 
off.  (See  Mem.  rle  Chirurgie  Militaire,  T.  1 , 
j p.  263 — 269.)  The  Baron  also  records  some 
cases  in  favour  of  amputation  at  the  com 
mencementof  tetanus  from  wounds,  and  es- 
pecially for  (he  relief  of  the  disease  in  the 
cliroruc  form.  He  has  likewise  adduced  an 
interesting  example,  in  which  speedy  relief 
and  a cure  followed  cutting  off’  all  commu- 
nication between  the  nerves  of  the  wound 
ed  part  and  the  sensorium  by  a suitable  in- 
cision. 

In  this  place  I think  it  right  to  remind  the 
reader,  that  although  Baron  Larrey  once  or 
twice  amputated  when  acute  tetanus  was 
somewhat  advanced,  he  does  not  advise  the 
practice,  and  he  expressly  restricts  his  sanc- 
tion of  amputation  to  chronic  or  quite  inci- 
pient ( ases  of  tetanus,  and  to  a few  instances 
in  which  the  ginglimoid  joints  are  fractured, 
accidents,  which,  independently  of  tetanus, 
would  generally  require  the  operation.  (See 
Mem.  de  Chir.  Mil.  T.  3.)  The  report  of  Sir 
James Macgrigor fully  confirms  the  stale;  ent 
of  1 jarrey  ; namely,  that  free  incisions  are 
of  little  avail  in  the  acute  and  fully  formed 
disease,  and  that  amputation  fails  in  the  same 


TETANUS. 


"kind  of  case.  After  Ihe  battle,  of  Toulouse, 
this  operation  was  extensively  tried  ; but 
without  success.  Th>'  French  are  also. said 
to  have  lo3t  an  immense  number  of  s Idieis 
from  tetanus  after  I lie  battle  of  Dresden, 
when  S i James  infers  that  the  practice, of 
amputation  must  have  been  fairly  tried.  (See 
Medico -Chir urgica l Trans.  Vol.  6,  p 456.) 
We  have  seen,  however,  that  according  to 
the  precepts  of  Larrey,  (lie  French  -urgeons 
would  only  have  performed  the  operation  in 
chronic  cases,  which  are  not  the  most  fre- 
quent,  or  if  in  other  instances  only  on  the 
very  first  accession  of  Ihe  symptoms.  Bui 
upon  the  whole,  notwithstanding  the  partial 
degree  of  success  attending  Larrey’s  experi- 
ments, I have  no  hesitation  in  declaring  my 
belief,  that  amputation  of  the  i jured  part  in 
cases  of  chronic  tetanus  will  never  be  exten- 
sively adopted.  Tne  uncertain  efficacy  of 
this  severe  measure,  and  the  occasional  pos- 
sibility of  curing  this  form  of  the  complaint 
by  milder  (dans,  will  tor  ever  constitute  insu- 
perable arguments  against  the  practice. 

Since  the  last  edition  of  this  Dictionary 
was  printed,  Sir  Astley  Cooper  has  published 
his  sentiments  respecting  the  plan  of  ampu- 
tating in  cases  of  tetanus,  and  ihpy  tend  to 
confirm  tRF  opinion  which  I have  always 
given  upon  the  subject.  In  one  case  of  te- 
tanus, i rom  a compound  fracture  just  above 
the  ankle,  the  operation  seemed  to  precipi- 
tate the  fatal  event.  In  another  case,  the 
finger  was  amputated  without  any  good  ; and 
a third  case  is  referred  to,  in  which  the  ope- 
ration also  failed  in  saving  the  patient's  life. 
In  chronic  tetanus,  amputation  is  regarded 
by  Sir  A.  Cooper  as  unjustifiable,  as  the  pa- 
tient often  recovers  w ithout  this  proceeding. 
The  medicine  which  has  appeared  to  this  gen- 
tleman most  useful  in  Mich  cases,  is  the  sub- 
muriate of  rne  cuiy,  joined  with  opium 
(Surgical  Essays.  Part  2 ,/>.  190.) 

On  the  subject  of  making  incisions  for  the 
purpose  of  separating  the  nervps  of  the 
wounded  part  from  the  seusorium,  Larrey 
states,  that  they  should  be  practised  before 
inflammation  lias  come  on  ; for  if  this  has 
made  progress,  (hey  would  be  useless,  and 
even  dangerous.  They  should  comprehend, 
as  much  as  possible, all  the  nervous  filaments 
and  membranous  parts  ; but  he  cond-  m ns 
all  incisions  into  joints,  as  exasperating  the 
symptoms  of  tetanus,  instances  of  which  lie 
has  witnessed..  The  Baron  has  recorded 
some  convincing  proofs ot  the  benefit  some- 
times arising  from  completely  dividing  the 
trunk  of  the  injured  nerve.'  in  one  instance, 
tetanic  symptoms  followed  an  injury  of  the 
supraorbitary  nerve,  but  were  immediately 
slopped  by  dividing  some  of  the  fibres  of  the 
occipito-frontalis,  and  the  nerves  and  vessels, 
down  to  the  bone. 

On  the  principle  of  destroying  the.  parts, 
which  are  Ihe  scat  of  the  local  irritation, 
Banm  Larrey  also  frequently  applied  the 
actual  and  potential  cautery  to  the  wound. 
The  application  ot  caustics,  says  he,  may  be 
practised  with  advantage  on  the  lit  si  attack 
of  the  symptoms,  the  same  precept  being  ob- 
served as  in  making  the  incision:  Bleeding, 


if  necessary,  and  the  use  ot  topical  emollients 
and  anodynes,  may  follow  these  operations  , 
though  in  general  they  have  little  effect 
(Man.  de.  Chir.  Militairc , T.\,p.  249.)  In  the 
third  volume  ot  this  interesting  work,  p.  297 
are  several  cases',  in  which  the  cautery 
was  employed  with  success.  We  must  not 
conclude,  however,  that  much  dependence 
ou  ht  <o  he  placed  in  the  use  of  the  cautery, 
since  Larrey  observes  in  another  place  ; 
“ The  moxa  and  actual  cautery  recommend 
ed  Ity  the  Father  of  Medicine,  have  been 
equally  unavailing.  The  moxa  was  employ- 
ed a1  Jaffa  upon  three  wounded  men  ; the 
disease  notwithstanding  followed  its  usual 
course,  and  terminated  fatally. 

‘ l have  cited  a striking  instance  of  the 
i efficacy  of  t he  second  method,  in  a case 
ot  opisthotonos.”.  (T.l,  p.258  ) This  au- 
thor also  adduces  some  cases  which  tend  to 
support  the  opinion,  that  tetanus  occasional- 
ly proceeds  from  the  inclusion  of  a large 
nerve  in  the  ligature  applied  to  an  artery. 
The.  son  of  General  Darmagnao  died  of  te 
tanus  consequent  to  amputation,  and  upon 
examining  the  slump,  the  median  nerve  was 
found  in  eluded  in  the  ligature  with  the  arte 
ry,  and  its  extremity  reddish  and  swollen 
(Mini,  de  Cfiir.  Mil.  T 3,  p.  287.)  In  ano 
tiler  case,  Larrey  suspected  the  tetanic  disor- 
der to  proceed  from  a principal  branch  of 
the  crural  nerve  being  tied  together  with  the 
femoral  artery,  and  he  cut  the  ligature  ; but 
the  relief  was  only  partial  and  temporary 
The  cautery  was  therefore  applied  deeply  to 
the  whole  surtace  of  the  slump.  A marked 
amendment  took  place  a few  hours  after- 
ward, and  the  patient  recovered.  A diapho 
retie  mixture,  with  camphor  and  opium,  was 
also  exhibited.  ( T.  3,  p.  297.) 

Among  other  local  means  for  the  relief  of 
tetanus,  we  miirht  as  well  notice  the  employ- 
ment of  blisters  as  near  as  possible  to  the 
wound,  or  their  application,  or  that  of  the 
O) ut uteri!  of  cantharides,  to  the  wound  itself. 
Almost  all  modern  writers  have  observed, 
that  tetanus  is  accompanied  at  its  commence- 
ment and  in  its  progress  with  an  interruption, 
or  total  cessation  of  suppuration  in  the 
wound.  Hence  the  indication  to  excite  this 
process  again  by  the  means  which  I have 
specified.  Larrey  seems  to  have  adopted 
both  plans  ',  but  he  particularly  applied  the 
ointment  of  cantharides  to  the  wound  itself 
in  an  early  stage  of  the  symptoms,  and  in 
cases  vyhere  there  not  only  was  a suppression 
of  the  discharge,  but  where  he  suspected  the 
nerves  of  the  wounded  part  had  suffered 
from  exposure  to  the  cold  damp  air,  on  the 
detachment  of  the  sloughs.  For  facts  in  fa 
vour  of  these  local  means,  the  reader  must 
refer  to  the  first  and  second  volumes  of  the 
Memoires  de  Chirurgie  Militaire. 

It  appears  also  from  Larrey’s  experience 
iu  Egypt,  that  poultices  made  of  the  leaves 
of  tobacco,  and  applied  to  the  wounds  of 
persons  labouring  under  tetanus,  are  follow- 
ed by  no  advantageous  effect.  The  alka- 
lies also  proved  of  no  service.  (Toni.  I ,p. 
257.) 

) shall  conclude  these  remarks  on  what 


TETANUS. 


may  be  called  the  local  treatment  ot'  tetanus, 
with  mentioning,  that  the  celebrated  Dr. 
Itush  recommended  the  wound  to  be  dilated 
and  dressed  with  oil  of  turpentine.  (See 
Trans,  of  the  American  Philos.  Society , Vol. 
2 ;)  and  that  our  naval  surgeons  often  use 
tincture  of  opium  as  a dressing. 

A great  degree  of  obscurity  prevails  re- 
specting the  most  eligible  general  or  constitu- 
tional plans  of  treating  tetanus,  and  I am 
afraid  it  must  be  confessed,  that  our  internal 
remedies  cannot  be  more  depended  upon, 
than  the  local  means  already  described. 
This  opinion  is  fully  confirmed  by  adverting 
to  the  discouraging  fact,  recorded  by  Sir 
James  Macgrigor,  viz.  that  out  of  several 
hundreds  of  cases  which  occurred  in  the 
British  army  during  the  late-  campaigns  in 
Spain  and  Portugal,  there  were  very  few 
which  terminated  successfully, or  in  which  the 
remedies,  however  varied,  seemed  to  have 
any  beneficial  influence  after  the  disease  had 
made  any  progress.  {Medico- Chir.  Trans. 

Vol.  6,  p.  449.)  The  possibility  of  doing 
much  good  by  internal  medicines  is  also 
sometimes  totally  prevented  by  the  inabili- 
ty of  swallowing  which  afflicts  the  patient. 
In  short,  the  present  state  of  our  knowledge 
respecting  tetanus,  will  not  allow  us  to  in- 
dulge much  hopes  of  cure  from  any  means 
yet  discovered,  except  in  the  chronic  form 
of  the  complaint,  the  instances  of  success 
in  the  treatment  of  acute  tetanus  being  by 
no  means  numerous. 

Of  all  medicines,  opium  is  that  which  has 
raised  the  greatest  expectation,  and  been  the 
most  extensively  tried  in  cases  of  tetanus. 
Indeed,  there  cannot  be  a doubt,  that  in 
many  chronic,  mild  cases,  it  is  competent  to 
effect  a cure.  But  for  this  purpose,  it  is  ab- 
solutely necessary  that  its  use  be  begun  from 
the  earliest  appearance  of  the  symptoms ; 
that  it  be  given  in  very  large  doses  ; and  that 
the  doses  be  repeated  at  short  intervals,  so 
that  the  system  be  kept  constantly  tinder  the 
influence  of  the  remedy,  ft  is,  indeed,  as- 
tonishing how  the  system,  when  labouring 
under  a tetanic  disease,  will  resist  the  opera- 
tion of  this  and  other  remedies,  which,  in  its 
ordinary  state,  would  have  been  more  than 
sufficient  to  overpower  and  destroy  it.  Pa- 
tients with  tetanus  will  bear,  with  impunity, 
quantities  of  opium,  which  at  any  other  time 
would  have  been  certainly  fatal.  Instances 
are  upon  record  of  five,  ten,  and  even  twen- 
ty grains,  being  taken  every  two  or  three 
hours,  for  many  days,  without  any  extraor- 
dinary narcotic  effects  being  produced  upon 
the  sensorium.  It  is  always  adviseable,  how- 
ever, to  begin  with  comparatively  moderate 
doses,  such  as  forty  or  sixty  drops  of  the 
tincture  of  opium,  which  may  be  repeated 
at  intervals  of  three  or  four  hours,  and  in- 
creased at  each  repetition,  until  some  sensible 
effect  is  produced  on  the  spasms.  It  seems 
requisite  to  augment  the  dose  rapidly,  a9  the 
disease  presses  upon  u?  every  hour,  and  no 
time  must  be  lost  while  there  is  yet  a chance 
of  controlling  its  fury.  The  approaching 
closure  of  the  jaw,  and  difficulty  of  degluti- 
tion, which  may  increase  so  as  to  render  it 
Vol.  II  SO 


hardly  possible  to  introduce  medicines  into 
the  stomach,  are  additional  motives  for  push- 
ing our  remedies  before  such  obstacles  arise. 
{Rees's  Cyclopaedia,  art.  Tetanus.)  I once  sup- 
posed it  might  be  possible  to  overcome  this 
impediment  by  introducing  a flexible  cathe- 
ter down  the  cesophagus  from  oue  of  the  nos- 
trils; but  the  attempt  to  do  this  always 
brings  on  a violent  paroxysm  of  spasms,  at- 
tended with  such  a sense  of  suffocation  that 
it  cannot  be  endured.  The  experience  of 
my  friend,  the  late  Mr.  Cruttwell,  of  Bath, 
and  that  of  Baron  Larrey,  have  fully  proved, 
that  no  assistance  can  be  derived  in  these 
circumstances  from  the  use  of  any  flexible 
tubes.  (See  M6m.  de  Chir.  Militaire , T.  l,p. 
247.)  Sometimes,  however,  the  obstacle  to 
the  administration  of  medicines,  arising  from 
the  closure  of  the  jaw,  is  prevented  bv  loss 
of  some  of  the  incisor  teeth,  and,  in  a few 
instances,  Baron  Larrey  adopted  the  plan  of 
extracting  two  of  them.  This  would  be  use- 
less; however,  when  deglution  is  totally  hin- 
dered, as  happened  in  one  instance  recorded 
by  the  latter  eminent  surgeon.  {Op.  cit.  T. 
3,p.  301.)  Glysters  are  the  only  resource, 
when  the  spasms  of  the  fauces  cannot  be 
overcome.  In  this  way,  as  much  as  a 
drachm  of  the  extract  of  opium  has  been  in- 
troduced into  the  bowels  at  oue  dose.  Opi- 
ate frictions  upon  the  jaws,  throat,  and  other 
parts  of  the  body,  have  been  practised.  Opi- 
ate plasters  have  also  been  applied  to  the 
masseter  muscles,  and  behind  the  ears.  This 
external  use  of  opium,  however,  can  only 
be  regarded  as  a feeble,  and  probably  useless 
method. 

As  the  costivemess  always  produced  by 
tetanus  is  rendered  still  more  obstinate  by 
opium,  laxative  medicines  and  glysters  should 
constantly  accompany  its  employment.  The 
testimony  of  the  army  physicians,  as  we  learn 
from  the  reporhof  Sir  James  Macgrigor,  is 
highly  in  favour  of  a rigid  perseverance  in 
the  U9e  of  purgatives,  given  in  adequate  doses 
to  produce  daily  a full  effect.  Dr.  Forbes 
states,  that  a solution  of  sulphate  of  magne- 
sia, in  infusion  of  senna,  was  found  to  an- 
swer better  than  any  other  purgative ; and  it 
was  daily  given  in  a sufficient  quantity  to 
procure  a copious  evacuation,  which  was 
always  dark-coloured  and  highly  offensive  ; 
and  to  this  practice  he  chiefly  attributes,  in 
one  severe  case,  the  removal  of  the  disease. 
(Medico- Chir.  Trans.  Vol.  6,  p.  452.) 

A spasmodic  rigidity  of  the  muscles  being 
the  most  prominent  symptom  of  tetanus,  it 
was  natural  for  practitioners  to  try  the  effica- 
cy of  some  other  antispasmodic  medicines  be- 
sidesopium,  and  thosewhich  have  been  prin- 
cipally the  subject  of  experiment,  are  casto- 
reum,  rether,  the  conium  maculatum,  musk, 
camphor,  and  latterly  the  digitalis.  In  many 
cases,  opium  and  camphor  have  been  exhi- 
bited together.  Indeed,  Larrey  asserts,  that 
of  all  the  medicines  hitherto  proposed  by 
skilful  practitioners,  the  extract  of  opium 
combined  with  camphor,  and  the  nitrate  of 
potassa,  dissolved  in  a small  quantity  of  the 
almond  emulsion,  and  given  in  doses  more 
or  less  strong,  produces  the  most  favourable 


( 


effects,  since  patients,  who  have  an  aver- 
sion to  other  fluids,  take  with  pleasure  this 
mixture,  the  action  of  which  must  be  pro- 
moted by  bleeding,  if  necessary,  and  blis- 
ters, under  the  circumstances  which  have 
been  specified.  (See  Mini,  de  Chir.  Militaire, 
T.  1,  p.  271.)  In  the  same  work  several 
ea£es  are  detailed  which  were  benefited  by 
such  treatment. 

Although  some  practitioners  have  thought 
that  they  have  seen  good  effects  result  from 
musk,  yet  the  majority  of  practitioners,  who 
have  made  trial  of  both  this  and  camphor, 
in  cases  of  tetanus,  have  found  no  reason  to 
recommend  these  medicines.  Possibly  this 
may  be  owing, in  some  instances  to  sufficient 
doses  not  having  been  exhibited,  or  to  the 
musk  not  being  of  a good  quality.  One 
hundred  and  fifty  grains  of  musk,  however, 
have  been  given  in  the  space  of  twelve 
hours,  to  a young  girl,  thirteen  years  old, 
affected  with  an  incipient  tetanus ; but  no 
salutary  effect  on  the  disorder  was  produced. 

We  learn  also  from  Sir  James  Maegrigor, 
that  aether,  camphor,  musk,  and  other  anti- 
spasmodics,  as  likewise  the  alkalies,  were 
tried  by  our  military  surgeons  in  Spain,  and 
found  unsuccessful.  (Medico- Chir.  Trans. 
Vol.  6,p.  458.) 

From  the  same  authority  we  find,  that 
digitalis,  in  large  doses,  was  tried  in  several 
cases  in  the  peninsula  ; and  that  it,  with  se- 
veral other  medicines  enumerated,  failed  in 
almost  every  case  of  acute  tetanus  which 
occurred.  (P.454.)  In  one  case  recorded, 
the  jaw  remained  fixed  to  the  last,  and  the 
patient  was  never  entirely  free  from  spasms. 
(P.  458.)  I am  not  acquainted  with  any 
cases  in  which  belladonna  has  been  given  ; 
but  it  is  certainly  a remedy  well  worthy  of 
trial. 

Analogy  has  also  led  to  the  employment 
of  the  warm  bath,  as  a plan  which  seemed 
to  promise  great  benefit,  by  producing  a re- 
laxation of  the  contracted  muscles.  But, 
notwithstanding  this  means  has  appeared  in 
a few  instances,  to  occasion  some  little  re- 
lief, particularly  when  the  practitioner  has 
been  content  with  mere  fomentations,  it 
generally  fails  and  often  has  even  done 
mischief.  This  may  perhaps  be,  in  some 
measure,  ascribable  to  the  disturbance  and 
motion  which  the  patient  must  necessarily 
undergo,  in  order  to  get  into  the  bath  ; for 
it  is  very  well  known,  that  every  exertion 
on  the  part  of  the  patient  is  very  apt  to  ex- 
cite most  violent  paroxysms  of  spasm.  The 
author  of  the  article  Tetanus,  in  the  Ency- 
clopedic Methodique,  mentions  his  having 
seen  the  warm  bath  do  harm,  in  two  or  three 
cases  in  which  it  was  expected  to  do  good. 
Though  numerous  writers  have  recommend- 
ed the  trial  of  the  plan,  it  would  be  difficult 
to  trace,  in  their  accounts,  any  facts  which 
decidedly  show  that  its  adoption  has  ever 
been  followed  by  unequivocal  benefit.  The 
warm  bath  was  tried  in  Spain,  and  found  to 
produce  only  momentary  relief.  ( Medico - 
Chir.  Tram.  Vol.  6,  p.  457.)  Dr.  Hillary, 
Avho  practised  a long  while  in  the  warm 
climate  of  America,  where  tetanus  is  very 


common,  disapproves  of  this  method  oi 
treatment.  He  observes,  that  although  the 
use  of  the  warm  bath  may  appear  to  be 
very  rational,  and  promise  to  be  useful,  he 
has  always  found  it  much  less  serviceable 
than  emollient  and  antispasmodic  fomenta- 
tions; and  he  also  mentions,  that  he  has 
sometimes  seen  patients  die  the  very  mo- 
ment when  they  came  out  of  the  bath,  not- 
withstanding they  had  not  been  in  it  more 
than  twenty  minutes,  the  temperature  of  the 
water  being  likewise  not  higher  than  29  or 
30  of  Reaumur’s  thermometer.  (See  Hilla- 
ry on  the  Air  and  Diseases  of  Barbadoes.) 

De  Haen  also  relates  a similar  fact  of  a 
patient  dying  the  instant  he  was  taken  out  of 
the  warm  bath. 

It  was  in  all*  probability,  the  bad  effects 
and  inefficacy  of  the  warm  bath  which  in- 
duced practitioners  to  try  what  might  be  ef- 
fected by  the  cold  one.  The  advantages  of 
the  cold  bath  were  first  explained  by  Dr, 
Cochrane,  in  the  Edinb.  Medical  Commen- 
taries ; and  the  plan  has  subsequently  re- 
ceived the  praises  of  Dr.  Wright,  the  emi- 
nent Dr.  Currie  of  Liverpool,  and  others. 
Of  all  the  remedies,  which  have  been  em- 
ployed in  cases  of  tetanus,  the  cold  bath 
seems  to  be  that  which  has  been  attended 
with  the  greatest  success.  Dr.  Wright  has 
published,  in  the  Medical  Observations  and 
Inquiries , Vol.  6,  a paper,  in  which  may  be 
found  a narrative  of  the  first  trials  of  this 
method,  which  were  all  successful.  The  plan 
is  said  to  be  at  present  preferred  throughout 
the  West  Indies,  The  way  adopted  consists 
in  plunging  the  patient  in  cold  water,  and 
in  that  of  the  sea,  when  at  band,  in  prefer- 
ence to  any  other;  or  else  in  throwing  from 
a certain  height  several  pails  of  cold  water 
over  his  body.  After  this  has  been  done,  he  is 
to  be  very  carefully  dried  with  a towel,  and 
put  to  bed,  where  he  should  only  be  lightly 
covered  with  clothes,  and  take  twenty  or 
thirty  drops  of  laudanum.  The  symptoms 
usually  seem  to  give  way,  in  a certain  de- 
gree, but  the  relief  which  the  patient  expe- 
riences is  not  of  long  duration,  and  it  is  ne- 
cessary to  repeat  the  same  measures  at  the 
end  of  three  or  four  hours.  They  are  to  be 
repeated  in  this  manner;  that  is  to  say,  at 
such  intervals,  until  those  of  freedom  from 
the  attacks  of  the  disorder  increase  in  length. 
This  desirable  event  generally  soon  follows, 
and  ends  in  a perfect  cure.  Wine  arid  bark 
were  sometimes  conjoined  with  the  forego- 
ing means,  and  seemed  to  co-opeiate  in  the 
production  of  the  good  effects.  Dr.  Wright 
concludes  the  account  with  the  following 
remark,  sent  to  him  with  a case  by  Dr. 
Drummond  of  Jamaica  ; — “ I am  of  opinion 
that  opiates  and  the  cold  bath  will  answer 
every  intention  in  the  tetanus  and  such  like 
diseases;  for  whilst  the  opium  diminishes 
the  irritability,  and  gives  a truce  from  the 
violent  symptoms,  the  cold  bath  produces 
that  wonderful  tonic  effect  so  observ- 
able in  this  and  some  other  cases.  Per- 
haps the  bark,  joined  with  these,  would 
render  the  cure  more  certain.  May  we  not. 
then  have  failed  in  many  cases,  by  using 


IETANUS. 


opiates  alone  in  targe  doses,  or  what  proba- 
bly is  worse,  with  the  warm  bath,  instead 
of  the  cold  bath  ? And  have  we  not  reason 
to  suspect  that  the  increased  doses  of  opium, 
that  seemed  requisite  when  the  warm  bath 
was  used,  may  have  proved  pernicious  ?”■ — 
( Vol . 6,  p.  161.) 

Our  urmy  surgeons,  who  were  in  Spain, 
are  said  to  have  found  the  cold  bath  worse 
than  useless,  (Medico- Chir.  Trans.  Vol.  6,  p. 
254.)  and  here  1 beg  to  remark  particularly, 
that  the  plan  seems  to  present  no  hope  of 
benefit  in  cases  of  tetanus  from  wounds, 
however  strong  the  evidence  is  of  its  utility 
in  other  examples  of  the  disease.  This  was 
the  opinion  of  Dr.  Cullen,  and  it  is  adopted 
by  Callisen,  who  observes,  “ Immersio  subita 
iterata  totius  corporis  in  aquam  frigidam  in 
tetano  a causa  interna  mire  prodest,  in  teta- 
no  a causa  externa  minorem  e dec  turn  praes- 
tat.”  (Systema  Chirurgice  Hodierncc , Part. 
1,  p.  169,  170,  Edii.  179S.)  On  the  sub- 
ject of  cold  effusion  and  bathing,  there 
are  on  record  two  cases  which  are  curious. 
One  is  related  by  Baron  Larrey.  It  was  an 
instance  of  tetanus  from  a gunshot  wound. 
The  cold  bath  was  used.  The  two  first  trials 
gave  the  patientextreme  pain,  and  no  amend- 
ment followed.  The  sight,  of  the  bath  the  next 
time  filled  him  with  an  invincible  dread  of 
the  water,  into  which  he  refused  to  be  put. 
He  was  covered,  how  ever,  with  a blanket, 
and  immersed.  The  tetanic  stiffness  was  im- 
mediately increased,  and  dreadful  convul- 
sions excited.  It  became  necessary  to  re- 
move him  directly  from  the  bath,  and  put  him 
to  bed  Deglutition  was  from  the  moment 
utterly  impeded,  and  the  contraction  of  the 
muscles  carried  to  the  most  violent  degree. 
A tumour,  about  as  large  as  an  egg,  suddenly 
made  its  appearance  near  the  linea  alba, 
below  the  navel.  After  death,  this  was 
found  to  be  caused  by  a rupture  of  one  of 
the  recti  muscles,  and  a consequent  extrava- 
sation of  blood.  (See  M6m.  de  Chirurgie 
Mil.  T.  3,  p.  287 — 289.)  This  case  is  deci- 
dedly in  support  of  the  truth  of  what  Pro- 
fessor Cullen  and  Callisen  have  observed. 
The  next  is  not  so:  it  is  mentioned  by  Sir 
James  Macgrigor,  that,  in  the  march  of  the 
guards  through  Gallicia,  one  of  them  was 
attacked  with  tetanus,  in  consequence  of  a 
slight  w7ound  of  the  finger.  As  it  was  impos- 
sible to  think  of  leaving  the  man  in  the 
wretched  village  where  he  w7as  taken  ill,  he 
was  carried  ou  a bullock  car,  in  the  rear  of 
the  battalion.  During  the  first  part  of  the 
day  he  was  drenched  with  rain,  the  thermo- 
meter standing  at  52°  ; but,  after  ascend- 
ing one  of  the  highest  mountains  in  Gallicia, 
the  patient  w7as  in  a cold  of  30° ; and  he 
W7as  exposed  from  six  in  the  morning  till 
ton  at  night,  when  he  was  found  half  starved 
to  death,  but  free  from  every  symptom  of 
tetanus.  (See  Medico- Chir.  Trans.  Vol.5}p. 
450.) 

Another  remedy,  which  is  said  to  have 
frequently  effected  a cure  in  tetanus,  is 
mercury.  It  has  been  employed  in  France 
with  the  greatest  success,  as  maybe  seen  bv 
referring  to  the  forty-fifth  volume  of  Journal 


475 

de  Medicine.  This  remedy,  however,  should 
be  resorted  to,  in  an  early  period  of  the  dis- 
order. Mercurial  frictions  are  preferred, 
and  these  are  to  be  put  in  practice  so  as  to 
bring  on  a quick  affection  of  the  mouth  ; 
care  being  taken,  however,  not  to  render 
the  soreness  and  salivation  too  violent.  Some 
contend,  that  itmatters  not,  whether  mercury 
be  rubbed  into  the  body,  or  given  internally. 
It  is  generally  allowed,  that  opium  may  be  ad- 
vantageously exhibited  at  the  same  time.  This 
practice  w as  first  adopted  in  the  West  Indies, 
(see  Edinb.  Physical  and  Literary  Essays , 
Vol.  3,)  where  it  succeeded  in  many  cases. 
Whatever  benefit,  however,  may  have  been 
experienced  from  this  plan  in  mild  cases, 
it  completely  fails  in  the  acute  form  of  the 
disease.  Mercurial  frictions  appeared  to 
Baron  Larrey  to  aggravate  the  symptoms, 
in  the  cases  where  the  plan  was  tried  in 
Egypt  (Mem.  de  Chir.  Mil.  T.  I,  p.  257;) 
and  Dr.  Emery,  Mr.  Guthrie,  and  other  me- 
dical officers,  attached  to  our  army  in  the 
peninsula,  tried  inunction  of  the  w7hole 
body,  three  times  a day,  w7ith  strong  mercu- 
rial ointment,  in  unlimited  quantity,  with  no 
degree  of  success.  Alter  the  battle  of  Tou- 
louse, a fatal  case  even  occurred  in  a man 
strongly  under  the  influence  of  mercury, 
which  he  had  been  previously  using  for  the 
cure  of  the  itch.  (Sir  J.  Macgrigor  in 
Medico- Chir.  Trans.  Vol.  6,  p.  454.)  The 
submuriate  of  mercury,  combined  W'ith 
ipecacuanha,  also  proved  inefficacious  in 
acute  cases;  but,  in  chronic  ones,  the  for- 
mer medicine  proves  serviceable  in  keeping 
open  the  bowels. 

Another  method  of  treating  tetanus  is 
that  of  administering  the  most  powerful 
tonics  and  stimulants,  such  as  wine,  brandy, 
aether,  preparations  of  ammonia,  bark,  cor- 
dials, &c.  The  introduction  of  this  plan 
was  chiefly  owing  to  the  eminent  Dr.  Rush, 
Professor  of  Medicine  in  Philadelphia,  who 
published  in  the  Transactions  of  the  Arne 
riaan  Philosophical  Society,  Vol.  2,  a paper 
entitled  “ Observations  on  the  Cause  and  Curt 
of  Tetanus Dr.  Rush  considers  tetanus 
as  a disease  essentially  connected  with  de- 
bility, and  he  recommends  for  it  the  exhibi- 
tion of  the  preceding  class  of  remedies.  He 
particularly  advises  the  liberal  use  of  w7ine 
and  Peruvian  bark  ; apd,  as  wre  have  already- 
stated,  when  tetanus  arises  from  a wound, 
he  directs  the  dilatation  of  it,  and  dressings 
with  oil  of  turpentine.  Considerable  suc- 
cess is  represented  as  having  attended  the 
practice.  Several  other  instances  of  suc- 
cess are  also  recorded  by  Dr.  Hosack. 
(American  Medical  Repository , Vol.  3.) 

Nothing  is  a more  certain  proof  of  our  not 
being  acquainted  w7ith  any  very  effectual 
method  of  treating  a disease,  than  a multi- 
plicity of  remedies,  which  are  as  opposite 
as  possible  in  their  effects.  We  have  seen 
that  the  celebrated  Dr.  Rush  conceived,  that 
tetanus  was  a disease  connected  with  debili- 
ty, and  he  has  recorded  examples,  in  which 
it  was  successfully  treated  by  tonics  and 
stimulants.  Extraordinary,  however,  as  it 
may  appear,  many  practitioners  ars  advc- 


1L  X 


THR 


476 

cates  for  venesection,  especially  in  the  early 
stage  of  tetanus.  Dr.  Dickson  thinks,  that 
in  a full  habit,  where  the  wound  is  swelled, 
inflamed,  and  painful,  venesection,  with 
free  purging,  and  such  other  means  as  are 
calculated  to  allay  the  general  and  local 
irritation,  affords  the  fairest  chance  of  avert- 
ing the  danger.  (See  Medico- Chir.  Tram. 
Vol.  7,  Pari  2.)  Larrey  has  also  published 
several  cases,  in  which  bleeding  had  a good 
effect.  We  are  informed  by  Sir  James  Mac- 
grigor,  that,  in  our  military  hospitals  in 
Spain,  venesection  bad  a fair  trial.  In  three 
cases  at  St.  Andero,  detailed  by  Mr.  Gu- 
thrie, this  was  the  principal  remedy.  One 
patient  with  tetanus,  from  a wound  of  the 
back  part  of  the  hand,  was  bled  nearly  ad 
deliquium  several  times  with  good  effect, 
calomel  and  diaphoretics  being  also  given, 
arid  he  recovered.  Another  patient  was 
bled  in  the  same  manner  with  such  amend- 
ment, that  he  suffered  but  little  from  spasm, 
and  could  open  his  mouth  very  well,  when 
he  was  seized  with  diarrhoea,  which  in  his 
debilitated  state,  carried  him  off.  la  the 
third  case,  which  was  one  of  acute  tetanus 
venesection,  pushed  to  the  utmost,  totally 
failed.  (Op.  cit.  Vol.  6,p.  455,  456.) 

The  powerfully  relaxing  effects  of  tobac- 
co clysters,  in  cases  of  hernia  and  enteritis, 
have  suggested  a trial  of  them  in  tetanus. 
In  one  very  acute  case,  the  plan  was  tried 
by  Mr.  Earle,  but  it  only  afforded  a tempora- 
ry alleviation  of  the  spasms,  and,  as  it  caused 
severe  agitation,  it  was  discontinued.  Ac- 
cording to  Sir  James  Macgrigor,  tobacco 
clysters,  tried  in  the  advanced  stage  of  the 
disease,  seemed  to  have  no  effect.  He  con- 
siders, however,  the  tobacco  fume  as  deserv- 
ing farther  trial. 

A remarkable  case  is  recorded  by  Dr. 
Phillips,  in  which  the  jaw  suddenly  fell  upon 
the  exhibition  of  an  enema  with  oil  of  tur- 
pentine. (See  Medico- Chir.  Trans.  Vol.  6, 
p.  65.) 

According  to  Barcn  Larrey,  frictions,  with 
oily  liniments,  as  recommended  by  some 
authors,  were  tried  by  the  French  surgeons 
at  Cairo;  but  they  produced  no  change  in 
the  state  of  the  disease.  We  learn, from  the 
same  authority,  that  the  application  of  blis- 
ters to  the  throat  also  failed  in  checking 
the  symptoms. 

The  Barbadoes  tar,  mentioned  by  Cullen, 
electricity,  the  colchicum  autumnale,  or 
meadow  saffron,  recommended  by  Dufres- 
noy,  and  several  other  means  formerly  in 
repute  for  their  virtues  in  cases  of  tetanus, 
have  now  been  fully  proved  by  experience 
to  possess  little  or  no  claim  to  this  character. 

Consult  Hippocrates  de  Morbis  Populari- 
bus,  Lib.  6 et  7.  Ccelius  Aurelianus  de  Morbis 
atiitis.  Medical  Observations  and  Inquiries , 
Vol.  !,  p.  1 and  87  ; Vol.  6,  p.  143.  Hillary 
on  the  Air  and  Diseases  of  Barbadoes , Edin. 
Physical  and  Literary  Essays,  Vol.  3.  Dr. 
Carter , in  Medical  Trans.  Dr.  Cochrane  in 
Edin.  Medical  Commentaries.  Cullen's  First 
Lines  of  the  Practice  of  Physic,  Vol.  3. 
Hush’s  Observations  on  the  Cause  and  Cure  of 
Tetanus , in  Vol.  2 of  the  Transactions  of  the 


American  Philosophical  Society.  Sir  Gilbert 
Blanc's  Observations  on  the  Diseases  of  Sea- 
men, Edit.S.  M.  Ward , Facts  establishing  the 
Efficacy  oj  the  Opiate  Friction  in  Spasmodic 
and  I ebrile  Diseases,  fyc.  8 vo.  Manchester , 
1809.  Larrey,  Mdmoires  de  Chir.  Mi  lit  air  e, 
T.  1,  p.  235,  ; T.  3,  p.  236,  <^c.  Callisen , 

Systema  Chir  ur give  llodiernre,  Pars  1,  p. 
165,  &/-c.  Sir  James  Macgrigor,  in  Med. 
Chir.  Trans.  Vol.  6,  p.  449,  <^c.  Dr.  Phil- 
lips’s Case  in  the  same  work  and  volume , p.  65. 
Dr.  Dickson's  Observations  on  Tetanus,  and 
Dr.  Macarthur’s  Letter  in  Vol.  7,  p.  448, 
tyc.  oj  the  same  book.  Trnka  de  Krzowitz , de 
Tetuno  tommentarius,  Vindob.  1777.  Riche- 
rand,  JSosogr.  Chir.  T.  2,  p.  338,  fyc.  Edit . 
4.  Edinb.  Med.  and  Surgical  Journal,  Vol.  1 , 
p.  67  ; Vol.  2,  p.  255—430  ; Vol.  4,  p.  45, 
tyc.fyc.  Boyer,  Trait6  des  Mai.  Chir.  T.  1, 
p.285,  fyc.  Paris,  1814.  Rees's  Cyclopaedia , 
art.  Tetanus.  C.  H.  Parry,  Cases  of  Tetauns, 
and  Rabies  Contagiosa,  tyc.  8t?o.  Lond.  1814. 
John  Morrison,  a Treatise  on  Tetanus,  8 vo. 
Newry,  1816.  Robert  Reid,  on  the  Nature 
and  Treatment  of  Tetanus  and  Hydrophobia, 
8vo.  Dublin,  1817,  Stewart,  in  Med.  Chir . 
Journ. ; Oil  of  Turpentine  tried.  Sir  Astley 
Cooper,  Surgical  Essays,  Part  2,  p.  190. 
Burmester,  in  Med.  Chir.  Trans.  Vol.  11. 

THORAX,  WOUNDS  OF.  See  Wounds 
of  the  Thorax. 

THROAT,  WOUNDS  OF.  Injuries  of 
this  kind  are  often  attended  with  considera- 
ble danger,  on  account  of  the  great  number 
of  important  parts,  which  are  interested  ; 
but  mere  cuts  of  the  integuments  of  the 
throat  and  neck  are  not  (generally  speaking) 
dangerous  cases,  and  do  not  materially 
differ  from  common  incised  wounds  of  the 
skin  in  any  other  part  of  the  body.  They 
are  not  liable  to  be  followed  by  any  parti- 
cular consequences,  and  require  the  same 
kind  of  treatment  as  cuts  in  general.  (See 
Wounds — Incised  Wounds.) 

In  wounds  of  the  throat  and  neck,  how- 
ever, the  larynx  and  trachea,  pharynx  and 
oesophagus,  the  trunk  of  the  carotid  artery, 
and  all  the  principal  branches  of  the  exter- 
nal carotid,  the  large  jugular  vein,  the  eighth 
pair  of  nerves,  and  the  recurrent  nerve, are 
all  exposed  to  injury;  some  much  more  so 
than  others,  but  all  of  them  being  occasion- 
ally reached  by  the  edge  of  the  knife  or 
razor,  or  the  point  of  the  sword,  or  other 
instruments. 

It  would  be  absurdity  to  offer  an  account 
of  what  is  to  be  done  in  cases  attended  with 
some  part  of  the  mischief  above  pointed 
out  ; for  no  patient  thus  wounded  would 
ever  be  found  alive.  Wounds  of  the  eighth 
pair  of  nerves  are  generally  considered  fatal, 
though  some  doubts  begin  to  be  entertained 
on  the  point.  Indeed,  Klein  positively 
states,  that  such  an  injury  is  not  fatal.  (See 
Journ.  der  -Chir.  B.  1,  p.  123,  Sro.  Berlin , 
1820.)  However,  if  such  a wound  is  not 
absolutely  fatal,  tiiere  can  be  no  doubt  of 
its  being  highly  perilous,  and  that  it  should 
be  cautiously  avoided.  These  nerves  as  is 
well  known,  proceed  down  the  neck  in  the 


THROAT, 


477 


same  shcatli  of  cellular  substance  which 
includes  the  carotid  artery,  and  lie  on  the 
outside  of  this  vessel,  between  it  and  the 
internal  jugular  vein. 

Wounds,  either  of  the  carotid  artery  or 
internal  jugular  vein,  must  generally  prove 
immediately  fatal,  in  consequence  of  the 
great  and  sudden  loss  of  blood.  However, 
were  any  surgeon  on  the  spot  at  the  mo- 
ment, he  should  instantly  secure  the  wound- 
ed vessel.  In  tying  the  carotid,  one  cau- 
tion is  highly  necessary,  viz.  always  to  be 
sure  that  the  par  vagum  is  excluded  from 
the  ligature  : for  were  this  nerve  to  be  tied, 
the  mistake,  if  not  absolutely  mortal,  would 
leave  but  a slight  possibility  of  recovery. 

If  the  mouth  of  the  vessel  could  not  be  at 
once  secured,  pressure  should  be  instantly 
resorted  to,  for  the  purpose  of  producing  a 
temporary  suppression  of  the  hemorrhage. 
The  surgeon  should  then  either  make  the 
necessary  enlargement  of  the  wound  in  the 
integuments,  with  a due  and  constant  recol- 
lection of  the  important  parts  near  the  place, 
or  else,  in  the  case  of  the  carotid  being  in- 
jured, he  should  cut  down  to  this  vessel  in 
the  manner  explained  in  the  article  Aneu- 
rism. 

In  lacerated  wounds,  the  carotid  artery 
may  be  injured,  and  yet  the  patient  not 
immediately  bleed  to  death  ; for  it  is  the 
nature  of  all  wounds,  attended  w ith  much 
laceration  and  contusion,  not  to  bleed  so 
freely  as  clean  cuts.  Mr.  Abernethy  has 
related  a case  in  which  the  carotid,  and  all 
the  chief  branches  of  it,  were  wounded  in 
a man  who  was  gored  in  the  neck  with  a 
cow’s  horn ; yet  death  did  not  directly 
followT,  and  there  was  time  to  have  recourse 
to  the  ligature.  Baron  Larrey  even  reports 
one  or  two  cases  in  which  the  bleeding 
from  the  carotid,  injured  by  a gunshot,  wras 
permanently  stopped  by  pressure.  (See 
Mem.  de  Chir.  Milil.)  Dr.  Hennen  also 
refers  to  another  instance  of  a similar  na- 
ture. (On  Military  Surgery , p.  106,  Ed.  2.) 

Punctured  w ounds  might  obviously  injure 
either  the  carotid,  or  the  internal  jugular 
vein,  w ithout  the  patient  expiring  of  hemor- 
rhage at  once  ; . because  the  smallness  of 
the  wound  in  the  skin  might  hinder  the  fa- 
tal effusion  of  blood. 

However,  frequently,  when  these  vessels 
are  wounded,  the  par  vagum  is  also  injured, 
and  the  case  is  mortal,  either  immediately, 
from  the  direct  effects  both  of  the  injury  of 
the  nerve,  and  sudden  loss  of  blood,  or  very 
soon  afterward,  the  bleeding  being  of  a 
slower  and  more  interrupted  kind  ; w'hich 
circumstance  must  depend  on  the  lacerated 
nature  of  the  wound,  the  small  size  of  the 
opening  in  the  vessel,  or  of  that  in  the 
skin,  & c. 

Persons  w7ho  attempt  suicide,  by  cutting 
their  throats,  do  not  often  divide  the  carotid 
artery,  on  account  of  their  incision  being 
made  too  high  up.  Where  the  carotid  arte- 
ries emerge  from  the  chest,  they  are  situa- 
ted by  the  side  of  the  trachea,  and  even  a 
little  more  forward  than  it.  However,  as 
these  vessels  proceed  up  the  neclc,  they  be- 


come more  laterally  situated  with  respect 
to  the  trachea  ; and  when  they  have  arrived 
at  the  upper  part  of  the  neck,  where  per- 
sons, wrho  aim  at  suicide,  almost  always  cut, 
they  become  situated  more  backward  than 
the  trachea,  inclining  towards  the  angle  of 
the  low  er  jaw. 

The  oesophagus  is  so  deeply  situated,  lying 
close  to  the  bodies  of  the  vertebrse,  and  be- 
hind the  trachea,  that  if  is  not  often  interest- 
ed in  any  incised  wounds,  which  do  not 
immediately  prove  fatal,  in  consequence 
of  the  division  of  other  important  parts. 
Yet  numerous  cases  are  recorded,  in  which 
the  oesophagus  is  said  to  have  been  wound- 
ed ; and  what  is  usually  set  down  as  a crite- 
rion of  the  fact,  is  the  passage  of  victuals 
through  the  wound.  In  many  of  these 
narrations  the  writers  seem  to  have  forgot- 
ten, that  w^ounds,  made  above  the  os  hyo- 
ides,  as  they  frequently  are,  may  enter  the 
mouth,  and  the  victuals  escape  through  the 
cut,  w ithout  the  oesophagus,  or  pharynx,  be- 
ing at  all  concerned. 

However,  no  doubt,  the  oesophagus  has 
occasionally  been  wounded,  together  with 
the  trachea,  not  only  without  the  patient 
perishing  so  immediately  as  to  be  incapable 
of  receiving  any  succour,  but  without  every 
chance  of  recovery  being  destroyed.  Stabs, 
and  gunshot  wounds,  may  injure  the  oeso- 
phagus, and  leave  all  other  important  parts 
untouched.  Nay,  w’hen  other  parts  of  con- 
sequence are  injured,  the  patient  is  some- 
times saved.  (See  Hennen's  Military  Sur- 
gery, p.  363,  Ed.  2.) 

Even  where  the  oesophagus  is  know'n  to 
be  wounded,  its  deep  situation  would  pro- 
hibit us  from  doing  any  thing  to  the  breach 
of  continuity  in  the  tube  itself.  The  best 
plan  wronld  be  to  have  recourse  to  antiphlo- 
gistic means,  and  to  introduce  a flexible 
elastic  gum  catheter  from  one  of  the  nos- 
trils down  the  oesophagus,  for  the  purpose 
•of  conveying  nourishment  and  medicines 
into  the  stomach,  without  any  risk  of  their 
passing  out  at  the  wound.  An  instrument 
of  this  kind  will  lie  in  the  above  situation 
for  any  length  of  time  without  occasioning 
much  inconvenience  ; and,  besides  being 
advantageous  for  injecting  nourishment  and 
medicines  down  the  passage,  and  keeping 
them  from  issuing  at  the  wound,  it  prevents 
all  necessity  for  the  wounded  oesophagus  to 
act  and  become  disturbed,  when  there  is 
occasion  to  take  any  kind  of  liquids,  whe- 
ther in  the  way  of  medicine  or  food.  The 
outer  wound  should  be  brought  together, 
and  treated  on  common  principles. 

When  persons  cut  their  throats,  as  I have 
explained,  they  do  not  often  divide  the 
carotid  artery,  owing  to  their  incision  being 
usually  made  high  up  in  the  neck,  w'here 
this  vessel  has  attained  a very  backward 
situation.  When  any  serious  hemorrhage 
does  arise,  it  is  sometimes  from  the  lower 
branches  of  the  lingual  artery,  but  most 
frequently  from  the  superior  thyroideal  ar- 
teries. Such  arteries  may  occasion  a fatal 
bleeding,  which,  indeed,  would  more  fre- 
quently be  the  event,  than  it  actually  is,  did 


THIi 


THU 


47S 

not  the  patient  often  faint,  in  which  state 
the  bleeding  spontaneously  ceases,  and  gives 
time  for  the  arrival  of  surgical  assistance. 

I need  hardly  tell  the  reader,  that  these 
arteries  are  to  be  tied,  and  that  this  impor- 
tant object  is  the  first  to  which  the  surgeon 
should  direct  his  attention.  The  danger  of 
bleeding  to  death  being  obviated,  as  soon  as 
possible,  the  other  requisite  measures  may 
be  more  deliberately  executed. 

With  respect  to  wounds  of  the  trachea, 
the  same  plan  of  conveying  food  and  medi- 
cines into  the  stomach,  through  an  elastic 
gum  catheter,  introduced  from  one  of  the 
nostrils  down  the  oesophagus,  is  highly 
proper,  though  too  much  neglected.  For 
nothing  creates  such  disturbance  of  the 
wound  as  the  convulsive  elevation  and  de- 
pression of  the  larynx  and  trachea,  which 
are  naturally  attendant  on  the  act  of  swal- 
lowing. 

When  the  trachea  is  cut,  the  patient’s 
power  of  forming  the  voice  is  more  or  less 
impaired,  in  consequence  of  the  air  passing 
into  and  out  of  the  lungs,  chiefly  through 
the  wound.  Besides  air,  a considerable 
quantity  of  the  natural  mucus  of  the  trachea 
is  also  continually  coming  out  of  the  wound. 

The  grand  means  of  accomplishing  the 
union  of  wounds  of  the  trachea,  are  a pro- 
per position  of  the  head,  and  a rigorous 
observance  of  quietude.  By  raising  the 
patient’s  head  with  pillows,  and  keeping 
his  chin  close  to  his  breast,  the  edges  of  the 
wound,  both  in  the  skin  and  trachea,  are 
placed  in  contact  even  without  any  other 
assistance,  unless  the  division  of  the  trachea 
be  exceedingly  large.  It  is  proper,  howe- 
ver, to  assist  the  effect  of  a suitable  position 
with  strips  of  sticking  plaster,  and  some- 
times with  a suture  or  two  But  the  neces- 
sity for  sutures  must  depend  on  the  extent 
of*  the  division  of  the  trachea  ; for  unless 
most  of  the  circle  of  this  tube  be  cut,  and 
position  be  neglected,  the  wound  in  it  will 
not  gape.  The  stitches  should  never  be 
passed  through  the  lining  of  the  trachea,  as 
this  method  would  be  likely  to  make  it  in- 
flame, and  occasion  considerable  coughing 
and  irritation,  attended  with  very  pernicious 
effects.  * 

Should  there  be  much  coughing,  apparent- 
ly arising  from  irritation  and  inflammation 
in  the  trachea,  bleeding  is  proper  if  other 
considerations  do  not  forbid  it.  The  sperma- 
ceti mixture,  with  opium,  is  also  frequently 
of  great  service  I never  saw  a wound  of  the 
trachea  unite  by  the  first  intention  (See  John 
Bell  on  Wounds,  Ed.  3.  Mermen's  Military 
Surgery,  p.  356,  fyc.  Ed.  2.  8 vo.  Edinb.  1820. 
Among  other  references  made  by  Dr.  Hennen, 
the  following  seem  to  me  to  merit  particular 
notice  : — An  interesting  case  of  wound  of  the 
neck,  succeeded  by  hemiplegia,  and  another  of 
gunshot  wound  of  the  throat,  succeeded  by 
paralysis  and  convulsions,  says  Dr.  Hennen,  is 
•riven  by  Forestus  in  his  Surgical  Observations. 
"Another,  with  loss  of  motion  in  the  arm,  from 
a wound  in  the  neck , is  to  be  found  in  the 
Edinb.  Med.  Essays,  Vol.  1.  And  in  the  Med. 
Commentaries,  try  Dr.  Dvrcan , Vol.  4,  p. 


434,  and  Vol.  8,  p.  356,  are  two  interesting 
cases.  Murinna,  in  his  Med.  Chir.  Btobach  - 
tungen,  relates  a case  of  removal  of  the  thyroid 
gland  by  a cannon  ball ; the  patient  survived 
fourteen  days , and  died  of  dysentery.  Wounds 
of  the  oesophagus  often  remain  open  for  inde- 
terminate periods , as  is  exemplified  in  a case 
reported  by  Trioen,  in  his  Fasciculus  Obser • 
valionum,  Ludg.  1745,  p.  40.  Mr.  Bruce  has 
recorded  an  interesting  case  of  wound  of  the 
(Esophagus,  in  Med.  Chir.  Journ.  Vol.  1,  p. 
369.  I would  also  refer  to  various  parts  of 
M6m  de  ( hir.  Milit.  4 Tomes,  by  Baron  Ear • 
rty.  And  Thomson's  Report  of  Obs.  made  in 
Mil.  Hospitals  in  Belgium,  8vo.  Edinb.  1816.) 

THROMBUS,  (from  3-go/zCoc,  coagulated 
blood.)  A clot  of  blood.  The  term  is  also 
applied  to  a tumour,  formed  by  a collection 
of  estravasated,  coagulated  blood,  under  the 
integuments  after  bleeding.  When  such  an 
extravasation  is  not  considerable,  it  is  usual- 
ly called  an  ecchymosis.  (See  this  word, 
and  Bleeding.) 

A thrombus  after  bleeding  generally  arises 
from  the  opening  in  the  vein  not  corres- 
ponding to  that  in  the  skin.  The  patient’s 
altering  the  posture  of  his  arm,  while  the 
blood  is  flowing  into  the  basin,  will  often 
cause  an  interruption  to  the  escape  of  the 
fluid  from  the  external  orifice  ot  the  punc- 
ture ; and  consequently,  it  insinuates  itself 
into  the  cellular  substance  in  the  vicinity  of 
the  opening  in  the  vein.  In  proportion  as 
the  blood  issues  from  the  vessel,  it  is  effused, 
in  the  cellular  membrane,  between  the  skin 
and  fascia,  covering  the  muscles,  and  this, 
with  more  or  less  rapidity,  and  in  a greater 
or  lesser  quantity,  according  as  the  edges  of 
the  skin  more  or  less  impede  the  outward  es- 
cape of  the  fluid.  Sometimes,  also,  a throm- 
bus forms  after  venesection,  when  the  usual 
dressings,  compress,  and  bandage,  have  been 
put  over  the  puncture,  and  the  patient  im- 
prudently makes  use  of  the  arm  on  which 
the  operation  has  been  done.  This  is  more 
particularly  liable  to  happen  when  the  open- 
ing in  the  vein  has  been  made  large. 

When  the  extravasation  i3  not  copious,  it 
is  of  little  importance,  the  tumour  generally 
admits  of  being  easily  resolved,  by  applying 
linen,  dipped  in  any  discutient  lotion.  It 
the  swelling  be  more  extensive,  applying  to 
it  a compress,  wet  with  a solution  of  com- 
mon sea-salt,  is  deemed  an  efficacious  plan 
of  promoting  the  absorption  of  the  extrava- 
sated  blood.  Brandy,  and  a solution  ot  the 
muriate  of  ammonia  in  vinegar,  are  likewise 
eligible  applications. 

It  sometimes  happens,  that  a thrombus 
induces  inflammation  and  suppuration  of  the 
edges  ot  the  puncture.  The  treatment  is 
now  like  that  of  any  little  abscess  : a com- 
mon linseed  poultice  may  be  applied,  and 
any  considerable  accumulation  of  matter 
should  be  prevented  by  making  an  opening 
with  a lancet  in  proper  time.  As  soon  as 
the  inflammatory  symptoms  have  ceased, 
discutients  should  be  employed  again,  tor 
the  purpose  of  dispersing  the  remaining  clots 
of  blood,  and  surrounding  induration. 

When  the  quantity  of  blood  is  large,  manv 


THYROID  GLAND. 


auliiors  recommend  opening  the  tumour  at 
once;  and,  despairing  of  the  power  of  the 
absorbents  to  remove  the  extravasation,  they 
recommended  as  much  of  the  blood  as  possi- 
ble to  be  pressed  out  through  the  incision.  I 
believe,  however,  that  making  an  opening 
is  seldom  necessary,  and  often  brings  on  in- 
flammation, and  suppuration,  when  they 
might  be  avoided.  I have  never  seen  any 
case,  in  which  there  was  real  occasion 
to  make  an  opening  for  the  discharge  of  the 
blood.  A case  of  this  kind,  however,  may 
be  conceived. 

THYROID  GLAND,  DISEASED.  (See 
JBronchocele.) 

THYROID  GLAND,  EXTIRPATION  OF. 
That  such  an  operation,  though  attended 
with  great  difficulties,  is  not  impracticable, 
is  proved  by  the  following  example  : — 

On  the  20th  of  March,  1791,  a woman 
presented  herself  for  admission  at  the  HOlel- 
Dieu,  with  a tumour  of  the  right  portion  of 
the  thyroid  gland.  The  swelling  was  two 
inches  in  diameter,  round,  hard,  and  at- 
tached to  the  right  and  middle  part  of  the 
trachea,  and  it  pushed  outwards  the  sterno- 
mastoideus  muscle.  Independently  of  its 
being  sensibly  raised  by  each  pulsation  of 
the  arteries,  it  obeyed  the  motions  of  de- 
glutition, and  in  a slight  degree  impeded 
the  passage  of  solid  aliment.  The  patient 
earnestly  desiring  to  get  rid  of  so  inconve- 
nient a deformity,  determined  to  submit  to 
its  extirpation,  which  appeared  tne  only  re- 
source. The  danger,  the  length  of  time, 
and  the  pain  necessarily  annexed  to  the  ope- 
ration, were  not  concealed  from  her.  De- 
sault made  a longitudinal  incision  through 
the  middle  of  the  tumour,  beginning  one 
inch  above,  and  finishing  one  inch  below  the 
swelling.  By  the  first  stroke,  he  cut  down 
as  far  as  the  gland,  dividing  the  integuments, 
the  platysma-myoides,  and  some  fibres  of 
the  sterno-hyoideii  and  sterno-thyroidei 
muscles.  An  assistant,  with  the  view  of 
fixing  the  tumour,  drew  towards  aside  the 
inner  edge  of  the  wound,  whilst  the  surgeon 
detached  the  swelling  from  the  sterno-mas- 
toideus  muscle.  In  dissecting  the  cellular 
substance,  which  united  the  parts,  two  small 
arteries  were  divided,  which  were  secured 
with  ligatures.  The  outer  portion  of  the 
tumour  being  thus  disengaged,  the  inner  was 
detached  in  the  same  way.  The  tumour 
was  then  drawn  outwards  by  means  of  a 
hook,  that  it  might  be  separated  with  more 
ease  from  the  trachea.  In  the  course  of  this 
dissection,  the  branches  of  the  thyroid  arte- 
ries were  successively  tied,  as  fast  as  they 
were  divided.  The  assistant,  who  held  the 
hook,  pulled  the  gland  from  within  and  tor- 
wards,  whilst  the  surgeon  finished  the  dis- 
section outwards  and  from  above  down- 
wards. This  part  of  the  operation  was  the 
most  difficult:  it  was  necessary  continually 
to  wipe  away  the  blood  with  a sponge, 
which  necessarily  prevented  the  parts  from 
being  easily  distinguished,  and  obliged  the 
surgeon  to  cut  but  a little  at  a time,  and 
always  to  examine  well  with  his  finger  those 
parts  which  he  was  about  to  rut.  By  this 


479 

cautious  dissection,  the  superior  and  inferior 
thyroid  arteries  were  laid  bare,  and  after- 
ward tied  with  the  aid  of  a blunt  crooked 
needle.  They  were  then  transversely  di- 
vided, and  the  remaining  part  of  the  tumour 
detached  from  the  trachea,  to  which  it 
strongly  adhered,  l'he  wound  resulting  from 
this  operation  was  near  three  inches  in 
depth  ; it  was  outwardly  bounded  by  the 
sterno-mastoideus  muscle,  and  inwardly  by 
the  trachea  and  oesophagus  ; posteriorly  by 
the  carotid  artery,  and  par  vagum,  which 
were  exposed  at  the  bottom  of  the  wound. 
The  extirpated  tumour  wTas  five  inches  in 
circumference ; and  on  examination  was 
found  to  differ  in  no  particular  from  scirrhous 
glands,  except  that  in  the  centre  there  was 
a cartilaginous  nucleus.  The  patient  left 
the  hospital  perfectly  well,  the  thirty-fourth, 
day  after  the  operation.  (See  Desault's  Paris- 
ian Chir.  Journ.  Vol  2,  p.  292,  296.) 

The  extirpation  of  the  thyroid  gland  is  an 
operation  extremely  difficult,  and  certainly 
highly  dangerous*  when  performed  by  an 
operator  but  moderately  exercised  in  the 
practice  of  his  profession.  The  number 
and  size  of  the  arteries  divided,  the  proxi- 
mity of  the  trachea,  oesophagus,  and  carotid, 
near  which  the  knife  must  necessarily  pass, 
are  the  principal  dangers.  They  have  de 
terred  the  majority  of  practitioners  from 
performing  the  operation,  and  it  must  be 
allowed,  that  they  are  such  as  ought  to  in- 
timidate every  man,  who  is  not  endued  with 
anatomical  knowledge,  and  the  most  un- 
daunted coolness.  Examples  of  this  opera- 
tion are  very  rare.  The  first  time  that 
Gooch  undertook  it,  he  was  deterred  from 
finishing  it  by  the  hemorrhage,  and  his  pa- 
tient died  on  the  eighth  day.  The  second 
time  he  succeeded  better,  but  was  incapable 
of  securing  the  vessels,  and  succeeded  in 
stopping  the  hemorrhage,  which  would  oth- 
erwise have  been  mortal,  by  causing  the 
parts  to  be  compressed  by  the  hand  of  an 
assistant  for  the  space  of  eight  days.  ( Gooch's 
Med.  and  Chir.  Obs.  p.  130.  Bell's  System  of 
Surgery,  Vol.  5,  p.  525.  Richter's  Bibl.  T. 

2,  p.  128.) 

A.  F.  Vogel  and  Theden  practised  the 
operation  with  complete  success.  All  dan- 
ger from  the  hemorrhage,  or  inconvenience 
arising  from  the  discharge  of  blood,  maybe 
obviated  by  taking  up  the  small  vessels,  ty  - 
ing them  as  fast  as  they  are  divided,  and  by 
discovering  and  tying  the  large  vessels  pre- 
vious to  their  division.  Other  parts  that 
cannot  be  wounded  without  danger,  are  to 
be  avoided  by  dissecting  slowly  and  a little 
at  a time,  and  feeling  with  the  finger  every 
part  previously^  i*s  division  with  the  bis- 
toury. 

A case,  in  which  Klein  removed  a vejv 
large  thyroid  gland,'  has  been  recently  pub- 
lished. The  patient,  a boy  eleven  years  of 
age,  died,  however,  on  the  operating  table, 
as  would  seem  from  Klein’s  account,  in  con- 
sequence of  apoplexy.  (See  Journ.  dec 
Chir.  B.  1 ,p.  120,  6 vo.  Berlin,  1820;  or  the 
Quarterly  Journ.  of  Foreign  Medicine , Vol.  2. 
p.  380.)  On  the  whole,  I consider  that  the 


TIC  DOUXOUREUX 


practice  of  tying  the  thyroidal  arteries  is 
generally  a safer  experiment  than  the  re- 
moval of  the  enlarged  gland  with  a knife. 
(See  Bronchocele .) 

*TIC  DOULOUREUX.  This  term  is  used 
to  signify  a disorder,  the  most  prominent 
character  of  which  consists  in  severe  at- 
tacks of  pain,  affecting  the  nerves  of  the 
face  ; most  frequently  the  filaments  of  that 
branch  of  the  fifth  pair,  which  comes  out  of 
the  infra-orbitary  foramen  ; but  sometimes 
the  other  branches  of  the  fifth  pair,  and  oc- 
casionally the  numerous  filaments  of  the 
portio  dura  of  the  auditory  nerve,  which 
are  distributed  upon  the  face.  The  com- 
plaint is  not  continual,  but  occurs  in  violent 
paroxysms,  which  vary  in  duration  in  dif- 
ferent instances.  It  is  the  trismus  dolorijicus 
of  Sauvage  ; the  Faciei  Morbus  Nervorum 
Crucians  of  Dr.  S.  Fothergill;  and  of  that 
order  of  diseases  which  Professor  Chaussier 
has  so  aptly  denominated  neuralgies  (from 
vi'j gov,  a nerve,  and  ctxyo s,  pain ;)  for  it  should 
be  known,  that  many  other  parts  of  the 
body  are  subject  to  a similar  affection. 

The  first  excellent  description  of  the  tic 
douloureux  was  published  in  the  year  1776, 
by  the  late  Dr.  Fothergill.  (See  Med.  Obs. 
and  Inq.  l ol.  5.)  It  is  not  true,  however, 
as  is  generally  stated  in  modern  medical 
works,  that  this  gentleman  was  the  first  au- 
thor who  noticed  the  complaint.  This  in- 
deed is  so  far  from  being  correct,  that  we 
even  find  an  account  of  an  operation  done 
long  ago  by  Louis,  for  the  relief  of  the  dis- 
ease, (See  No.  36  de  la  Gazette  Salutaire , 
1766  ;)  and  this  identical  case  actually  be- 
came a subject  of  hot  dispute  between  the 
physicians  and  surgeons  of  the  French  me- 
tropolis. (See  a Thesis,  entitled  u Utrum  in 
pertinacibus  capitis  et  faciei  doloribus  aliquid 
prodesse  possit,  sectio  ramorum  nervi  quinti 
paris  ? Proponebat  Viellart,  1768,  conclusio 
negativa 

Tic  douloureux  conveniently  admits  of 
being  divided  into  four  species,  called  by  the 
French  frontal , suborbitary,  and  maxillary 
neuralgia,  and  the  neuralgia  of  the  facial 
nerve. 

In  the  frontal  neuralgia,  the  pain  usually 
begins  in  the  situation  of  the  supra-orbitary 
foramen,  extending  at  first  along  the  branch- 
63  and  ramifications  of  the  frontal  nerve 
distributed  to  the  soft  parts  upon  the  crani- 
um, and  afterw  ard  shooting  in  the  direction 
of  the  trunk  of  the  nerve  towards  the  bot- 
tom of  the  orbit.  In  a more  advanced 
stage,  the  conjunctiva  and  all  the  surface  of 
the  eye  participate  in  the  effects  of  the  dis- 
order, and  become  affected  with  chronic  in- 
flammation, which  is  described  as  a particu- 
lar species  of  ophthalmy.  At  length,  the 
pain  passes  beyond  the  distribution  of  the 
branches  of  the  frontal  nerve,  and  affects  all 
the  corresponding  side  of  the  face  and  head. 
It  seems  as  if  it  extended  itself  to  the  facial, 
sub-orbitary,  maxillary,  and  even  to  the 
temporal  and  occipital  nerves,  through  the 
communications  naturally  existing  between 
the  filaments  of  all  those  organs  of  sensa- 
tion. Each  paroxysm  produces  a spasmo- 


dic contraction  of  the  eyelids,  and  a eopi 
ous  effusion  of  tears. 

The  sub-orbitary  neuralgia  is  first  felt 
about  the  sub-orbitary  foramen.  The  seat 
is  probably  in  the  nerve  of  this  name,  and 
the  pain  extends  to  the  lower  eyelid,  the 
inner  canthusof  the  eye,  the  muscles  about 
the  zygoma,  the  buccinator,  cheek  in  gene- 
ral, ala  of  the  nose,  and  the  upper  lip.  At 
a later  period,  the  pain  appears  to  extend 
backward  to  the  trunk  of  the  nerye,  and 
those  branches  which  are  given  off  in  its 
passage  through  the  sub-orbitary  canal. 
Hence,  pains  are  then  experienced  in  the  up- 
per teeth,  the  zygomatic  fossa,  the  palate, 
tongue,  and  within  the  cavity  of  the  nose. 
As  the  disorder  advances,  it  may  extend, 
like  other  neuralgiae  of  the  face,  to  all  the 
same  side  of  the  head.  During  the  pa- 
roxysms, wrhen  the  disease  i9  fully  formed, 
an  abundant  salivation  usually  takes  place. 
In  general  the  attendant  toothach  deceives 
the  practitioner,  who  in  the  belief  that  the 
pain  arises  from  another  cause,  uselessly 
extracts  several  of  the  teeth. 

The  tic  douloureux  of  the  lower  jaw,  or 
maxillary  neuralgia,  is  usually  first  felt  about 
the  situation  of  the  anterior  orifice  of  the 
canalis  mentalis,  and  it  extends  to  the  lower 
lip,  chin,  neck,  teeth,  and  temple.  This 
form  of  the  complaint  is  more  uncommon 
than  the  preceding ; but,  after  it  has  pre- 
vailed some  time,  is  equally  remarkable  for 
its  intensity. 

With  respect  to  the  neuralgia  of  the  facial 
nerve,  or  portio  dura  of  the  auditory  nerve, 
it  is  a case,  which  very  soon  cannot  easily 
be  distinguished  from  the  other  species  of 
tic  douloureux.  The  pains  at  an  early  pe- 
riod are  no  longer  confined  to  the  passage 
of  the  principal  branches  of  this  nerve  be- 
tween the  parotid  gland  and  ramus  of  the 
jaw.  The  numerous  communications  of  the 
portio  dura  with  the  rest  of  the  nerves  of 
the  face  seem  to  facilitate  the  extension  of 
the  disease,  so  that  the  agony  is  soon  felt 
over  the  whole  side  of  the  head.  The  original 
source  of  the  disorder  can  only  be  detected 
by  attentively  considering  the  progress  of 
the  complaint  in  all  its  stages.  (See  Del- 
pech,  Traitd  des  Maladies  Reputes  Chirurgi- 
cales , T.  3,  Sect.  7,  p.  214,  $*.) 

Tic  douloureux  may  be  known  from 
rheumatism  by  the  paroxysm  being  excited 
by  the  slightest  touch,  by  the  shortness  of 
its  duration,  and  the  extreme  violence  of  the 
pain.  In  acute  rheumatism,  also,  there  is 
fever,  with  redness,  heat,  and  generally  some 
degree  of  swelling ; and,  in  chronic  rheu- 
matism, the  pain  is  obtuse,  long-continued, 
and  often  increased  at  night ; none  of  which 
symptoms  characterize  tic  douloureux. 

It  may  easily  be  distinguished  from  henii- 
crania  by  the  pain  exactly  following  the 
course  of  the  branches  of  the  affected  nerve. 

It  is  known  from  the  toothach  by  the  com- 
parative shortness  of  the  paroxysms  ; the 
quickness  of  their  succession  ; the  intervals 
of  entire  ease;  the  darting  ol  the  pain  ill 
the  track  of  the  particular  nerve  affected  . 
the  more  superficial  and  lancinating  kind  ol 


TIC  DOULOUREUX 


481 


$>ain  j and  the  convulsive  twitchings,  which 
sometimes  accompany  the  complaint. 

The  dhuses  of  tic  douloureux  may  be  said 
to  be  in  general  unknown  ; but  there  are  a 
tew  instances  recorded  which  appear  to 
be  the  consequence  of  external  violence, 
wounds,  contusions,  &c.  A modern  writer 
has  related  a very  curious  instance  of  a re- 
sembling disease  in  the  arm,  where  the  af- 
fection proceeded  from  the  lodgment  of  a 
small  bit  of  a bullet  in  the  radial  nerve.  ( Den - 
snark,  in  Med.  Chir.  Tram.  Vol.  4,  p.  48.) 
Dr.  Parry  attributed  the  pain  to  increased 
vascularity,  or  determination  of  blood,  (per- 
haps amounting  to  inflammation)  to  the  neu- 
rilerna,  or  vascular  membranous  envelope  of 
the  nerves  affected.  {Elements  of  Pathology 
and  Therapeutics.) 

Stimulating  embrocations,  blisters,  caustic 
issues,  fomentations,  leeches,  frictions  w ith 
mercurial  ointment,  ( Edinb . Med.  and  Surg. 
Journ.  Vol.  3,)  electricity,  opium  in  large 
doses,  the  arsenical  solution,  and  a variety 
of  antispasmodic  medicines,  are  the  princi- 
pal means,  which  have  been  tried  ; but  for 
the  most  part,  they  only  afford  partial  and 
temporary  relief.  From  some  facts  recent- 
ly published  by  Dr.  Marcet,  the  extract  of 
stramonium,  in  doses  of  one-eighth  and  half 
a grain  thrice  a day,  seems  to  be  sometimes 
capable  of  alleviating  the  distressing  agony 
of  the  present  disorder.  (See  Med.  Chir. 
Trans.  Vol.  7,  p.  75,  fyc.  also  Kirby's  Cases , 
S vo.  Lond.  1819.) 

The  operation  of  dividing  the  trunk  of  the 
affected  nerve,  and  even  of  dissecting  out  a 
portion  of  it,  so  as  to  prevent  all  chance  of 
a relapse  from  the  reunion  of  the  ends  of  the 
nerve,  is  a plan,  which  has  sometimes  been 
practised  with  permanent  benefit.  Thus,  any 
one  of  the  three  branches  of  the  fifth  pair  of 
nerves  may  be  divided  at  the  point,  where  it 
comes  out  upon  the  face.  But,  before  having 
recourse  to  this  means,  the  surgeon  should  be 
sure,  that  the  particular  nerve,  which  he  is 
about  to  expose  and  divide,  is  really  the  prin- 
cipal seat  of  the  disease  ; for,  when  all  the 
nerves  of  the  face  generally  are  affected,  or 
when  the  branches  of  the  portio  dura  are 
especially  concerned,  there  is  little  hope  of 
success.  In  fact,  it  must  be  confessed,  that 
the  operation  has  had  many  failures  and  re- 
lapses, either  from  the  cases  not  having  been 
duly  discriminated,  or  from  the  neglect  to 
remove  a portion  of  the  exposed  nerve. 
Richerand,  Delpech,  and  most  of  the  lead- 
ing surgeons  in  France  express  their  prefe- 
rence to  the  application  of  the  moxa,  or 
cautery,  which,  they  say,  proves  more  fre- 
quently successful,  than  the  knife.  This 
should  be  done  directly  over  the  apertures, 
from  which  the  nerves  emerge  on  the  fore- 
head, cheek,  or  chin,  and  Richerand  asserts, 
that  by  such  treatment,  the  pains  may  al- 
ways be  cured,  or  at  all  events,  rendered 
supportable.  ( Nosogr . Chir.  T.  2,  p 218, 
Edit.  4.)  Delpech  also  affirms,  that  the  sec- 
tion of  the  nerve  very  often  fails,  and  that 
issues,  and  the  repeated  use  of  the  cautery 
have  been  attended  with  the  greatest  suc- 
cess. (See  Pr6cis  dzs  Mai  Chir.  T.  3,  p.  213  > 

Vol,  II,  <51 


The  disfigurement  of  the  countenance  by 
burning  applications  must,  how’ever,  be  very 
objectionable,  and,  as  I think  there  is  no 
positive  evidence  of  the  superiority  of  this 
method  over  the  use  of  the  knife,  l consider 
what  Richerand  and  Delpech  have  staled 
only  as  another  instance  of  the  extreme 
partiality  of  the  French  surgeons  to  the 
moxa  and  cauterization.  Delpech  confesses, 
however,  that,  when  the  pains  seem  to  be 
the  consequence  of  a ganglion,  or  thicken- 
ing of  a part  of  a nerve,  the  excision  of 
such  part  is  indispensable.  There  can  be 
little  doubt,  that  this  would  have  been  more 
proper  than  amputation  in  Mr.  Denmark's 
case,  to  which  I have  already  referred. 
The  theories  of  Dr.  Parry,  senior,  who  was 
generally  inclined  to  refer  the  effects  of  dis- 
ease to  increased  determination  of  blood  to 
the  parts  affected,  led  him  to  believe  that  the 
operation  of  cutting  the  nerve,  as  performed 
by  Dr.  [faighton  and  others,  did  good  rather 
by  the  division  of  the  arterial  branch  sup- 
plying the  affected  ramification  of  the  trige- 
minus nerve,  than  by  the  division  of  that  ra- 
mification itself.  {Parry,  Elements  of  Pa- 
thology,  fyc.) 

There  have  been  many  examples  of  tic 
douloureux,  which,  after  resisting  all  at- 
tempts to  cure  them,  have  been  left  to  them- 
selves, and,  after  a long  time  spontaneously 
subsided.  ( Delpech , Traite  des  Maladies 
Chir.  T.  3,  p.  212,  215.)  This  author  has 
seen  the  operation  of  dividing  the  chief 
branches  of  the  portio  dura,  in  front  of  the 
parotid  gland,  undertaken,  and  even  a por- 
tion of  the  soft  parts  cut  away ; but  without 
any  favourable  consequences.  (P.218.) 

I have  already  stated,  that  the  nerves  of 
the  extremities  are  subject  to  affections  very 
analogous  to  tic  douloureux.  The  following 
instance  related  by  Mr.  Abernethy  will  be 
found  interesting ; — 

A lady  became  gradually  affected  with  «• 
painful  state  of  the  integuments  under,  and 
adjoining  to,  the  inner  edge  of  the  nail  of 
the  ring-finger  of  the  left  hand.  No  injury 
to  the  part  was  remembered,  which  could 
have  brought  on  this  disease.  The  pain  oc- 
curred at  irregular  intervals,  and  was  ex- 
tremely severe  during  the  time  of  its  con- 
tinuance, which  was  fora  day  or  two,  when 
it  usually  abated.  Accidental  slight  injuries 
always  produced  great  pain,  and  frequently 
brought  on  the  paroxysms,  which  however 
occasionally  occurred  spontaneously,  or 
without  any  evident  exciting  cause.  In  all 
these  particulars,  the  disease  correctly  re- 
sembled the  tic  douloureux  of  the  nerves  of 
the  face.  As  the  pain  increased,  the  disor- 
der seemed  to  extend  up  the  nerves  of  the 
arm.  After  the  patient  had  endured  this 
painful  affliction  for  seven  years,  she  sub- 
mitted to  have  the  skin,  which  was  the  ori- 
ginal seat  of  the  disorder,  burnt  with  caustic. 
This  application  gave  her  intense  pain,  and 
on  the  healing  of  the  wound,  she  found  her 
sufferings  rather  augmented  than  diminished, 
by  the  experiment.  After  four  more  years 
of  suffering,  she  consulted  Mr.  Abernethy, 
when  the  circumstances  of  the  case  wert 


4*: 


TOE 


TIC 

such  as  to  render  an  operation  indispensably 
necessary.  The  pain  of  the  part  was  into- 
lerable, and  it  extended  all  up  the  nerves  of 
the  arm  ; and  this  general  pain  was  so  con- 
stant during  the  night,  as  to  deprive  the  pa- 
tient of  rest.  The  muscles  of  the  bach  of  (he 
neck  were  occasionally  affected  with  spasms. 
The  integuments  of  the  affected  arm  were 
much  hotter  than  those  of  the  opposite  arm, 
and  sometimes  the  temperature  was  so  in- 
creased as  to  cause  a burning  sensation  in 
them.  Underthese  circumstances,  Mr.  Aber- 
nethy  did  not  hesitate  to  divide  the  nerve  of 
the  finger,  from  which  all  this  disorder  seem- 
ed to  originate.'  He  laid  it  bare  by  a longi- 
tudinal incision  of  about  three  quarters  of  an 
inchin  length,  from  the  second  joint  of  the 
linger,  and  divided  it  opposite  to  that  joint, 
by  a curved  sharp-pointed  bistoury,  which 
xvas  conveyed  under  it.  He  then  took  hold 
of  the  nerve  with  a pair  of  forceps,  and  re- 
jecting it  downwards,  removed  a portion  of 
it,  half  an  inch  in  length,  so  that  the  possibi- 
lity of  a quick  reunion  might  be  prevented. 
The  wound  was  brought  together  with  stick- 
ing plaster,  and  it  united  by  adhesion  ; but 
the  upper  part  of  the  wound,  opposite  to  the 
upper  end  of  the  nerve,  became  slightly  in- 
flamed, and  was  very  painful.  However,  in 
the  course  of  three  weeks,  ihe  appearance 
of  inflammation  gradually  went  off.  After 
the  operation,  Mr.  Abernethy  pinched  the 
originally  affected  integuments  sharply  with 
bis  nails,  without  causing  any  sensation  ; but 
if,  in  so  doing,  he  moved  the  finger,  then 
pain  was  felt.  He  found  it  difficult  to  con- 
vince the  patient  that  the  skin  at  that  part 
was  actually  devoid  of  sensation  ; for  she 
still  continued  to  feel  similar  sensations  to 
those  which  formerly  occurred,  though  in  a 
much  diminished  degree;  but  she  became 
gradually  as  perfectly  convinced  as  any  me- 
dical man  could  be,  that  these  sensations 
arose  from  (he  irritated  state  of  the  end  of 
the  nerve,  above  the  place  where  it  was  di- 
vided. The  painful  affection  of  the  nerves 
of  the  arm  still  continued,  though  considera- 
bly lessened  in  violence  ; however  it  was  suf- 
ficiently severe  to  make  the  patient  appre- 
hend that  little  permanent  benefit  would 
arise  from  the  operation.  This  pain  conti- 
nued occasionally  about  four  months  with 
varying  degrees  of  severity,  but  the  tempe- 
rature of  the  skin  was  not  hotter  than  that 
of  the  opposite  side,  as  it  hhd  been  before 
the  operation.  At  the  expiration  of  three 
months,  the  patient  ascertained  that  the  in- 
teguments at  the  end  of  the  finger  actually 
felt  when  any  thing  was  applied  to  them, 
arid  this  proved  a new  source  of  alarm.  Mr. 
Abernethy  adds,  that  mure  than  nine  months 
have  now  elapsed  since  the  performance  of 
the  operation,  and  the  general  pains  in  the 
nerves  have  become  very  trivial ; but  the 
sensation  in  the  integuments  at  the  end  of 
the  finger,  has  during  that  time  gradually  in- 
creased, and  the  skin  has  now  its  natural 
sensibility,  so  as  accurately  to  distinguish 
the  tangible  properties  of  any  body  applied 
to  it.  If  also  the  originally  affected  part  be 
slightly  compressed,  painful  sensations  re- 
sembling those  which  formerly  occurred 


take  place.  (Mernethy's  Surgical  Work 
Fol.  2,  p.  203.)  In  a case  resembling  the 
former,  but  the  consequence  of  a wound  of 
the  finger,  M . Laurence  also  cut  down  to  the 
nerve,  and  removed  » portion  of  it  wi‘h  per- 
manent success  Father fill's  Paper  in  ol. 
5 of  the  Medical  Ohs.  and  Inq.  Dr.  Haigh - 
Ion's  Obs.  in  Ihe  Med.  Recants  and  Researches . 
Darwin's  Zoononia.  JlbenvAhf  s Surg. 

Works,  Fol  2,  p.  20*3,  fyc.  Richerand,  No- 
sogr.  ( hir . T.  2 p.  216.  ifc.  Edit.  4.  Del- 
pech,  Precis  des  Maladies  Chir.  T.  3,  p.  206, 
fyc.  Dr.  S Fothergill'.s  Systematic  Account  of 
Tic  Douloureux,  1804.  Mcdico-Chir.  Trans . 
Fol  4,  p.  48,  Fol.  7,  p.  575,  fyc.  Kirby's 
Cases,  8vo.  Lond.  1819. 

TINCTURA  KERRI  MURIATIS.  This 
tincture  has  sometimes  been  exhibited  in 
gleets  ; but  a more  important  use  has  been 
assigned  it  by  Mr.  Cline,  who  orders  it  in 
dysuria  from  stricture,  in  the  dose  of  ten 
drops  every  twenty  or  thirty  minutes,  until 
nausea  is  excited.  Where  chalybeates  are 
indicated,  (his  preparation  is  one  very  much 
approved  of 

“ Mr.  Justamond^s  liquid  for  external  use 
in  cancers,  and  which  the  original  inventor 
called  his  panacea  anticancrosa,  partook  con- 
siderably of  the  nature  of  this  tincture, 
which,  indeed,  with  an  equal  quantity  of 
spirit  ol  wine,  was  sometimes  substituted  for  it, 

“ Lastly,  it  is  remarkably  efficacious  in 
destroying  venereal  or  other  warts,  either 
used  alone,  or  diluted  with  a small  propor- 
tion of  water  ” ( Pharm . Chir.) 

TINCTURA  LYTTdS.  Sometimes  em- 
ployed in  cases  of  gleets,  and  incontinence 
of  urine,  arising  from  a want  of  proper  ac- 
tion in  the  sphincter  vesicae  muscle.  The 
usual  dose  is  from  ten  to  forty  drops, 
twice  or  thrice  a day  ; but  its  effects  should 
be  carefully  w atched  ; for  it  is  apt  to  occa- 
sion dangerous  inflammation*  of  the  urinary 
organs,  violent  stranguries,  and  retention  of 
urine  If  is  occasionally  used  in  various 
liniments,  when  die  object  is  to  stimulate 
the  skin  considerably,  and  rouse  the  action  of 
the  nerves  and  absorbents,  as  in  certain  ca- 
ses of  ptosis,  paralysis,  &,c.  Mr.  Anthony 
Todd  Thomson  has  found  it  an  useful  appli- 
cation in  the  mortification  of  the  extremities, 
sometimes  happening  without  any  apparent 
cause  ; and  also  to  frost-bitten  parts.  ( Lon- 
don Dispensatori /,  p.  65S,  Ed.  2.) 

TINCTURA  THEBAIC  A.  (See  Vinum 
Opii.) 

TINEA  CAPITIS.  (See  Porrigo.) 

TOBACCO  is  used  for  promoting  the  re- 
duction of  strangulated  hernia,  either  in 
the  form  of  a fluid  clyster,  or  of  smoke,  which 
latter  is  introduced  up  the  rectum  by  means 
of  an  Apparatus.  Excepting  the  operation, 
the  power  of  tobacco,  particularly,  when 
assisted  by  the  topical  application  of  cold 
to  the  tumour,  is  most  to  be  depended  upon 
for  bringing  about  the  return  of  the  protru- 
ded viscera.  (See  Hernia,  and  Enema.)  It 
has  also  been  tried  in  tetanus  ; and  Mr.  Earle 
has  found  tobacco  clysters  very  efficacious 
in  certain  cases  of  retention  of  urine.  (See 
Tetanus,  and  Urine , Retention  of.)  Consult 
T Fowhr . Medical  Reports  of  the  Effects  of 


TONGUE 


Tobacco,  Svo.  Lond.  1785.  A.  P.  Wilson,  An 
Experimental  Essay  on  the  manner  in  which 
Opium  and  Tobacco  act  on  the  living  animal 
Body,  Svo.  Edinb.  1 795.  It.  Hamilton , He 
JYicotiams  Viribus  in  Medicina,  fyc.  Svo. 
Edinb.  17S0. 

TONGUE,  DISEASES  OF.  This  part 
is  subject  to  various  diseases,  as  ulcers,  tu- 
mours, and  such  enlargements  as  sometimes 
put  the  patient  in  imminent  danger  of  suffo- 
cation. 

Carious  teeth,  with  points  and  inequali- 
ties, producing  continual  irritation,  are  the 
most  frequent  cause  of  ulcerations  of  the 
tongue.  The  sores,  thus  arising,  often  re- 
sist every  kind  of  remedy,  and  ignorance  of 
the  cause  sometimes  leads  the  practitioner 
to  consider  them  as  incurable  ; whereas,  a 
cure  may  easily  be  effected  by  extracting 
the  carious  tooth,  or  simply  filing  off  its 
sharp  irregularities,  as  was  anciently  direct- 
ed by  Celsus. 

The  glandular  papillae  which  are  situated 
on  the  dorsum,  or  upper  surface  of  the 
tongue,  have  a narrow  base,  and  a broad 
termination  or  head,  like  a mushroom. 
They  are  capable  of  becoming  considerably 
enlarged,  so  as  to  form  preternatural 
tumours,  which  may  be  mistaken  for  can- 
cerous excrescences. 

A young  man,  eighteen  years  of  age,  had 
on  the  middle  of  his  tongue  a circumscribed 
tumour,  about  as  large  as  a middle-sized 
nutmeg.  Louis,  who  was  consulted,  per- 
ceived that  the  swelling  was  only  of  a fun- 
gous nature,  and  he  tied  its  base  with  a liga- 
ture, with  the  noose  of  which  he  con- 
tracted the  diameter  of  the  pedicle,  while, 
with  the  ends,  he  kept  down  the  tongue. 
Then  with  one  stroke  of  a pair  of  cur- 
ved scis  ors,  he  cut  off  the  tubercle.  Caus- 
tic was  afterward  applied  to  the  base  of 
the  tumour,  and  the  patient  was.  perfectly 
well  in  five  or  six  days.  ( Sur  les  Maladies 
de  la  Langue,  in  M6 moires  de  I'Acad.  de  Chir. 
f.b.) 

Morgagni  speaks  of  similar  tubercles ; 
but  he  never  advised  their  extirpation,  not 
even  when  they  were  hard  and  scirrhous  ; 
for,  if  he  had  not  deemed  the  operation  im- 
practicable, he  should  not  have  had  any 
confidence  in  the  surgeons  who  were  .con- 
sulted. 

The  tongue  is  occasionally  affected  with 
a true  cancerous  disease*,  one  of  the  most 
afflicting  cases,  indeed,  which  can  possibly 
happen,  as  may  be  conceived,  when  it  is 
known,  that,  in  the  advanced  stage  of  the 
disease,  the  patient  can  hardly  take  his  food, 
which  must  be  conveyed  over  the  tongue 
by  some  means  or  another,  before  it  can  be 
swallowed,  while  he  is  obliged  to  wrrite  what- 
ever he  wishes  to  say.  (See  Home's  Pract. 
Obs.  on  Cancer , p.  112.)  Cancer  of  the 
tongue  seems  to  differ  from  other  carcino- 
matous affections  in  frequently  occurring  in 
youngish  subjects.  In  the  course- of  the 
disease,  the  glands  behind  the  jaw  and  in 
the  neck  are  sometimes  affected.  Louis 
saw  a lady,  who  had  an  ulcerated  cance- 
rous tubercle  on  the  left  edge  of  the  tongue. 
The  little  swelling  was  circumscribed,  ,;*its 


483 

size  did  not  exceed  that  of  a filbert;  the 
pains  were  lancinating  ; the  sore  had  pene- 
trated deeply  ; and  its  tuberculated  edges 
were  affected  with  a scirrhous  hardness. 
Extirpation  of  the  disease  seemed  to  present 
the  only  chance  of  cure  *,  but  the  patient 
refused  to  accede  to  any  thing  but  palliative 
plans,  and  she  died  in  the  course  of  a few 
months. 

Forestus  makes  mention  of  four  women, 
who  were  attacked  with  cancer  of  their 
tongues,  and  died  from  the  ravages  of  the 
disease,  and  hemorrhage.  In  the  writings 
of  Hildanus,  there  is  a description  of  the 
origin  and  progress  of  a cancerous  tubercle 
on  a young  man’s  tongue,  whose  breath 
was  intolerably  fetid  and  who  died  in  the 
most  excruciating  pain.  The  same  author 
informs  us  of  another  case,  exhibiting  the 
good  effects  of  sedative  remedies  in  palliat- 
ing a cancerous  ulcer  of  the  tongue,  and 
the  fatal  consequences  of  an  opposite  line 
of  conduct.  In  authors,  many  other  ex- 
amples of  the  same  kind  are  to  be  met  with. 

Surgery,  however,  is  not  destitute  of  re- 
sources against  diseases  of  so  formidable  a 
nature.  The  following  case  exemplifies  the 
benefit  which  may  be  effected  by  this  useful 
profession,  when  not  exercised  by  men  of 
too  timorous  a character. 

An  elderly  woman  had  an  ulcerated  hard- 
ness on  her  tongue.  It  had  been  several, 
times  cut  away,  and  as  repeatedly  returned.. 
Ruysch  was  called  into  consultation  with 
one  of  the  surgeons,  who  was  attending  the 
patient,  and  who  had  already  extended  his 
incisions  very  deeply  for  the  removal  of  the 
disease.  The  result  of  their  deliberations 
was  another  attempt  to  extirpate  the  tu- 
mour, and  they  also  determined  that  after 
it  had  been  cut  away,  the  actual  cautery 
should  be  freely  applied,  with  a view  of 
destroying  the  roots  of  the  fungus.  The  pa- 
tient consehted  to  the  plan,  and  bore  the 
operations  with  great  fortitude.  The 
tongue  was  taken  hold  of  with  a cloth,  and 
Pierre  Le  Memnonite,  a sufgeon  of  emi- 
nence, removed  the  disease  with  a curved 
bistoury.  The  inside  of  the  mouth  was  then 
protected  with  wet  cloths,  and  the  actual 
cautery  applied  several  times  to  the  wound 
in  the  tongue.  The  pain  was  appeased,  and 
the  separation  of  the  eschar  promoted  by 
emollient  gargles.  Under,  the  use  of  a gar- 
gle of  honey  of  roses,  and  the  tincture  ot 
myrrh  and  aloes,  the  place  soon  healed. 

It  is  much  easier  to  cut  off  a portion  of 
the  tongue,  through  all  its  diameter,  than  to 
remove  a cancerous  ulceration,  situated-at 
one  of  its  edges. 

In  both  cases,  there  is  a good  deal  of  dif- 
ficulty in  fixing  the  part,  for  it  is  so  very 
moveable,  that  it  is  not  easy  to  keep  it  in  a 
steady  position.  For  this  purpose,  Louis  re- 
commended the  employment  of  forceps, 
with  blades  terminating  in  hook-like  extre- 
mities. With  this  instrument,  the  part  of 
the.  tongue  to  be  amputated  can  be  kept 
from  slipping  away. 

However,  very  malignant  ulcers  on  the 
tongue  have  sometimes  been  cured  by  mild- 
er means.  Sores  of  this  description  are  re- 


48.4 


lOXGTJE. 


ported  t6  have  yielded  to  the  repeated  ap- 
plication of  leeches  under  the  tongue,  after 
a vast  number  of  other  remedies  had  been 
tried  in  vain.  In  the  Encyclopedic  MAlho- 
dique,  art.  Langue , there  is  an  account  of  a 
very  alarming  affection  of  the  tongue,  (re- 
puted to  be  cancerous,  though  this  may  be 
doubted,)  which  got  completely  well  under 
a very  simple  plan  of  treatment.  A woman, 
thirty-five  years  of  age,  subject  to  cutaneous 
diseases,  and  ill-conditioned  ulcers,  com- 
plained, for  seven  or,  eight  months,  of  little 
swellings,  accompanied  with  heat  and  pain, 
which  made  their  appearance  on  the  edge, 
and  towards  the  apex  of  the  tongue.  At 
length,  the  part  affected  began  to  swell,  grow 
hard,  and  cause  lancinating  pains.  Its  sur- 
face .became  irregular  and  rough  ; and  all 
the  side  of  the  tongue  was  considerably 
swelled.  The  patient  could  not  put  her 
tongue  out  of  her  mouth,  nor  swallow  any 
thing  except  liquids  ; and  her  breath  was 
intolerably  fetid.  Various  sedative  remedies 
had  been  employed  without  success.  Ci- 
euta  had  been  used  as  a topical  application  ; 
it  had  been  exhibited  internally  in  large 
doses;  the  patient  had  taken  for  a long 
while,  the  oxymuriate  of  mercury  ; but  no- 
thing proved  of  any  avail.  At  length  the 
palieni  was  so  tired  of  trying  the  effects  of 
medicines  and  applications,  that  she  gave 
them  up  entirely;  and  contented  herself  with 
trying  the  experiment  of  keeping  some  ho- 
ney continually  in  her  mouth.  As  this  method 
seemed  to  give  her  some  ease,  she  was  pre- 
vailed upon  to  persist  in  it,  and  in  this  way, 
the  pains  were  gradually  appeased ; the 
swelling  was  diminished,  and  at  the  end  of 
two  or  three  months,  the  woman  was  quite 
well,  except  that  an  indurated  cicatrix  re- 
mained on  the  part  affected,  and  considera- 
bly obstructed  the  extension  of  the  tongue 
on  that  side. 

On  this  case,  however,  it  might  be  re- 
marked, the  retardation  of  the  cure  seem3 
also  ascribable  to  the  injury  of  the  health 
produced  by  the  hemlock,  mercury,  &c.  and 
that  the  amendment,  following  their  dis- 
continuance, might  rather  arise  from  the 
consequent  improvement  of  the  patient’s 
health,  than  from  any  effect  of  the  honey. 

Many  writers  confirm  the  fact,  that  very 
inveterate  diseases  of  the  tongue  are  some- 
times cured  by  hemlock.  Jn  the  work  last 
cited,  is  mentioned  an  instance  of  a very 
unhealthy  looking  ulcer,  near  the  apex  of 
the  tongue,  attended  with  a considerable 
thickening  of  the  part,  and  of  some  dura- 
tion, which  was  cured  by  giving  large  doses 
of  cicuta.  But  of  all  the  medicines  which 
have  the  greatest  reputation  for  their  bene- 
ficial effects  upon  malignant  ulcers  of  the 
lip  and  tongue,  none  perhaps  is  deserv- 
ing of  so  much  confidence,  as  arsenic.  (See 
C.  Lane's  case  of  iU-condilioned  Ulcer  of  Ike 
Tongue , successfully  treated  by  arsenic ; Med. 
Chir.  Trans.  Vol.  8,  p.  201.) 

However,  notwithstanding  many  facts,  of 
this  kind  on  record,  medicines  should  not 
be  tried  too  long,  that  is  to  say,  so  as  to  let 
the  disease  attain  a condition,  in  which  it 
will  no  longer  admit  of  being  cut  away. 


When  the  disease  makes  progress,  the  kniie 
should  be  employed  before  it  is  too  late. 

When  any  part  of  the  tongue  is  to  be  am- 
putated, authors  very  properly  recommend 
the  chief  vessels  to  be  tied,  if  possible  ; but 
when  this  cannot  be  accomplished,  they 
advise  the  employment  of  astringent  gar- 
gles, such  as  a strong  solution  of  alum,  dis- 
tilled vinegar,  or  diluted  sulphuric  acid. 
When  these  methods  fail,  the  continental 
surgeons  recommend  the  actual  cautery  as 
the  only  resource.  Where  only  a piece  of 
the  tongue  is  cut  out,  in  the  shape  of  the 
letter  V,  the  best  mode  of  stopping  tbe 
bleeding  is  to  bring  the  sides  of  the  in- 
cision together  with  a suture,  by  which 
means  the  deformity  will  also  be  lessened, 
and  the  union  expedited,  as  is  exemplified 
in  a case  recorded  by  Langenbeck.  (Neuc 
Bibl.  B.  2,  p.  489.)  Bather  than  suffer  a 
patient  to  die  of  hemorrhage,  if  the  cautery 
and  other  means  fail,  the  lingual  artery 
should  be  taken  up  where  it  passes  over  the 
cornu  of  tbe  os  hyoides.  Diseased  portions 
of  the  tongue  admit  of  removal  with  the 
ligature.  (La  Motle  Chirurgit  Obs.  208; 
Godarl  in  Journ.  de  Med.  T.  13,  p.  66 ; Sir 
Everard  Home , Pract.  Obs.  on  Cancer , p. 
207 ; Inglis , in  Edinb.  Med.  and  Surgical 
Journ.  1805,  No.  1,  p.  34.)  Sir  Everard 
Horne  generally  passed  a double  ligature 
through  the  centre  of  the  tongue,  behind 
the  diseased  portion,  and  then  tied  the 
threads  tightly  over  each  half  of  the  organ, 
so  as  to  make  all  the  part  in  front  of  the 
constriction  slough  away. 

The  whole  of  the  tongue  sometimes  in- 
flames, and  becomes  considerably  enlarged, 
either  spontaneously,  and  without  any  ap- 
parent cause,  or  in  consequence  of  some 
other  disease  ; or  else  from  some  particular 
irritation,  such  as  that  of  mercury,  or  some 
poisonous  substance.  Siegel,  a German 
physician,  who  was  at  Paris  about  the  mid- 
dle of  the  17th  century,  saw  a patient  in  a 
salivation,  whose  tongue  became  so  enor- 
mously enlarged,  that  the  mouth  could  not 
contain  it.  Pimprenelle,  an  eminent  sur- 
geon of  that  time,  was  sent  for,  and  finding 
that  all  trials  to  relieve  the  affection  were  in 
vain,  amputated  one  half  of  the  tongue, 
with  the  view  of  preventing  its  mortifica- 
tion. After  the  wound  had  healed,  it  is  said 
the  patient  could  articulate  very  well.  Louis, 
from  whom  this  fact  is  quoted,  very  justly 
remarks,  that  the  measure  resorted  to  by 
Pimprenelle  was  an  exceedingly  violent 
one;  for  he  has  often  seen  urgent  symptoms 
occasioned,  during  a salivation,  by  a rapid 
and  enormous  swelling  of  the  tongue,  very 
quickly  yield  to  bleedings,  purgative  glys- 
ters,  change  of  air,  and  leaving  off  meren- 
cury.  Two  or  three  facts,  confirming  this 
statement,  have  fallen  under  my  own  notice. 

Trincavellius  mentions  two  women,  who 
had  considerable  enlargements  of  their 
tongues.  Ono  of  these  patients,  who  was 
young,  had  been  rubbed  with  mercurial 
ointment  even  on  her  head  ; and  the  other, 
who  was  about  fifty  years  old,  had  her 
tongue  attacked  with  the  ravages  of  the 
smfuLpox.  The  excessive  swelling  of  the 


TONSILS, 


longue,  in  both  these  instances,  terminated 
in  resolution. 

When  the  urgency  is  such,  that  an  imme- 
diate diminution  of  the  swelling  becomes 
necessary  for  the  relief  of  the  symptoms, 
the  plan  of  making  one  or  two  deep  inci- 
sions along  the  tongue  is  strongly  recom- 
mended. See  the  cases  inserted  by  De  la 
Malle,  in  the  5th  vol.  4to.  of  the  Mem.  de 
VAcad.  Chirurgie , and  some  others,  related 
by  Louis  in  the  paper  above  cited. 

A man,  recovering  from  a bad  fever,  was 
suddenly  attacked  with  a pain  in  his  tongue, 
followed  by  a swelling  equaliy  large  and 
rapid  in  its  formation.  In  less  than  five 
hours  the  part  became  thrice  as  large  as  it 
is  in  its  natural  state,  and  in  this  space  of 
time  De  la  Malle,  who  had  been  consulted, 
had  bled  the  patient  successively  in  his  arm, 
neck,  and  foot.  The  man  felt  very  acute 
pain  ; his  skin  was  excessively  hot ; his  face 
was  swelled;  his  pulse  was  hard  and  con- 
tracted ; and  his  look  wild.  He  could  hardly 
breathe:  the  tongue  filled  all  the  cavity  of 
the  mouth,  and  protruded  out  between  the 
lips.  In  this  very  urgent  case,  the  mouth 
was  kept  a little  more  open  than  the  swell- 
ing of  the  tongue  actually  caused  it  to  be, 
and  three  parallel  incisions  were  made  along 
this  organ,  one  along  its  middle,  and  the 
other  two  between  the  one  in  the  centre 
and  the  edges  of  the  part  affected.  The 
cuts  extended  through  two-thirds  of  the 
preternatural  swelling,  and  had  all  the  good 
effect  which  could  possibly  be  desired. 
There  was  a great  deal  of  hemorrhage,  and 
the  enlargement  of  the  tongue  subsided  so 
much,  that,  an  hour  after  the  operation,  the 
patient  was  able  to  speak.  The  next  day 
the  incisions  had  the  appearance  of  being 
only  superficial  scarifications,  and  the  tongue 
was  in  its  natural  state.  In  short,  the  inci- 
sions healed  in  a few  days,  with  the  use  of 
a simple  gargle. 

De  la  Malle  quotes  several  other  cases, 
all  of  which  tend  to  show  the  success  which 
he  met  with  from  this  practice  in  other 
similar  cases.  He  confirms  his  own  senti- 
ments, by  quoting  the  testimony  of  some 
authors,  antecedent  to  him,  who  have  re- 
commended the  method  ; and  in  particular, 
he  cites  a case,  in  which  Job  a Meckren 
adopted  this  practice,  in  a case  where  the 
tongue,  together  with  the  tonsils  and  palate, 
became  spontaneously  affected  with  a sud- 
den and  dangerous  degree  of  swelling. 

From  the  preceding  observations  it  may 
be  concluded,  that  making  incisions  in  the 
tongue  would  have  saved  numerous  patients, 
who  have  been  suffocated  in  consequence 
of  enormous  enlargements  of  this  organ. 
In  the  small-pox,  the  tongue  sometimes  be- 
comes immensely  swelled ; and  it  is  more 
than  probable,  that,  in  many  instances,  the 
employment  of  the  above  method  would 
have  afforded  great  relief  to  patients,  whom 
the  disease  has  been  known  to  have  entirely 
bereaved  of  the  power  of  swallowing.  It 
is  a curious  fact,  that  after  the  loss  of  very 
considerable  portions,  or  even  what  may  be 
called  the  whole  tongue,  patients  often  re- 


tlSb 

cover  the  power  of  speech,  mastication,  and 
deglutition.  ( Louis  in  M6m.  de  VJicad.  de 
Chir.  T.  5 ; also,  J.  Rowland , Aglossostomo- 
graphie , ou  Description  d’une  Bouche  sani 
langue , laquelle  parle,  el  fait  naturellement 
toutes  sts  autres  functions,  l2ino.  Saumur , 
1630.  Louis,  sur  les  Maladies  de  la  Languet 
Mdmoires  de  VAcad.  de  Chir.  T.  5 ; also  the 
memoir  of  De  la  Malle  in  the  same  volume. 
Encyclopedic  Methodique,  Fartie  Chir.  art. 
Langue.  Sir  Ecerard  Home's  Fract.  Obs.  on 
C ncer,8vo.  Loud.  1805.  Langenbeck , JYeue 
Bibl.  B.  2 ,p.  487,  8ro.  Hanover , 1820.) 

TONSILS.  The  tonsils,  like  all  other 
parts  at  the  back  of  the  mouth,  are  subject, 
to  different  kinds  of  swelling,  which  vary  as 
much  in  their  nature  as  their  conseqhences. 
Some  are  rapid  in  their  progress,  and  these 
are  frequently  observed  to  affect  persons  of, 
what  is  termed,  a sanguineous  temperament. 
They  are  also  prone  to  attack  young  peo- 
ple, and  such  as  labour  bard,  and  they  have 
all  the  essential  characters  of  inflammation. 

Other  swellings  of  the  tonsils  are  slower 
in  their  progress,  occur  in  damp  cold  wea- 
ther, and  in  indolent,  and,  what  the  old 
physicians  used  to  call,  phlegmatic  consti- 
tutions. 

Lastly,  another  kind  of  enlargement  of 
the  tonsils,  which  is  usually  contagious, 
readily  falls  into  a sloughing,  gangrenous 
state,  sometimes  extends  to  the  neighbour- 
ing parts,  and  too  often  proves  fatal.  Hence 
the  various  species  of  angina  have  been 
named  by  some  writers  inflammatory,  ca- 
tarrhal, and  gangrenous.  The  two  first 
kinds  frequently  terminate  in  resolution  ; 
but  sometimes  the  affected  tonsils  after- 
ward assume  a scirrhous  hardness,  obstruct 
respiration  and  deglutition,  so  that  it  be- 
comes indispensably  necessary,  either  to 
extirpate  the  diseased  parts  with  the  ligature 
or  knife. 

The  cutting  away  of  enlarged  tonsils  was 
an  operation  which  was  performed  by  the 
ancients,  and  in  different  ways.  Sometimes 
they  tore  with  their  fingers  the  membrane 
covering  the  tonsil,  and  then  pulled  this 
part  out  of  the  situation  which  it  occupies 
between  the  pillars  of  the  velum  pendulum 
palati.  In  other  instances,  in  which  they 
experienced  too  much  resistance, Mthey  sei- 
zed the  diseased  tonsil  with  a kind  of  hook, 
and  then  cut  it  away  with  a bistoury,  which, 
Paulus  iEgineta  informs  us,  was  concave  on 
the  side  towrards  the  tongue. 

The  moderns,  who,  for  a long  while,  were 
timid  in  the  employ  ment  of  both  these  me- 
thods, adopted  plans  of  a more  cruel  de- 
scription. The  actual  cautery  was  proposed, 
and  some  partial  success  which  followed  its 
use,  at  once  established  its  reputation. 
Caustics  were  afterward  employed,  instead 
of  actual  fire  ; but  the  inconvenience  of  not 
being  able  to  limit  their  action,  and  the 
hazard  of  their  falling  down  the  oesophagus, 
soon  caused  them  to  be  relinquished  by  all 
rational  practitioners.  Then  the  operation 
of  cutting  away  the  tonsils  was  revived,  and 
it  was  performed,  sometimes  in  the  manner 
of  the  old  surgeons,  sometimes  with  various 


TONSILS. 


486 


kinds  of  curved  scissors,  or  knives.  Instead 
of  the  simple  tenaculum  used  by  the 
ancients,  a sort  of  double  one  came  into 
fashion. 

Bichat  describes  the  following,  as  once 
the  common  plan  : the  surgeon  is  to  open 
the  mouth  very  wide,  and  depress  the  tongue 
with  any  flat  instrument,  which  is  to  be 
held  by  an  assistant.  The  operator  is  then 
to  take  hold  of  the  diseased  tonsil  with  a 
tenaculum,  and  with  a common  scalpel, 
having  the  back  half  of  its  blade  covered 
with  rag,  he  now  removes  as  much  of  the 
tonsil  as  ought  to  be  taken  away.  In  com- 
mon cases,  it  is  deemed  sufficient  to  cut  on 
a level  with  the  pillars  of  the  velum  pendu- 
lum palati.  Any  other  portion,  needing  re- 
moval, should  next  be  taken  away.  The 
operation  being  finished,  the  patient  is  fre- 
quently to  wash  his  mouth  with  proper  gar- 
gles. 

The  preceding  method  was  long  adopted 
by  Desault.  However,  one  objection  is 
urged  against  it,  viz.  that  when  the  end  of 
the  knife  is  conveyed  far  into  the  mouth,  it 
may  do  mischief,  not  (as  has  been  alleged) 
to  the  internal  carotid  artery,  the  backward 
situation  of  which  completely  keeps  it  out 
of  ali  danger  of  being  wounded,  but  to  the 
membranous  covering  of  the  palate,  in  a 
place  not  corresponding  to  the  tonsils.  De- 
sault thought  this  objection  was  the  more 
forcible,  as  when  the  hook  is  introduced  in- 
to the  tonsil,  the  danger  of  the  above  mis- 
chief is  considerably  increased  by  a general 
spasm,  which  seems  to  aifect  every  part  of 
the  mouth.  Hence  this  eminent  surgeon 
used  to  employ,  for  the  removal  of  diseased 
tonsils,  an  instrument,  which  w'as  first  in- 
vented for  dividing  cysts  of  the  bladder.  It 
consisted  of  a sharp-edged  blade,  which  wTas 
included  in  a silver  sheath.  The  latter  had 
at  its  extremity  a kind  of  notch,  in  which  the 
gland,  which  was  to  be  extirpated,  W'as  re- 
ceived. The  rest  of  the  instruments  were 
similar  to  those  commonly  used.  Desault 
proceeded  as  follows: 

1.  The  patient  being  seated  on  a high 
chair,  w ith  his  head  supported  on  an  assist- 
ant’s breast,  he  is  to  open  his  mouth  very 
wide,  and  the  lowmrjaw  is  to  be  kept  thus 
depressed,  by  some  solid  body  placed  be- 
tween the  teeth,  and  held  there  by  an  assist- 
ant. 

2.  The  tongue  is  to  be  kept  down  with  a 
broad  spatula. 

3.  The  surgeon  is  next  to  take  hold  of  the 
tonsil  with  a double  hook,  w ith  which  he  is 
to  raise  and  draw  it  a little  towards  him. 
He  is  then  to  take  the  above  cystitome,  and 
put  the  tonsil  in  the  notch,  on  a level  w ith 
the  place  where  the  incision  is  intended  to 
be  made. 

4.  When  the  portion  which  is  to  be  cut 
oft',  is  engaged  in  the  notch,  the  operator  is 
to  draw  the  part  towards  him,  so  -as  to 
stretch  it,  and  press  the  instrument  against 
it  from  below  upward.  The  blade  being 
next  pushed  across  the  notch,  the  necessary 
section  is  accomplished.  When  the  division 
is  not  complete,  which  is  particularly  liable. 


to  happen,  when  the  diseased  gland  is  of 
considerable  magnitude,  the  blade  is  to  be 
drawm  back,  and  the  section  completed  by 
applying  the  instrument  to  the  wound, 
W’hiph  it  has  already  made.  Sometimes 
even  a third  application  may  possibly  be- 
come requisite. 

5.  The  patient  is  to  be  directed  to  wash 
his  mouth.  Bichat  states,  that  this  plan  of 
operating,  adopted  by  Desault,  is  as  simple 
and  easy  as  the  method  above  related,  with 
the  advantage  of  being  safer.  Such  is  the 
construction  of  the  blade  of  the  instrument, 
that  when  it  slides  across  the  notch,  it 
presses  against,  and  steadily  fixes  the  parts 
which  are  to  be  d.vided  ; an  advantage 
which  neither  the  knife  nor  scissors  have, 
under  the  action  of  which  the  parts  are 
quite  moveable.  Hence  there  is  difficulty 
in  cutting  them.  Wnen  the  introduction  of 
the  instrument  from  above  downward  is 
difficult,  it  is  better  to  withdraw  it ; and, 
alter  turning  the  notch  in  the  opposite  di- 
rect ion,  pass  it  from  below  upward.  In 
general,  however,  the  first  of  these  methods 
is  preferable,  because  the  gland,  when  half 
cut  through,  cannot  now  fall  back  and  db- 
struct  the  rima  glottidis,  so  as  to  bring  on 
danger  of  a sudden  suffocation  ; a circum- 
stance which  Wiseman  and  Moscati  saw 
happen.  With  a view  of  preventing  this 
occurrence,  Louis  recommended  the  com- 
mon scalpel  to  be  used,  with  its  edge  direct- 
ed upward,  as  has  been  advised  for  the 
above  instrument ; which  latter  contrivance, 
however,  being,  according  to  Bichat’s  ac- 
count, more  easy  and  safe,  merits  the  pre- 
ference. Besides  the  advantage  of  fixing 
the  soft  parts,  which  are  to  be  cut,  it  has 
that  of  not  contusing  them,  like  most  other 
instruments  ot  this  nature,  as,  for  instance, 
scissors.  The  oblique  disposition  of  its 
blade  enables  it  to  divide  parts,  in  the  man- 
ner of  a saw. 

This  invention,  as  Bichat  allows,  is  cer- 
tainly increasing  the  number  of  surgical  in- 
struments ; a thing,  w'hich  all  the  best  mo- 
dern surgeons  endeavour  to  avoid  But  it 
is  to  be  recollected,  that  this  instrument  is 
not  exclusively  applicable  to  any  particular 
operation.  It  may  be  employed  for  cutting 
away  the  tonsils  and  uvula  ; dividing  mem- 
branous fraena  in  the  rectum,  vagina,  and 
bladder;  amputating  lungous  excrescen- 
ces, polypi  of  the  nose,  (if  this  mode  of 
extirpating  them  were  preferred)  and  va- 
rious tumours  in  general,  which  are  deeply 
situated  in  different  cavities  of  the  body, 
where  instruments  introduced  unguardedly 
might  injure  parts  which  should  be  avoided, 
or  where  the  base  of  the  tumour  should  be 
steadily  fixed,  when  its  division  is  to  be  ac- 
complished. The  latter  object  cannot  safely 
be  rife,  ted  by  scissors  When  the  base  ot 
t ie  tumour  is  too  large  to  be  received  in  the 
notch,  one  part  is  first  to  be  divided,  and 
then  another,  till  its  whole  thickness  is  cut 
through. 

In  England,  when  a diseased  tonsil  is  to 
be  cut  away,  surgeons  generally  prefer  a 
common  scalpel 


rot/  487 


As  a general  practice,  I consider,  that 
the  excision  of  an  enlarged  tonsil  is  a better 
practice  than  the  extirpation  of  it  with  a li- 
guture,  which  also  sometimes  answers  very 
well,  and,  perhaps,  in  children  and  timid 
patients  may  merit  the  preference.  The 
chief  objections  to  the  ligature  are.  that  its 
operation  is  rather  tedious,  sometimes  pro- 
ductive of  a great  deal  of  irritation,  and,  on 
the  whole,  at  least  as  painful  as  the  knife. 

Moscati  having  once  adopted  Ibis  plan, 
very  severe  pain  and  inflammation  ensued; 
the  difficulty  of  swallowing  and  breathing 
) compelled  him  to  amputate  the  tumour  at 
the  place  where  the  ligature  was  applied, 
and  all  the  bad  symptoms  immediately  ceas- 
ed. Besides,  when  the  ligature  is  used, 
there  is  no  oozing  of  blood  from  the  vessels, 
a circumstance  which  tends  so  much  to  di- 
minish the  inflammation.  The  base  of  the 
! swelling  is  also  sometimes  broader  than  its 
upper  part,  and  does  not  admit  of  being 
properly  surrounded  with  a ligature.  And, 
when  it  has  a narrow  base,  it  can  then  be 
so  easily  removed  with  a scalpel,  or  with 
Desault’s  instrument,  and  with  so  little  pain, 
that  one  of  the  last  modes  is  generally  pre- 
ferable. 

The  Hgature,  however,  has  had  its  advo- 
cates. Heister  recommends  it,  in  certain 
cases  ; Sharp  praises  it  ; and  others  approve 
its  use  ; while  the  plans  ot  employing  it 
have  been  as  various  as  the  inventive  genius 
of  the  different  partisans  of  the  practice. 
Some  make  use  of  Levret’s  double  cannula, 
which  is  furnished  with  a silver  wire  noose, 
in  which  the  tumour  is  to  be  engaged  By 
twistingthe  instrument,  the  diseased  part  be- 
comes constricted ; and  this  plan  being 
repeated  every  day,  the  circulation  is  inter- 
cepted, and  the  gland  mortifies,  and  sloughs 
away.  Some,  after  putting  the  noose  of  a 
ligature  over  a kind  of  tenaculum,  hook 
hold  of  the  tonsil,  push  the  ligature  over 
the  enlarged  gland,  which  they  tie,  without 
having  any  means  of  increasing  the  con- 
striction afterward.  Some  employ  Bello- 
que’s  instrument  for  putting  the  ligature 
over  the  tonsil.  Others  require  no  instru- 
ment whatever  for  the  purpose,  and  accom- 
plish the  business  with  their  fingers. 

Desault  employed  an  instrument,  which 
the  French  call  un  Serrc-ncnid,  which  is  in 
fact,  nothing  more,  than  a long,  narrow, 
round  piece  of  silver,  terminating  at  one  end 
in  a little  ring,  or  hole,  and,  at  the  other,  in 
a kind  of  groove  or  notch. 

The  following  was  Desault’s  method  of 
extirpating  the  tonsils  with  a ligature. 

1.  The  patient  wTas  seated  on  a high  chair, 
I with  his  head  held  back,  on  an  assistant’s 
; breast;  his  mouth  was  opened  very  wide, 

his  tongue  depressed,  and  the  diseased  ton- 
sil taken  hold  of  with  a double  hook. 

2.  The  surgeon  took  the  serre-noeud , in 
which  a ligature  had  been  passed,  so  as  to 

| form  a noose.  The  noose  was  put  over  the 
* handle  of  the  hook,  which  was  committed 
1 to  the  charge  of  an  assistant,  and  the  noose 
then  pushed  over  the  tonsil,  so  as  to  embrace 
it  completely 


i>.  The  surgeon  now  drew  the  ligature 
strongly  towards  him,  and  pushed  forward 
the  serre-noeud,  so  as  to  product  the  requisite 
constriction  of  the  tumour.  In  general,  the 
ligature  was  not  made  very  tight  the  first 
day. 

4.  When  the  necessary  constriction  had 
been  made,  the  double-hook  was  withdrawn, 
and  the  ligature  tw  isted  round  the  notch,  at 
the  outward  end  of  the  instrument. 

5 The  next  day,  the  gland  became  unu- 
sually large,  in  consequence  of  the  impedi- 
ment to  the  return  of  the  venous  blood. 
The  ligature  was  unfastened  from  the  notch- 
ed end  of  the  instrument  and  drawn  more 
out,  so  as  to  increase  the  constriction,  after 
which  it  was  again  twisted  round  the  notch, 

I his  plan  wras  followed  up  t IS  the  tumour 
was  detached,  which  usually  happened  on 
the  fourth,  or  fifth  day. 

Mr.  Chevalier,  a few  years  ago,  described 
a particular  mode  of  passing  and  securing 
the  ligature.  He  passes  a flat  spear  pointed 
hook  behind  the  diseased  tonsil,  and  its 
point  is  then  pushed  forward,  so  as  to  perfo- 
rate it  through  the  middle  of  its  base.  The 
needle  is  then  to  be  withdrawn,  and  an  eye  > 
probe,  very  much  curved,  and  armed  with, 
a long  double  ligature,  may  then  be  readily 
passed  through  the  perforation,  and  brought 
out  at  tne  mouth,  the  ligature  divided,  and 
one  portion  tied  round  the  upper  half  of  the 
tonsil,  and  the  other  round  the  lower.  “ A 
single  knot  being  first  made  upon  one  end  of 
the  thread,  the  end  so  knotted,  is  to*  be 
brought  forward  upon  the  other,  and  to 
make  a single  noose  upon  itself  including 
the  other,  and  to  be  drawn  tight  upon  it, 
close  to  the  first  knot.  The  free  end  of  the 
thread  is  then  to  be  passed”  through  a ring 
at  the  end  of  an  instrument  for  the  purpose, 
and  ‘ beingthen  held  firm,  and  thering  push- 
ed forward  upon  the  knot,  the  loop,  now 
formed,  may  be  readily  tightened,  so  as 
completely  to  strangulate  the  diseased  part ; 
and  in  the  same  manner,  it  may  be  tighten- 
ed, from  Jay  to  day,  till  the  part  is  entirely 
detached.”  (See  Med.  Chi'.  Trans.  I ol.3,p, 
80,  fyc.)  The  subject  is  more  intelligible 
with  the  plate. 

In  cases  of  angina,  the  tonsils  are  some- 
times suddenly  attacked  with  such  a degree 
of  swelling,  that  respiration  is  dangerously 
obstructed.  This  c^se  is  analogous  to  the 
occasional  enormous  inflammatory  swelling 
of  the  tongue,  and,  if  it  resist  venesection 
and  leeches,  the  most  prompt  mode  of  re- 
lief is  that  of  making  several  deep  scarifi- 
cations with  a knife  in  the  part.  Many 
cases,  confirming  the  good  effects  of  this 
practice,  have  been  seen  by  Langenbeck, 
(See  JVeue  Bibl.  B.  2,  p.  492,  fyc.) 

TOPHUS.  A swelling,  wrhich  particular- 
ly affects  a bone,  or  the  periosteum.  See 
JYode. 

TORTICOLLIS,  (from  torqueo , to  Iwdst ; 
and  collvm,  the  neck.)  The  wry-neck.  See 
Wry-neck. 

*TOURl\IQU£T.  ( French , from  lourner, 
to  turn.)  An  instrument  used  for  stopping  the 
flow  of  blood  into  a limb,  until  some  reqm- 


I017KNIQUET. 


site  operation  has  been  performed,  or  some 
more  permanent  plans  of  checking  hemor- 
rhage have  been  put  in  practice. 

The  old  surgeons  used  to  surround  the 
limb  with  a band,  with  which  they  made 
such  a degree  of  constriction,  that  the  cir- 
culation was  quite  stopped.  They  also  be- 
lieved, that  the  pressure  of  the  band  was  ad- 
vantageous, in  benumbing  the  limb,  and 
moderating  the  pain  of  operations. 

The  violent  pain  and  contusion,  how- 
ever, which  such  a tourniquet  occasioned, 
being  frequently  followed  by  mortification 
and  abscesses,  surgeons  found  it  necessary 
to  devise  some  other  method  of  checking 
hemorrhage.  The  application  of  the  circu- 
lar band  was  first  improved,  so  that  it  caused 
less  pain,  and  less  mischief  to  the  skin.  'I  he 
limb  was  surrounded  with  a very  thick  com- 
press, over  which  the  band  was  placed. 
Two  small  sticks  were  nest  put  under  the 
band  ; one  on  the  inside,  the  other  on  the 
outside  of  the  limb  ; and  they  were  twisted 
till  the  band  was  rendered  sufficiently  tight. 
It  is  in  this  manner,  says  Dionis,  in  his 
Trait6  d-  Operations,  that  carriers  tighten  the 
cords  which  fasten  the  bales  of  goods  in 
their  carts.  A French  surgeon,  named 
Morel,  is  said  to  have  maJe  this  first  im 
provement  in  the  application  of  tourni- 
quets. 

J.  L.  Petit,  in  1718,  presented  to  the  Aca- 
demy of  Sciences  a tourniquet  of  his  own 
invention,  which  was  much  more  perfect 
than  any  previously  contrived.  It  consists 
of  two  pieces  of  wood,  one  of  which  is  su- 
perior, the  other  inferior.  The  inferior 
piece  is  about  four  inches  and  a half  long, 
and  nearly  two  broad.  Its  under  surface  is 
somewhat  concave,  while  its  upper  one  is  a 
Tittle  convex,  and  the  ends  are  hollowed 
out.  From  its  middle  part  rises  a round 
eminence,  about  seven  lines  high,  and  eight 
and  a half  broad.  The  superior  piece  is 
almost  the  same  as  the  inferior  one,  but 
rather  shorter.  The  eminence,  which  as- 
cends from  its  middle  part,  is  six  lines  high, 
and  an  inch  and  a half  in  diameter.  This 
eminence  is  hollow  within,  and  calculated 
to  receive  a wTooden  screw,  the  top  of  which 
is  a sort  of  button  for  turning  the  screw. 
The  grooves  of  Petit  s screw  were  about 
four,  or  live,  and  each  of  them  four  lines  in 
diameter,  in  order  that  a half  turn  might 
produce  the  necessary  elfect.  Lastly,  all 
the  pieces  of  the  instrument  were  fastened 
together  with  an  iron  pin,  which  went 
through  the  middle  of  the  two  pieces  of 
wood,  and  through  the  w hole  length  of  the 
screw.  This  iron  pin  was  riveted  under  the 
inferior  piece,  and  at  the  top  of  the  button, 
in  such  a manner,  however,  that  the  screw 
was  capable  of  turning  on  it,  as  on  a pivot. 

In  order  to  apply  this  tourniquet,  the  limb 
is  to  be  surrounded  with  a double  strap, 
about  four  finger-breadths  wide,  and  made 
of  chamois  leather,  which  is  the  softest  ma- 
terial that  can  be  used.  To  one  end  of  the 
strap  a double  little  cushion  is  fastened,  of 
the  same  length  and  breadth  as  the  lower 
piece  of  the  tourniquet.  A narrow  com- 


press, or  cylindrical  pad,  is  also  requisite- 
for  the  purpose  of  compressing  the  track  of 
the  vessels.  This  compress  consists  of  a 
very  firm  roll  of  linen,  covered  with  cha- 
mois leather.  The  ends  of  a piece  of  tape 
are  sewed  to  the  outer  part  of  the  pad,  and 
thus  the  tape  leaves  a passage  for  the  lea- 
ther strap.  By  this  artifice,  the  pad  can  be 
moved  to  any  situation  on  the  strap,  as  they 
bulk  of  the  limb  may  require. . The  middle 
of  the  tape  is  to  be  fastened  to  the  outside 
of  the  leather  strap.  The  cylindrical  com- 
press, or  pad,  is  to  be  put  over  the  course  of 
the  vessels.  The  double  cushion  is  to  be 
placed  on  the  opposite  side  of  the  member, 
while  the  leather  strap  is  to  surround  the 
limb.  All  the  different  pieces  of  the  appa- 
ratus are  next  to  be  retained  by  means  of 
the  tape,  which  is  to  be  tied  at  the  side  of 
the  cushion. 

The  tourniquet  is  nowrto  be  put  over  the 
cushion,  on  that  side  of  the  limb  which  is 
furthest  from  the  track  of  the  large  vessels, 
and  is  to  be  fastened  in  this  situation  with  a 
double  band,  that  has  a hole  in  it  for  the  re- 
ception of  the  upper  part  of  the  screw. 

In  order  to  make  the  proper  compression, 
the  screw  is  to  be  half  turned  round,  from 
the  right  to  the  left.  The  upper  piece  of  the 
tourniquet  becoming  now  further  from  the 
lower  one,  the  double  band  draws  the  pad, 
and  presses  it  against  the  vessels,  so  as  to 
make  the  due  degree  of  compression. 

The  following  are  the  advantages,  attend- 
ing the  use  of  Petit’s  tourniquet : 1.  It  com- 
presses the  lateral  parts  of  the  limb  less 
than  the  tourniquet  previously  in  use.  2.  It 
requires  the  aid  of  no  assistant,  either  to 
hold,  tighten,  or  loosen  it.  3.  The  operator 
is  able  of  himself  to  stop  the  flow  of  blood 
in  the  artery,  by  means  of  the  screw.  4. 
When  there  is  any  danger  of  hemorrhage 
after  an  operation,  this  kind  of  tourniquet 
may  be  left  on  the  limb,  and,  in  case  of  the 
bleeding  coming  on,  the  patient,  if  no  one 
be  at  hand,  can  tighten  the  instrument  him 
self,  as  much  as  is  necessary.  5.  The  con-’ 
striction,  which  this  tourniquet  produces, 
does  not  create  any  danger  of  mortification, 
because  it  does  not  altogether  stop  the  flow 
of  blood  through  the  collateral  arteries. 

The  tourniquet  here  described  is  certainly 
very  complex,  when  compared  with  that, 
which  is  used  by  the  best  modern  practi- 
tioners; but,  still  it  is  the  original  of  the 
latter,  and  both  are  constructed  on  the  same 
principles.  All  the  pieces  of  modern  tour- 
niquets are  kept  connected  together,  and  in- 
stead of  two  pieces  of  wrood,  used  by  Petit, 
there  is  contrived  a brass  bridge,  which  is 
capable  of  being  elevated,  or  depressed,  by 
means  of  a screw,  made  of  the  same  metal 
Over  this  bridge  a very  strong  band  pro- 
ceeds, and  by  passing  under  tw  o little  roll- 
ers, at  each  end  of  the  bridge,  it  .always  re- 
mains connected  with  the  instrument.  A 
convex  firm  pad  is  sewed  to  the  band,  and 
put  immediately  over  the  artery,  where  the 
instrument  is  applied.  There  are  no  cush- 
ions for  the  opposite  side  of  the  limb  under 
the  screw ; but.  a thick  piece  of  leather 


TREPHINE. 


4S9 


through  which  the  baud  proceeds  in  two 
places,  is  always  situated  under  the  lower 
surface  of  the  brass,  and  serves  to  prevent 
any  bad  effects  of  its  pressure.  It  is  usual 
also  for  the  surgeon  to  fold  some  rag,  and 
to  put  it  in  this  situation,  at  the  time  of  ap- 
plying the  instrument.  (See  Hemorrhage.) 
The  interruption  of  the  circulation  in  parts 
of  the  body  by  the  tourniquet,  has  been  tried 
as  a means  of  relieving  diseases.  (See  G. 
Kellie,  Obs.  on  the  Medical  Effects  of  Com- 
pression by  the  Tourniquet,  8vq.  Edinb.  1797.) 

TRACHEA,  Wounds  of.  See  Throat. 

TRACHEOTOMY.  (from  r^ua,  the 
windpipe,  and  re/uvee,  to  cut.)  The  opera- 
tion of  cutting  an  openinginto  the  windpipe 
for  various  surgical  purposes.  See  Bron- 
chotomy. 

TREPAN,  (from  rpi >7r*u,  to  perforate.) 
Trepanum ; Terebellum  ; Modiolus.  A cir- 
cular saw,  by  means  of  which  the  skull  is 
perforated  in  the  operation  called  trepan- 
ning, or  a circular  portion  of  any  bone  may- 
be sawn  out.  It  bears  a considerable  re- 
semblance to  the  well-known  instrument 
named  a wimble,  and  is  worked  in  the  same 
manner.  Formerly,  the  saw  was  sometimes 
made  of  a conical  shape  ; (see  Abapliston ) 
but  this  construction  rendered  the  action 
of  the  instrument  difficult.  In  this  country, 
the  trepan  is  now  superseded  by  the  instru- 
ment called  a trephine,  which  has  a different 
handle,  and  is  not  worked  in  the  same  way. 
On  the  continent,  however,  the  trepan  still 
has  the  preference. 

TREPHINE.  The  instrument  now  com- 
monly preferred  for  perforatingthe  cranium, 
for  purposes  which  I shall  presently  explain. 
It  consists  of  a simple  cylindrical  saw,  with 
a handle  placed  transversely,  like  that  of  a 
gimlet ; and,  from  the  centre  of  the  circle, 
which  the  teeth  of  the  saw  describe,  a sharp 
little  perforator  projects,  named  the  centre- 
pin.  The  upper  part  of  the  centre-pin  is 
made  to  screw  in  a corresponding  hole  at 
the  inside  of  the  top  of  the  saw,  and  is  ca- 
pable of  being  taken  out,  or  put  in,  at  the 
surgeon’s  option,  by  means  of  a little  key 
for  the  purpose.  Its  use  is  to  fix  the  tre- 
phine, when  it  is  first  applied,  that  is,  before 
the  teeth  of  the  instrument  have  made  a 
sufficient  circular  groove,  in  w hich  they  can 
steadily  work.  When  this  has  been  ac- 
complished, the  centre-pin  must  always  be 
removed;  because  now  it  is  not  only  not 
needed,  but  if  left,  it  would  retard  the  pro- 
gress of  the  operation,  and  inevitably  wound 
the  dura  mater  and  brain,  when  the  teeth  of 
the  saw  had  cut  to  a certain  depth  through 
the  cranium.  My  trephines  have  their 
centre-pins  contrived  to  slide  up,  or  dow  n, 
and  to  lie  fixed  in  either  position  by  turning 
a little  screw.  This  method  seems  to  me 
both  ingenious  and  convenient. 

The  cylindrical  part  of  the  trephine  is  often 
termed  the  crown  of  the  instrument.  The 
surgeon  should  have  at  least  two  or  three 
cylindrical  saws  of  various  sizes  ; for  it  is 
always  a commendable  rule,  never  to  saw 
away  any  more  of  the  cranium  than  is  abso- 
lutely requisite  for  the  accomplishment  of 
Vo l.  II 


some  rational  objpct.  There  is  no  occasion, 
however,  for  having  any  more  than  one  han- 
dle, which  maybe  made  to  screw  on  any  of 
the  saws. 

Trephines  are  also  occasionally  applied  to 
other  bones,  besides  those  of  the  cranium. 
In  the  articles  Antrum , Caries,  Exostosis , 
Fractures  of  the  Sternum,  JYecrosis,  Spina 
Ventosa,  other  cases  are  mentioned,  in  which 
the  employment  of  these  instruments  some- 
times becomes  proper. 

It  is  not  always  desirable  to  remove  a com- 
plete circular  portion  of  the  cranium,  the 
taking  away  a piece  of  smaller  size,  and  of 
a different  shape,  being  frequently  much  more 
advantageous.  Some  surgeons,  i understand, 
who  object  to  removing  any  unnecessary- 
quantity  of  the  cranium,  have  been  in  the 
habit  of  employing  a trephine,  terminating 
only  in  a semi-circular,  instead  of  a circular 
saw,  by  which  means  they  can  often  cut 
across  the  base  of  a depressed  portion  of  the 
skull,  and  take  it  away,  without  any  occasion 
for  removing  also  a circular  piece  of  bone. 
An  i -ftrument  of  the  latter  kind  may  cer- 
tainly be  sometimes  useful. 

The  saws,  however,  which  Mr.  Hey  has 
described,  should  constantly  be  kept  in  every 
case  of  trephining  instruments.  This  prac- 
tical writer  remarks,  that  “the  purposes  for 
which  any  portion  of  the  cranium  is  remo- 
ved, are,  to  enable  the  surgeon  to  extract 
broken  Iragments  of  bone,  to  elevate  what 
is  depressed,  and  to  afford  a proper  issue  to 
blood  or  matter  that  is,  or  may  be,  confi- 
ned, kc. 

“ When  a broken  fragment  of  bone  is 
driven  beneath  the  sound  contiguous  part  of 
the  cranium,  it  frequently  happens,  that  the 
extraction  cannot  be  executed  without  remo- 
ving some  of  the  unbroken  part,  under  which 
the  fragment  is  depressed.  This  might  gene- 
rally be  effected  with  very  little  loss  of  sound 
bone,  if  a narrow  portion  of  that  which  lies 
over  the  broken  fragment  could  be  removed. 
But  such  a portion  cannot  be  removed  with 
the  trephine.  This  instrument  can  only  saw 
out  a circular  piece.  And  as,  in  executing 
this,  the  central  pin  of  the  saw  must  be  placed 
upon  the  uninjured  bone,  it  is  evident  that  a 
portion  of  the  sound  bone,  greater  than  half 
the  area  of  the  trephine,  must  be  removed 
at  every  operation.  When  the  broken  and 
depressed  fragment  is  large,  a repeated  ap- 
plication of  the  trephine  is  often  necessary, 
and  a great  destruction  of  sound  bone  must 
be  (he  consequence. 

“ When  the  injury  consists  merely  of  a 
fissure  with  depression,  a small  enlargement 
of  the  fissure  would  enable  the  surgeon  to 
introduce  the  point  of  the  elevator,  so  as  to 
raise  the  depressed  bone.  But  a small  en 
largement  of  the  fissure  cannot  be  made  with 
the  trephine.  When  it  is  necessary  to  apply 
the  elevator  to  different  parts  of  the  de- 
pressed bone,  a great  deal  of  the  sound  cra- 
nium must  be  removed,  where  a very  narow 
aperture  would  have  been  sufficient. 

li  The  same  reasoning  will  apply  to  the 
case  of  openings,  made  for  the  purpose  of 


I 


TREPHINE. 


giving  a discharge  to  extravas&led  blood  or 
matter. 

“ If  a saw  could  be  contrived  which  might 
be  worked  with  safety  in  a straight,  or  gently 
curvilineal  direction,  it  would  be  a great  ac- 
quisition to  the  practical  surgeon.  Such  a 
saw  I can  now  with  confidence  recommend, 
after  a trial  of  twenty  years,  during  which 
time  I have  rarely  used  the  trephine  in  frac- 
tures of  the  skull.  Its  use  has  been  adopted 
by  my  colleagues  at  the  General  Infirmary 
in  Leeds  ; and  will  be  adopted,  I hope,  by 
every  surgeon  who  has  once  made  trial  of 
it.”  Mr.  Hey  next  informs  us,  that  the  in- 
strument was  first  shown  to  him  by  Dr. 
Cockell,  of  Pontefract  ; but  that  there  is  a 
saw  formed  on  the  same  principle  in  Scul- 
tetus’s  Armamentarium  Chirurgicum.  The 
saws  alluded  to  are  very  short  ones,  fixed  at  the 
end  of  a longish  straight  handle  ; theTr  edges 
are  made  eiihe>  straight  or  semicircular.  The 
latter  construction  qualifies  the  instrument 
for  cutting  in  a curvilineal  direction,  which 
is  often  proper.  The  edge  of  the  saw  should 
always  be  made  a little  thicker  than  the  rest 
of  the  blade,  by  which  means  it  will  work 
in  the  groove,  which  is  cut  with  more  faci- 
lity. 

Saws  made  on  the  principle  just  described, 
are  also  oi  infinite  use  in  cutting  away  dis- 
eased portions  of  other  bones  besides  the 
skull,  exostoses,  &c.  In  cases  of  necrosis, 
when  a dead  part  of  a bone  is  quite  wedged 
in  the  substance  of  the  surrounding  new 
bony  matter,  Mr.  Hey’s  saws  may  often  be 
advantageously  employed  tor  cutting  away 
the  parts,  which  mechanically  prevent  the 
detachment  of  the  dead  pieces.  The  saws 
invented  by  Mr.  Machell  and  Professor 
Graefe,  are  also  highly  ingenious,  and  parti- 
cularly merit  attention,  when  there  is  very 
little  room  for  the  working  of  the  instrument, 
and  the  bone  to  be  cut  lies  rather  deep. 
They  are  wheel-like  saws,  turned  by  ma- 
chinery. 

Besides  trephines  of  various  sizes,  and  the 
saws  just  now  noticed,  the  surgeon  should 
also  take  care  to  have  in  his  case  of  trephi- 
ning instruments  a little  brush  for  occasion- 
ally cleansing  away  the  particles  of  bone 
from  the  teeth  of  the  saw  in  the  progress  of 
the  operation  3 a pair  of  forceps  for  extract- 
ing the  round  piece  of  bone  after  it  has  been 
detached  by  the  saw  ; a lenticular  for  remo- 
ving any  inequalities  which  may  present 
themselves  round  tlfte  sawn  edge  of  the  cra- 
nium after  the  circular  piece  is  taken  out  j 
a raspatory  for  the  same  purpose,  and  also 
for  scraping  the  bone  in  order  to  see  whether 
it  will  bleed,  which  is  a eircumsta'gce  in  some 
cases  very  important  to  be  attended  to  j 
(see  Head , Injuries  of  ,*)  a largish  common 
scalpel  for  dividing  the  scalp,  &i.c. ; and  some 
elevators  for  raising  depressed  pieces  of 
bone. 

The  common  elevator  is  now  generally 
used  by  all  the  best  English  surgeons  ; but 
several  others  have  been  proposed,  as,  for 
instance,  the  tripod  elevator ; and  another 
invented  by  J.  L.  Petit,  and  afterward  im- 
proved by  M.  Louis. 


Before  beginning  the  description  of  Che 
operation,  I think  it  highly  proper  to  remind 
ttie  reader  of  what  has  been  so  forcibly  dwelt 
upon  in  the  article.  Head,  Injuries  of ’ — that, 
generally,  the  removal  of  pressure  off  the 
brain,  w hich  pressure  must  also  actually  oc 
casion  dangerous  symptoms,  can  form  the 
only  true  and  vindicate  reason  for  employ- 
ing the  trephine,  or  sawing  away  any  portion 
of  the  skull.  There  are  very  few  exceptions 
to  this  remark  : it  may,  indeed,  be  now  and 
then  proper  to  saw  away  the  bony  edges- 
around  some  fungous  excrescences,  which 
grow  from  the  dura  mater,  and  make  their 
way  outward,  by  occasioning  ari  absorption 
of  the  part  of  the  skull  immediately  over 
them.  (See  Dura  Mater.)  Ii  may  also  be 
sometimes  proper  to  saw  out  diseased  por- 
tions of  the  skull,  though,  it  must  lie  confess 
ed,  that  in  general  their  separation  should  bo 
left  to  time  and  nature. 

In  the  records  of  surgery,  innumerable 
facts  may  be  consulted,  where  the  prudent 
and  judicious  employment  of  ihe  trepan  has 
effected  wonderful  cures,  and  been  the  only 
thing  by  which, the  patients’  lives  could  pos 
sibly  have  been  saved.  Ihe  benefit  which 
the  operation  brings  about,  is  also  sometimes 
so  sudden  and  >stouishirig,  that  in  no  in- 
stance does  the  interposition  of  the  surgical 
art  display  itself  to  greater  advantage.  The 
immediate  restoration  of  sight  by  the  de 
pre-siun,  or  extraction  of  an  opaque  sub- 
stance from  (he  eye,  is  not  more  beautiful 
and  striking,  than  the  instantaneous  conitnu- 
ideation  of  the  intellectual  faculties,  and  of 
the  powers  of  speech,  of  feeling,  &.c.  toge- 
ther with  voluntary  motion,  to  a person  ly- 
ing in  an  apparently  lifeless  state  from  an  in- 
jury of  the  head.  The  utility  of  the  trepan 
is  occasionally  manifested  even  in  this  de- 
gree. In  the  valuable  essay  of  Mr.  Aberne- 
thy  on  injuries  of  the  head,  a case  may  be 
seen,  in  which  the  patient,  who  had  been  in 
a condition  almost  bereft  of  animation,  rose 
up  and  spoke  the  instant  the  exlravasated 
blood  was  removed  from  the  surface  of  the 
brain.  And  among  the  wounded  at  the  bat- 
tle of  Waterloo,  there  was  a soldier  of  the 
44th  regiment,  whose  case  is  of  equal  inte- 
rest. He  had  been  struck  by  a musket-ball 
on  the  right  parietal  bone,  which  was  expo- 
sed, but  had  no  appearance  of  being  fractu- 
red. As  however  the  symptoms  of  com- 
pression were  urgent,  and  (he  patient  w as  in 
nearly  a lifeless  state,  I conceived  it  right  to 
apply  the  trephine  to  Ihe  part  on  which  the 
violence  had  acted.  I had  not  sawn  long 
before  the  external  t * ble  came  away  in  the 
hollow7  of  the  trephine,  leaving  ihe  inner 
table  behind,  which  was  not  only  splintered 
but  driven  at  one  point  more  than  half  an 
inch  into  the  membranes  and  substance  of 
the  brain.  No  sooner  were  the  fragments 
taken  out  with  a pair  of  forceps,  than  the 
man  instantly  sat  up  in  his  bed,  looked  round , 
and  began  to  speak  with  the  utmost  rationali- 
ty. It  is  a most  extraordinary  fact,  that  this 
patient  got  up  and  dressed  himself  (he  same 
day,  without  leave  from  the  medical  officers, 
and  never  had  a bad  symptom  afterward. 


TREPHINE. 


‘191 


Immediately  the  operation  was  finished,  the 
temporal  arteries  were  opened,  and  some 
purgative  medieines  exhibited. 

In  a case  of  fungus  of  the  dura  mater, 
with  diseased  bone,  mentioned  by  Schmuck 
er,  the  trepan  was  applied  eleven  times  in 
less  than  a month,  and  the  operation  U3ed  to 
cause  so  little  indisposition,  that  the  patient 
hardly  ever  required  to  go  to  bed  afterward, 
and,  on  one  occasion,  actually  went  to  mar- 
ket an  hour  after  its  performance.  ( Wahrneh- 
w1  tnvngen,  D.  I,;?.  456.) 

Let  not  the  young  surgeon,  however,  draw 
from  these  dagzling  cases  of  success  an  im- 
moderate solicitude  to  perform  the  opera- 
tion ; for  it  should  never  be  undertaken  but 
in  the  most  pressing  circumstances,  and 
when  the  symptoms  unequivocally  show 
that  a dangerous  degree  of  pressure  on  the 
brain  exists.  1 recollect  an  unfortunate  ex- 
ample, in  which  the  late  Mr.  Ranisden,  of  St. 
Bartholomew’s  Hospital,  ventured  to  saw  out 
a portion  of  the  frontal  bone  for  a mere  tong- 
continued  pain  in  the  part : the  patient  was 
attacked  with  inflammation  of  the  dura  ma- 
ter, and  perished  in  three  or  four  days.  We 
may  therefore  conclude,  that  the  operation 
is  not  itself  exempt  from  danger  j and  it  is 
certain,  that  it  ought  never  to  be  resolved 
on  without  deep  cons  deration.  “ Gravis 
tam&n  satis  est  operatio , ut  nunquam , nisi  in- 
dicaliones  sujjwienles  admit,  instil ui  debet  ” 
(Callisen  Syst.  Chir.  Hodiern.  Tom.  I,  p. 
658.) 

The  trepan,  or  trephine,  is  never  neces- 
sary in  injuries  of  the  head,  except  for  the 
purpose  of  relieving  the  brain  from  pressure. 
Such  pressure  may  be  caused  by  a depressed 
portion  of  the  cranium,  or  it  may  be  pro- 
duced by  an  extravasation  of  blood,  or  the 
lodgment  of  matter,  betwixt  the  skull  and 
the  dura  mater.  The  chief  danger  of  con- 
cussion, when  the  accident  is  not  directly 
or  soon  fatal  from  the  disorganization  and 
mischief  done  to  the  brain,  depends  upon 
> the  consequent  inflammation  of  this  organ, 
and  therefore  can  be  little  likely  to  be  be- 
nefited by  the  use  of  the  trepan.  If  the 
operation  becomes  proper  in  such  a case,  it 
is  when  an  abscess  has  formed  under  the 
cranium,  and  when  the  confined  matter  it- 
self creates  bad  symptoms  by  its  pressure 
on  the  brain.  This  state  of  things,  how- 
ever, cannot  come  on  till  after  the  inflam- 
mation of  the  brain  and  its  membranes  has 
prevailed  a certain  time,  and  it  is  always 
accompanied  with  a detachment  of  the  pe- 
ricranium and  a puffy  tumour  of  the  scalp 
or,  if  there  be  a wound  of  the  latter  part’ 
immediately  over  the  abscess,  the  lips  of 
the  injury  suddenly  acquire  an  unfavour- 
able appearance,  arid  lose  their  vermilion 
„ colour.  I he  patient  has  also  had  much 
preceding  febrile  disorder,  pain  and  tension 
over  the  whole  head,  redness  and  turges- 
cence  of  the  eyes,  and  generally  more  or 
less  delirium.  When  the  matter  is  forming, 
there  are  usually  some  rigours,  and,  as  soon 
as  it  is  formed,  the  patient  falls  into  a co- 
matose state,  and  paralytic  symptoms  show 
{ themselves.  Here  the  urgency  for  the 

i 


prompt  application  of  the  trephine  is  very 
great,  and  the  patient’s  chance  of  living  is 
almost  essentially  connected  with  the  imme- 
diate performance  of  the  operation.  This 
important  case  has  been  particularly  dwelt 
upon  in  the  writings  of  Mr.  Pott. 

In  the  article,  Head,  Injuries  of,  I have 
laid  down  the  most  remarkablasymptoms  of 
concussion,  and  compression  of  the  brain,  a 
subject  which  every  surgeon  should  study 
with  earnest  attention,  before  he  ever  pre- 
sumes to  employ  the  trepan.  For,  some- 
times these  accidents  are  extremely  difficult 
to  be  discriminated  ; sometimes  they  exist 
together  in  the  same  individual  ; a compli- 
cation which  is  peculiarly  embarrassing;  and 
in  every  instance  where  the  symptoms  are 
those  of  concussion,  the  operation,  so  far 
from  being  indicated,  would  be  a step  of 
all  others  the  most  likely  to  do  harm,  by  in- 
creasing the  irritation  and  inflammation  of 
the  brain  and  its  membranes.  A fall  upon 
the  back,  or  upon  the  head,  occasions  a di- 
rect concussion  of  the  brain,  and  the  shock 
not  being  materially  weakened  by  the  in- 
tervention of  any  yielding  elastic  structure, 
is  the  more  dangerous.  When«a  person  has 
fallen  from  a certain  height,  and  pitched  on 
his  head,  his  back,  the  buttocks,  the  knees, 
or  even  the  soles  of  the  feet;  when  he  has 
been  instantly  deprived  of  his  senses,  and 
then  by  degrees  recovered  them  and  come 
to  himself  again  ; the  fact  of  his  having  suf- 
fered cory^ussion  of  the  brain  is  clear  and 
indisputable.  Concussion  has  likewise  taki  n 
place,  though  in  a slighter  degree,  when  the 
patient  has  been  only  stunned  by  the  fall, 
and  experienced  a sensation  of  sparks.  But 
a multitude  of  degrees  separate  this  feeble 
concussion  from  that  in  which  the  substance 
'of  die  brain  is  instantaneously  disorganized, 
so  that  (lie  patient  has  not  the  possibility  of 
recovery. 

The  symptoms  of  concussion  of  the  brain 
are  attended  with  coma,  and  the  compres- 
sion of  this  organ  by  an  extravasation  is 
also  accompanied  with  lethargic  heaviness. 
How  then  is  the  surgeon  to  ascertain, 
whether  the  comatose  disorder  arises  from 
one  or  the  other  of  these  aflectious  ? 

Here  in  order  to  avoid  repetitions,  I beg 
leave  to  refer  to  the  observations  already 
made  in  the  article  quoted  above.  But  there 
is  one  criterion  of  such  first-rate  importance, 
that  it  may  prevent  innumerable  fatal  mis- 
takes, and,  indeed,  without  the  continual  re- 
collection of  it,  no  man  ought  to  be  rash 
enough  to  interfere  with  this  dark  and  ab- 
struse part  of  surgery.  On  (bis  account,  f 
shall  mention  it  here,  notwithstanding  it  has 
been  already  noticed  elsewhere.  If  the  pa- 
tient is  knocked  down  and  stunned  directly 
by  the  blow,  and  remains  in  a state  of  insen- 
sibility, these  primary  symptoms  are  ascri- 
babie  to  the  concussion.  On  the  contrary, 
when  the  coma  and  loss  of  sense  do  not 
take  place  till  an  hour  or  two  alter  the 
blow,  they  are  to  be  imputed  to  an  extrava- 
sation. 

The  shock  given  to  the  brain  by  concus- 
sion must,  like  every  other  impulse  comma- 


TREPHINE. 


192 


nicated,  continue  to  diminish  until  it  ceases 
altogether.  If  at  the  very  time  of  the  blow, 
the  shock  has  not  been  forcible  enough  to 
produce  alarming  symptoms,  such  symptoms 
will  not  afterward  come  on  when  their  cause 
is  weakened.  Hence  the  reason  why  com- 
pression can  be  distinguished  from  concus- 
sion of  the  brain,  when  there  has  been  an 
interval  of  sense  between  the  receipt  of  the 
blow  and  the  occurrence  of  the  bad  symp- 
toms.  But  the  distinction  of  the  symptoms 
into  primary  and  consecutive  cannot  be 
made  when  concussion  and  extravasation 
exist  together. 

Having  made  these  few  remarks  on  con- 
cussion arid  compression  of  the  brain,  re- 
marks which  seemed  necessary  before  I 
entered  into  a description  of  the  operation 
of  the  trepan,  I shall  next  premise  some 
observations  relative  to  contusions  and 
fractures  of  the  skulj,  cases  on  which  the 
most  erroneous  opinions  have  been  enter- 
tained. It  is  true,  that  l have  in  another 
place  (see  Head , Injuries  of ) considered  the 
subject;  but  it  may  be  better  to  recapitulate 
certain  points  here,  because  they  have  such 
immediate#connexion  with  the  application  of 
the  trephine. 

Contusions  of  the  head  not  unfrequently 
occasion  a small  kind  of  tumour  which  is 
soft  in  the  centre,  but  hard  and  resisting  at 
the  circumference,  especially  when  the  vio- 
lence has  been  considerable.  Now  the  ease 
with  which  the  centre  or  seat  of  the  extra- 
vasated  fluid  admits  of  being  depressed, 
while  the  circumference  remains  hard  and 
elevated,  is  extremely  apt  to  give  rise  to  the 
belief,  that  a fracture  with  depression  has 
happened.  The  true  nature  of  this  accident 
was  first  clearly  explained  by  J.  L.  Petit, 
and  since  his  time  the  proper  cautions  not 
to  fall  into  a mistake  concerning  it,  have 
been  laid  down  by  tbe  generality  of  surgical 
\v  iters. 

Often  nothing  is  more  obscure,  than  the 
diagnosis  of  fractures  of  the  craniu  m : their 
existence  indeed  can  only  be  made  out  with 
certainty,  when  they  can  be  felt  or  seen. 
Thus  a fracture  of  the  skull,  attended  with  a 
wound  of  the  scalp,  and  exposure  of  the 
bone,  shows  itself  in  the  form  of  a fissure 
more  or  less  wide  and  extensive,  and  taking 
various  directions.  The  accident  may  also 
be  known  by  the  touch  even  when  the  soft 
parts  continue  entire,  particularly  if  the  frac- 
t ire  is  accompanied  with  splinters,  or  the  edges 
of  the  fissure  are  materially  separated.  When 
there  are  many  splinters  entirely  detached, 
a crepitus  will  likewise  serve  to  explain  the 
nature  of  the  accident;  but  unassisted  by 
these  symptoms,  imparted  to  him  by  the 
sight,  the  hearing,  or  the  touch,  the  prac- 
titioner cannot  at  once  offer  a decided 
opinion  as  to  whether  a fracture  exists  or 
not. 

In  order  to  procure  more  positive  infor- 
mation, would  it  be  right  and  judicious  to 
make  several  incisions  and  uncover  the 
bone  ? But  here  tbe  surgeon  would  be  em- 
barrassed in  the  very  commencement  of  his 
proceedings  : for  how  would  he  be  able  to 


judge  where  the  kite  should  be  applied:' 
Why  also  should  he  resort  to  an  useless  and 
painful  operation,  which  (to  say  the  best  of 
it)  could  only  render  the  patient’s  cure  more 
distant  ? 

The  symptoms  indicating  compression  of 
the  brain,  can  alone  justify  an  examination 
of  the  fracture.  These  symptoms  also  must 
be  urgent  and  alarming ; for  when  they  pre- 
vail in  a slight  degree,  bleeding  and  evacua- 
tions promise  more  benefit  than  any  opera- 
tion on  the  skull,  and  consequently  all  exa- 
mination of  the  part  supposed  to  be  broken, 
must  be  unnecessary.  The  precept  too 
commonly  given,  to  cut  through  the  scalp 
for  the  purpose  of  bringing  tbe  fracture  into 
view,  will  no  longer  be  matter  of  surprise, 
when  it  is  known,  that  among  some  sur 
geons,  the  operation  of  the  trepan  is  a thing 
of  course  in  all  fractures  of  the  cranium. 

Even  w hen  the  cranium  has  been  denu- 
ded, so  that  the  sight  can  convey  due  infor- 
mation respecting  the  solution  of  conti- 
nuity in  the  bone,  care  must  be  taken  not  to 
be  deceived  by  a suture,  or  by  the  groove  of 
a vessel.  In  cases  of  doubt,  a modern  sur- 
gical author  advises  us  to  scrape  the  outside 
of  the  bone  ; and  he  tells  us,  that  if  after  the 
removal  of  the  external  scale,  the  fissure  yet 
appear,  and  a thread  of  blood  be  seen  at  its 
outer  part,  no  doubt  exists  of  its  being  a real 
fissure.  As  however  making  this  examina- 
tion can  answer  no  purpose,  except  with  a 
view  to  determining  the  place  where  the 
trepan  should  be  applied,  I cannot  recom- 
mend the  plan,  except  where  the  sj’rnptoms 
are  such  as  to  render  this  information  de- 
sirable. On  the  contrary,  it  appears  to  me, 
that  all  examinations  of  the  bone,  made 
seemingly  from  mere  curiosity,  and  without 
any  true  surgical  object,  should  be  depreca- 
ted as  rash  and  hurtful. 

The  danger  of  fractures  of  the  skull  does 
not  depend  upon  tbe  simple  solution  of  con- 
tinuity : it  bears  altogether  a relation  to  the 
concussion  and  compression  of  the  brain, 
with  which  the  injury  of  the  bone  may  be 
complicated.  The  pressure  which  is  caused 
by  depressed  splinters  of  bone,  is  less  alarm- 
ing, inasmuch  as  the  cause  of  the  compres- 
sion is  easy  of  removal.  The  pressure  arising 
from  extravasated  fluid  is  far  more  serious,  in 
consequence  of  the  difficulty  of  ascertaining 
positively  the  existence  and  precise  situation 
of  such  extravasation. 

The  seat  of  the  extravasation  is  sometimes 
between  the  skull  and  the  dura  mater,  which 
has  been  detached  from  the  bone.  More 
frequently  it  occurs  either  between  the  dura 
mater  and  tunica  arachnoides ; in  the  sub- 
stance of  tbe  brain  ; or  else  in  the  ventri- 
cles. The  quantity  of  extravasnted  fluid  is 
generally  less  in  those  extravasations,  which 
are  situated  between  tbe  dura  mater  and  the 
skull.  The  extravasations  which  are  formed 
in  the  substance  of  the  brain  itself,  are  not 
only  more  considerable,  but  also,  as  they 
mostly  depend  upon  concussion,  are  more 
alarming  than  effusions  on  the  surface  of  the 
dura  mater.  It  is  indeed  extremely  difficult, 
if  not  impossible,  to  ascertain  the  situation 


of  the  extravasated  fluid.  In  such  cases  the 
trepan  is  likewise  of  no  use  ; while  concus- 
sion, when  so  violent  as  to  produce  internal 
extravasation,  is  invariably  fatal.  In  extrava- 
sations between  the  dura  mater  and  the  skull, 
which  are  almost  the  only  cases  of  the  kind 
to  which  surgery  can  administer  relief,  when 
the  effused  fluid  lies  under  a part  of  the  skull 
accessible  to  the  trepan,  the  extravasated 
fluid  is  almost  always  small  in  quantity. 
The  danger,  however,  is  not  the  less  : ten  or 
twelve  drops  of  fluid  are  sometimes  enough 
to  produce  a fatal  compression.  When  the 
extravasation  Tias  happened  in  the  substance 
of  the  brain,  the  compression  is  far  more 
perilous  : in  short,  it  may  be  said  to  prove 
with  very  few  exceptions,  certainly  mortal. 
The  danger  is  not  so  great,  when  the  extra- 
vasation is  situated  between  the  skull  and 
dura  mater. 

The  lethargy,  the  degrees  of  which  in- 
crease from  mere  drowsiness  into  the  most 
perfect  coma ; and  the  paralysis  of  the  op- 
posite side  of  the  body  to  the  seat  of  the  ex- 
travasation ; are  the  characteristic  symptoms 
of  this  accident  in  cases  of  injury  of  the 
head.  Having  explained  elsewhere  (see 
Head,  Injuries  of)  some  other  symptoms, 
such  as  stertorous  respiration,  dilated  pupils, 
&c.  which  usually  indicate  pressure  on  the 
brain,  it  is  unnecessary  here  to  dwell  upon 
them.  The  subsequent  increase  of  the  coma, 
and  paralytic  affections,  and  the  gradual 
augmentation  of  their  intensity,  serve  to 
render  these  symptoms  distinguishable  from 
others,  which  are  suddenly  brought  on  by 
concussion.  But  there  are  instances,  as  every 
man  of  experience  knows,  in  which  concus- 
sion ruptures  the  blood-vessels,  and  produces 
an  extravasation  of  blood.  In  this  circum- 
stance, it  is  obvious  that  the  symptoms  of 
compression  are  blended  with  those  of  con- 
cussion. The  symptoms  proceeding  from 
the  latter  cause  always  diminish  in  propor- 
tion to  the  time,  which  has  elapsed  from  the 
moment  of  the  injury ; w'hile  those  of  com- 
pression succeed,  and  on  the  contrary,  in- 
crease in  intensity,  in  proportion  as  the 
quantity  of  extravasated  fluid  becomes  more 
considerable.  Notwithstanding  these  dis- 
tinctions,however,  it  must  be  acknowledged, 
tbat  there  are  many  cases  in  which  the  sur- 
geon is  obliged  to  remain  in  doubt,  with  re- 
gard to  the  particular  cause  of  the  symptoms. 
This  indecision  is  the  more  embarrassing, 
because  the  operation  of  the  trepan  is  neces- 
sary in  cases  of  extravasation,  but  useless  in 
those  of  concussion.  Even  when  extrava- 
sation is  known  to  exist,  the  practitioner  re- 
quires more  information  ; for  he  ought  to 
Know  the  precise  situation  of  the  effused 
fluid.  It  is  true,  indeed,  that  paralysis  of 
one  side  of  the  body  generally  indicates  the 
pressure  to  be  upon  the  opposite  hemisphere 
of  the  brain.  But  what  surgeon  would  ven- 
ture to  follow  the  practice  advised  by  Van 
Swieten,and  apply  to  the  suspected  side  o£ 
the  head  three  crowns  of  the  trepan  ? Possi- 
bly not  one  of  them  might  fall  on  the  situa- 
tion of  the  extravasated  fluid.  When  the 
-ckul!  is  broken,  tbe  extravasation  exist?  on 


493 

the  same  side  as  the  fracture.  When  it  is  the 
effect  of  concussion,  or  when  the  breach  of 
continuity  in  the  skull  is  what  is  termed  a 
counter-fissure  ; the  effusion  is  generally  on 
the  side  of  the  head  most  remote  from  tbe 
blow.  If  the  pressure  is  caused  by  a detach- 
ment of  the  internal  table  of  the  skull,  the 
nature  of  the  case  cannot  be  ascertained  be- 
fore tbe  operation  of  the  trepan  has  been 
performed  on  the  part  of  the  skull,  upon 
which  the  violence  has  acted.  When  there 
are  two  extravasations  ; one  depending  upon 
a fracture,  and  situated  immediately  under 
it,  between  the  dura  mater  and  the  skull  ; 
the  other  arising  from  concussion,  and  situa- 
ted at  some  point  directly  opposite,  either 
between  the  dura  mater  and  tunica  arach- 
noides,  or  within  the  substance  of  the  brain 
itself;  paralysis  may  occur  on  tbe  same  side 
as  the  fracture,  and  hence  it  may  be  inferred, 
that  the  palsy  does  not  always  take  place  on 
the  side  opposite  to  the  extravasation.  But, 
says  Richerand,  an  examination  of  the  body 
quickly  proves,  that  the  case  does  not  devi- 
ate from  the  common  rule.  The  extravasa- 
tion produced  by  concussion,  being  almost 
invariably  more  considerable  than  that 
caused  by  a fracture,  accounts  for  the  ex- 
tension of  the  palsy  to  the  same  side  of  the 
body.  Sometimes  the  side  which  is  not  pa- 
ralytic, is  effected  with  convulsions  ; the 
pulse  is  full  and  hard  ; and  the  respiration 
stertorous  ; in  short, the  symptoms  are  analo- 
gous to  those  caused  by  apoplexy. 

The  evacuating  plan,  recommended  for 
the  treatment  of  concussion,  (see  Head , 
Injuries  of)  is  all  that  can  be  done,  when 
every  thing  is  uncertain  relative  to  the  situa- 
tion of  the  extravasation.  It  is  all  that  can 
be  done  in  those  frequent  instances,  where 
the  effusion  has  taken  place  in  the  substance 
of  the  brain,  so  that  it  cannot  possibly  be 
voided.  The  trepan  then  is  indicated  only 
when  there  is  an  extravasation  between  the 
dura  mater  and  the  bone,  the  fracture  being 
situated  at  a part  of  tbe  skull  accessible  to 
instruments,  and  not  at  the  base.  We  will 
not  here  dwell  upon  the  doubtful  example, 
w here  the  fluid  lies  between  the  dura  mater 
and  the  arachnoides.  But,  are  the  cases, 
which  have  just  been  described,  as  frequent 
as  they  are  supposed  to  be  ? Cannot  the 
effused  blood  be  sometimes  discharged 
through  the  interspaces  of  the  broken  pieces 
of  bone  ? Is  the  trepan  usually  necessarv 
for  the  relief  of  injuries  of  the  head,  as 
Quesnay,  Pott,  and  the  members  of  the 
French  Academy  of  Surgery  maintained  ? 
Many  of  the  best  surgeons  now  think  not — 
The  operation  is  often  useless,  and  some- 
times dangerous.  I believe  that  it  should  be 
limited  to  a small  number  of  cases,  in  which 
not  only  the  existence  and  situation  of  the 
pressure  are  known,  but  in  which  the 
symptoms,  arising  from  this  cause,  are  ur- 
gent and  dangerous,  and  the  pressure  can 
be  removed  by  no  other  means. 

Richerand  contends,  that  extravasations 
between  the  skull  and  the  dura  mater,  so 
considerable  as  to  produce  compression  of 
the  brain,  and  render  the  trepan  necfessarv. 


TREPHINE. 


494 

are  much  less  common  than  many  surgeons 
think.  Even  when  they  do  occur,  the  dura 
mater  is  always  detached  to  a certain  extent, 
and,  according  to  this  writer,  if  the  bone  is 
much  broken,  the  interspaces  of  the  frag- 
ments are  quite  sufficient  for  the  evacuation 
of  the  effused  blood.  The  following  case  is 
quoted  in  proof  of  this  observation.  A wo- 
man injured  her  head  by  falling  from  a 
height  of  fifteen  feet.  The  fracture  reached 
the  whole  breadth  of  the  skull,  so  that  when 
the  os  frontis  was  taken  hold  of  with  one 
hand,  and  the  os  occipitis  with  the  other, 
the  two  halves  of  the  cranium  admitted  of 
being  manifestly  moved  and  separated. 
Blood  issued  from  the  fissure,  the  edges  of 
which  were  kept  apart  by  a small  wedge  of 
wood  in  such  a manner,  that  the  pulsations 
of  the  brain  were  visible.  On  the  sixth  day, 
as  nothing  was  discharged  from  the  fissure, 
the  bit  of  wood  w'as  removed,  and  on  the 
fifty-second  the  wound  had  completely  heal- 
ed without  any  exfoliations.  On  the  seventy- 
second,  the  patient  was  discharged  from  the 
H6tel-Dieu,  perfectly  cured.  ( JYosogr . Chir. 
T.  2,  p.  292,  Edit.  3.) 

Thus  we  see,  that  the  trepan  is  not  always 
necessary  in  injuries  of  the  head  with  frac- 
ture of  the  skull,  notwithstanding  there  may 
be  some  degree  of  bleeding  from  the  edges 
of  the  bone.  This  doctrine  is  very  different 
from  what  is  taught  in  t|ie  memoirs  of  M. 
Quesnay  in  the  first  volume  of  those  of  the 
French  Academy  of  Surgery.  Desault  in 
the  last  years  of  his  practice  abandoned  the 
operation  of  the  trepan  altogether.  It  had 
been  remarked  for  many  years,  that,  in  the 
H6tel-Dieu, this  operation  was  almost  always 
unsuccessful ; a circumstance,  which  once 
excited  a suspicion,  that  the  foul  air  of  the 
wards  of  that  establishment  might  have  a 
share  in  bringing  on  the  unfavourable  event. 
I shall  not  here  expatiate  on  the  bad  effect 
of  the  atmospheric  air  on  the  membranes  of 
the  brain;  a thing,  of  which  B.  Bell  seems 
to  have  convinced  Richerand. 

When  the  skull  is  fractured  by  a blow',  or 
fall,  and  the  case  is  a simple  fissure,  the 
trepan  ought  to  be  applied  upon  the  solu- 
tion of  continuity,  if  the  symptoms  indicate  a 
dangerous  degree  of  pressure  on  the  brain,  and 
the  edges  of  the  fracture  are  not  sufficiently 
separated  to  let  the  extravasated  lluid  es- 
cape. 

When  the  detached  portions  of  bone  are 
depressed,  so  as  to  compress  the  brain,  the 
operation  is  still  requisite,  if  they  cannot 
be  elevated  by  other  means.  But  Richerand 
maintains,  that  a positive  indication  for  tre- 
panning is  not  frequent,  either  because  it  is 
difficult  to  judge  of  the  existence  and  situa- 
tion of  extravasations,  or  because  extrava- 
sated fluids  readily  escape  through  the  in- 
terspaces of  the  fragments,  when  there  is  a 
splintered  fracture.  Such  facility  is  also 
increased,  when  one  of  the  portions  of 
broken  bone  is  totally  detached,  so  that  it 
can  be  removed,  leaving  an  aperture  equi- 
valent to  what  would  be  produced  by  the 
, application  of  the  trepan. 

When  the  operation  is  determined  on, it 


is  more  convenient  to  have  the  head  sha- 
ved : indeed,  this  is  often  done  immediately 
the  surgeon  is  called,  in  order  that  he  may 
have  abetter  opportunity  of  seeing  what  parts 
of  the  scalp  have  been  struck  ; for  it  Is  in 
such  situations  that  he  has  most  reason  to 
apprehend  fractures  of  the  bone,  or  extra- 
vasations beneath  it.  If,  however,  the 
violence  has  occasioned  a large  wound,  or 
laceration  of  the  scalp,  the  practitioner, 
knowing  where  the  force  has  been  applied, 
is  frequently  content  with  having  a little  of 
the  hair  shaved  off  the  parts  surround- 
ing the  injury.  All  that  need  be  said  on 
this  subject  is,  that  it  is  always  better  to 
have  enough  of  the  hair  taken  away,  to 
afford  the  surgeon  an  uninterrupted  oppor- 
tunity of  examining  the  scalp  freely,  and 
doing  whatever  may  be  necessary.  The  loss 
of  a little  hair  is  of  very  little  consequence, 
while  the  concealment  of  the  seat  of  a de- 
pressed fracture,  or  extravasation,  might 
lead  to  fatal  consequences. 

When  the  propriety  and  necessity  of  tre- 
phining are  fully  indicated,  provided  the 
wound,  or  laceration  of  the  scalp,  should 
not  have  exposed  a sufficient  surface  of  the 
bone  for  the  application  of  the  crown  of  the 
trephine,  an  adequate  dilatation  of  such 
wound  ought  immediately  to  be  made.  If, 
in  the  situation  of  the  blow,  there  should 
only  be  a contusion,  or  a lump,  unattended 
with  any  wound,  a division  of  this  part  of 
the  scalp  is  to  be  made  by  carrying  the 
knife  quite  down  to  the  bone.  In  those 
cases,  in  which  the  swelling  occasioned  by 
the  violence  is  considerable,  and  attended 
with  the  sensation  of  a crepitus ; as  well  as 
in  other  instances,  in  which  there  is  only 
a contusion,  under  which  a fracture  and  dis- 
placed pieces  of  bone  may  be  felt ; the 
scalp  must  be  divided  in  the  same  manner, 
only  with  greater  caution,  lest  the  point  of 
the  knife  should  insinuate  itself  through  the 
fracture,  and  do  mischief  to  the  dura  mater 
and  brain. 

Authors  recommend  the  shape  of  the  in- 
cision to  be  different  according  to  the  kind 
of  fracture,  and  the  parts  of  the  head,  on 
which  the  violence  has  operated.  When 
the  whole  extent  of  the  injury  can  be 
brought  into  view,  by  means  oi  an  incision, 
having  the  form  of  a letter  T,  the  surgeon 
should  be  content  with  such  a division  ; but 
if  this  be  not  sufficient,  he  may  give  it  a 
crucial  shape.  When  the  trephine  is  to  be 
applied  to  the  squamous  part  of  the  temporal 
bone,  we  are  recommended  to  make  the 
incision  as  much  as  possible,  in  shape  of  the 
letter  V,  the  branches  of  which  are  to  be 
upward,  and  the  angle  downward,  in  order 
that  as  little  as  possible  of  the  temporal 
muscle  may  be  cut,  and  that  the  division  ot 
its  fibres  may  be  avoided  as  far  as  it  is  in 
our  power. 

Having  divided  the  scalp,  the  next  object 
Is  to  reflect  it ; but  no  man  would  be  w ar- 
ranted in  cutting  any  part  of  it  away,  al- 
though such  practice  is  advised  by  Pott  and 
many  other  eminent  writers.  1 he  purposes 
of  the  operation  do  nol  require  any  removal 


TREPHINE. 


490 


ot  this  kind ) and  the  method  would  leave 
a wound,  which  would  be  long  in  healing, 
and  when  healed,  never  exempt  from  de- 
formity. In  short ,4he  reflected  flaps  ot  the 
scalp  are  capable  of  adhering  to  the  parts, 
on  which  they  are  laid  after  the  operation, 
and  consequently  ought  never  to  be  wan- 
tonly cut  away. 

The  scalp  being  reflected,  authors  nejit 
advise  us  to  scrape  aw*ay  the  pericranium, 
either  w ith  the  knife,  or  the  raspatory.  Per- 
haps this  measure  may  be  considered  as 
one,  which  does  neither  much  harm  nor 
much  good.  The  design  is  to  facilitate  the 
application  of  the  trephine  to  the  bone. 
Howrever,  the  teeth  of  a proper  instrument, 
in  good  order,  will  not  be  impeded  by  the 
slender  periosteum  ; and  scraping  this  mem- 
brane away  from  parts  of  the  skull,  which 
are  not  to  be  removed,  must  be  conducive 
to  exfoliations. 

Sometimes  the  bleeding  from  branches  of 
the  temporal,  or  occipital  artery,  is  so  co- 
pious, that  the  bone  cannot  be  very  conveni- 
ently perforated  before  the  hemorrhage  is  sup- 
pressed. If  it  be  prudent  to  wait  a little, 
and  the  case  (as  it  generally  does)  should  be 
likely  to  be  benefited  by  the  evacuation  of 
blood,  it  is  as  wrell  to  let  the  bleeding  con- 
tinue for  a certain  time.  The  surgeon  may 
then  just  direct  an  assistant  to  put  the  end 
of  one  of  his  fingers  on  the  mouth  of  the 
vessel,  and  proceed  in  the  operation.  ll> 
some  cases  the  bleeding  might  be  so  trou- 
blesome, that  it  would  be  better  to  tie  the 
artery  at  once. 

All  parts  of  the  cranium  do  not  admit  of 
being  trephined  wdth  equal  convenience  and 
safety.  It  has  usually  been  set  dow'n  by 
surgical  authors,  that  the  trephine  cannot 
be  applied  belowr  the  transverse  ridge  of  the 
os  occipitis.  There  are  some  cases,  howr- 
ever,  which  prove  that  such  an  operation 
may  be  safely  done,  and  that  we  ought  not 
in  urgent  circumstances,  to  be  afraid  of  di- 
viding the  trapezius  and  complexus  muscles, 
in  order  to  be  enabled  to  apply  the  trephine 
to  the  bone.  (See  Hutchison's  Casein  Med. 
Chir.  Trans.  Vol.  2,  p.  104,  fyc.) 

The  majority  of  writefs  also  forbid  the 
application  of  the  trephine  to  the  frontal 
sinuses,  in  consequence  of  the  indeterminate 
depth  of  these  cavities,  and  the  apprehen- 
sion of  incurable  fistulas.  Howrever,  Larrey 
has  deviated  from  this  precept  in  several 
instances,  and  his  practice  confirms  the 
statement  of  Mr.  C.  Bell,  that,  by  opening 
the  frontal  sinus  with  a large  trephine,  and 
then  using  a small  one,  the  internal  parietes 
of  this  cavity  may  be  trephined  with  perfect 
safety,  and  no  risk  of  injuring  the  dura 
mater  with  the  saw.  (See  Larrey' s Mem.  de 
Chirurgie  Militaire,  T.  2 ,p.  135 — 138,  T.  4.) 

Writers  also  caution  us  not  to  apply  the 
trephine  to  the  anterior  inferior  angle  of 
the  parietal  bone,  in  consequence  of  the 
middle  artery  of  the  dura  mater  lying  un- 
der it,  generally  in  a groo.ve  of  the  bone, 
and  occasionally  in  a canal  in  its  very  sub- 
stance. In  the  latter  circumstance,  this 
portion  of  the  parietal  bone  could  not  pos- 


sibly be  taken  away,  without  wounding  the 
vossel.  However,  notwithstanding  this  ad- 
vice, which  has  been  unthinkingly  banded 
down  by  one  writer  to  another,  from  genera- 
tion to  generation,  I very  much  question  the 
soundness  of  the  doctrine.  We  undoubtedly 
ought  to  avoid  trephining  this  part  of  the  cra- 
nium, when  w e can  prudently  do  so.  But  the 
causes  demanding  this  operation  are  ahvays 
so  urgent,  that  the  patient’s  sole  chance  of 
existence  depends  on  their  cjuiek  removal. 
Hence,  wrnre  there  pressure  on  the  brain, 
either  from  a depressed  portion  of  bone, 
from  blood,  or  matter,  and  such  pressure 
could  not  be  removed  without  trephining 
the  anterior  inferior  angle  of  the  parietal 
bone,  wrhat  operator  would  be  afraid  of  do- 
ing so  ? Besides,  the  fear  of  the  hemor- 
rhage has  been  very,  unfounded  ; for  the 
lodgment  of  the  artery?  :i  a bony  furrow,  or 
canal,  which  authors  have  pointed  out  as 
rendering  the  suppression  of  the  hemorrhage 
more  difficult,  is  a mere  visionary  idea,  as 
it  is  well  known,  that  a little  plug  of  lint 
pushed  into  the  orifice  of  a vessel  so  situa- 
ted, will  ahvays  stop  the  bleeding,  with  as 
much  certainty  and  ease  as  can 'possibly  be 
imagined. 

The  foregoing  suggestion  was  made  in  the 
early  editions  of  my  w'orks,  and  I now’  see 
the  safety  of  the  practice  has-been  confirm- 
ed. “ I have  also  applied  the  trepan  (says 
Larrey)  over  the  track  of  the  spheno-soi- 
*nous  artery,  at  the  inferior  anterior  angteof 
the  parietal  bone.  The  artery  w^as  divided  - 
but  I stopped  the  hemorrhage  almost  imme- 
diately, by  applying  an  iron  probe  red-hot.” 
(Mem,,  de  Chir.  Militaire,  T.  2,  p.  138.) 

Writers,  until  very  lately,  also  prohibited 
us  from  trephining  over  any  of  the  sutures, 
and  especially  over  the  sagittal  suture,  be- 
neath which  the  longitudinal  sinus  is  situa- 
ted. The  fear  of  the  dura  mater  being  in- 
jured, and  of  this  vessel  being-  wounded, 
wras  the  reason  for  the  advice.  With  regard 
to  the  sutures  in  general,  the  trephine  may 
be  applied  to  them,  as  well  as  to  any  other 
part ; and  as  for  the  sagittal  suture,  many 
facts  confirm  the  propriety  of  not  being  de- 
terred even  by  it,  though  situated  immedi- 
ately over  the  longitudinal  sinus.  Jt  is  to 
be  remembered,  also,  that  the  dura  mater, 
in  cases  of  extravasated  blood  and  matter, 
beneath  the  cranium,  is  detached  by  the 
intervention  of  such  fluids  from  the  inner 
table. 

By  means  of  a perforation  practised  over 
the  sagittal  suture,  Garengeot  successfully 
elevated  a portion  of  bone  which  pressed 
upon  the  longitudinal  sinus,  and  made  the 
patient  quite  comatose.  The  depressed 
piece  of  the  cranium  could  not  have  been 
so  advantageously  raised,  had  the  trepan 
been  applied  in  any  other  situation.  But  a 
still  stronger  argument  in  favour  of  this 
practice,  when  the  case  at  all  requires  it,  is 
the  fact,  that  wounds  of  the  longitudinal 
sinus,  and  the  hemorrhage  resulting  from 
them,  are  not  attended  with  any  serious 
danger.  Sharp  mentions  his  having  twice 
seen  a bleeding  of  this  kind.  Another  in 


490  TftErHINK. 


stance  is  also  recorded  in  Warner's  Cases' 
A child  received  a wound  on  its  forehead  : 
the  two  parietal  bones  were  fractured,  and 
a portion  of  each  was  depressed  on  the  dura 
mater.  The  child  lived  a month,  without  any 
operation  being  done;  but  at  the  end  of  this 
time,  Warner  applied  the  trepan.  He  found 
a splinter  of  bone  sticking  in  such  a way 
into  the  longitudinal  sinus,  that  it  could  not 
easily  be  got  out;  consequently,  he  enlar- 
ged with  a lancet  the  opening  in  which  the 
splinter  was  entangled.  The  hemorrhage, 
which  was  copious,  was  easily  suppressed 
by  the  application  of  a little  dry  lint,  and 
the  child  was  relieved,  though  it  died  at  the 
end  of  two  months,  after  suffering  a variety 
of  symptoms,  which  had  no  connexion  with 
the  wound  of  the  sinus,  the  opening  of 
which  soon  healed.  The  fourth  case,  rela- 
ted by  Marchettis,  also  proves,  that  wounds 
of  the  longitudinal  sinus  are  not  fatal.  Pott 
and  Callisen  have  since  recorded  other 
facts,  tending  to  the  same  conclusion.  (See 
Syst.  Chir.  Hodierna , Part  1,  p.  659,  Edit . 
1798.) 

Whenever  a depressed  fracture  can  be  ele- 
vated to  its  proper  level,  without  applying  the 
trephine,  and  with  the  mere  aid  of  a pair  of  for- 
ceps, or  an  elevator,  trephining  should  never 
be  performed,  unless  there  be  strong  reason 
to  apprehend,  that  blood,  or  matter,  lodged 
on  the  surface  of  the  dura  matter,  contributes 
to  the  production  of  the  bad  symptoms,  and 
ought  to  be  discharged. 

The  scalp  having  been  divided,  if  neces- 
sary, and  the  pericranium  scraped  from  the 
surface  of  the  bone,  according  to  the  com- 
mon precepts  and  practice,  the  next  thing  is 
the  application  of  the  crown  of  the  trephine. 

The  surgeon  is  first  to  make  a little  impres- 
sion with  the  point  of  the  centre-pin,  for 
the  purpose  of  marking  the  place  where  it 
will  work,  when  the  crown  of  the  trephine  is 
applied  in  the  proper  situation  ; for,  where 
such  impression  is  made,  the  operator  must 
make  a small  hole  with  a perforator,  in  order 
to  fix  the  point  of  the  centre-pin,  on  which 
the  crown  of  the  instrument  turns  back- 
ward and  forward,  as  on  an  axis,  during  the 
first  stage  of  the  operation.  Mr.  Savigny’s 
centre-pins  make  a perforation,  without  the 
need  of  any  particular  instrument  for  the 
purpose,  and,  in  this  respect,  are  advan- 
tageous. 

The  point  of  the  centre-pin  having  been 
fixed,  the  trephine  is  to  be  turned  by  regular 
semi-circular  motions,  alternately  to  the 
right  and  left,  which  object  is  effected  by 
steady  pronations  and  supinations  of  the 
operator’s  hand.  The  teeth  of  the  saw 
having  made  a tolerable  circular  groove,  in 
which  they  can  steadily  work,  the  centre-pin 
becomes  useless,  and,  as  it  would,  if  not 
withdrawn,  or  removed,  certainly  injure  the 
dura  mater  and  brain,  by  reason  of  its  pro- 
jecting further  than  any  other  part  of  the 
instrument,  it  would  be  an  unpardonable 
blunder  to  let  it’  remain,  after  a proper  cir- 
cular groove  has  been  formed  by  the  teeth 
of  the  saw. 

The  beginning  of  the  sawing  may  be 


executed  boldly  and  quickly ; for,  the 
operator  runs  no  hazard  of  doing  mischief. 
It  is  necessary  occasionally,  with  a view  of 
facilitating  the  action  of  the  instrument,  to 
clean  away  the  particles  of  bony  matter, 
vfith  a little  brush,  usually  kept  for  the  pur- 
pose in  every  box  of  trephining  instruments. 
Were  this  plan  neglected,  the  action  of  the 
cylindrical  saw  would  be  very  much  clogged. 

The  operator,  however,  must  increase  his 
caution,  when  the  sawing  has  made  greater 
progress  ; for,  were  he  to  be  too  bold,  he 
might  sometimes  lacerate  the  membranes  of 
the  brain  with  the  teeth  of  the  instrument, 
particularly,  as  the  thickness  of  the  cranium 
is  subject  to  infinite  variety,  both  in  different 
parts  of  the  same  head,  and  in  different  sub- 
jects. Let  the  surgeon,  therefore,  never  for- 
get to  examine  frequently  with  the  point  of 
a quill,  whether  any  part  of  the  circular 
groove  is  cut  through  or  nearly  so ; for, 
when  this  is  the  case,  the  instrument  must 
only  be  worked  in  such  a way,  as  to  make 
pressure  upon,  and  cut  the  part  of  the  cir- 
cle which  yet  remains  to  be  divided.  In 
some  few  cases,  it  is  said,  that  the  surgeon 
can  distinctly  feel,  when  the  teeth  of  the 
saw  reach  the  diploe,  or  medullary  struc- 
ture, between  the  two  tables  of  the  cranium, 
and  some  writers  have  rashly  directed  us  to 
saw  with  boldness,  till  the  sensation  of  this 
occurrence  is  communicated  to  our  hand  and 
iibgers.”  However,  I believe,  this  possibi- 
lity of  discriminating  the  arrival  of  the  teeth 
of  the  saw  at  the  diploe  is  so  uncommon, 
and  so  fallacious,  that  it  should  never  be  ex- 
pected, or  relied  cn.  Nor  ought  the  surgeon 
to  saw  with  incautious  force  and  rapidity, 
till  he  sees  the  teeth  of  the  trephine  bloody, 
which  appearance  has  been  set  dowti  as 
another  criterion  of  their  having  reached 
the  diploe.  I have  already  stated,  that  a 
great  many  skulls  have  hardly  any  space  be- 
tween several  parts  of  the  two  tables. 
This  is  particularly  often  the  case  in  old 
persons. 

A prudent  man  will  always  prefer  exerting 
a little  force  for  the  purpose  of  breaking 
some  of  the  bony  connexion,  retaining  the 
circular  piece  of  bone, to  running  any  hazard 
of  injuring  the  dura  mater,  by  sawing  too 
deeply.  After  a certain  time,  therefore,  it 
is  better  to  lay  down  the  trephine,  and 
endeavour  to  elevate  the  portion  of  bone, 
with  the  aid  of  a pair  of  forceps,  construct- 
ed for  the  purpose,  and  kept  in  most  cases  of 
trephining  instruments,  or  else  by  means  of 
an  elevator,  which  is  still  more  calculated 
for  the  purpose. 

When  the  circular  piece  of  bone  has  been 
taken  out,' and  the  edges  of  the  perforation 
are  unequal,  and  splintered,  the  irregularities 
are  to  be  cut  off  with  the  lenticular  knife. 
When  there  is  extravasated  blood  under- 
neath the  opening  which  has  been  made, 
it  sometimes  spontaneously  makes  its  escape, 
and,  if  it  should  not  do  so,  the  surgeon 
must  remove  it  himself.  If  one  perforation 
of  the  skull  should  not  suffice  for  letting  out 
the  blood,  as  much  more  pf  the  cranium 
ought  to  be  removed  with  the  trephine. 


TftEFHINL. 


mi 


circumstances  way  require  ; there  being  no 
comparison  between  the  danger  of  repeating 
the  application  of  the  instrument,  and  that 
of  leaving  a quantity  of  undischarged,  com- 
pressing fluid,  on  the  surface  of  the  brain. 
Certainly,  many  facts  on  record  evince,  that 
the  dura  mater  may  be  very  extensively  un- 
covered, without  dangerous  consequences. 
Sarrau  saw  a whole  parietal  bone  exfoliate, 
in  consequence  of  a blow  on  the  head. 
Blegny  relates  a similar  case  ; and  Saviard 
makes  mention  of  a woman,  who  had  lost 
the  upper  part  of  the  os  frontis,  both  the 
parietal  bones,  and  a large  portion  of  the  os 
occipitis,  all  of  which  had  come  away  at  the 
same  ; yet  she  recovered.  Vaugion,  how- 
ever, who  also  seems  to  relate  this  identical 
case,  describes  the  exfoliation  as  not  being 
quite  so  extensive. 

I am  of  opinion,  notwithstanding  these 
facts,  that  exposing  a large  part  of  the  dura 
mater  with  the  trephine  is,  by  no  means,  an 
operation  exempt  from  serious  danger.  And, 
what  I conceive  confirms  this  statement,  is 
my  having  known  instances,  in  which  per- 
sons, who  had  been  rashly  advised  to  submit 
to  being  trephined,  for  the  cure  of  violent 
pains  in  the  head,  &,c.  died,  in  consequence 
of  the  operation.  I make  this  observation, 
well  aware  of  the  successful  instance  of  the 
practice  recorded  by  Schrnucker.  ( Walir - 
7iehin.  B.  1 , p.  434.) 

However,  [perfectly  coincide  with  writers, 
who  direct  the  removal  of  as  much  bone,  as 
is  necessary  in  order  to  be  able  to  remove 
the  whole  of  the  pressure  from  the  surface  of 
the  dura  mater. 

The  application  of  the  trephine,  in  cases 
of  large  extravasations,  must  in  particular 
be  made  several  times,  when  the  situation 
of  the  fluid  does  not  favour  its  escape. 
However,  in  this  circumstance,  Sabatier 
iays,  that  we  should  not  make  numerous 
perforations  all  along  the  extent  of  the  ex- 
travasation ; but,  only  a counter  opening,  as 
is  done  on  the  soft  parts.  This  author  ex- 
presses his  surprise  at  there  not  being  on  re- 
cord many  examples  of  counter-openings 
made  in  the  cranium,  since  analogy  demon- 
strates their  utility.  I cannot  help  remark- 
ing on  this  part  of  the  subject,  that  one  very 
obvious  objection  to  make  openings  of  this 
kind  in  the  cranium,  is  the  impossibility  of 
knowing  with  certainty,  whether  blood  lies 
under  any  particular  part  of  the  skull ; 
whereas,  in  abscesses  of  the  soft  parts,  the 
surgeon  feels  the  fluctuation  of  the  matter, 
and  knows  that  his  counter-opening  will  be 
made  in  the  cavity  containing  it.  One  might 
also  have  occasion  to  make  more  than  one 
perforation,  in  order  to  discharge  blood  ex- 
travasated  beneath  the  skull,  when  the  blow 
has  happened  near  a suture,  to  which  the 
dura  mater  continues  adherent ; for,  a single 
opening  made  only  on  one  side  of  the  suture, 
might  only  give  vent  to  a part  of  the  extra- 
vasation. 

If  we  should  not  find  blood  lodged  under 
the  cranium  ; but  the  dura  mater  should 
seem  elevated,  tense,  dark-coloured,  forming 
a prominent  fluctuating  tumour,  outward,  it 

Vor.  U*  A3 


may  be  cautiously  opened  with  a lancet,  or 
bistoury,  with  a view  of  letting  out  any 
collection  of  blood  underneath.  In  the  arti 
cle  Head , Injuries  of,  l have  stated  the  result 
of  Mr.  Abernethy’s  experience,  in' regard  to 
the  operation  of  opening  the  dura  mater. 
This  gentleman  found, that  the  method  never 
effectually  discharged  all  the  blood,  but 
only  the  serous  part^of  it.  The  evacuation 
of  any  of  the  compressing  fluid  must,  how- 
ever, be  desirable  ; and,  if  the  surgeon  can 
not  do  more,  yet  he  has  fulfilled  bis  profes- 
sional duty. 

The  utility  of  trephining  is  not  limited  to 
discharging  extravasated  blood,  or  matter, 
lodged  underneath  the  skull.  This  operation 
frequently  enables  us  to  elevate  depressed 
portions  of  bone.  The  latter  objects  can 
often  be  accomplished  by  merely  making 
one  perforation.  Sometimes,  several  per- 
forations are  requisite  to  be  made  near  each 
other.  Authors  even  state,  that  it  may  also 
become  necessary  to  remove  the  interve- 
ning portions  of  bone  with  a pair  of  cutting 
forceps.  The  depressed  part  may  then  be 
easily  raised  by  means  of  an  elevator.  Oc- 
casionally, indeed,  I may  say  very  often, 
the  best  practice  is  to  remove  the  depressed 
portion  entirely,  when  its  total  separation 
from  the  rest  of  the  skull  can  be  accom- 
plished by  cutting  across  the  base  of  the  de- 
pressed piece.  If  any  splinter  stick  in  the 
dura  mater,  and  should  not  admit  of  being- 
withdrawn,  without  enlarging  the  wound  in. 
the  membraue,  the  surgeon  ought  not  to  be 
afraid  of  doing  this  with  a sharp  instrument 

According  to  some  quick-inferring  writers, 
if,  after  dividing  the  dura  mater,  the  surface 
of  the  brain  appears  smooth  and  flabby,  with 
a fluctuation,  we  may  conclude  there  is  an 
abscess  in  its  substance  ; and  these  authors, 
more  enterprising  with  their  pens,  it  is  to  be 
hoped,  than  with  their  scalpels,  sanction  the 
method  of  carrying  the  point  of  the  bistoury 
to  the  depth  of  an  inch,  if  circumstances  ren- 
der so  deep  a puncture  necessary.  “ But,” 
says  Richerand,  “ prudence  forbids  us  to  go 
further.  Cutting  the  surface  of  the  brain 
causes  no  pain,  and  it  produces  less  danger, 
than  one  might  apprehend  ; but,  experience 
and  observation  have  proved,  that  the  essen- 
tial parts  of  this  organ  are  situated  near  its 
base,  and  that  its  surface  may  be  removed 
without  danger,  or  pain .”  ( JVosogr . Chir.  T 

2,  p.  301,  Edit.  3.) 

After  the  operation  of  trephining,  the  di- 
vided scalp  is  to  be  placed  as  nearly  as  possi- 
ble in  its  natural  situation,  and  lightly  dress- 
ed with  a simple  pledget  of  any  common 
unirritating  ointment.  In  applying  the  dress- 
ings, the  surgeon  should  invariably  keep  in 
view  these  objects  ; namely,  to  let  whatever 
•is  put  on  the  wound  be  as  light  as  possible, 
not  apt  to  make  pressure  on  the  brain,  and 
of  a nature,  which  cannot  excite  irritation. 
All  stimulants  are  to  be  strictly  avoided  ; 
nor  will  any  bandage  be  better  than  an 
ordinary  night-cap  of  sufficient  size  to  be  put 
on  with  facility.  It  may  be  secured  with  bits 
of  tape,  which  are  to  be  tied  under  the  jaw. 

The  practitioner  should  not  now  conceive, 


TRICHIASIS. 


iite 


that  he  has  done  ail  that  he  ought  to  do. 
Let  him  remember  the  urgent  necessity  of 
keeping  off",  or  diminishing,  the  inflamma- 
tion of  the  dura  mater  and  brain,  which  is 
still  to  be  feared.  Let  him  bleed  the  pa- 
tient largely  and  repeatedly  ; exhibit  saline 
purges,  glysters,  and  antimonials ; and  if  the 
symptoms  continue,  let  him  apply  a blister 
to  some  part  of  the  head  I shall  avoid, 
however,  any  repetitions  on  this  subject,  by 
referring  to  Head,  Injuries  of. 

The  aperture  in  the  skull  usually  becomes 
closed  with  soft  granulations,  which  slowly 
acquire  a hard  consistence.  These  almost 
constantly  grow  from  the  edge  of  the  per- 
foration, and  seldom  from  the  surface  of  the 
dura  mater.  While  the  cicatrix  is  soft,  it 
should  be  protected  from  external  injury 
with  a thin  piece  of  horn,  or  metal.  Exfo- 
liations from  the  margin  of  the  perforation 
sometimes  retard  the  healing  of  the  wound  ; 
but,  now  that  the  practice  of  dressing  with 
drying  spirituous  applications  has  been  ex- 
ploded, and  the  removal  of  any  part  of  the 
scalp  is  condemned  by  all  the  best  surgeons, 
these  unpleasant  consequences  are  rendered 
much  less  frequent,  than  in  former  days. 

The  reader  may  find  an  account  of  the 
operation  of  trepanning,  or  trephining,  in 
every  system  of  surgery  ; but,  he  should 
particularly  consult  the  writings  of  Sharp, 
Le  Bran,  Dionis,  Bertrandi,  Pott,  Sabatier, 
Schmucker,  Abernethy,  Desault,  Callisen, 
liicherand,  &c.  Several  parts  of  the  Me- 
moires  de  l’Acad.  de  Chirurgie  are  also  high- 
ly deserving  of  perusal 

TRICHIASIS,  (derived  from  the 

hair)  denotes  a faulty  inclination  of  the  eye- 
lashes inwards  against  the  globe  of  the  eye. 
According  to  Scarpa,  the  disease  presents 
itself  under  two  distinct  forms  : the  first  is, 
where  the  cilia  are  turned  inwards,  without 
the  natural  position  and  direction  of  the 
tarsus  being  at  all  changed  ; the  second  con- 
sists in  a morbid  inclination  of  the  tarsus  in- 
wards, ( Entropium ) and  consequently  of  the 
eyelash  towards  the  eyeball.  ( Trichiasis .) 

The  first  form  of  this  disease  is  said  both 
by  Beer  and  Scarpa  to  be  uncommon,  nor 
has  it  come  under  the  observation  of  the 
latter  writer  more  than  once-  and,  in  this  in- 
stance, only  some  of  the  hairs  had  changed 
their  direction.  On  this  point,  however,  Mr. 
Travers  is  completely  at  variance  with  the 
foregoing  authors,  as  he  describes  an  inver- 
sion of  the  cilia  as  frequently  existing  inde- 
pendent of  entropeon.  {Synopsis,  p.  232.) 
The  second  species,  or  form  of  trichiasis,  or 
that  which  consists  in  a folding  inwards  of 
the  tarsus  and  cilia  at  the  same  time,  is  the 
case  which  is  commonly  met  with  in  prac- 
tice. It  may  be  either  complete,  affecting 
the  whole  of  the  tarsus  ; or  incomplete,  oc- 
eupying  only  a certain  portion  of  the  edge 
of  the  eyelid,  most  frequently  near  the  ex- 
ternal angle  of  the  eye.  Sometimes,  the 
disease  is  confined  to  one  eyelid  ; at  other 
times,  it  affects  both  ;.  and  occasionally  the 
patient  is  afflicted  with  it  in  both  eyes. 

Some  writers,  among  whom  is  Beer, 
( hrjnr  r.on  fan  Avgenkr.  R.  2,  v-  U8,)  ad- 


mit a case,  which  they  call  disliehiasis,  aim 
which  they  suppose  to  be  produced  by  a 
double  and  unusual  row  of  hairs.  But  ac- 
cording to  Scarpa,  this  third  species  is  only 
imaginary,  and  the  reason  of  such  subdivi- 
sion seems  to  have  arisen  from  not  recol- 
lecting, what  was  long  ago  remarked  by 
Winslow  and  Albinus,  that  although  the 
roots  of  the  cilia  appear  to  be  disposed  in 
one  line  only,  they  form  two,  three,  and  in 
the  upper  eyelid  even  four  rows  of  hairs, 
unequally  situated, ‘and  as  it  were  confused. 
Whenever,  therefore,  in  consequence  of  dis- 
ease, a certain  number  of  hairs  are  separated 
from  each  other  in  a contrary  direction  and 
disorderly  manner,  the  eyelash  will  appear 
to  be  composed  of  a new  and  unusual  row 
of  them,  while,  in  fact,  there  is  no  change^ 
either  with  respect  to  their  number,  or  na- 
tural implantation. 

It  is  not  an  easy  matter  to  determine  pre 
cisely,  says  Scarpa,  what  are  the  causes, 
which  sometimes  make  a few  of  the  hairs 
deviate  from  their  natural  direction,  while 
the  tarsus  continues  in  its  right  position 
They  are  commonly  referred  to  cicatrices 
in  consequence  of  previous  ulceration, 
whereby  the  cilia  fall  off,  and  those  which 
are  growing  are  hindered  from  taking  their 
proper  direction.  There  must,  however,  be 
other  causes  sometimes  concerned  ; for,  in 
the  case  seen  by  Professor  Scarpa,  two  or 
three  hairs  were  turned  inwards  against  the 
eyeball,  although  there  had  been  no  preced- 
ing ulceration,  nor  cicatrices,  of  any  part  of 
the  tarsus.  Indeed,  Scarpa  is  inclined  to 
believe,  that  the  small  ulcers  and  scars, 
which  are  sometimes  formed  upon  the  in- 
ternal margin  of  the  tarsus,  are  more  likely 
to  cause  the  second  form  of  the  disease,  or 
the  inversion  of  the  edge  of  the  eyelid,  and, 
consequently,  of  the  cilia  towards  the  globe 
of  the  eye.  As  these  ulcers,  when  neglect- 
ed, destroy  the  internal  membrane  of  the 
eyelids  near  the  tarsus,  it  necessarily  follows 
that,  in  proportion  as  they  heal  and  dimi- 
nish, they  draw  along  with  them  and  turn 
inwards  the  tarsus,  and  hairs  inserted  into 
it.  And  since  they  do  not  always  occupy 
the  whole  extent  of  the  internal  margin  of 
the  eyelid,  but  are  sometimes  confined  to  a 
few  lines,  in  the  middle,  or  extremity,  near 
the  external  angle  of  the  eyelid,  so  alter  the 
cicatrices  are  formed,  the  whole  of  the  hairs 
are  not  invariably  turned  inwards,  but  only 
a certain  number  of  them,  which  correspond 
to  the  extent  of  the  ulccr9  previously  situa- 
ted along  the  internal  edge  of  the  tarsus. 
Indeed,  in  every  case  of  imperfect  trichiasis 
from  a cicatrix  of  the  inner  margin  of  tk6 
eyelid,  the  tarsus  and  cilia  are  every  where 
in  their  natural  situation,  except  opposite  the 
part,  where  the  ulcers  formerly  existed 
Also,  if  the  eyelid  be  everted,  its  internal 
membrane,  near  that  part  of  the  margin  cor- 
responding to  the  seat  of  the  trichiasis,  will 
be  found  pale, rigid,  and  hardened,  the  inver- 
sion of  the  cartilaginous  border  and  of  the 
cilia  being  plainly  the  effect  of  the  contrac- 
tions of  the  cicatrized  point. 

Chronic,  ophthalmies  of  lon£Continuanre 


TRICHIASIS, 


*m 


sometimes  bring  on  the  complaint,  in  conse- 
quence of  the  skin  of  the  eyelids  being  kept 
for  a long  time  in  a state  of  distention  and 
oedema,  terminating  in  a considerable  relax- 
ation of  it.  And,  according  to  Beer,  the  too 
long  continued  use  of  emollient  poultices 
may  have  the  same  effect.  ( Lehre , 4'C.  B.  2, 
p.  113.)  The  cartilaginous  margin  of  the 
eyelid  then  loses  the  proper  support  of  the 
integuments,  inclines  towards  the  eyeball, 
and  afterward  turns  inwards,  drawing  the 
eyelashes  along  with  it  in  the  same  impro- 
per direction.  Long-continued  puriform 
discharges  from  the  ciliary  glands  likewise 
spoil  the  shape  and  consistence  of  the  car- 
tilage of  the  eyelid,  and  therefore  not  unfre- 
quently  occasion  trichiasis.  Scarpa  doubts, 
whether  a spasmodic  contraction  of  the 
orbicularis  palpebrarum  muscle  can  ever  be 
a cause  of  the  disease. 

The  annoyance,  which  must  necessarily 
result  from  the  hairs  perpetually  pressing 
upon  the  cornea  and  white  of  the  eye,  as 
Scarpa  observes,  may  be  easily  imagined. 
The  evil  is  rendered  still  greater  by  the  hairs, 
which  are  turned  inwards,  becoming  much 
longer  and  thicker,  than  those  wffiich  retain 
their  natural  direction.  And  although  the 
trichiasis  be  confined  to  one  eye,  both  the 
eyes  usually  suffer  from  the  effects  of  the 
disease.  Indeed,  generally,  the  eye  on  the 
sound  side  cannot  be  moved  without  occa- 
sioning pain  in  that  which  is  exposed  to  the 
irritation  and  friction  of  the  inflected  hairs. 
In  almost  all  instances,  both  the  eyes  are 
very  irritable,  and  incapable  of  bearing  the 
light.  As,  in  cases  of  incomplete  trichiasis, 
she  patient  retains  some  little  power  of  open- 
ing the  eyelids  for  the  purpose  of  seeing,  and 
that  most  frequently  towards  the  internal 
angle  of  the  eye,  the  head  and  neck  are 
often  inclined  in  an  awkward  manner,  so 
that  in  children  a distortion  of  the  neck  and 
shoulders  is  at  last  produced,  which  cannot 
he  rectified  without  difficulty,  even  after  the 
trichiasis  is  cured.  Unfortunately,  also, 
children  are  impatient  of  the  uneasiness  ari- 
sing from  the  inflected  hairs,  and,  therefore, 
are  continually  rubbing  the  eyelids,  whereby 
all  the  ill  effects  of  the  complaint  are  much 
increased. 

The  cure  of  the  second  species  of  trichia- 
sis, or  that  which  is  commonly  met  with  in 
practice,  is  accomplished  by  artificially 
everting  the  eyelid,  and  fixing  it  permanently 
in  its  natural  position,  together  with  the 
eyelashes,  which  irritate  the  globe  of  the 
eye.  According  to  Professor  Scarpa,  this 
indication  is  perfectly  fulfilled  by  the  exci- 
sion of  a piece  of  the  skin  close  to  the  edge 
of  the  eyelid,  of  such  a breadth  and  extent 
that,  when  the  cicatrix  is  formed,  the  tarsus 
and  margin  of  the  eyelid  may  be  turned  out- 
wards, and  sufficiently  separated  from  the 
eyeball,  the  cicatrix  of  the  integuments  af- 
fording a point  of  support  fully  adequate  to 
keeping  the  parts  in  their  natural  position 
and  direction.  Scarpa  believes,  that  there 
are  now  very  few  modern  surgeons,  who, 
with  a view  to  the  radical  cure  of  this  dis- 
ease, place  any  confidence  either  in  pluck- 
ing ont  the  inverted  eyelashes,  bending  them 


outwards,  .and  retaining  them  so  by  means 
of  adhesive  plaster;  or  in  plucking  them 
out,  and  destroying  their  roots  with  caustic  : 
much  less  in  extirpating  the  edge  of  the 
eyelid  along  with  the  hairs,  or  dividing,  the 
orbicularis  muscle  on  the  internal  surface  of 
the  eyelid,  under  an  idea  that  the  disease  is 
sometimes  produced  by  a spasmodic  con- 
traction of  it. 

The  following  is  the  mode  of  proceeding 
recommended  by  Scarpa.  The  patient  be- 
ing seated  in  a chair,  if  an  adult,  or,  if  a 
child,  laid  upon  a table,  with  the  head  rais- 
ed, and  firmly  held  by  an  assistant,  who  must 
stand  behind  the  patient ; the  surgeon  is  to 

()nsh  outward,  with  the  end  of  a probe,  the 
lairs,  which  irritate  the  eye.  Then,  with  a 
pair  of  dissecting  forceps,  or  the  ends  of  his 
fore-fingerand  thumb  (which  answer  equally 
well,  and  in  many  cases  much  better,  than 
forceps,)  the  operator  should  lift  up  a fold 
of  the  skin  ot  ihe  affected  eyelid,  taking 
great  care  that  the  piece  which  is  taken  hoid 
of  corresponds  exactly  to  the  middle  of  the 
whole  extent  of  the  trichiasis  ; for  some- 
times the  whole,  sometimes  a half,  and,  in 
other  instances,  only  a third  of  the  extent 
of  the  tarsus  is  inverted.  The  surgeon,  with 
bis  left  band,  must  raise  the  fold  of  the  skin, 
more  or  less,  according  as  the  relaxation  of 
the  integuments,  and  the  inversion  of  the 
tarsus,  are  more  or  less  considerable.  The 
reason  of  this  is  evident,  viz.  the  greater  the 
quantity  of  skin  is  which  is  raised,  the  greater 
is  the  quantity  which  will  be  cut  away.  Sup- 
posing the  patient  to  he  an  adult,  as  soon  as 
the  fold  of  skin  has  been  raised  in  a certain 
degree,  the  surgeon  must  request  him  to  open 
his  eye,  and  if  in  this  act  the  tarsus  and  eye- 
lashes resume  their  natural  place  and  direc- 
tion, file  portion  of  skin  already  raised  will 
be  sufficient  for  the  purpose.  When  the  in- 
teguments are  elevated,  by  means  of  a pair 
of  dissecting  forceps,  and  care  is  taken  to 
lay  hold  of  the  skin  precisely  at  the  middle 
point  of  the  whole  extent  of  the  trichiasis,  it 
necessarily  follows,  that  the  consequent  sec 
tion^f  the  skin  will  form  an  oval,  and  that 
the  greatest  width  of  the  wound  will  cor- 
respond exactly,  or  nearly  so,  to  the  middle 
of  the  eyelid,  and  its  narrowest  parts  to  the 
angles,  or  commissures  of  the  same.  This 
contributes  very  materially  to  make  the  ci 
catris  correspond  to  the  natural  fold  of  the 
eyelid,  and  hinder  the  origin  of  a disease  of 
an  opposite  nature  to  the  one  about  to  be  re- 
medied, towards  the  angles  of  the  eye,  viz. 
a turning  out  of  the  commissures  of  the  eye 
lids.  See  Ectropium. 

Besides  this  caution,  relative  to  the  situa- 
tion and  figure  of  tue  fold  of  the  integuments 
to  be  cut  off,  the  surgeon  must  be  careful 
that  the  division  of  the  skin  be  made  very 
near  the  inverted  tarsus.  Were  this  circum- 
stance neglected,  the  operator  might  have 
the  mortification  of  finding  after  the  wound 
is  healed,  that  although  the  eyelid  is  shorten* 
ed  on  the  whole,  from  the  eyebrow  to  the 
place  of  the  recision,  yet  it  is  not  equally  so 
at  the  space  which  is  between  tbe  edge  of  the 
eyelid  and  the  cicatrix  of  the  skin  IJcnce 
the  tarsus  would  not  be  turned  ontward 


5.00 


TRICHIASIS. 


ficiently  to  keep  the  eyelashes  from  rubbing 
against  the  eye. 

The  surgeon  holding  up  the  fold  of  skin 
by  means  of  the  forceps  in  his  left  hand,  is 
with  a pair  of  probe-pointed,  sharp-curved 
scissors,  to  cut  off  (he  whole  of  the  duplica- 
ture,  being  first  sure  (hat  one  of  the  blades 
of  the  instrument  is  applied  close  to  the 
edge  of  the  eyelid.  If  the  eyelids  should  be 
affected,  the  same  operation  musr  immedi- 
ately be  done  upon  bolh  of  them,  with  such 
cautions,  and  in  such  proportion,  as  the  ex- 
tent of  the  disease,  and  the  degree  of  inver- 
sion of  each  eyelid  may  require. 

Scarpa  next  dissuades  us  from  employing 
any  suture  to  unite  the  wound,  and  repre- 
sents that  it  will  be  sufficient  to  keep  the 
eyebrow  as  much  downward  as  possible,  if 
Ihe  operation  has  been  done  on  the  upper 
eyelid,  or  if  on  the  lower,  to  support  it  against 
the  inferior  arch  of  the  orbit,  by  pressing  it 
from  below  upwards,  so  as  to  keep  the  edges 
of  the  wound  from  becoming  separated. 
Then  the  lips  of  the  wound  arj^to  be  brought 
exactly  together  by  means  of  adhesive  plas- 
ter, which  should  extend  from  the  superior 
arch  of  the  orbit  to  the  zygoma,  and  the 
maintenance  of  this  state  of  the  wound  will 
be  still  more  securely  effected,  by  placing 
two  compresses,  one  on  the  eyebrow,  and 
another  on  the  zygoma,  together  with  a 
bandage.  On  the  other  hand,  Laugenbeck 
disapproves  of  the  omission  of  sutures,  by 
which  he  finds  that  the  wound  may  be  both 
more  accurately  and  expeditiously  united. 
Indeed,  he  expresses  himself  generally  in  fa- 
vour of  sutures,  where  the  wounded  part  is 
liable  to  be  disturbed  by  the  continual  ac- 
tion of  the  muscles.  ( JYeue  Bibl.  B.  1,  p. 
4J5,  fyc.  12mo.  Hanover , 1818.)  Langen- 
feeck,  however,  takes  care  to  withdraw  the 
ligatures  in  about  twelve,  or  at  most  twenty- 
four  hours,  as  their  longer  continuance 
would  produce  suppuration.  Beer  also  par- 
ticularly insists  upon  the  utility  of  bringing 
the  edges  of  the  incision  together  with  a su- 
ture ; and  both  he  and  Langenbeck  employ 
forceps,  the  ends  of  which  have  transverse 
pieces,  calculated  to  take  better  hold  of  the 
slip  of  skin  to  be  removed.  (Le/tre,  fye.  B. 
‘2,p.  114.) 

On  taking  off  the  first  dressings,  the  third 
day  after  the  operation,  the  surgeon  will 
find,  says  Scarpa,  that  the  patient  can  open 
his  eye  with  ease,  and  that  the  inverted 
tarsus  and  eyelashes  have  resumed  their 
natural  position  and  direction.  In  the  par- 
tial or  incomplete  trichiasis,  or  that  which 
only  occupies  a half,  or  a third  of  the  whole 
length  of  the  tarsus,  and  in  subjects  who 
have  had  the  skin  of  the  eyelids  very  loose, 
Scarpa  has  often  found  the  wound  perfectly 
united  on  removing  the  first  dressing. 

When,  however,  only  a part  of  the  inci- 
sion has  healed,  while  the  rest  seems  dispo- 
sed to  heal  by  suppuration  and  granulation, 
the  surgeon  i3  to  cover  the  wound  with  a 
small  piece  of  lint,  spread  with  the  unguen- 
tum  cerussai ; and  if  the  sore  should  be- 
come flabby.  it  must  be  occasionally  touched 


with  the  argentum  nitratum,  until  the  cure 

is  finished. 

With  regard  to  the  first  form  of  this  dis- 
ease, or  that  in  which  the  eyelashes  pro- 
ject against  the  eyeball,  without  the  natural 
position  of  the  tarsus  being  at  all  altered, 
(a  case  which  is  fortunately  rare)  the  ac- 
complishment of  a cure  is  very  difficult, 
since  neither  the  pulling  out  of  the  hairs, 
nor  burning  the  situation  of  their  roots,  are 
means  at  all  to  be  depended  upon  for  pro- 
ducing a complete  cure  of  the  disorder ; 
and  turning  the  tarsus  out  of  its  natural  po 
sition  would  make  the  patient  liable  to  an 
irremediable  dropping  of  the  tears  over  the 
cheek  attended  with  a chronic  thickening 
of  the  lining  of  the  eyelid.  It  has  only- 
been  in  youngish  individuals  that  Beer  has 
ever  seen  the  repeated  and  careful  extrac- 
tion of  the  cilia  effect  a radical  cure.  (See 
Lehr e von  den  Augenkr.  B.  2,  p.  121.)  In 
the  instance  of  this  form  of  the  disease, 
which  Scarpa  met  with,  only  two  or  three 
of  the  eyelashes  inclined  against  the  eyeball. 
He  found,  on  turning  the  eyelid  a little  out, 
opposite  to  the  situation  of  the  faulty  hairs, 
that  he  could  not,  indeed,  completely  put 
them  in  their  natural  position  ; but  he  saw' 
that  he  could  thus  remove  them  so  far  from 
the  cornea  that  they  would  not  rub  against 
it  without  altering  the  position  of  the  eye- 
lids so  much  as  to  occasion  a perpetual  dis- 
charge of  the  tears  over  the  cheek.  And, 
as  in  the  patient  alluded  to,  the  skin  about 
the  eyelid  was  very  tense,  Scarpa  made  an 
incision  with  the  back  of  the  lancet,  near 
the  tarsus,  three  lines  long,  and  took  away 
a small  piece  of  skin  of  the  same  length,  but 
very  little  more  than  one  line  broad.  When 
the  cut  healed,  the  operation  was  found  to 
answer  as  well  as  the  nature  of  the  case 
would  allow,  though  the  cure  was  not 
complete. 

The  trichiasis  being  cured,  something 
more  always  remains  to  be  done  for  the 
purpose  of  correcting  the  cause  of  the  dis- 
ease, as  well  as  curing  the  disorder  of  the 
eye,  occasioned  by  the  previous  friction  and 
irritation  of  the  inverted  hairs.  The  usual 
indications  are  to  restore  the  tone  of  the 
vessels  of  the  conjunctiva,  to  lessen  the 
swelled  Meibomian  glands, and  obviate  opa- 
city of  the  cornea. 

Some  new  methods  of  performing  the 
operation  for  the  cure  of  trichiasis,  have 
been  proposed  by  Dr.  Crampton,  Mr.  Saun- 
ders, and  Schre^er. 

The  following  is  the  account  which  Dr. 
Crampton  gives  of  his  plan,  which  lie  tried 
in  one  instance  with  complete  success 
“ Let  the  eyelid  be  well  turned  outwards 
by  an  assistant ; let  the  operator  then,  with 
a lancet,  divide  the  broad  margin  of  the 
tarsus  completely  through  by  two  perpendi- 
cular incisions,  one  on  each  side  of  the  in- 
verted hair  or  hairs  ; let  him  then,  by  a 
transverse  section  of  the  conjunctiva  of  the 
eyelid,  unite  the  extremities  of  the  perpen- 
dicular incisions.  The  portion  of  cartilage 
contained  within  the  incisions,  can  then, 
if  inverted,  with  case  he  restored  to  its  ori- 


TRICHIASIS. 


oinal  situation,  and  retained  there  by  small 
strips  of  adhesive  plaster,  or,  perhaps  what 
is  better,  by  a suspensorium  palpebrec, 
adapted  to  the  length  of  the  portion  of  the 
tarsus,  which  it  is  intended  to  sustain,  should 
one  or  two  hairs  be  displaced  without  in- 
version of  the  tarsus.”  ( Essay  on  the  En- 
tropeon,  p.  55.) 

Mr.  Travers  informs  us,  that,  in  cases  of 
a circumscribed  inversion,  “ produced  by  ci- 
catrix from  burn  or  wound,"  he  has  found 
Dr.  Crampto'n’s  method  an  etfeciual  remedy. 

It  is,added;  that  the  complete  division  of 
the  conjunctiva  and  tarsal  cartilage,  inclu- 
ding the  inverted  portion,  and  parallel  to 
its  border,  with  the  aid  of  sticking  plaster, 
sometimes  proved  sufficient.  Mr.  Travers 
also  sees  no  objection  to  the  entire  removal 
of  that  portion  of  the  tarsal  edge  which  is 
incorrigibly . inverted  from  such  a cause, 
especially  when  combined  with  a preterna- 
tural growth  of  cilia  from  the  Meibomian 
border  of  the  tarsus.  ( Synopsis , p.  356.) 
In  one  inveterate  case,  which  was  not 
effectually  relieved  by  the  frequent  extrac- 
tion of  the  cilia,  cauterizing  the  edge  of  the 
tarsus,  the  excision  of  a slip  of  skin,  and 
smearing  the  eyelid  with  concentrated  sul- 
phuric acid,  as  proposed  by  Helling,  ( Hufe - 
land's  Journ.  St.  4,  p 115)  Schreger,  with  a 
pair  of  curved  scissors,  cut  out  a triangular 
piece  of  the  cartilage  of  the  eyelid  at  the 
place  where  the  cilia  were  most  trouble- 
some. The  great  benefit  derived  from  the 
operation  then  led  the  same  practitioner  to 
suggest  the  removal  of  the  whole  of  the  in- 
verted edge  of  the  tarsus,  towards  the  inner 
canthus,  where  some  irritation  was  yet 
maintained.  The  plan,  though  followed  by 
severe  pain,  appears  to  have  succeeded. 
(C7«r.  Versilche , B.  2,  p.  253.) 

Mr.  Saunders  entertained  a favourable 
opinion  of  Dr  Crampton’s  operation  for  the 
cure  of  the  disease  in  its  early  stage;  but, 
he  contended,  such  a vicious  bending  of 
the  tarsus  inward  was  often  the  consequence 
of  repeated  ophthalmy,  attended  with  ulce- 
ration of  the  conjunctiva  and  inside  of  the 
eyelid,  so  that  every  endeavour  to  rectify 
the  wrong  position  of  the  tarsus,  and  restore 
its  original  direction,  would  be  fruitless. 
Hence  he  believed  that  its  excision  was  de- 
cidedly indicated  ; an  operation  which  is 
said  to  be  followed  by  no  pain  nor  uneasi- 
ness, and  which  is  6ure  in  its  effect.  No 
particular  shortening  of  the  eyelid  ensues  ; 
the  deformity  is  materially  lessened  ; and, 
unless  the  cornea  be  already  too  opaque, 
perfect  vision  is  re-established.  Mr.  Saun- 
ders directs  a piece  of  thin  horn  or  a plate 
of  silver,  having  a curvature  corresponding 
to  that  of  the  eyelid,  to  be  introduced  un- 
der this  part,  with  its  concavity  towards  the 
eyeball.  On  this  instrument  the  eyelid  is 
to  be  stretched.  An  incision  is  to  be.  made 
through  the  integuments  aud  orbicularis 
palpebrarum  down  to  the  tarsus,  immedi- 
ately behind  the  roots  of  the  cilia.  The  cut 
should  extend  from  the  punctum  laebry male 
to  the  external  angle.  The  exterior  sur- 
face of  the  tarsus  is  then  to  be  dissected1 


until  the  orbital  margin  is  exposed,  when 
the  conjunctiva  is  to  be  cut  through  di 
rectly  by  the  side  of  the  tarsus,  which  must 
now  be  disengaged  at  each  extremity.  The 
punctum  lachrymale  must  be  left  uninjured. 
The  operation  is  described  as  being  simple, 
and  if  any  embarrassment  arises,  it  is  from 
the  hemorrhage  of  the  ciliary  artery,  the 
blood  sometimes  obscuring  the  punctum 
lachrymale,  just  when  the  operator  is  about 
to  divide  the  tarsus  by  the  side  of  it.  No 
dressings  are  required,  it  being  merely  ne- 
cessary to  keep  the  eye  covered  for  a few 
days.  The  skin  will  continue  to  be  eleva- 
ted, just  as  the  perfect  eyelid  was  ; and, 
though  less  completely,  yet  enough  to  leave 
the  pupil  clear  when  the  eye  is  moderately 
directed  upward.  In  all  the  cases  in  which 
Mr.  Saunders  operated,  a fungus  grew  from 
the  wound.  He  recommends  the  excres- 
cence to  be  destroyed  with  caustic  or  the. 
knife. 

Respecting  this  operation  I shall  merely 
observe,  that  it  is  more,  severe  than  that 
advised  by  Professor  Scarpa,  and  even  than 
the  method  of  Schreger,  and  must  leave 
greater  disfigurement.  Unless,  therefore., 
the  latter  methods  prove  ineffectual,!  should 
consider  the  practice  unjustifiable.  Nor  is 
Schreger’s  method  allowable,  except  in 
cases  which  resist  the  milder  plan, sanction 
ed  by  Beer,  Scarpa,  and  all  the  best  practi- 
tioners in  ophthalmic  surgery. 

Inversion  of  the  lower  eyelid  is  much  less 
common  than  that  of  (be  upper  one.  The 
late  Mr.  Saunders  never  saw  this  disease 
arise  from  the  same  causes  which  induce  it 
in  the  upper  eyelid,  though  he  acknowledges 
the  possibility  of  such  a case.  However, 
he  met  with  several  instances  of  the  affec- 
tion, in  consequence  of  encysted  tumours, 
which, as  they  increased,  carried  the  orbital 
edge  of  the  tarsus  outwards,  and,  in  the 
same  proportion,  inclined  the  ciliary  edge 
towards  the  globe  of  the  eye. 

An  inversion  of  the  inferior  palpebra  is 
sometimes  produced  by  inflammation  and 
swelling  of  that  part  of  the  conjunctiva 
which  connects  the  eyelid  with  the  eyeball. 
In  cases  of  ophthalmy  this  membrane  often 
forms  between  the  latter  parts  a distinct 
fold,  which  is  situated  just  on  the  inside  of 
the  orbital  edge  of  the  tarsus,  and  pushes  it 
outward;  while  the  contraction  of  the  orbi- 
cularis muscle  turns  the  ciliary  edge  in- 
wards, and  inclines  it  between  the  swelling 
of  the  conjunctiva  and  the  eye.  In  this 
particular  case,  Mr.  Saunders  assures  usv, 
that  replacing  the  eyelid  in  the  early  stage 
of  the  disease,  and  maintaining  it  so  until 
the  ophthalmy  has  been  lessened  by  proper 
means,  will  be  found  effectual.  But  when 
the  conjunctiva  is  much,  thickened  and  in- 
durated, Mr:  Saunders  recommends  cutting 
such  diseased  part  of  it  away,  and  the  ap- 
plication of  compresses  to  keep  the  orbital 
margin  of  the  tarsus  inward.  (See  also 
Travers’s  Synopsis,  p.  234  and  355.) 

Albinus  has  recorded  a species  of  trichi- 
asis which  originated  from  the  growth  and 
inversion  of  one  of  the  linjrs  upon  the  ffa- 


\J  jAOSSj* 


5U2 

runcula  lachrymalis.  The  plan  ot  relief  con- 
sisted in  plucking  out  the  irritating  hair ; 
but  it  is  not  mentioned  whether  the  hair 
grew  again. 

J.  Scultetus , Trichiasis  Admiranda , sive 
Jlforbus  Pilaris  Mirabilis,  12 mo.  Norib.  1658. 
Scarpa  suite  principali  Malattie  dtu.ll  Occhi. 
II.  Crampton,  Essay  on  the  Entropeon,  Lond. 
1805.  Saunders's  Obs.  on  several  practical 
Points  relative  to  the  Diseases  of  the  Eye, 
Edit.  3.  Richter's  Anfangsgriinde  der  fVun- 
darzneykunst , B 3.  G.  J.  Beer,  Lchre  von 
den  Augen/crankeiteri,  B.2,p.  1 1 1—1 17, 8t>o. 
Wien.  1817.  Schreger,  Chirurgische  Ver- 
stiche,  B.  2.  JYeue  Methods  die  Trichiasis  zu 
Operiren,  p.  253,  8vo.  JYilrnberg.  1818.  B. 
Travers,  Synopsis  of  the  Diseases  of  the  Eye, 
p.  232—354.  fyc.  8 vo.  Lond.  1820. 

TRISMUS,  (from  to  gnash  the 

teeth.)  The  locked  jaw.  See  Tetanus. 

TROCHAR,  or  Trocar.  (from  the 
French,  trois-quart,  three-fourths,  from  its 
point  being  of  a triangular  form.)  An  in- 
strument used  for  discharging  aqueous  fluids, 
and  now  and  then,  matter  from  different 
cavities  in  the  body,  particularly  those  of 
the  peritoneum,  and  tunica  vaginalis,  in 
oases  of  ascites  and  hydrocele.  Trocars 
are  also  employed  for  tapping  the  bladder, 
dropsical  ovaries,  &c. 

A trocar  consists  of  a perforator,  or  sti- 
lette,  and  of  a cannula,  which  latter  is  so 
adapted  to  the  first  piece  of  the  instrument, 
that  when  the  puncture  is  made,  they  both 
enter  the  wound  together,  with  perfect  ease, 
after  which  the  stilette  being  withdrawn, 
the  cannula  remains  in  the  wonnd,  and  gives 
a ready  passage  for  the  fluid  outward. 

Such  are  the  uses  of  a trocar,  and  the 
principles  on  which  it  should  be  construct- 
ed, It  would  be  unnecessary  in  this  w ork 
to  detail  every  little  particularity  in  the  in- 
strument. I shall  merely  observe,  that  the 
triangular-pointed  trocars  seem  to  retain 
the  greatest  share  of  approbation  ; for,  al- 
though those  of  a flat,  lancet-pointed  shape 
outer  parts  with  more  ease,  their  cannulas 
are  not  large  enough  for  the  ready  escape  of 
fluids  which  are  at  all  thick,  gelatinous,  or 
blended  with  hydatids,  and  flaky  substan- 
ces. 

The  trocar  for  puncturing  the  bladder 
from  the  rectum,  should  be  longer  than  a 
common  trocar,  and  of  a curved  form  ; but 
as  Mr.  Carpue  has  explained,  it  should  not 
be  passed  too  high  up  the  rectum,  lest  the 
peritonaeum  be  wounded. 

Surgeons  ought  always  to  have,  at  least 
three  trocars  ; one  of  full  size,  another  of 
middling  width,  and  a third  of  small  dimen- 
sions. In  cases  of  hydrocele,  the  latter  is 
often  preferable. 

*TRUSS.  ( trousse . French.)  Rracherium. 
A bandage,  or  apparatus,  for  keeping  a her 
ilia  reduced.  A truss,  which  fulfils  its  in- 
tention properly,  should  compress  the  neck 
of  the  hernial  sac,  and  the  ring,  or  external 
opening  of  th~  hernia,  in  such  a manner, 
teat  a protrusion  of  any  of  the  contents  of 
the  abdomen  will  be  prevented  w ith  com- 
plete, security.  Hence,  it.  is  the  indispensa- 


ble quality  of  a good  truss,  first  to  make 
effectual  and  equal  pressure  on  the  parts  in- 
dicated, without  causing  pain,  or  inconve 
nience  to  the  patient , secondly,  not  easilv 
to  slip  oat  of  its  right  situation,  in  the  vary- 
ing motions  and  positions  of  the  body. 

Trusses  are  either  of  an  elastic  or  non- 
elastic kind.  The  latter  are  composed  of 
leather,  fustian,  dimity,  or  similar  materials. 
These  cannot  be  at  all  depended  on,  and 
should,  therefore,  be  entirely  banished  from 
surgery.  Since,  (as  Mr.  Lawrence  has  re- 
marked) the  size  of  the  abdomen  varies, 
according  to  the  different  states  of  the  vis- 
cera, and  to  the  motions  of  its  parietes  in 
respiration,  a non-elastic  bandage  must  vary 
constantly  in  its  degree  of  tightness,  and 
keep  up  either  too  great,  or  too  little  pres- 
sure. The  omentum,  or  intestine,  easily 
slips  out  when  the  opening  is  not  exactly 
closed,  and  the  patient  who  wears  such  a 
bandage  must  be  in  a state  of  constant  inse- 
curity. Those  who  lead  an  active  life,  or 
are  obliged  to  use  laborious  exertions,  will 
be  more  particularly  exposed  to  risk.  If 
the  patient,  after  experiencing  these  defects, 
endeavours  to  remedy  them  by  drawing  the 
bandage  tighter,  he  may  confine  the  viscera  , 
but  he  produces  other  inconveniences.  The 
increased  pressure  injures  the  spermatic 
chord,  and  may  affect  the  testicle  : the  inte- 
guments become  red,  painful,  and  excori  - 
ated ; and  the  bandage  must  be  entirely  laid 
aside,  until  the  parts  have  recovered.  Rich  - 
ter has  often  seen  painful  tumefaction  of 
the  testicle,  hydrocele,  and  even  cirsocele, 
produced  from  this  cause,  and  entirely  dis- 
sipated by  the  employment  of  a proper  truss. 
( Trait6  des  Hernies,  p.  24.)  He  also  saw  the 
pad  of  a non-elastic  bandage  excite,  in  the 
region  of  the  abdominal  ring,  a consider 
able  inflammation,  which  terminated  after 
a few  days  in  suppuration.  The  hernia  ne- 
ver appeared  again  after  the  cure  of  the 
abscess.  The  inflammation  nad  extended 
to  the  neck  of  the  sac,  and  obliterated  that 
part. — ( Lawrence  on  Ruptures , Edit.  3,  p.  69, 
70.)  The  spring  is  a very  essential  part 
of  every  elastic  truss,  and  it  consists  of  a 
flat  long  piece  of  steel,  which  is  adapted  to 
the  side  of  the  body,f>n  which  the  hernia 
is  situated  It  is  not  a great  many  years 
since  the  spring  used  to  be  made  of  com- 
mon iron,  and  Arnaud  and  Richter  express 
their  preference  to  a mixture  of  malleable 
iron  and  steel,  so  that  the  instrument  may 
be  moulded  by  the  hand  to  any  particular 
shape  ; but,  as  Mr.  Lawrence  well  observes, 
a truss,  which  admits  of  such  management, 
must  be  more  or  less  liable  to  the  objections 
which  apply  to  inelastic  bandages,  and  the 
only  material,  which  possesses  the  requisite 
qualities  of  firmness  and  elasticity,  •»  well- 
tempered  steel.  The  front  part  of  the  steel 
spring  has  an  expanded  form,  anil,  w hen 
the  truss  is  properly  applied,  ought  to  be 
situated  over  the  mouth  of  the  hernial  soc. 
The  spring  of  a truss  has  commonly  been  a 
semicircle,  with/the  posterior  end  resting 
on  the  spine.  Camper  proposed  to  carry 
it  round  to  the  anterior  superior  spine  of 


TltUSo. 


the  ilium  oa  the  sound  side ; a plan,  of 
which  Scarpa  highly  approves.  Trusses  of 
this  form  lit  with  a degree  of  steadiness, 
which  cannot  be  given  to  others,  by  tighten- 
ing the  strap.  They  keep  up  the  rupture 
better  than  even  a stronger  spring  of  the 
common  kind.  Under  the  back  surface  of 
the  anterior  end  of  the  spring  is  placed  the 
pad,  which  should  be  adapted  in  shape  and 
size  to  the  passage,  which  is  intended  to  be 
shut  up.  The  steel  spring  is  usually  covered 
with  leather,  is  lined  with  soft  materials, 
and  after  being  put  on  the  patient,  is  fas- 
tened in  its  situation  by  means  of  a strap, 
which  extends  from  the  two  ends  of  the 
spring,  round  that  side  of  the  body,  on 
which  the  hernia  is  not  situated.  Hare- 
skin;  with  the  fur  outwards,  is  sometimes 
considered  the  best  covering  for  preserving 
the  spring  from  the  ill  effects  of  perspi- 
ration. 

When  it  is  necessary  to  make  strong 
compression,  as  in  large  old  ruptures,  and 
in  persons  who  cannot  avoid  labour  and 
exercise,  the  elastic  spring  should  be  made 
accordingly  thicker  and  broader.  But,  an 
object  of  the  first-rate  importance  is  to 
make  the  spring  press  equally  upon  every 
point  of  the  body  which  it  touches.  This 
is  what  demands  the  earnest  atteation  both 
of  the  surgeon  and  the  instrument-maker, 
especially  as  the  hips  of  some  individuals 
are  fiat  and  narrow,  while  those  of  other 
persons  are  broad  and  prominent.  A thick, 
flexible,  metallic  wire,  accurately  applied 
round  the  pelvis,  will  serve  to  take  the  mea 
sure  and  proper  shape  of  the  spring,  which 
may  afterward  be  altered  a little  if  found 
necessary.  The  wire,  however,  should  be 
somewhat  longer,  on  account  of  the  length 
of  the  spring.' 

The  springs  of  trusses  intended  for  chil- 
dren, and  persons  who  do  not  undergo 
much  labour  and  exertion,  need  not  be 
made  so  strong  as  those  designed  for  hard- 
working, active  people. 

The  idea,  that  children  cannot  wear  steel 
trusses,  is  as  erroneous  as  it  is  dangerous  in 
its  practical  consequences ; a point,  on 
which  tVjr.  Pott  has  strongly  insisted. 

Trusses  are  sometimes  fabricated  with  a 
pad  moveable  on  the  spring,  instead  of 
being  riveted  to  it.  This  may  be  inclined 
upwards,  or  downwards,  according  to  the 
form  of  the  abdomen  ; and  it  is  retained  at 
the  desired  point  by  a spring  fitting  into  the 
teeth  of  a rack,  in  others,  the  plate  con- 
tains a screw,  by  which  the  cushion  is 
pushed  further  inward,  or  allowed  to  recede 
at  pleasure.  Although  there  cannot  be  a 
doubt,  that  some  of  these  inventions  possess 
considerable  merit,  and  are  in  certain  in- 
stances superiorly  useful,  it  must  be  con- 
fessed, that,  in  general,  their  utility  is  not 
samuch  greater,  than  that  of  common  pads, 
as  to.  make  amends  for  the  want  of  simpli- 
city and  the  increase  of  expense.  I should 
be  sorry,  however,  to  say  any  thing  that 
would  unfairly  discourage  all  such  inge- 
nious endeavours  to  improve  an  instrument. 


603 

so  difficult  10  bring  lo  perfection  a3  a truss; 
especially  as  I believe  there  are  particular 
cases,  in  which  pads,  with  racks,  screws,, 
springs,  kc.  gaay  be  employed  with  great 
advantage. 

jNot withstanding  every  care,  sometimes 
even  elastic  trusses  cannot  be  hindered 
from  slipping  away  from  the  part,  which 
they  are  designed  to  compress.  Sometimes 
they  slip  downwards,  which  in  fat  subjects 
is  generally  caused  by  the  projection  of  the 
abdomen.  Occasionally, ‘the  fault  consists 
in  the  instrument  becoming  displaced  in 
the  direction  upwards,  which  mostly  hap- 
pens in  thin  persons,  and  is  produced  by  the 
flatness  of  the  abdomen.  In  the  first  case* 
the  displacement  is  to  be  prevented  by  the 
use  of  an  elastic  scapulary  ; in  the  second, 
the  slipping  of  the  pad-  upwards  is  to  be 
prevented  by  the  employment  of  a thigh 
strap. 

When  a patient  is  afflicted  with  a rupture 
on  each  side,  the  two  protrusions  may  be 
very  well  kept  up  by  means  of  a single 
truss,  made  with  two  pads,  which  are  joined 
together,  at  the  exact  distance  of  the  rings 
from  each  other,  by  a piece  of  steel,  ap- 
plied over  the  convexity  of  the  symphysis 
of  the  pubes,  and  proportioned  in  length  to 
the  space  between  the  two  openings,  through 
which  the  viscera  descend.  In  such  cases,, 
however,  it  is  absolutely  necessary  to  have 
the  spring  stronger,  than  if  there  were  only 
one  rupture.  The  truss  should  also  be  put 
ou  that  side  of  the  body,  upon  which  the 
hernia  most  difficult  to  retain  is  situated. 
There  are  some  practitioners,  however,  who 
give  the  preference  to  the  use  of  two  single 
trusses,  joined  together  in  front  and  behind 
with  suitable  straps. 

With  respect  to  the  application  and  use 
of  trusses,  the  following  instructions  seem 
to  merit  attention. 

1.  A truss  should  never  be  first  applied, 
or  changed,  except  when  the  patient  is  in 
the  horizontal  posture,  and  it  is  knownP 
with  certainty,  that  all  the  contents  of  the 
rupture  are  completely  reduced. 

2.  The  first  applications  of  a truss  should 
always  be  made  under  the  superintendency 
of  the  surgeon  himself  j and  care  should  be 
taken  to  put  on  the  instrument  in  such  a 
manner,  that  the  lower  third  of  the  pad  will 
compress  the  neck  of  the  hernial  sac  against 
the  os  pubis,  while  the  upper  portion  will 
compress  the  abdominal  ring.  The  surgeon 
should  also  make  the  patient  acquainted 
with  the  right  manner  of  applying  the 
truss ; the  principles  on  which  it  keeps  up 
the  bowels,  and  affords  a chans  e of  a rad  cal 
cure  ; the  requisite  cautions  to  be  observed, 
he.  When  a patient  first  begins  to  wear  a 
truss,  he  should  be  particularly  careful  not 
to  he  guilty  of  any  imprudent  exertions,  and 
it  behoves  him  to  observe  most  attentively, 
that  the  instrument  does  not  slip  from  its 
proper  situation  It  will  also  be  necessary 
for  him  to  pay  attention  to  the  instrument 
being  neither  too  ti^ht,  nor  too  loose. 


TRET 


&04 

3.  The  patient  ought  to  be' provider  with 
at  least  two  trusses,  which  should  be  chan- 
ged every  morning  in  bed.  In  order  to  save 
the  truss,  especially  in  fat  persons  who  per- 
spire a gr^at  deal,  it  is  a good  plan  to  lay  a 
soft  piece  of  calico  under  the  pad. 

4.  An  uneasiness  about  the  ring,  which 
always  gives  rise  to  a suspicion  that  a por- 
tion of  intestine,  or  omentum,  is  protruded, 
makes  it  proper  to  take  off  the  truss,  care- 
fully examine  the  parts,  and  reduce  them  if 
they  have  descended. 

5.  When  the  skin  is  excoriated  by  the 
truss,  the  part  may  be  cured  by  sprinkling 
upon  it  the  povvder  of  acetite  of  lead,  Ful- 
ler’s earth,  lapis  calamiriaris,  &.c  or  bathing 
the  part  with  an  astringent  lotion,  it  will 
also  be  right  to  protect  the  excoriated  place 
with  a piece  of  linen  put  under  the  truss. 

<5.  When  the  pressure  of  the  truss  excites 
affections  and  swellings  ot  the  spermatic 
chord  and  testicle,  either  the  thigh  strap 
must  be  relaxed,  or  the  lower  part  of  the 
pad  made  less  prominent.  And  when  strong 
pressure  is  absolutely  necessary  to  keep  the 
hernia  reduced,  the  pad  should  have  an  ex- 
cavation in  it  over  the  spermatic  chord. 
Whoevef  wears  a truss  should  be  careful  to 
employ  it  day  and  night,  without  interrup- 
tion, so  that  there  may  be  no  opportunity 
for  the  hernia  to  protrude  again.  If  under 
the  employment  of  a truss,  the  rupture  once 
descends  again,  either  a strangulation  hap- 
pens from  the  narrowness  of  the  neck  of  the 
sac  ; or,  at  all  events,  the  hope  of  a radical 
cure,  which  may  have  been  entertained  for 
years  and  months,  is  destroyed  in  a mo- 
ment ; for,  experience  has  put  it  beyond  all 
doubt,  that,  by  the  continual  unremitted  use 
of  a truss,  and  the  steady  retention  of  the 
contents  of  the  hernia,  the  neck  of  the  her- 
nial sac,  and  the  nog,  may  be  gradually 
lessened  in  diameter,  until  they  are  entirely 
closed,  and  n radical  cure  of  the  rupture 
effected.  This  is  more  frequently  observed 
in  young  subjects,  seldom  in  aduits,  and 
scarcely  ever  in  persons  of  advanced  years. 
But  trusses  must  be  worn  along  while  ; nor 
should  the  patient  venture  to  lay  aside  their 
use  till  after  many  cautious  attempts ; be- 
ginning the  experiment  at  first  only  in^the 
night-time,  and  not  making  it  in  the  day  till 
after  a considerable  period  from  the  time, 
when  he  first  thinks  himself  safe.  The 
longer  and  more  attentively  a truss  is  worn, 
the  greater  is  the  hope  of  a radical  cure. 
( Callisen , Syst.  Ckir.  Hod.  T.  2.) 

In  the  2d  vol.  of  the  last  edition  of  the 
First  Lines  of  the  Practice  of  Surgery,  the 
truss  for  navel  ruptures,  which  was  devised 
by  Mr.  England  and  latterly  preferred  by 
Mr.  Hey,  is  described  ; and  in  the  article 
Hernia , an  account  is  given  of  the  truss  for 
umbilical  hernia,  invented  by  Mr.  Murrison 
of  Leeds,  and  described  by  Mr.  Hey.  In 
the  same  part  of  this  Dictionary  may  also  be 
found  some  observations,  relative  to  the 
place,  against  which  the  pressure  of  the 
pads  of  trusses  should  be  directed  in  cases 
of  inguinal  hernia,  iri  conformity  to  Sir  A. 
Cooper’s  description  of  the  situation,  at 


t m. 

which  the  parts  first  protrude  from  the  ab- 
domen. 

TUMOUR.  A swelling.  In  the  present, 
article,  I intend  only  to  treat  of  what  are 
usually  called  sarcomatous  and  encysted 
tumours.  Mr.  Abernethy  thinks,  that  the 
manner  in  which  tumours  are  formed  is  best 
illustrated  by  those  which  hang  pendulous 
from  the  membranous  lining  of  different  ca- 
vities. This  gentleman  adverts  to  an  ex- 
ample noticed  by  Mr.  Hunter,  in  which,  ca 
the  cavity  of  the  abdomen  being  opened, 
there  appeared  lying  upon  the  peritoneum, 
a small  portion  of  red  blood  recently  co- 
agulated. This,  on  examination,  was  found 
to  be  connected  with  the  surface,  upon 
which  it  bad  been  deposited,  by  means  of 
an  attachment,  half  an  inch  long,  and  this 
neck  had  been  formed  before  the  coagulum 
had  lost  its  red  colour.  (See  Trans. for  the 
Improvement  of  Med.  and  Ckir.  Knowledge, 
Vol.  1,  p.  231.)  Mr  Abernethy  observes, 
that  if  vessels  had  shot  through  the  slender 
neck,  and  organized  the  clot  of  blood,  this 
would  then  have  become  a living  part : it 
might  have  grown  to  an  indefinite  magni- 
tude, and  its  nature  and  progress  would 
probably  have  depended  on  the  organiza- 
tion, which  it  had  assumed.  He  mentions 
his  possession-of  a pen,  found  growing  from 
the  surface  of  the  peritoneum,  and  which 
was  undoubtedly  formed  in  the  same  man- 
ner as  the  tumour  noticed  by  Mr.  Hunter, 
viz.  by  vessels  shooting  into  a piece  cf  ex- 
travasated  blood,  or  lymph,  and  rendering 
it  a living  organized  substance.  Tumours, 
in  every  situation,  and  of  every  description, 
are  probably  formed  in  the  same  way.  The 
coagulating  lymph  being  effused,  either  ac- 
cidentally, or  in  consequeiTee  of  disease,  is 
afterward  converted  into  a living  part,  by 
the  growth  of  the  adjacent  vessels  and 
nerves  into'  it.  Mr.  Abernethy  remarks, 
that,  when  the  deposited  substance  has  its 
attachment  by  a single  thread,  all  its  vascu- 
lar supply  must  proceed  through  that  part : 
but,  in  other  cases,  the  vessels  shoot  into  it 
irregularly  at  various  parts  of  its  surface 
Thus,  an  unorganized  concrete  becomes  a 
living  tumour,  which  has  at  first  no  percep- 
tible peculiarity  as  to  its  nature.  Although 
its  supply  of  blood  is  furnished  by  the  ves- 
sels oi  the  surrounding  parts  it  seems  to  live 
and  grow  by  its  own  independent  powers, 
while  its  future  structure  seems  to  depend 
on  the  operation  of  its  own  vessels.  Mr. 
Abernethy  conceives, that  the  altered  struc- 
ture of  an  enlarged  gland  affords  no  contra- 
diction to  the  above  account,  as,  in  this 
latter  case,  the  substance  of  the  gland  is  the 
matrix,  in  which  the  matter,  forming  the 
tumour,  or  enlargement,  is  deposited.  The 
structure  of  a tumour,  he  observes,  is  some- 
times like  that  of  the  parts,  near  which  it 
grows.  Such  as  arc  pendulous  in  joints, 
a re  cartilaginous,  or  osseous.  Fatty  tumours 
frequently'  form  in  the  midst  of  the  adipose, 
substance  ; and  he  has  seen  some  tumours 
growing  from  the  palate,  which  had  a slen- 
der attachment,  and  resembled  the  palate 
in  structure. 


TUMOUR. 


However,  this  resemblance  of  the  struc- 
ture of  a tumour  to  that  of  the  neighbouring 
parts,  is  not  always  observable.  I have  in 
my  own  possession  a completely  cartilagi- 
ft  nous  tumour,  which  I found  in  the  midst  of 
the  fat  near  the  kidneys.  The  pendulous 
portion  of  fat,  growing  from  the  perito- 
neum, and  mentioned  by  Mr.  Abernethv, 
serves  as  another  instance  of  the  fact ; and, 
one  might  add,  that  every  polypus  which 
we  meet  with, bears  no  resemblance  in  struc- 
ture to  the  neighbouring  parts.  Mr  Aberne- 
thy  mentions  his  having  seen  bony  tumours, 
which  were  unconnected  with  bone,  or  the 
periosteum,  and  he  observes,  that  the  struc- 
ture of  a tumour  is,  in  general,  unlike  that 
of  the  part  in  which  it  is  produced. 

When  the  eoagulable  part  of  the  blood  is 
effused,  and  the  absorbents  do  not  take  it 
away,  the  surrounding  blood-vessels  are  sup- 
posed to  grow  into  it,  and  convert  it  into  a 
vascular  tumour.  The  effusion  of  the  coa- 
gulable  part  of  the  blood  may  be  the  effect 
of  accident,  or  of  a common  inflammatory 
process,  or  it  may  be  the  consequence 
of  some  diseased  action  of  the  surround- 
ing vessels,  which  (diseased  action)  may  in- 
fluence the  organization,  and  growth  ot  the 
tumour. 

In  the  former  cases,  the  parts  surrounding 
the  tumour  maybe  considered  simply  as  the 
sources,  from  which  it  derives  its  nutriment, 
while  it  grows  apparently  by  its  own  in- 
herent powers,  and  its  organization  depends 
upon  actions  begun  and  existing  in  itself.  If 
such  a tumour  be  removed,  the  surrounding 
parts  being  sound,  soon  heal,  and  a complete 
cure  ensues.  But  if  a tumour  be  removed, 
whose  existence  depends  on  the  disease  of 
the  surrounding  parts,  which  are  still  left, 
and  this  disease  be  not  altered  by  the  sti- 
mulus of  the  operation,  no  benefit  is  ob- 
tained. These  parts  again  produce  a dis- 
eased substance,  which  has  generally  the  ap- 
pearance of  fungus,  and,  in  consequence  of 
being  irritated  by  the  injury  of  the  operation, 
the  disease  is  in  general  increased  by  the 
means  which  were  designed  for  its  eure.  it 
appears,  therefore,  that  in  some  cases  of  tu- 
mours, the  newly-formed  partalone  requires 
removal,  whilst  in  others,  the  surrounding 
substance  must  be  taken  away,  or  a radical 
cure  cannot  be  effected.  {Abernethy’s  Surg. 
Obs.  1804.)  This  gentleman  conceives,  that 
the  irritation  of  the  tumour  itself,  when 
once  the  swelling  has  been  produced,  keeps 
up  an  increased  action  in  the  surrounding 
vessels,  so  as  to  become  a sufficient  cause  of 
the  disease  continuing  to  grow  larger.  As 
the  tumour  becomes  of  greater  magnitude, 
it  condenses  the  surrounding  cellular  sub- 
stance, and  thus  makes  for  itself  a sort  of 
capsule.  The  close,  or  loose  manner,  in 
which  tumours  become  connected  with  the 
surrounding  parts,  seems  to  depend  very 
much  on  the  degree  of  irritation  and  inflam- 
mation excited  in  the  circumjacent  parts. 
When  a tumour  has  been  at  all  tender,  pain- 
ful, and  inflamed,  it  is  generally  found  inti- 
mately adherent  to  all  the  neighbouring  parts. 
Mr.  Abernethv  also  believes,  that  the  increa' 
Voi.  II  64 


sed  irritation  whicli  a tumour  creates  when 
it  has  exceeded  a certain  size,  may  explain 
why  some  tumours,  which  are  at  first  slow 
in  their  progress,  alterward  begin  to  grow 
with  great  rapidity. 

Ihe  process  by  which  tumours  are  form- 
ed, is  commonly  thought  to  be  attended 
with  an  increased  action  of  the  vessels, 
which  supply  the  swellings  with  blood.  It 
is  supposed,  in  short,  to  be  (he  same  kind  of 
process,  which  forms  all  the  thickenings  and 
indurations,  which,  under  various  circum- 
stances, occur  in  different  parts  of  the  human 
body.  It  has  sometimes  been  named  chronic 
inflammation,  to  distinguish  it  from  that 
which  is  more  quick  in  the  production  of 
certain  effects,  aud  is  often  attended  with  a 
manifest  throbbing  in  the  part  affected. 
This  subject  of  chronic,  or  passive  inflamma- 
tion is  one,  about  which  very  little  certain 
is  known  ; and  the  very  name  has  commonly 
been  admitted  only  on  the  supposition,  that 
some  kind  of  increased  action  exists  in  the 
vessels,  though  of  a slower  and  less  evident 
kind,  than  what  prevails  in  acute  inflamma- 
tion. According  to  Dr.  Wilson  Philip,  the 
difference  between  what  is  called  active  and 
passive  inflammation  seems  to  depend  upon 
“ the  degree,  in  which  the  arteries  supplying 
the  i«a  a tergo  to  the  debilitated  vessels  are 
excited.”  ( Laws  oj  the  Vital  Functions,  p. 
^82,  Edit.  2.)  If  this  position  be  satisfac- 
torily established,  one  important  step  will  be 
made  to  a knowledge  of  the  differences  be- 
tween acute  and  chronic  inflammation  ; but, 
much  would  yet  remain  for  explanation  be- 
fore our  ideas  of  the  latter  process  would  be 
at  all  complete 

In  a work  of  considerable  merit,  Dr.  Baroa 
of  Gloucester,  offers  many  considerations 
against  the  correctness  of  the  ordinary  doc- 
trines, respecting  the  formation  of  tubercles 
and  tumours.  By  tubercles,  he  means  disor- 
ganizations composed  of  one  cyst,  “ what- 
ever be  its  magnitude,  or  the  nature  of  its 
contents,”  and  by  tumours,  he  would  under- 
stand “ morbid  structures,  that  appear  to  be 
composed  of  more  than  one  tubercle.”  {On 
1 uberculated  Accretions  of  Serous  Membranest 
fyc.  p.  213.)  From  certain  appearances, 
traced  in  dissections,  Dr.  Baron  infers,  (hat 
all  tubercles,  wherever  situated,  and  of  what- 
ever 9ubs(ance  composed,  were  at  their 
commencement  small  vesicular  bodies,  with 
fluid  contents  ; hydatids,  as  he  endeavours  to 
prove.  “ It  is  impossible  to  say,  how  minute 
they  may  have  been  at  their  origin,  nor  how- 
large  they  may  grow,  before  their  transfor- 
mations begin  ; nor  are  we  acquainted  with 
the  circumstances  which  occasion  such 
transformations.”  To  these  changes  in  hyda- 
tids, (accordingtothis  writer,)  certain  tuber- 
cles owe  their  existence,  and  on  the  size, 
relative  position,  and  structure  of  the  tubercles, 
which  are  so  formed,  depend  the  characters  of 
many  of  the  most  formidable  disorganisations, 
to  which  the  human  body  is  exposed.  (P. 
215.)  A single  hydatid,  when  it  is  trans- 
formed (says  Dr.  Baron)  will  give  rise  to 
one  tubercle.  “ It  may  be  pendulous,  or 
embedded  in  any  soft  part,  or  it  mav  be- 


TL'MOl/H 


found  between  the  layers  of  membranes, 
ami  wherever  the  textures  are  of  such  a na- 
ture as  to  admit  of  its  growth.  It  may  be 
so  small  as  to  be  scaicely  visible,  or,  it  may 
acquire  a very  great  magnitude.  Single  tu- 
bercles are  often  seen  in  a viscus,  while  all 
the  rest  of  the  organ  is  free  from  disease,  and 
its  functions  are  performed  in 'an  uninter* 
vupted  manner.  But,  it  is  evident,  that  the 
same  state  of  the  system,  (whatever  that 
may  be,)  which  calls  one  tubercle  into  ex- 
istence, may  generate  an  indefinite  number. 
They  may  be  diffused  through  the  whole  of 
a viscus,  leaving  nothing  of  its  original  tex- 
ture, or  they  may  occupy  any  proportion  of 
it,  or  extend  to  the  contiguous  parts,  and  in- 
volve them  in  the  same  form  of  disease.” 
(P.  216.)  When  hydatids  growing  in  clusters, 
and  hanging  within  cavities,  become  changed 
into  tubercles,  Dr.  Baron  conceives,  that  the 
morbid  appearances  must  of  course  corres- 
pond in  some  degree,  with  the  original  dis- 
tribution of  the  parts.  He  has  seen  tubercles 
attached  in  this  form  to  the  choroid  plexus, 
to  the  valves  of  the  heart,  to  the.  fimbriated 
extremities  of  the  Fallopian  tubes,  aud  to 
the  omentum,  and  convolutions  of  the  bow- 
els. In  the  latter  instance,  they  were  very 
minute,  the  largest  not  being  bigger  than  the 
head  of  a pin,  and  their  number  defied  all 
calculation. 

“ Other  varieties  in  the  arrangement  of 
the  elementary  parts  of  morbid  growths, 
will  of  course  cause  corresponding  varieties 
in  their  appearance.  Thus,  when  hydatids 
art  enclosed,  the  one  within  the  other , and  are 
transmitted  into  solid  substances , a section  of 
these  substances  will  exhibit  a series  of  concen- 
tric laminae .” 

Another  variety  pointed  out  by  Dr.  Baron, 
is  “ when  an  immense  number  of  very  small 
tubercles  are  generated  in  juxtaposition,  and 
unite  together.  Wherever  such  an  event 
occurs,  the  original  texture  of  the  part  is  en- 
tirely lost,  and  a mass  of  varying  degrees  of 
density  and  firmness  formed.  In  the  earlier 
stages  of  its  growth,  a granulated  appearance 
may  be  distinctly  traced  ; but,  in  process  of 
time,  this  disappears,  the  consolidation  be- 
comes more  complete,  and  substances  of  a 
gristly,  or  cartilaginous,  or  scirrhous  texture 
may  be  found.  1 have  traced  (says  Dr. 
Baron,)  the  whole  of  these  gradations  in 
the  liver,  the  lungs,  the  pleura, the  omentum, 
the  peritoneum,  and  in  tumours  in  other 
parts.”  (P.  219.) 

“ Sometimes,  small  hydatids  grow  from 
the  outer  or  inner  surface  of  large  ones,  or 
float  within  them.  I have  seen,  (says  Dr. 
Baron,)  from  a source  of  this  kind,  the  uterus 
and  its  appendages  converted  into  an  enor- 
mous misshapen  mass,  tubercles  of  the  size 
of  the  fist  growing  from  it,  while  these 
again  were  surmounted  by  smaller  ones  in 
many  gradations.  Some  had  glairy  contents, 
others  were  in  a state  of  scirrhosity,  and 
others  were  but  little  changed,  having  thin 
delicate  cysts,  and  containing  a transparent 
fluid. 

“ But,  perhaps,  (remarks  Dr.  Baron)  the 
xuost  important  variety  of  all,  is  when  tuber- 


cles, originally  distinct  irom  each  other,  ap  - 
proximate as  they  increase  in  size,  ulti- 
mately unite,  and  form  tumours,  which  have 
received  different  designations,  according  to 
the  predominant  character  of  their  contents 
and  internal  structure.  It  was  chiefly  to 
elucidate  this  part  of  the  subject,  that  I 
made  the  distinction  between  the  words 
tumour  and  tubercle,  Sic.”  (P.219.)  By  thus 
adverting  to  the  primitive  arrangement, 
number,  size,  &.c.  of  hydatids,  and  their  sub- 
sequent mutations,  Dr.  Baron  tries  to  ac- 
count for  the  varieties  of  encysted  and  sar- 
comatous tumours,  fungus  hcematodes,  tu~ 
berculated  sarcoma,  scirrhous  swellings,  &c. 
kc.  The  late  Dr.  Adams,  as  is  well  known, 
referred  cancer  to  the  living  state,  growth, 
and  multiplication  of  the  hydatid.  (On  the 
Cancerous  Breast , p.  77.)  In  order  to  account 
for  the  various  appearances  of  the  disease, 
he  has  divided  hydatids  into  a number  of 
species,  as  iymphatica,  cruenta,  and  carcino- 
matosa,  and  suspectsthat  there  may  be  others. 
These,  he  affirms,  are  lodged  in  different 
cavities,  or  enclosed  in  a fungus,  which  is 
occasioned  by  any  individual,  or  numbers, 
stimulating  the  surrounding  parts  to  gene- 
rate it,  for  the  purpose  of  dividing  the  dead 
from  the  living.  This  fungus  is  a nidus, 
formed  altogether  for  the  protection  of  an- 
other generation  ; by  means  of  it,  the  living 
families  are  separated  from  the  dead,  and 
their  preservation  is  secured.  They  die,  he 
says,  without  otherwise  affecting  the  body 
in  which  they  existed,  but  by  their  local 
stimulus,  and  he  declares,  that  his  object  is 
to  prove  the  animalcular  existence  of  carci- 
noma. Now,  according  to  Dr.  Baron,  this 
main  position  is  the  fundamental  error  of 
Dr.  Adams’s  book;  for,  “ in  no  rational,  nor 
legitimate  point  of  view  may  cancer  be 
said  to  have  an  animalcular  existence ; be- 
cause admitting,  for  the  sake  of  argument, 
that  hydatids  are  animalcules,  it  has,  I trust, 
been  shown,  (says  Baron,)  that  it  is  to  the  loss 
of  the  hydatical  character  altogether,  and  the 
transformations  of  these  bodies , that  the  mor- 
bid appearances  in  this,  and  many  other  dis- 
eases, ure  to  be  referred .”  (P.  276.) 

Although  1 consider  the  evidence  and  re- 
marks, which  Dr.  Baron  has  adduced,  in  sup- 
port of  his  opinions  in  many  respects  inter- 
esting, the  facts  brought  forward  do  not  ap- 
pear to  me  to  justify  the  conclusion,  that  the 
formation  of  tubercles  and  tumours  original- 
ly depends  upon  hydatids,  and  their  transfor- 
mation. That  hydatids  are  sometimes  found 
within  diseased  structures,  and  that  cells, 
cysts,  granulated,  and  tuberculated  appear- 
ances ure  often  noticed  in  tumours  of  differ- 
ent kinds,  are  facts  universally  received 
But  the  presence  of  hydatids  in  the  unchanged 
state  is  only  an  occasional  circumstance, 
whereas,  if  they  were  generally  a cause  of 
tumours  by  undergoing  some  unexplained 
transformation,  it  is  impossible  to  suppose, 
that  some  of  them,  at  least,  would  not  be 
more  commoulyfou  d in  a distinct,  unaltered 
form  within,  or  around  all  swellings,  imagined 
to  proceed  from  clusters  of  them.  As  the 
growth  of  tumours,  formed  on  these  prind 


11  MOL  R 


507 


pies,  could  not,  1 imagine, "be  accounted  for, 
without  supposing  a continual  multiplication 
and  transformation  of  hydatids,  either  witli- 
in,  or  around  the  swellings,  one  would  ex- 
pect, that  some  visible  hydatids,  previously 
to  tbeir  transfiguration,  would  certainly  be 
apparent  on  minutely  examining  the  interior 
and  the  circumference  of  the  diseased  struc- 
ture. Yet,  I am  not  aware,  that,  such  fact 
has  been  proved  to  be  generally  the  case, 
either  by  the  aid  of  the  scalpel,  or  the  mi- 
croscope. The  observation  of  cavities,  cells, 
and  tuberculated  appearances  in  some  kinds 
of  tumours,  is  no  proof  that  such  modifica- 
tions of  structure  are  transformed  hydatids. 
Besides,  if  my  limits  would  allow  me  to  con- 
sider this  topic  further,  many  reasons  might 
be  urged  against  the  hydatid  doctrine,  arising 
from  the  consideration  of  the  changes  evi- 
dent in  the  blood-vessels,  supplying  parts, 
in  which  a considerable  tumour  is  situated. 
Thus,  we  often  see  the  trunks  of  the  arteries, 
running  towards  such  parts,  doubled  in  size, 
just  as  is  noticed,  with  respect  to  the  carotid 
in  the  natural  growth  of  the  stag’s  horn, 
and  indicating,  at  least,  that  the  formation 
and  increase  of  swellings  are  effected  through 
the  medium  of  the  blood-vessels.  The  sud- 
den effect  of  tying  the  arteries,  by  which  a 
tumour  is  supplied  with  blood,  would  also  be 
difficult  to  explain,  if  the  growth  of  the 
swelling  really  depended  upon  some  unde- 
fined transformation  of  hydatids. 

It  seems  to  be  generally  admitted,  that  the 
growth  of  all  tumours  may  be  retarded,  and 
that  sometimes  they  may  even  be  diminished 
by  means  of  topical  bleeding  w ith  leeches, 
and  keeping  the  parts  in  a continuaiiy  cool 
state,  by  the  incessant  application  of  cold 
sedative  washes.  Afterward,  when  the  in- 
creased action  of  the  vessels  seems  checked, 
and  the  tumour  ceases  to  enlarge,  discu- 
tients  are  indicated,  such  as  frictions  with 
mercurial  ointment,  pressure,  electricity, 
rubefacient  plasters,  solutions  of  salts,  blis- 
ters, and  issues.  Very  few  sarcomatous  or 
encysted  tumours,  howrever,  are  ever  com- 
pletely removed  by  these  local  means.  The 
swelling,  on  the  contrary,  generally  increas- 
es, notwithstanding  them,  and  the  irritation 
of  the  disease  by  stimulants  is  not  altogether 
unattended  with  danger  of  the  affection  be- 
coming changed  by  them  into  very  malig- 
nant and  dangerous  cases,  sometimes  to  a! I 
appearances  cancerous.  The  most  odviseable 
plan  is  to  recommend  the  removal  of  sar- 
comatous tumours  with  the  knife,  while 
they  are  small,  and  in  an  incipient  state. 
For  thus  they  are  got  rid  of  by  an  operation, 
which  is  certainly  trivial,  compared  with 
what  might  afterward  become  requisite,  if 
the  disease  were  allow  ed  to  proceed,  and 
attain  an  enormous  magnitude. 

Tumours,  Sarcomatous.  These  have 
been  so  named,  from  their  firm,  fleshy  feel. 
They  are  of  many  kinds,  some  of  which  are 
simple,  while  others  are  complicated  w ith 
a malignant  tendency.  Mr.  Abernethy  has 
attempted  to  form  a classification  of  sarco- 
matous tumours,  for  the  different  species  of 
which  be  has  proposed  names,  deduced  from 


the  structure,  which  they  exhibit  on  dissec- 
tion. This  gentleman  has  named  the  kind 
of  swellings,  which  lie  first  considers,  Com- 
mon Vascular,  or  Organized  Sarcoma.  Un- 
der this  title,  Mr.  Abernethy  includes  all 
those  tumours,  which  appear  to  be  con 
posed  of  the  gelatinous  part  of  the  blood, 
rendered  more  or  less  vascular  by  the 
growth  of  vessels  through  it.  The  vessels 
which  pervade  this  substance  are,  in  differ- 
ent instances,  either  larger  or  smaller  ; and 
more  or  less  numerous;  being  distributed 
in  their  usual  arborescent  manner,  without 
any  describable  peculiarity  of  arrangement. 
Perhaps  all  the  varieties  of  sarcomatous  tu- 
mours are  at  first  of  this  nature.  The  struc- 
ture under  consideration,  is  met  with  not 
only  in  distinct  tumours,  but  also  in  the 
testis,  mamma,  and  absorbent  glands.  When 
a common  vascular,  or  organized  sarcoma 
has  attained  a certain  magnitude,  the  veins 
of  the  skin  seem  remarkably  large,  and  their 
winding  under  the  integuments  excites  no- 
tice. This  kind  of  sarcoma  is  not  at  all 
tender,  so  that  it  may  be  freely  handled, 
and  also  electrified,  without,  giving  pain. 
The  tumour  sometimes  grows  to  such  a size 
that  the  skin  bursts,  the  substance  of  the 
swelling  sloughs  out,  and  the  disease  isgot 
rid  of.  However,  this  mode  of  cure  is  at- 
tended with  such  terrible  local  appearances, 
and  so  much  fever,  &ic.  that  the  removal  of 
the  disease  w ith  the  knife  is  to  be  preferred. 

The  second  kind  of  sarcomatous  tumour, 
noticed  in  Mr.  Abernethy ’s  classification,  is 
the  Adipose  Sarcoma.  Every  one,  at  all  in 
the  habit  of  seeing  surgical  diseases,  must 
know,  that  fatty  tumours  are  exceedingly 
common.  Mr.  Abernethy  believes,  that 
these  swellings  are  formed  in  the  same 
manner  as  others,  viz.  in  the  first  instance 
they  were  coaguiablc  lymph,  rendered  vas- 
cular by  the  grow  th  of  vessels  into  it,  and 
that  their  future  structure  depended  on  the 
particular  power  and  action  of  the  vessels. 
According  to  Sir  Astley  Cooper,  “ they  are 
not  composed  of  fatty  matter  only  ; but  the 
adipose  membrane  is  increased,  and  their 
structure  is  similar,  only  somewhat  more 
compact,  to  that  of  the  fatty  membrane  i:i 
other  parts  of  the  body.”  (Med.  Chir.  Trans. 
Vol.  11,  p.  440.),  This  fact  is  very  muck 
against  the  doctrine,  which  ascribes  the  ori- 
gin of  tumours  to  hydatids  and  their  trans- 
formation. Adipose  sarcomatous  tumours 
always  have  a thin  capsule,  formed  by  the 
simple  condensation  of  the  surrounding  cel- 
lular substance.  It  adheres  very  slightly  to 
the  swellings,  and,  chiefly  by  means  of  ves- 
sels, which  pass  through  this  memoranons 
covering  in  orderto  enter  the  tumour.  As 
Mr.  Abernethy  has  accurately  described, 
the  vessels  are  so  small,  and  the  connexion 
so  slight,  that,  in  removing  the  tumour,  no 
dissection  is  requisite,  as  the  operator  may 
easily  put  his  fingers  between  the  swelling 
and  its  capsule,  so  as  to  break  the  little  vas- 
cular connexions,  and  entirely  detach  the 
disease. 

The  substance  of  adipose  tumours  is  never 
furnished  with  verv  large  blood-vessels,  and 


I'UMOUB 


the  fear  of  hemorrhage,  w^ich  frequently 
deters  surgeons  from  operating,  is  quite  un- 
founded. It  is  an  undoubted  Tact,  that  there 
is  no  species  of  tumour,  that  c air  be  removed 
with  so  much  celerity,  with  such  apparent 
dexterity,  or  with  such  complete  security 
against  future  consequences,  as  those  of  an 
adipose  nature.  However,  now  and  then, 
when  the  tumour  has  been  at  all  in  an  in- 
flammatory state,  the  capsqle  becomes  thick- 
ened, and  intimately  adherent  to  the  surface 
ot  the  swelling,  so  that  the  separation  of  the 
disease  is  more  difficult,  and  requires  the 
knite  to  be  more  freely  employed.  The 
tumour  also  sometimes  becomes,  after  in- 
flammation, closely  adherent  to  the  conti- 
guous parts.  Adipose  tumours  often  ac- 
quire an  enormous  magnitude.  Indeed, 
there  can  be  no  doubt  of  the  fact  stated  by 
Sir  Astley  Cooper,  that  they  acquire  a 
greater  magnitude  than  any  other  swelling 
ever  reaches.  Mr.  Abernethy  relates  an 
example  of  one,  removed  by  Mr.  Cline, 
which  weighed  between  14  and  15lbs.,  and 
which  I saw  myself  previously  to  the  opera- 
tion. Sir  Astley  Cooper  also  mentions  the 
successful  extirpation  of  several  adipose  tu- 
mours of  immense  size  : one  weighing  141b. 
105.  removed  by  himself;  another. weigh- 
ing I5lbs.  removed  by  Mr.  Cline  and  a 
third,  weighing  221bs.  removed  from  a lady’s 
thigh  by  Mr.  Copeland.  But  the  most  re- 
markable case  is  one,  in  which  Sir  Astley 
Cooper  lately  removed  a fatty  swelling  which 
weighed,  independently  of  the  blood  in  it, 
371bs.  lOozs.,  and  was  situated  on  the  ab- 
domen of  a man,  aged  57.  (See  Med.  Ckir. 
Trans.  Vol.  11  ,p.  440.)  Although  it  is  true, 
that  when  adipose  swellings  attain  an  enor- 
mous bulk,  the  immense  size  of  a wound 
requisite  for  their  removal,  must  he  danger- 
ous, and  is  a strong  argument  in  favour  of 
having  recourse  to  the  operation  at  an  ear- 
lier period,  yet  it  is  equally  true,  that  large 
fatty  swellings  may  be  taken  out,  with  a 
greater  prospect  of  success,  than  any  other 
kind  of  tumour  of  equal  size. 

The  next  species  of  sarcoma,  noticed  in 
Mr.  Abernethy’s  classification,  is  what  this 
gentleman  names  pancreatic,  from  the  re- 
semblance of  its  structure  to  that  of  the  pan- 
creas. This  kind  of  disease,  according  to 
Mr.  Abernethy,  is  occasionally  formed  in 
the  cellular  substance  ; but,  more  frequent- 
ly, in  the  female  breast,  on  that  side  of  the 
nipple  which  is  next  to  the  arm.  When  a 
pancreatic  sarcoma  is  indolent,  and  in- 
creases slowly,  the  surrounding  parts,  and 
the  glands  in  the  axilla,  are  not  affected. 
But  some  of  these  swellings  deviate  from 
their  common  character,  and  become  of  a 
very  irritable  nature,  occasioning  severe 
and  lancinating  pain,  and  producing  an  in- 
flammatory state  of  the  skin  covering  them, 
so  that  it  becomes  adherent  to  their  surface. 
The  absorbents  leading  to  the  axiila  are  also 
irritated,  and  the  glands  enlarged.  Pancre- 
atic sarcoma  does  not  grow  to  a very  large 
size  ; but,  when  its  progress  is  unrestrained, 
the  pain  attendant  on  the  disease  becomes 
Janeinating,  and  so  severe  as  to  make  the 
patients  Feverish,  and  lose tbeir  health  and 


strength.  Mr.  Abernethy  remarks,  that, 
when  the  axillary  glands  become  affected, 
one  generally  swells  at  first,  and  is  extreme- 
ly tender  and  painful ; but  afterward  the 
pain  abates,  arid  the  part  remains  indurated. 
Another  is  then  affected,  and  runs  ihrougk 
the  same  course. 

To  another  species  of  sarcoma,  Mr.  Aber- 
nethy applir  s the  epithet  mastoid,  or  mam- 
mary, from  the  resemblance  which  this  gen- 
tleman conceives  its  structure  bears  to  that 
of  the  mammary  gland.  This  kind  of  dis- 
ease, Mr.  Abernethy  says  he  has  not  often 
seen.  In  the  example  which  he  met  with, 
the  tumour  was  about  as  large  as  an  orange, 
and  situated  on  a woman’s  thigh.  The 
swelling  was  removed  by  an  operation  ; but 
the  wound  afterward  degenerated  into  a 
malignant  ulcer,  attended  with  considerable 
induration  of  the  surrounding  parts,  and  the 
woman  died  of  the  disease  in  two  months. 
Mr.  Abernethy  conceives,  that  the  whole  of 
thes  morbid  part  had  been  cut  away,  but 
that  the  contiguous  parts  had  a disposition 
to  disease,  which  was  irritated  by  the  ope- 
ration, and  that  if  the  nature  of  the  case 
could  have  been  known  beforehand,  it 
would  have  been  right  to  have  made  a freer 
removal  of  the  substance  surrounding  the 
tumour. 

Mr.  Abernethy  places  the  mastoid  sarco- 
ma, between  such  sarcomatous  swellings  as 
are  attended  with  no  malignity,  and  the  fol- 
lowing ones,  which  have  this  quality  in  a 
very  destructive  degree. 

The  tuberculated  sarcoma  is  composed  of 
a great  many  small,  firm,  roundish  tumours 
of  different  sizes  and  colours,  connected  to- 
gether by  cellular  substance.  Some  of  the 
tubercles  are  as  large  as  a pea  ; others  equal 
a borsebean  in  size  ; most  of  them  are  of 
a brownish  red  colour;  but  some  are  yel- 
lowish. Mr.  Abernethy  mentions  his  hav- 
ing seen  this  species  of  sarcoma  chiefly  in 
the  lymphatic  glands  of  the  neck.  The  dis- 
ease proceeds  to  ulceration ; becomes  a 
painful  and  incurable  sore,  and  ultimately 
occasions  death. 

Another  kind  of  sarcoma,  mentioned  in 
Mr.  Abernethy’s  classification  of  tumours, 
is  distinguished  by  the  epithet  medullary , 
from  its  having  the  appearance  of  the  me- 
dullary matter  of  the  brain.  It  appears  to 
be  an  exceedingly  malignant  disease  ; com- 
municates to  the  lymphatic  glands  a similar 
distemper;  ulcerates  and  sloughs,  and  at 
last  proves  fatal.  It  is  particularly  apt  to 
make  its  attack  on  the  testis,  and  it  is  treat- 
ed of  in  another  part  of  this  book.  (See 
Testicle,  Diseases  of.) 

Mr.  Abernethy  includes  also  in  his  classi- 
fication, carcinomatous  sarcoma.  (See  Can 
cer.) 

1 must  refer  to  another  article,  (Mamma. 
Removal  of)  for  an  account  of  the  plan  of 
removing  sarcomatous  tumours. 

Besides  many  operations,  which  have  of 
late  years  been  performed,  and  are  remark- 
able, on  account  of  the  great  size  ot  the 
swellings  removed,  others,  still  more  inte- 
resting, claim  attention,  on  account  ot  the 
nature  and  situation  of  the  parts  extirpated, 


TUMOUR. 


509 


On  the  excision  of  the  thyroid  gland,  I need 
not  here  dwell,  as  it  is  elsewhere  noticed. 
(See  Thyroid.  Gland ;)  but  I feel  called  up- 
on to  mention  some  other  very  bold  ope- 
rations, executed  within  the  last  few  years- 
The  first  is  that  performed  by  Mr.  Goodlad, 
oi  Bury,  in  Lancashire.  The  case  was  an 
immense  tumour,  situated  on  the  left  side 
of  the  face  and  neck,  and  the  base  of  which 
was  about  twenty-eight  inches  in  circum- 
ference. The  disease  extended  from  the 
external  canthus  of  the  eye  above  to  within 
three-quarters  of  an  inch  of  the  clavicle 
below,  and  some  idea  of  the  depth  of  its  at- 
tachments may  be  conceived,  when  it  is 
known,  that  the  whole  parotid  gland  was 
involved  in  it.  For  the  purpose  of  obvia- 
ting all  danger  of  hemorrhage,  Mr.  Goodlad 
began  with  tying  the  carotid  artery.  The 
nature  of  the  operation  will  be  best  under- 
stood by  adverting  to  the  appearances  after- 
ward presented  by  the  wound.  “ The 
whole  sterno-mastoid  muscle  was  exposed, 
and  its  fibres  dissected  clean,  except  about 
half  an  inch  from  its  insertion  into  the  cla- 
vicle. The  wound  extended  backwards 
from  behind  the  mastoid  process  to  the  tra- 
chea anteriorly,  but  became  narrower  in 
the  direction  of  the  muscle  at  the  lower  part 
of  the  neck.  The  submaxillary  gland  was 
exposed,  and  about  one-fifth  of  its  substance, 
not  appearing  healthy,  was  removed.  The 
digastric  and  the  greater  portion  of  the 
myln-hyoideus  were  exposed  The  ramus 
of  the  jaw  w as  only  covered  by  periosteum, 
except  where  covered  by  the  masseter  mus- 
cle, part  of  which,  not  appearing  healthy, 
was  dissected  away  The  wrho!e  of  the 
condyloid  process  of  that  bone  was  laid 
bare  in  the  same  manner,  and  behind  it  the 
pterygoid  muscles  were  also  exposed.  The 
membrane  of  the  cheek  was  only  covered 
by  a cellular  substance,  which  did  not  ap- 
pear healthy;  but  sufficient  skin  was  saved 
to  cover  the  zygoma.  The  parotid  gland 
was  entirely  removed This  enormous 
wound  healed  in  ten  weeks  ; but  unfortu- 
nately the  cure  was  not  permanent ; the 
disease  returned,  and,  fifteen  months  after 
the  operation,  the  poor  w^oman  died.  (See 
Med.  Chir.  Tram.  Vol.  7,  p.  112,  fyc.  Vol.  8, 

1 5§2-) 

Respecting  the  foregoing  severe  opera- 
tion, many  surgeons  may  be  inclined  to 
doubt  the  propriety  of  tying  the  carotid  ar- 
tery, as  a preparatory  step,  and,  indeed,  it 
is  positively  condemned  in  an  anonymous 
note  attached  to  the  above  case,  simple 
temporary  pressure  on  the  exposed  vessel 
being  represented  as  preferable.  It  appears 
tome,  however,  that  Mr.  Goodlad's  method 
was  justifiable,  and  on  the  whole  the  best, 
because  the  application  of  the  ligature  to 
the  carotid  not  only  removed  the  dangers  of 
hemorrhage  during  the  operation,  but  obvi- 
ated them  afterward,  and  no  doubt  lessened 
the  necessity  for  a prodigious  number  of 
ligatures,  for  vessels,  wdiich  wTould  other- 
wise have  poured  out  a profuse  quantity  of 
blood. 

Nayf  the  hemorrhage  is  so  profuse  from 


the  main  branches  of  the  external  carotid, 
and  mere  pressure  so  uncertain  of  always 
commanding  the  flow'  of  blood,  that  the  pa  - 
tient may  actually  die  from  sudden  loss  of 
blood,  as  nearly  happened  in  another  very 
interesting  case  of  removal  of  a large  tu- 
mour involving  also  the  parotid  gland,  and 
connected  with  the  transverse  process  of 
the  atlas,  the  basis  of  the  skull,  the  meatus 
auditories,  mastoid  process,  and  angle  of 
the  jaw.  The  operator,  Mr.  Carmichael,  in 
order  to  complete  the  dissection,  was  obli  - 
ged to  divide  the  trunk  of  the  facial  artery  ; 
“ instantly  (says  he)  an  alarming  gush  of 
biood,  which  evidently  came  from  a large 
vessel,  followed  the  division  ; and  the  dan- 
ger appeared  the  more  imminent  as  the  pres- 
sure, which  Mr.  Todd  applied,  with  all  the 
force  he  could  exert  vpon  the  carotid  trunk , 
was  actually  incapable  of  repressing  the  ior- 
rent.  There  was  not  a moment  to  be  lost. 
Mr.  Collbs  plunged  a dry  sponge  to  the  bot- 
tom of  the  wound,  and  firmly  pressed  on  the 
bleeding  vessel,  while  1 made  a horizontal 
section  of  the  tumour,  till  1 arrived  at  the 
cavities  occupied  by  the  sponge,  with  the 
view  of  exposing  as  quickly  as  possible 
the  mouth  of  the  bleeding  vessel.  This 
was  accomplished  in  sufficient  time  to  save 
the  patient’s  life.’  Mr.  Carmichael,  at  the 
conclusion  of  the  history,  remarks,  that,  if 
he  were  called  upon  to  perform  such  an 
operation  again,  he  would , in  the  frsl  in- 
stance, pass  a ligature  under  the  carotid  trunk, 
which  might  be  tightened,  or  not,  as  occasion 
should  require.  The  case  here  spoken  of 
had  a successful  termination.  One  remark- 
able consequence  was  a paralysis  of  one 
side  of  the  face,  brought  on  by  the  division 
of  the  trunk  of  the  portio  dura  in  the  opera- 
tion. (Bee  Trans,  of  the  King’s  and  Queen’s 
College  of  Physicians,  Vol.  2,  p.  101,  8vo. 
Dublin,  1818.) 

The  next  instance  which  I shall  notice,  of 
the  removal  of  an  enormously  enlarged  pa- 
rotid gland,  is  that  lately  recorded  by  Klein, 
the  eminent  operating  surgeon  at  Stuttgardt. 
The  patient  w as  a woman  of  seventy,  and 
the  swelling  extended  from  the  ear  to  the 
shoulder.  In  the  operation,  all  the  branches 
of  the  facial  nerve  were  divided  ; a piece 
of  the  masseter  was  left  hanging  ; the  ex- 
ternal carotid  artery  and  par  vagum  were 
left  quite  bare  ; the  dissected  sterno-mastoid 
lay  on  on  side  ; and  the  temporal,  external 
maxillary,  and  auricular  arteries  were  of 
course  divided,  along  with  several  arteries 
of  the  neck,  yet  the  largest  of  these  being 
tied,  the  bleeding  was  very  inconsiderable. 
The  event  was  so  successful,  that  at 'the  be- 
ginning of  the  third  week,  the  wound  was 
entirely  healed. 

The  same  distinguished  surgeon  also  re- 
moved a fatty  tumour,  extending  from  the 
buttock  to  the  ham,  and  measuring  thfoe  feet 
one  inch  in  length,  and  two  feet  six  inches  in 
circumference.  Klein  undertook  its  remo- 
val, on  the  supposition,  that  it  was  an  en- 
cysted tumour  lying  above  the  fascia  lata  ; 
but  it  turned  out  to  be  a steatoma  coming 
from  beneath  it,  and  reaching  to  the  thigh- 


>10 


TUMOUR. 


bone,  and  in  every  direction  among  the 
muscles,  nerves,  and  blood-vessels  of  the 
thigh.  At  length,  partly  with  the  fingers, 
and  partly  with  the  knife,  the  fatty  mas3 
was  separated  from  all  its  important  con- 
nexions. Several  vessels  were  tied,  and 
among  them  the  profunda  femoris.  How- 
ever, not  more  than  a pound  of  blood  was 
lost.  The  tumour,  after  its  removal,  weigh- 
ed 27lb.  and  three  quarters.  The  patient,  a 
woman  44  years  of  age,  went  on  very  well 
for  eight  days;  but  on  the  ninth,  she  was 
constantly  complaining  of  uneasiness  in  the 
foot  of  the  affected  limb  ; her  pulse  became 
weak  and  intermitting  ; and  she  sunk  in  the 
most  unexpected  manner.  (See  Journ.fiir 
Chirurgie  herausgegeben  von  D.  L.  Graefe 
und  D.  P.  F.  Walther,  B.  1 , p.  106,  fyc.  Svo. 
Berlin,  1820;  or  Quarterly  Journal  of  Fo- 
reign Medicine,  $fc.  Vol.  2,  p.  373,  <^c.) 

A question  may  be  entertained,  whether, 
in  some  morbid  enlargements  of  the  parotid 
gland,  and  parts  extending  deeply  about  the 
throat,  it  would  not  sometimes  be  better  to 
be  content  with  simply  tying  the  carotid 
artery,  and  trying  whether  stopping  this 
large  supply  of  blood  to  the  diseased  parts, 
would  not  be  followed  by  an  absorption  of 
the  tumour  ? Some  facts,  appertaining  to 
this  question,  are  noticed  in  the  article 
Aneurism , where  the  aneurism  by  anasto- 
mosis falls  under  consideration.  It  will 
there  be  seen,  that  the  result  of  this  experi- 
ment is  not  sure  of  permanently  repressing 
the  growth  of  a tumour  of  this  last  kind, 
even  when  it  has  this  effect  at  first.  This 
uncertainty  will,  no  doubt,  incline  many 
practitioners  to  prefer  the  bold  method  of 
extirpation.  Yet  others  will  perceive,  that 
such  an  operation,  notwithstanding  its  suc- 
cess in  a few  examples,  is  dreadfully  severe, 
and  must  of  itself  in  the  generality  of  cases 
have  fatal  consequences.  They  will  also 
be  encouraged,  in  any  similar  instance,  to 
try  the  effect  of  the  ligature,  by  the  cure 
which  Sir  A.  Cooper  accomplished,  of  an 
enormous  cutaneous  enlargement  of  the 
lower  extremity  by  tying  the  artery  in  the 
groin.  Indeed,  I atn  sure,  that  as  the  im- 
provements in  modern  surgery  advance,  the 
plan  of  curing  tumours  by  cutting  off  their 
main  supply  of  blood,  will  be  much  more 
extensively  adopted,  than  has  hitherto  been 
the  case.  In  this  way,  the  surgeon  may 
4 attempt  the  dispersion  of  many  tumours, 
which  could  not  be  meddled  with  in  any 
other  manner,  and  which,  if  left  to  them- 
selves, must  have  a fatal  termination. 

Tumours  Encysted.  These,  which  are 
commonly  named  wens,  consist  of  a cyst, 
which  is  filled  .with  different  substances. 
When  the  contained  matter  is  fatty,  it  is 
termed  a steatoma ; when  somewhat  like 
honey,  meliceris ; when  like  pap,  atfuroma. 
These  are  the  three  species,  into  which 
writers  usually  divide  encysted  tumours. 
However,  some  of  these  swellings  do  not 
conform  to  either  of  the  above  distinctions, 
as  their  contents  are  subject  to  very  great 
variety  indeed,  and  are  occasionally  of  an 
earthy,  bony,  or  horny  nature.  Some  en- 


cysted tumours  of  the  latter  description 
occasionally  burst,  and  assume  the  appear- 
ance of  horns,  by  the  gradual  projection  of 
the  matter  secreted  within  their  cysts. 
(See  Sir  Evcrard  Home's  Obs.  on  the  Growth 
of  Horny  Excrescences , in  Phil.  Trans,  for 
1791.) . I remember  seeing  an  excrescence 
of  this  kind  removed  some  years  ago  from 
the  scrotum  of  a man  in  St.  Bartholomew’s 
Hospital.  Sir  James  Earle  performed  the 
operation,  and  if  I am  not  mistaken,  the 
preparation  of  the  disease  is  now  in  Mr. 
Abernethy’s  museum.  But  still  more  re- 
markable specimens  of  such  excrescences 
are  preserved  in  the  Anatomical  Museum  of 
St.  Thomas’s  Hospital ; one  in  particular, 
which  resembles  a ram’s  horn  in  shape,  and 
was  removed  from  a gardener’s  head  at 
Kingston,  by  Dr.  Roots.  A further  account 
of  the  case  is  given  in  Rees’s  Cyclopajdia, 
article  Horny  Excrescence. 

I suppose  every  body  in  London  has  now 
seen  in  the  British  Museum  the  horn  depo- 
sited there  as  a curiosity,  and  which,  with 
another  ol  the  same  size,  grew  upon  the 
head  of  a human  subject  What  i3  equally 
curious,  hairs  are  not  unfrequently  found 
growing  in  the  cavities  of  encysted  tumours, 
( Delpech  Precis  des  Mai.  Chir.  T.  3,  p.  412  ;) 
and  even  teeth,  more  or  less  perfectly  form- 
ed, have  been  strangely  met  with  in  the 
same  situations.  An  interesting  specimen 
of  the  latter  occurrence,  in  a double  encys- 
ted tumour  in  the  orbit,  was  published  some 
time  ago  by  my  friend  Mr.  Barnes,  of  Exe- 
ter. (See  Med.  Chir.  Trans.  Vol.  4,  p.  316.) 

It  is  observed  by  Sir  Astley  Cooper,  that  it 
is  when  encysted  tumours  are  situated  upon 
the  temple,  and  near  the  eyebrows,  and 
other  hairy  parts,  that  they  sometimes  con- 
tain hairs : these  11  have  no  bulbs,  nor  ca- 
nal, and  differ  therefore  from  those,  which 
are  produced  in  surfaces  of  the  body,  which 
naturally  form  hair.”  In  sheep,  the  cysts 
sometimes  contain  wool.  ( Surgical  Essays , 
Part  2,  p.  233.)  The  manner  in  which 
these  horny  excrescences  are  produced,  is 
stated  to  be  as  follows : “ The  horn  begins 
to  grow  from  tiie  open  surface  of  the  cyst ; 
at  first,  it  is  soft,  but  soon  acquires  consider- 
able hardness  ; at  first  it  is  pliant,  but  after 
a few  weeks,  it  assumes  the  character  of 
horn.”  (Vol.  cit.  p.  235;  see  also  Home  in 
Phil.  Trans,  for  1791.) 

Encysted  tumours  are  generally  of  a 
roundish  shape,  and  are  more  elastic  than 
fleshy  swellings.  However,  the  latter  cir- 
cumstance depends  very  much  upon  the 
nature  Of  their  contents,  and  the  thickness 
of  their  cysts.  As  far  as  my  observation 
extends,  encysted  tumours  form  more  fre- 
quently on  the  head  than  any  other  part ; 
but  they  are  very  frequently  met  with  in  all 
situations  under  the  integuments,  and  some- 
times in  deeper  places.  Encysted  tumours 
are  also  very  often  seen  on  the  eyelids. 

According  to  Sir  Astley  Cooper,  they  mein 
general  nearly  globular,  and  when  seated 
on  the  head,  feci  very  firm,  but  upon  tho 
fare  they  are  attended  with  a fluctuation, 


TUMOUR 


51 1 


more  or  less  obscure.  The  skin  covering 
them,  is  generally  uninflamed  ; but  it  is  now 
and  then  streaked  with  blood-vessels,  which 
are  larger  than  those  of  the  surrounding  in- 
teguments. “In  the  centre  of  the  tumour 
on  the  skin,  it  often  happens  that  in  its  early 
state,  a black,  or  dark-coloured  spot  may  be 
seen,  which  sometimes  continues  through 
the  whole  course  of  the  disease.  In  general 
they  are  unattended  with  pain,  are  never  in 
themselves  dangerous,  and  only  require  re- 
moval from  the  parts  in  which  they  occur, 
and  the  unseemly  appearance  they  produce. 
They  move  readily  within  the  cellular 
membrane,  if  they  are  free  from  inflamma- 
tion, but  the  skin  in  general  does  not  easily 
move  over  them.”  (Surgical  Essays,  Pari 
2,  p.  230.)  The  greatest  number  of  encyst- 
ed tumours,  which  this  experienced  surgeon 
has  met  with  in  the  same  individual,  was 
sixteen,  situated  upon  the  head  ; and  he  has 
seen  nine  in  another  patient,  as  many  as 
which  number  on  one  person  I have  seen 
myself.  Four,  five,  and  six,  as  Sir  Astley  re- 
marks, are  not  uncommon.  The  largest, 
which  he  has  ever  seen,  was  equal  in  size  to 
an  ordinary  cocoa  nut,  and  grew  upon  the 
head  ; but  in  general,  they  are  not  more 
than  one  or  two  inches  in  diameter.  He 
considers  them  in  some  degree  hereditary, 
as  he  has  often  heard  a patient  observe  ; “ I 
have  several  swellings  upon  my  head,  and 
ray  father  (or  my  mother)  had  several.” 
They  also  frequently  occur  in  several  of 
the  same  family.  (A  231.) 

According  to  Sir  Astley  Cooper,  when  en- 
cysted tumours  are  dissected,  some  part  of 
their  surface  is  found  firmly  adhering  to  the 
skin,  while  other  parts  are  connected  to  it 
merely  by  the  cellular  membrane.  The  cyst 
itself  is  imbedded  more  or  less  deeply  in 
the  cellular  membrane,  and  its  thickness  is 
different  in  different  parts  of  the  body.  On 
the  face,  or  near  the  outer  canthus,  the  cyst 
is  very  thin;  but  on  the  back,  it  is  much 
thicker,  and  on  the  head,  it  is  so  thick 
and  firm,  that  it  retains  its  form  after  the 
discharge  of  its  contents,  and  is  so  elastic, 
that  after  being  compressed,  it  readily  ex- 
pands again  to  its  former  size.  Within  the 
cyst,  Sir  Astley  Cooper  remarks,  there  is  a li- 
ning of  cuticle,  which  adheres  to  its  interior, 
and  several  desquamations  of  the  same  sub- 
stance are  formed  within  the  first  lining.  If 
the  vessels  of  the  cyst  are  injected,  they 
are  found  to  be  numerous,  but  of  small  size. 
The  cysts  are  occasionally  met  with  in  an 
ossified  state.  ( Surgical  Essays,  Part  2,  p. 
232,233.)  It  is  the  opinion  of  Sir  Astley 
Cooper,  that  encysted  tumours  arise  from 
the  enlargement  of  the  follicles,  or  glandu- 
lar pores,  in  consequence  of  the  obstruction 
of  their  orifice.  (P.  23d.)  If  this  senti- 
ment were  correct,  the  fact  would  furnish 
another  consideration  against  the  view 
taken  of  the  formation  of  the  tumours  by 
Dr.  Baron.  However,  it  appears  to  me,  that 
there  are  some  reasons,  which  render  the 
adoption  of  Sir  Astley’s  explanation  diffi- 
cult; for,  if  encysted  tumours  were  only 
enlarged  follicles,  they  would  not  be  found 


so  far  from  the  skin  as  they  frequently  are, 
as  for  instance  within  the  orbit,  and  in  other 
situations  yet  further  from  the  surface  of 
the  body  ; and  the  collections  of  sebaceous 
matter,  which  so  often  collects,  as  this  gen- 
tleman observes,  in  the  follicles  of  the  skin 
of  the  nose,  and  may  be  pressed  from  them 
in  the  form  of  worms,  would,  if  the  cause 
assigned  were  true,  make  encysted  swell- 
ings on  the  nose  itself  exceedingly  com- 
mon ; yet  this  part  is  not  so  often  the  seat 
of  such  tumours,  as  other  parts  of  the  face. 
As  far  also  as  my  observations  extend,  pres- 
sure cannot  be  said  to  have  any  share  in 
giving  rise  to  the  formation  of  encysted  tu- 
mours, because  1 have  seen  them  chiefly  in 
situations,  where  this  kind  of  cause  could 
not  be  suspected,  as  for  instance,  on  the 
face  and  about  the  vertex,  and  not  particu- 
larly round  that  part  of  the  head,  which 
is  compressed  by  the  hat.  If  also  encys- 
ted swellings  were  owing  to  obstruction  of 
the  cutaneous  pores  with  sebaceous  matter, 
i apprehend  few  persons  would  escape  the 
disease.  The  cure  in  the  early  stage  would 
also  be  as  easily  effected  by  the  timely  re- 
moval of  the  alleged  obstruction,  as  the 
cure  of  the  little  tender  points  on  the  nose, 
really  caused  by  the  lodgment  of  the  seba- 
ceous matter  in  the  cutaneous  pores.  This 
does  not  appear  to  me  to  be  consonant  to 
general  experience.  How  the  formation  of 
steatomatous  encysted  swellings  is  to  be 
thus  accounted  for,  I cannot  at  all  conceive. 
And,  lastly,  it  is  to  be  noticed,  that  the  lit- 
tle swellings  on  the  nose,  arising  in  the  way 
described,  are,  when  they  occur,  frequently 
attended  with  soreness,  from  which  true 
encysted  tumours,  at  least  in,  the  early 
stage,  are  completely  free.  These,  and 
other  reflections,  lead  me  to  believe,  that 
the  origin  of  encysted  swellings  cannot  be 
satisfactorily  explained  upon  the  principles 
suggested  by  the  above  distinguished  prac- 
titioner. However,  as  all  his  opinions  on 
surgical  questions  are  deservedly  valuable, 
I subjoin  the  advice  which  he  has  given, 
founded  upon  the  preceding  doctrine.  If 
the  follicle  can  be  seen  only  as  a black  spot . 
filled  with  hardened  sebaceous  matter,  Sir 
Astley  Cooper  recommends  introducing  a 
probe  into  it,  and  squeezing  the  sebaceous 
matter  out  of  the  tumour,  which  is  done 
with  little  inconvenience.  But,  if  the  con- 
tents cannot  be  pressed  out  without  such 
violence  as  would  create  inflammation,  he 
says,  that  the  best  plan  is  to  make  the  open 
ing  larger.  Other  surgeons  have  tried  to 
cure  encysted  tumours  by  pricking  them 
with  needles,  and  squeezing  out  their  con 
tents  ; or  by  applying  stimulating  and  dis- 
cutient  applications  to  them.  However,  it 
is  a practice  which  mostly  fails,  and,  some- 
times, converts  the  case  into  a terrible  dis- 
ease, in  which  a frightful  fungus  shoots  out 
from  the  inside  of  the  cyst,  attended  with 
immense  pain  and  irritation,  and  often  pro- 
ving fatal.  (See  Mernethy’s  Surgical  Ob- 
servations, 1804,  p.  94.) 

Similar  dangerous  fungous  diseases  may 
also  arise,  whenever  the  surgeon,  in  cuttin? 


51 2 


TUMOUR. 


out  encysted  tumours,  leaves  any  part  of 
the  cyst  behind. 

The  most  adviseabie  method,  I believe,  is 
to  have  recourse  to  the  knife,  before  an  en- 
cysted tumour  has  attained  any  considera- 
ble size.  However,  if  it  is  large  at  the  time 
of  the  operation  being  done,  a portion  of 
the  skin  must  be  taken  away  with  the  swell- 
ing, in  the  manner  described  in  the  article 
Mamma,  Removal  of.  The  chief  piece  of 
dexterity  in  the  operation  consists  in  detach- 
ing all  the  outside  of  the  cyst  from  its  sur- 
rounding connexions,  without  wounding  it. 
Thus,  the  operator  takes  the  part  out  in  an 
entire  state,  and  is  sure,  that  none  of  the 
cyst  remains  behind.  When  the  cyst  is  open- 
ed, some  of  the  contents  escape,  it  collapses, 
and  the  dissection  is  rendered  more  tedious 
and  difficult. 

Such  is  the  common  opinion,  which  has 
always  appeared  to  me  correct.  However, 
Sir  Astley  Cooper  states,  that  the  best  man- 
ner of  doing  the  operation  is  to  make  an  in- 
cision into  the  swelling,  and  then  to  press 
the  sides  of  the  skin  together,  by  which 
means  the  cyst  may  be  easily  everted  and 
removed.  If  the  attempt  be  made  to  ex- 
tract the  tumour  whole,  “ the  dissection  is 
most  tedious,  and  before  it  is  completed, 
the  cyst  is  either  cut,  or  burst.  So  many 
incisions,  and  so  much  pain,  maybe  readily 
prevented  by  opening  it  freely  by  one  inci- 
sion, raising  its  edge  between  the  forceps,” 
and  dissecting  it  from  its  adhesions  to  the 
surrounding  membrane.  ( Surgical  Essays, 
Part  2,  p.  240.)  When  the  swelling  is  in 
the  scalp,  Sir  Astley  directs  an  incision  to 
be  made  through  its  centre,  from  one  side 
to  the  other,  when  its  contents,  which  in 
this  situation  are  very  solid,  are  immedi- 
ately discharged  in  a mass  of  the  same  shape 
as  the  tumour.  The  cyst  being  raised  with  a 
tenaculum,  may  then  be  easily  separated. 

With  respect  to  encysted  tumours  of  the 
eyelids,  the  atheroma  and  meliceris  are  said 
by  Beer  to  form  only  upon  the  upper  eyelid, 
on  the  side  towards  the  temple,  while  he  has 
always  found  the  steatoma  to  be  seated  ei- 
ther in  the  vicinity  of  one  of  the  eyelids,  or 
sometimes  over  the  lachrymal  sac.  The  athe- 
roma and  meliceris,  he  says,  usually  lie  in  the 
loose  cellular  substance  directly  under  the 
skin  of  the  eyelid,  though  sometimes  more 
deeply  under  the  orbicularis  muscle,  or  even 
quite  underneath  the  levator  palpebrae  supe- 
rioris,  upon  the  convex  surface  of  the  tarsal 
cartilage,  to  which  the  swelling  is  then  ge- 
nerally so  firmly  adherent,  that  it  is  impos- 
sible to  remove  this  part  of  the  cyst.  En- 
cysted tumours  of  the  upper  eyelid  are  com- 
monly so  moveable,  that  they  can  be  push- 
ed above  the  superciliary  ridge  of  the  os 
frontis  ; which  is  regarded  by  Beer  as  a very 
favourable  circumslance  in  the  operation. 
Though  the  atheroma  and  meliceris  of  the 
upper  eyelid  occasionally  become  as  large 
as  a pigeon’s  egg,  Beer  has  never  known  a 
stentoma  in  the  vicinity  of  the  eyelids  ex- 
ceed the  size  of  a hazel  nut.  Encysted  tu- 
mours of  the  upper  eyelid  itself  sometimes 
appear  moveable,  though  they  may  be  at 


the  same  time  closely  adherent  to  the  car- 
tilage. Hence,  Beer  recommends  moving 
the  tumour  about  for  a few  days  before  the 
operation,  and  trying  to  push  it  above  the 
superciliary  ridge  ; and  if  this  cannot  be 
done,  the  circumstance  will  prove  that  the 
swelling  is  connected  with  the  cartilage,  or, 
at  least,  is  under  the  orbicular  muscle,  and 
the  mode  of  operating  regulated  according- 
ly. With  the  yellow  pappy  substance,  found 
in  the  cysts  of  arethoraatous  tumours  of  the 
eyelids,  fine  short  hairs,  scarcely  one  line 
in  length,  are  frequently  blended.  Some- 
times, as  Beer  remarks,  the  whole  inside  of 
the  cyst  is  covered  with  these  little  short 
hairs,  which  may  all  be  washed  out,  and 
are  destitute  of  bulbs ; a fact  also  noticed 
by  Sir  Astley  Cooper.  It  merits  attention, 
however,  that  in  tumours  of  the  meliceris 
kind,  formed  upon  the  eyelid,  Beer  never 
met  with  hairs.  ( Lekre  von  den  Augenkr. 
B.  2,  p.  607 — 609.)  He  remarks,  that  when 
encysted  swellings  of  the  eyelid  are  let 
alone,  he  has  never  known  them  produce 
any  injury  to  the  eye  itself,  excepting  the 
hinderance  to  the  opening  of  it,  when  they 
are  large.  On  the  other  hand,  if  they  be 
unskilfully  removed,  or  rashly  attacked 
with  caustic,  various  ill  consequences  may 
ensue  ; as  for  instance,  fistulae  of  the  lachry- 
mal gland,  entropium  from  a shrinking  of 
the  tarsal  cartilage,  ectropium  from  destruc- 
tion of  the  skin,  and  the  hare-eye  from  an 
actual  shortening  of  the  upper  eyelid.  In 
consequence  of  the  inflammation  caused 
by  escharoties,  Beer  has  more  than  once 
found  the  integuments  so  adherent  to  the 
tumour,  that  in  the  operation,  the  removal 
of  a considerable  piece  of  them  was  una- 
voidable. But,  says  he,  when  swellings  of 
this  nature  are  properly  treated  in  good 
time,  they  may  be  removed  without  leaving 
any  vestige  behind,  excepting  a trivial  scar. 
Professor  Beer  joins  all  the  best  modern 
surgeons  in  considering  the  entire  removal 
of  the  sac,  and  the  reunion  of  the  wound  by 
the  first  intention,  as  the  safest  and  most  ef- 
fectual method  of  curing  encysted  tumours 
of  the  eyelids.  He  admits,  however,  that 
the  hinder  portion  of  the  cysts  of  some 
swellings  of  this  nature  upon  the  upper  eye- 
lid cannot  be  dissected  out,  because  it  may 
be  so  closely  adherent  to  the  cartilage,  that 
its  excision  would  injure  the  latter  part  too 
much,  and  produce  either  an  incurable  eu- 
tropium,  or  an  irremediable  shortening  of 
the  eyelid.  But  steatomatous  tumours,  near 
the  eyelids,  may  almost  always  be  com- 
pletely dissected  out,  the  only  exceptions 
being  cases  in  which  the  swellings  happen 
to  be  situated  between  the  lachrymal  sac 
and  the  orbicular  muscle,  and  so  intimately 
connected  with  the  first  of  these  parts,  that 
the  back  portion  of  the  cyst  could  not  be 
cut  away,  without  permanently  destroying 
the  functions  of  the  excreting  parts  of  the 
lachrymal  organs.  However,  when  the 
swelling  is  not  too  strongly  attached  to  the 
cartilage  of  the  eyelid,  Beer  sanctions  the 
removal  of  the  whole  of  the  cyst.  He  par 
ficularly  insists  upon  the  utility  ol  moving 


TUMOUR. 


the  tumour  a good  deal  about  daily,  for  a 
few  days  before  the  operation,  so  as  tt> 
loosen  its  connexions,  and  enable  the  sur- 
geon to  push  it  over  the  edge  of  the  orbit, 
where  it  may  be  steadily  fixed  during  its  re- 
moval. (Z>\  2,  p.  612.)  Excepting  a few 
instances,  in  which  the  skin  was  diseased, 
and  firmly  adherent  to  the  cyst,  Beer  has 
never  found  it  necessary,  in  the  excision  of 
encysted  swellings  of  the  eyelids,  to  remove 
any  portion  of  the  integuments,  and  he  has 
cut  away  some  tumours  of  this  kind  which 
were  as  large  as  a pigeon’s,  or  hen’s  egg. 
The  incision  through  the  skin,  he  says, 
should  be  longer  than  the  tumour,  so  as  to 
facilitate  the  extraction  of  the  distended 
cyst.  ( B . 2,  p.  613.)  When  it  is  not  ad  vise- 
able,  for  reasons  above  stated,  to  attempt 
to  dissect  out  every  particle  of  the  cyst, 
Beer  fills  the  cavity  with  lint,  lets  the  wound 
suppurate,  and  if  this  plan  is  not  sufficient, 
he  applies  stimulants  and  caustic.  It  is  no- 
ticed by  Sir  Astley  Cooper,  that  encysted 
tumours,  at  the  outer  canthus,  are  often  dif- 
ficult of  removal,  on  account  of  their  extend- 
ing into  the  orbit,  and  being  adherent  to 
the  periosteum.  (Surgical  Essays f Part  2 ,p. 
241.)  Professor  Scarpa  has  strongly  recom- 
mended making  the  incision  for  the  extrac- 
tion of  encysted  swellings  of  the  palpebraj, 
on  the  inside  of  these  parts.  But,  as  Mr. 
Travers  correctly  remarks,  the  swellings 
are  often  situated  superficially,  and  loosely 
connected  with  the  tarsus,  in  which  case 
the  operation  should  be  done  on  the  outside 
of  the  eyelid.  The  latter  writer  admits, 
however,  that  the  cyst  is  often  formed  be- 
twixt the  cartilage  and  the  ligamentary, 
membrane  which  covers  it,  and,  in  his  opi- 
nion, it  is  only  when  an  intricate  adhesion 
subsists,  and  the  appearance  of  a white  cir- 
cumscribed indentation  is  seen  upon  the 
everted  tarsus,  that  the  excision  should  be 
performed  on  the  inside  of  the  eyelid,  by 
dividing  the  cartilage.  Synopsis  of  Hit  Dis- 
eases of  the  Eye , p.  357.) 

I shall  conclude  the  subject  of  tumours 
with  a few  observations,  delivered  by  Sir 
Astley  Cooper,  and  Professor  Langenbeck 
“ The  removal  of  encysted  tumours,  (the 
first  gentleman  observes,)  is  not  entirely 
unattended  with  danger.  I have  seen  three 
instances  of  severe  erysipelatous  inflamma- 
tion succeed  the  operation  of  removing 
these  swellings  upon  the  head,  and  I believe 
it  is  owing  to  the  tendon  of  the  occipito- 
frontalis being  wounded  in  the  attempt  to 
dissect  them  out  whole  ’ (Surgical,  Essays, 
Part  2,  p.  241.) 

In  the  extirpation  of  tumours  about  the 
neck,  Langenbeck  adopts  the  following 
rules:  he  makes  a free  division  of  the  in- 
* teguments,  and  dissects  the  muscles  from  the 
tumour  which  lie  over  it,  but  he  avoids  cut- 
ting through,  or  injuring  them  : in  this  man- 
ner the  swelling  is  rendered  more  moveable. 
By  the  situation  of  the  muscles,  he  is  then 
enabled  to  know  the  place  of  the  chief 
blood-vessels  ; and  on  this  account,  he  par- 
ticularly advises  young  surgeons  to  study 
myology  with  the  greatest  care  As  Lan 
Vot.iL  65 


513 

genbeck  remarks,  it  is  indeed  an  important 
advantage,  after  a muscle  is  exposed,  to 
know  vvliat  vessels  lie  at  its  edges,  or  under 
neath  it.  Thus,  the  surtorius  is  a sure 
guide  to  the  crural  artery,  arid  the  sterno- 
cleido-masloideus  to  the  carotid.  A surgeon 
who  knows  correctly  the  anatomy  9!  the 
parts,  will  not  be  in  danger  of  wounding 
unintentionally  any  large  vessel.  When 
the  surface  of  the  tumour  has  been  cleared, 
but  t lie  base  of  it  is  yet  firmly  attached, 
Langenbeck  commences  the  separation  on 
the  side  which  presents  the  'east  risk,  that  is, 
where  the  least  considerable  blood-vessels 
are,  and  thence  he  proceeds  by  degrees  to- 
wards the  most  hazardous  side.  In  favour 
of  this  method,  lie  offers  the  following  con- 
siderations-: if.  by  chance)  an  artery  requi 
ring  a ligature  should  be  cut,  it  can  now  be 
more  easily  secured,  as  the  base  of  the  tu- 
mour is  already  partly  detached.  The  loos- 
ened swelling  may  also  be  drawn  away 
from  the  large  vessels  with  the  hand,  or  a 
tenaculum.  Langenbeck  never  introduces 
the  knife  deeply,  when  there  are  large  blood 
vessels  there,  but  pulls  the  swelling  out- 
ward, and  then  divides  the  cellular  sub- 
stance thus  stretched,  which  is  situated  up- 
on the  already  exposed  portion  of  the  tu- 
mour. In  this  manner  the  swelling  can  al- 
ways be  drawn  more  and  more  away  from 
the  vessels,  until,  at  last,  there  is  no  danger 
of  wounding  them.  By  attending  to  these 
principles,  Langepbeck  has  succeeded  in  re- 
moving many  very  large  tumours  from  the 
neck,  where  nearly  ail  the  muscles  of  that 
part  were  exposed  in-  the  dissection,  and  the 
carotid  denuded.  After  one  of  these  ope- 
rations, not  only  the  styloid  process  could 
be  felt,  but  ail  tne  muscles,  originating  from 
it,  could  be  distinctly  seen.  (Bibl.  fur  die 
Chir.  B.  2,  p.  312,  fyc.  12 rno.Goliingen,  1808.) 
C.  G.  Slenlsei,  De  Sleatomatibm  in  prim  ipio 
Aorta1,  rc perlis  et  Cysticis  in  gen*  re  excrescen- 
tibus.  lit!:  sb.  1723.  J.  J.  P.enck,  JYovupi 
Sy sterna  Tumoruni,  quo  hi  morbi  in  sun  ge- 
nera ct  species  rediguntur . Purs  prior.  I'P.mo. 
Vienna.  1767.  lVui.  Ogle.,  Letter  concerning 
the  Cure  of  Encysted  and  other  kinds  of  Tu- 
mours with  : at  the  Knife.  8 10.  Lend.  1754. 
Ph.  Tr.  Walther,  aber  die  angebohrnen  Fd 
thaulgeschmdsien  mid  and  ere  Bildungsjeh  - 
ler.  fol.  Landshul.  1814.  .<  P.  IV cidmanu , 

Annolatio  de  Siealomatibus  4to.  Maguntiaci , 
1817.  JV.  Hey,  Practical  Observations  in 
Surgery,  p 517,  Eci  2,  8 vo.  Land.  1810  Al- 
lan Bui  us,  Surgical  Anatomy  of  the  Head 
and  Neck,8vo.  Edin.  ■ 1.81-1 : this  work  coi<,- 
tains  much  valuable  in  forma:  ion , respecting 
the  extirpation  of  swellings  about  the  neck. 
Schreger  Chirurgisrhe  Versiiche . B.  \ ,p.  297  ; 
Ueber  Lipoma  und  Ex tir patio  derselben.  Svo. 
JVurubcrg.  1811,  John  Baron,  An  Inquiry, 
illustrating  the  nature  of  Tuberculoled  Accre- 
tions'of  Serous  Membranes,  and  the  Origin  cf 
Tubercles  and  Tumours  in  different  textures 
of  the  Body  $ko.  Loud.  1819.  Sir  Astley 
Cooper.  Surgical  Essays,  Part  2.  C.  J.  ,W. 
Langenbeck , Bibl.  far  die  Chir  B.  2,  p.  312. 
Gutt.  1808.  Also,  Gesrhichte  einer  gross en 
Speckgesehvjulst  wehher  mit  deni  Unterkiefer 


•14 


ULCERATION 


so  fcst  zusanuneuliing , dass  die  Trennung  mit 
dir  Sage  verrxchtel  werden  music  : Neue  Bibl. 
B.  I,  p.  295.  12mo.  Hanover.  1817.  B.  H. 
Jacobsen,  de  Tumoribus  Cysticis , 4 to.  Jena , 
3793.  C.  G.  Ludwig  Manila  de  cxscindcn- 


dis  Tumoribus  tunica  inclusis,  4 io.  Lips. 

1758. 

TYMPANUM.  For  an  account  of  its  dis- 
eases, see  Ear . 


u. 

i 


LCERATION,  is  the  process  by  which 
sores  or  ulcers  are  produced  in  animal 
bodies.  In  this  operation,  the  lymphatics 
appear  to  be,  at  least,  as  active  as  the  blood- 
vessels. An  ulcer  is  a chasm  formed  on  the 
surface  of  the  body  by  the  removal  of  parts 
back  into  the  system  by  the  action  of  the 
absorbents.  At  first,  it  may  be  difficult  to 
conceive  how  a part  of  the  body  can  be  re- 
moved by  itself;  but  there  is  not  more  diffi- 
culty in  conceiving  this,  than  how  the  body 
can  form  itself.  Both  facts  are  equally  well 
confirmed.  When  it  becomes  necessary  that 
some  whole  living  parts  should  be  removed, 
it  is  evident,  says  Mr.  Hunter,  that  nature, 
in  order  to  effect  this  object,  must  not  only 
confer  a new  activity  on  the  absorbents  ; but 
must  throw  the  part  to  be  absorbed  into  a 
state  which  yields  to  this  operation.  The 
absorption  of  whole  parts  in  disease,  arises 
from  five  causes;  pressure  : irritation  of  sti- 
mulating substances  ; weakness;  inutility  of 
parts;  death  of  them.  ( Hunter  on  Inflam- 
mation, *c.  p.  442 — 446.) 

Ulceration  takes  place  much  more  readily 
in  the  cellular  and  adipose  substance,  than 
in  muscles,  tendons,  ligaments,  nerves,  and 
blood-vessels.  Hence,  in  the  progress  of 
pus  to  the  surface  of  the  body,  ulceration  of- 
ten takes  a circuitous  course  for  the  purpose 
of  bringing  the  matter  to  the  skin.  The 
skin  itself,  also,  being  highly  organized,  con- 
siderably retards  the  bursting  of  abscess- 
es. On  the  same  account,  when  ulce- 
ration is  spreading,  the  edges  of  the  skin 
hang  over  the  ulcerated  surface.  ( Hunter , 
p.  447.) 

New-formed  parts,  such  as  cicatrices,  cal- 
lus, and  all  adventitious  new  matter,  such 
as  tumours,  readily  admit  of  being  absorbed. 
The  adventitious  matter,  indeed,  is  more 
prone  to  be  absorbed  than  that  which  is  a 
substitute  for  the  old.  Mr.  Hunter  explain- 
ed this  circumstance  on  the  principle  of 
weakness. 

When  ulceration  takes  place,  in  conse- 
quence of  the  death  of  an  external  part,  it 
occurs  first  on  the  outer  edge,  between  the 
dead  and  living  substance. 

Abscesses  constantly  make  their  way  to 
the  surface  of  the  body  by  ulceration  ; but 
as  some  textures  more  readily  admit  of 
being  absorbed  than  others,  the  matter  of- 
ten follows  a circuitous  course,  before  it 
can  arrive  at  the  skin.  ( Hunter , p.  448, 
449.) 

A tumour,  when  it  makes  equal  pressure 
in  every  direction  around,  will  only  make 

its  wav  in  an  external  course,  because 


what  Mr.  Hunter  termed  interstitial  absorp- 
tion happens  in  n«  other  direction.  (P. 

449.) 

The  parts  which  are  situated  between  an 
abscess,  or  any  extraneous  substance,  and 
the  nearest  surface,  are  those  which  are  most 
susceptible  of  ulceration.  This  is  one  of 
the  most  curious  phenomena  connected  with 
the  process  under  consideration.  It  shows 
that  there  is  a principle  in  the  human  body, 
by  which  parts  are  always  prone  to  free 
themselves  frbm  disease.  Slight  pressure 
from  without  will  often  produce  a thicken- 
ing of  parts,  and  hence  Mr.  Hunter  remarks, 
there  even  appears  to  be  a corresponding 
backwardness  to  admit  disease.  ( P . 449.) 
Both  these  facts,  he  observes,  are  shown  in 
the  case  of  fistula  lachrymalis ; for  though 
the  matter  is  nearest  the  cavity  of  the  nose, 
still  it  makes  its  way  externally,  by  means  of 
ulceration,  while  the  Schneiderian  mem- 
brane even  becomes  thickened,  so  as  to  be- 
come a barrier  against  the  progress  of  the 
disease  inward.  (P.  451.) 

There  is  one  difference  between  the  ad- 
vancement of  an  encysted  tumour  to  the 
surface  of  the  body,  and  the  progress  of  an 
abscess  in  the  same  direction,  viz  that  the 
former  does  not  excite  ulceration  of  the 
c> st : but  an  interstitial  absorption  of  the 
sound  parts  between  the  cyst  and  skin, 
till  the  cyst  and  external  skin  come  into  con- 
tact, at  which  period  inflammation  takes 
place,  and  absorption  becomes  accelerated 
into  ulceration.  In  an  abscess,  the  progres- 
sive ulceration  begins  in  the  cyst,  at  the 
same  lime  that  the  interstitial  absorption  in 
the  sound  part  covering  the  matter  is  going 
on.  (P.  452—457.) 

The  action  of  progressive  absorption  is  to 
remove  surfaces  contiguous  to  irritating  I 
causes,  which  Mr.  Hunter  referred  to  pres- 
sure, irritation,  and  weakness.  In  cases  of 
tumours,  pressure  becomes  a cause.  The 
buttocks  and  hips  of  persons  who  lie  long 
on  their  backs,  often  ulcerate.  The  heels  of 
many  patients,  with  fractures,  who  lie  for  a 
great  while  in  the  same  position,  are  apt  to 
ulcerate.  In  the  latter  instances,  Mr.  Hun 
ter  conceived  that  ulceration  is  a substitute 
for  mortification,  and  is  at  the  same  time,  a 
proof  of  a certain  degree  of  strength  ; for  if 
the  patient’s  constitution  were  very  weak, 
the  same  parts  would  mortify.  (P.  453.) 
That  pressure  is  a frequent  cause  of  ulcera- 
tion, is  also  evinced  by  the  occasional  ef- 
fects of  chains  on  prisoners,  and  harness  on 
horses. 


ULUEKS. 


515 


ihat  irritating  substances  produce  ulcera- 
tion, needs  no  illustration. 

Progressive  absorption  may  occur  either 
with  or  without  suppuration.  We  have  in- 
stances of  the  latter  in  cases  of  extraneous 
bodies,  which  travel  about  the,  body  with- 
out  producing  irritation  enough  to  give 
rise  to  the  secretion  of  pus.  In  the  pro- 
gress of  aneurisms  of  the  aorta,  and  of 
fungous  tumours  of  the  dura  mater  to  the 
sort  ace,  the  same  tact  is  also  illustrated.  (P. 
455.) 

Absorption  with  suppuration,  in  other 
words,  ulceration  either  happens  in  conse- 
quence of  suppuration  already  begun,  in 
which  event  the  pus  acts  as  pressure ; or 
else  absorption  attacks  external  surfaces 
from  particular  irritations  or  weakness,  in 
which  case  suppuration  must  follow.  (P. 
45fl.) 

The  production  of  ulceration  requires 
much  greater  pressure  from  without  than 
from  within.  The  process  is  always  dis- 
posed to  take  place  more  quickly,  when  near 
the  surface  of  the  body,  and  its  progress  be- 
comes accelerated  in  proportion  as  it  arrives 
near  the  skin. 

The  adhesive  inflammation  precedes  the 
suppurative,  and  prevents  the  pus  from  be- 
coming diffused,  as  soon  as  it  is  secreted, 
and  w hen  the  cyst  afterward  ulcerates,  in 
order  to  let  the  matter  approach  the  skin,  the 
adhesive  inflammation  still  continues  to  go 
before  the  ulcerative  process,  and  thus  pre- 
vents the  matter  from  insinuating  itself  into 
the  interstices  of  the  cellular  substance.  (P. 
457.) 

The  pain  of  ulceration  is,  in  some  degree, 
proportioned  to  its  quickness.  When  ulce- 
ration begins  on  a surface,  or  takes  place  for 
the  purpose  of  bringing  matter  to  the  skin, 
the  pain  is  always  considerable.  When  ul- 
ceration takes  place,  in  order  to  separate  a 
dead  part,  as  in  sloughing,  exfoliations,  &c. 
there  is  seldom  any  particular  pain.  (P. 
459.) 

The  ulcerating  sore  always  exhibits  little 
cavities,  while  the  edge  ol  the  skin  is  scal- 
loped, and  thin,  at  the  same  time  turning  a 
little  out,  and  overhanging,  more  or  less, 
the  ulcerated  surface.  The  face  of  the 
sore  appears  foul,  and  the  discharge  is  very 
thin. 

When  ulceration  stops,  the  edges  of  the 
skin  become  regular,  smooth,  a little  round- 
ed, or  turned  in,  and  of  a purple  colour, 
covered  with  a semi-traiispaivnt  while. 
(Hunter  on  Inflammation,  fyc.  p.  460.) 

The  reader,  desirous  of  further  informa- 
tiorijshuuld  particularly  consult  this  last  pub- 
lication, and  Professor  Thomson's  Lectures  on 
Inflammation , p.  349,  <§/-c. 

ULCERS.  Surgeons  usually  define  an 
ulcer  to  he  a solution  of  continuity  in  any 
of  the  soft  parts  of  the  body,  attended  with 
a secretion  of  pus,  or  some  kind  of  dis- 
charge. 

In  the  present  part  of  this  Dictionary,  there 
will  not  be  occasion  to  speak  ot  several  kinds 
of  sores,  which  have  been  treated  of  in  other 


articles.  (See  Cancer,  Scrofula,  and  Vene- 
real Disease.) 

Ulcers  are  divided  into  local  and  constitu- 
tional. As  Professor  Thomson  has  well  ob- 
served, however,  it  is  only  within  certain 
limits, that  this  distinction  is  well  founded; 
for  an  ulcer,  which  is  at  first  completely  lo- 
cal, may  in  time  affect  the  system,  so  as  to 
become  constitutional ; and  ulcers  which 
derive  their  origin  from  some  general  affec- 
tion of  the  system,  may  remain  after  the  re- 
moval of  the  constitutional  disorderly  which 
they  were  originally  produced.  ( Lectures  on 
Inflammation,  p.  427.) 

“ Ulcers  (sa\s  Dr.  Thomson)  have  usually 
been  distinguished  from  each  other  by  the 
causes  by  which  they  are  induced,  by  the 
symptoms  whi^h  they  exhibit,  and  by  the  parts 
of  the  body  in  which  they  occur.  The  wantof 
a disposition  to  heal  in  a suppurating  surface 
may  depend  upon  some  specific  action  in 
the  cause  from  which  it  proceeds,  upon 
something  peculiar  in  the  constitution  of  the 
patient  in  whom  it  exists,  or  merely  upon 
an  improper  mode  of  management : and 
hence,  rhe  distinction  that  has  long  been 
made  of  ill-conditioned  -ores,  or  ulcers,  into 
those  which  are  specific  in  their  nature,  and 
into  those  which  are  simple. 

“ Specific  sores,  or  ulcers,  may  be  occa 
sioned  by  specific  poisons,  or  by  particular 
diatheses.  The  sores  or  ulcers  which  arise 
from  specific  poisons,  may  be  either  local, 
that  is,  confined,  tike  a primary  syphilitic 
ulcer,  to  one  spot ; or  constitutional,  that  is, 
liable  to  occur  in  any  part,  texture,  or  or- 
gan, such  as  secondary  syphilitic  ulcers. 
Of  diatheses,  predisposing  to  ulcers,  we  have 
examples  in  the  scrofulous,  scorbutic,  and 
arthritic  diatheses,  and  also  in  the  syphiloid 
diatheses,  or  that  which  arises  not  unfre- 
quently  in  those  who  have  had  syphilis,  from 
the  too  tree  and  injudicious  use  of  mercury. 

lt  Every  ulcer,  strictly  speaking,  is  of  a 
local  nature;  but  there  are  ulcers,  which, 
though  necessarily  local  iif  their  appearance, 
are  connected  with,  or  dependent  upon,  dis- 
eases, which  affect  the  general  system. 
These  ulcers  ought  to  be  regarded  as  modi- 
fications of,  or  forms  in  which  the  diseases 
appear,  with  which  they  are  connected. 
Considered  in  this  light,  it  is  obvious,  that 
specific  ulcers  can  be  treated  of  with  pro- 
priety, only  under  the  head  of  the  diseases 
to  which  they  respectively  belong. 

“ We  call  those  sores,  ulcers,  simple,  which 
do  not  appear  to  proceed  from  any  specific 
disease,  or  morbid  diathesis  existing  in  the 
constitution  of  those,  in  whom  they  take 
place.  They  are  usually  solitary  occurren- 
ces, and  the  consequences  of  accidental 
injuries,  and  improper  modes  of  manage- 
ment. They  may  occur  in  every  part  of 
the  body,  but  they  appear  most  frequently 
upon  the  lower  extremities.” 

Professor  Thomson  afterward  remarks, 
that  “ the  appearances,  which  different  ul- 
cers exhibit,  seem,  at  first  view,  to  afford  an 
excellent  foundation  for  distinctions. among 
them,  and  so  they  undoubtedly  do  in  .manj; 
respects ” 


“ But  (says  he)  it  is  to  be  regretted,  that 
the  characters,  upon  which  the  distinctions 
of  ulcers,  as  well  as  of  many  other  local 
diseases,  are  founded,  are  neither  very  uni- 
Gjnti  in  their  appearance,  nor  are  very  easily 
distinguishable  from  one  another.  JNotonly 
are  the  local  appearances  which  present 
themselves  in  simple  ulcers  liable  to  great 
variations  in  the  different  stages  of  the  same 
ndividual  affection,'  but  they  are  often  ap- 
parently the  same  with,  or  at  least  not  easily 
distinguishable  from,  those  which  occur  in 
specific  diseases,  and  which  require  for  their 
cure  peculiar  modes  of  treatment.  It  is 
this  circumstance,  winch  renders  it  so  ne- 
cessary for  us,  in  endeavouring  to  distinguish 
a. nl  to  cure  ulcers,  to  avail  ourselves  of  all 
the  information,  wuich  we  can  procure  from 
tiic  history  of  the  ulcer,  from  ihe  nature  ot 
the  exciting  cause,  by  which  it  lias  been  in- 
duced, and  from  ihe  efiects  of  the  remedies 
which  have  been  employed,  as  well  as  from 
ihe  particular. appearances,  which  the  ulcer 
itself  exhibits.” 

In  noticing  another  ground  of  distinctions 
among  ulcers,  or  that  derived  from  the  parts 
in  -a  hich  they  occur,  Dr.  Thomson  observes 
that  “ every  texture  and  organ  of  the  body 
possesses  physical  and  vital  qualities  pecu- 
liar to  itself  ; and  these  qualities  must  neces- 
sarily modify  the  appearances),  which  each 
texture  and  organ  respectively  exhibits  in 
the  state  of  disease.  Specific  diseases  ren- 
der some  parts  more  liable  than  others  to 
attacks  of  ulceration.  Thus,  secondary 
syphilis  appears  most  frequently  in  the 
throat ; scurvy  in  the  gums;  cancer  in  the 
lower  lip  ; and  lupous  and  scroiulous  ulce- 
rations in  the  upper  lip,  or  in  the  nose. 
Cancer  seldom  or  never  appears  primarily 
• rt  the  upper  lip  ; but  syphilis,  when  it  at- 
tacks this  part,  puts  on  many  of  the  appear- 
ances of  cancer  j”  a fact,  which  Dr.  Thom- 
son says  he  iirT.t.bmmsd  from  Mr.  Pearson. 
(Bee  Lectures  *•;!  'Inflammation, p.  427 — 430  ) 

in  the  vikm'aie  treatise  on  ulcers,  publish* 
edvby  Sir  Everard  Home,  these  complaints 
are  divided  into  six  principal  kinds,  viz. : 

1.  Ulcers  in  parts,  which  have  sufficient 
strength  to  carry  on  the  actions,  necessary 
for  their  recovery. 

2.  Ulcers  in  parts,  which  are  too  weak  for 
that  purpose. 

‘6.  Ulcers  in  parts,  whose  actions  arc  too 
violent  to  form  healthy  granulations,  whe- 
ther this  arises  from  the  state  of  the  parts, 
or  of  the  constitution. 

. 4.  Ulcers  in  parts,  whose  actions  are  too 
indolent,  whether  tins  arises  from  the  stale 
of  the  parts,  or  of  the  constitution. 

5.  Ulcers  in  parts',  which  have  acquired 
some  specific  action,  either  from  a diseased 
state  of  the  parts,  or  of  the  constitution. 

6.  Ulcers  in  parts,  which  are  prevented 
from  healing  by  a varicose  state  of  the  su- 
perficial veins  of  the  upper  part  of  thedimb. 

Ait  hough  I have  chosen,  in  the  subse- 
quent columns,  to  adopt  this  nomenclature, 
I am  perfectly  aware  of  its  being  on  some 
accounts  objectionable,  but  especially  be- 
cause it  assumes  hypotheses,  the  truth  of 


which  can  never  be  established,  nor  proved 
This  is  one  of  the  considerations,  which 
have  induced  Professor  Thomson  to  prefer 
the  old  names  usually  applied  to  ulcers  ; 
(Op.  cit.p.  4 35,  438.)  and  he  therefore  treats 
of  the  simple  purulent  ulcer  ; Inflamed  ulcer  ; 

F ungo us  ulcer  ; Callous  ulcer ; Sloughing  ul- 
cer ; Ulcerative  ulcer ; Carious  ulcer  ; and 
Specific  ulcers. 

or  ULCEUS  IN  PARTS,  WHICH  HAVE  SUFFICIENT 
STRENGTH  TO  CARRY  ON  TIIE  ACTIONS  NE- 
CESSARY FOR  THEIR  RECOVERY,  SIMPLE 
PURULENT,  OR  HEALTHY  ULCERS. 

Sir  E.  Home  remarks,  that  in  this  species 
of  ulcer,  the  pus  is  of  a white  colour,  thick 
consistence,  and  readily  separates  from  the 
surface  of  the  sore,  and  when  diluted,  and 
examined  in  a microscope,  is  found  to  be 
made  up  of  small  globules,  swimming  in  a 
transparent  fluid.  The  granulations  are 
small,  florid,  and  pointed  at  the  top.  As 
soon  as  they  have  risen  to  the  level  of  the 
surrounding  skin ; those,  next  to  the  old 
skin,  become  smooth,  and  are  covered  with 
a thin,  semi-transparent  film,  which  after- 
ward becomes  opaque,  and  forms  cuticle. 

In  the  treatment  ot  this  ki/id  of  ulcer,  it 
is  only  necessary  to  keep  the  surface  clean, 
and  prevent  the  natural  processes  from  being 
interrupted.  Sir  E.  Horne  observes,  that 
this  is  in  general  best  done  by  the  applica- 
tion of  dry  lint,  for  the  purpose  of  absorbing 
and  retaining,  the  matter,  which  serves  as  a 
soft  covering  for  the  granulations,  and  by 
putting  over  the  lint  a pledget  of  any  simple 
ointment,  in  order  to  hinder  the  matter  from 
evaporating,  by  which  means  the  dressings 
will  not  become  adherent,  and  may  be  easily 
taken  off,  as  often  as  requisite 

Although  healthy  ulcers  require  no  medi- 
cated application  to  be  made  to  them,  the 
dressings  must  be  such  as  do  not  disagree 
with  the  granulations,  or  surrounding  skin. 

With  some  patients,  a roller  applied  with 
moderate  lightness*  with  a view  of  retaining 
the  dressings,  which  cause  uneasiness  in 
the  part,  and  make  the  ulcer  lose  its  healthy 
appearance.  Bir  E Horne  states,  that  he 
has  seen  several  such  cases,  in  which  the 
proper  appearance  of  the  sore 'returned  as 
soon  as  the  bandage  was  discontinued. 

In  some  patients,  ointment  irritates  and 
inflames  the  neighbouring  skin  ; and  certain 
superficial  ulcers  will  not  heal,  while  kept  in 
a moist  state,  and  unexposed  to  the  air  ; but 
heal,  when  allowed  to  become  dry  and  co- 
vered with  a scab. 

Sir  E.  Home  refers  these  particularities  to 
constitutional  causes,  and  not  disease  ; for 
the  ulcers  neal  as  soon  as  *the  particular 
things,  which  disagree  with  them,  are  dis- 
continued. These  peculiarities  in  certain 
healthy  sores  may  also  attend  others  of  a 
dilferent  description,  and  should  always  be 
discriminated  from  the  effect*  ot  disease. 

Sir  E.  Home  very  judiciously  recom- 
mends inquiring  of  patients,  who  have  pre- 
viously had  sores,  what  kind  of  applications 
they  derived  most  benefit  from,  and  what 
dressings  were  found  to  disagree. 


ULCERS. 


■A1 


TREATMENT. 

1.  Applications  in  the  form  of  vapour,  and 
fomentations,  should  never  be  employed,  as 
they  render  the  texture  of  the  granulations 
looser,  and  diminish  the  disposition  to  form 
skin. 

2.  With  respect  to  fluid  applications,  Sir 
E.  Home  also  very  properly  condemns  poul- 
tices, as  well  as  fomentations.  He  speaks 
of  alcohol,  as  being  an  application,  which 
promotes  the  formation  of  a scab,  when  this 
mode  of  cure  is  chosen 

3.  in  regard  to  ointments,  their  only  use, 
in  cases  of  healthy  ulcers,  is  to  keep  the 
matter  from  evaporating.  The  most  simple 
ointments  are  the  best  for  the  purpose  ; par- 
ticularly the  one  composed  of  white  wax 
and  olive  oil. 

Sir  E.  Home  observes,  that  the  great  ob- 
jections to  the  common  simple  ointments 
are,  that  they  sometimes  disagree  with  the 
skin,  even  when  recent  a*nd  free  from  all 
rancidity.  When  they  have  acquired  the 
latter  quality,  they  still  more  frequently 
create  a greater  degree  of  irritation. 

4.  With  respect  to  applications  in  the  form 
of  powder.  Sir  E.  Home  remarks,  that  when 
it  is  desirable  to  form  a scab  on  the  ulcer, 
any  inert  powder  mav  be  sprinkled  on  the 
sore;  but  he  prefers  dry  lint.  Nothing 
should  touch  the  powder,  or  lint;  and  to 
prevent  this  circumstance.  Sir  E.  Home  re- 
commends applying  a little  bolster  on  each 
side  of  the  sore,  and  over  them  a roller, 
which  will  go  from  one  bolster  to  the  other 
in  the  manner  of  a bridge. 

For  healthy  ulcers,  dry  lint  is  to  be  re- 
garded as  being  upon  the  whole  the  most 
eligible  application.  When  the  sore  does 
not  secrete  pus  enough  in  twenty-four  hours 
to  moisten  the  lint,  the  dressings  are  only  to 
be  changed  every  other  day. 

When  a moderately  tight  bandage  is  not 
forbidden  by  constitutional  peculiarities,  it  is 
useful  both  in  supporting  the  muscle?  and 
skin,  which  are  often  in  a flabby  state  from 
the  unexercised  state  of  the  limb,  and  in  de- 
fending the  newly  formed  parts.  (See  Home 
on  Ulcers.) 

ULCERS  IN  PARTS  WHICH  ARE  TOO  WEAK  TO 

CARRY  ON  THE  ACTIONS  N ECESsAR V FOlT 

THEiR  RECOVERY  ; THE  OVERACTING  UL 

CERS  OF  MR.  BURNS  ; THE  FUNGOUS  ULCERS 

OF  OLDER  WRITERS. 

This  is  the  second  of  the  classes,  into 
which  Sir  Everard  Home  has  divided  ulcers 
in  general. 

The  granulations  of  these  sores  are  larger, 
more  round  on  their  external  surface,  and 
of  a less  compact  texture,  than  those  formed 
on  ulcers  in  healthy  parts.  Sir  E.  Home 
has  aiso  noticed  their  semi-transparent  ap- 
pearance. When  they  have  filled  up  the 
cavity  of  an  ulcer  to  a level  with  the  surface 
of  the  body,  they  do  not  readily  form  skin, 
but,  rising  up  in  a still  higher  manner,  often 
lose  altogether  the  power  of  producing  new 
mtis.  When  the  parts  are  still  weaker,  the 


granulations  sometimes  continue  gradually 
to  fill  up  the  hollow  of  the  ulcer,  and  then, 
all  on  a sudden,  are  s iddenly  absorbed,  so 
as  to  leave  the  sore  as  deep  as  it  was  before. 

Ulcers  may  be  weak  from  the  firs%  or  be- 
come so  in  the  progress  of  the  case  Even 
granulations  of  the  most  healthy  kind,  if 
they  are  not  skinned  over  in  a certain  time, 
gradually  lose  their  primitive  strength. 

Sores  on  the  legs  are  greatly  under  the  in- 
fluence of  all  natural  peculiarities  of  the 
constitution,  and  every  thing  which  affects 
the  health.  When  the  constitution  becomes 
in  the  least  weaker  or  stronger,  the  appear- 
ance of  the  granulation  becomes  changed 
accordingly,  and  this  effect  of  constitutional 
weakness  , or  strength  on  ulcers  is  greater, 
in  proportion  as  the  sores  are  further  from 
the  source  of  the  circulation. 

V\  bile  the  constitution  is  undergoing  anv 
kind  of  disturbance,  the  healing  of  an  ulcer 
is  suspended.  Mental  anxiety  is  very  apt 
to  retard  cicatrization. 

Such  effects  of  the  constitutional  kind  ou 
ulcers  are  greater  in  weak  and  delicate  per- 
sons, than  in  the  strong  and  robust.  Change 
of  weather  nas  considerable  influence  over 
the  healing  of  sores.  Sir  E.  Home  mentions 
in  proot  of  this  fact,  that  when  there  were 
several  hundreds  of  uicers  in'  the  Naval 
Hospital  at  Plymouth,  in  177S,  every  time 
the  weather  changed  from  a dry  to  a moist 
state,  the  ulcers  universally  assumed  an  un- 
healthy appearance  ; but  put  on  a better  as- 
pect when  the  weather  became  dry  again. 

In  the  treatment  of  this  kind  of  ulcer, 
tonics  are  to  be  exhibited,  particularly  bark 
and  steel,  and  every  thing  which  disagrees 
with  the  constitution  is  to  be  avoided.  Wine 
and  cordial  medicines  are  also  usually  pre- 
scribed. Porter,  however,  is  deemed  better 
than  wine  for  working  people. 

bir  E.  Home  observes,  that  the  first  ob- 
ject in  the  local  part  of  the  treatment,  is  to 
keep  he  granulations  from  rising  above  the 
edge  of  the  surrounding  skin.  This  gentle- 
man (jn  my  opinion)  very  judiciously  repre- 
sents the  greater  propriety  of  preventing 
the  granulations  from  ever  becoming,  loo 
high  by  the  employment  of  proper  applica- 
tions, than  following  the  com -non  plan  of 
destroying  the  high  granulations  with  es- 
char*.tics,  after  they  have  risen  toa-i  impro- 
per height.  There  cannot  be  the  smallest 
doubt,  that  if  the  granulations  could  always 
be  prevented  from  rising  too  much  the  pa- 
tient would  suffer  a great  deal  less  pain. 

Instead  of  applying  to  the  surface  of  the 
uic-rs,  now  uridr-r  consideration,  lunar  caus- 
tic, blue  vitriol,  red  precipitate,  &e.  bir  E. 
Home  prefers  mixing  these  escbarotles 
with  other  substances,  so  us  to  render  ihem 
only  strong  stimulants;  ami  using  them  in 
this  latter  torm.  He  conceives,  that  when 
toe  high  granulations  are  destroyed  with 
escharotics,  the  disposition  of  iht-  surface 
underneath  to  reproduce  them  is  increased, 
but  that  this  is  not  the  case  when  the  luxuri- 
ant parts  me  only  stimulated,  so  as  to  be 
come  absorbed. 

The  same  gentleman  seems  to  think,  that 


ULCERS. 


G18 


when  animal  substances  grow  with  great  ra- 
pidity. the)  are,  like  vegetable  ones,  weaker 
than  when  produced  in  a slower  manner. 
Hence  Sir  E.  Home  is  of  opinion,  that  the 
growth  of  granulations  ought  to  be  cheeked 
in  the  early  stage  of  their  formation,  by  some 
resistance  which  they  are  just  able  to  over- 
come, under  which  circumstances  they  de- 
rive strength  from  the  limited  increase  of  ac- 
tion which  they  are  obliged  to  undergo. 

On  the  same  principle,  according  to  Sir 
E.  Home,  the  pressure  of  tight  bandages  is 
advantageous,  and  ulcers  which  heal  while 
the  patient  is  vv  Iking  about*  are  not  so  apt 
to  break  out  again  as  others  healed  while  the 
parts  are  in  a state  of  perfect  rest. 

In  the  treatment  of  these  ulcers,  when  the 
granulations  have  come  to  a proper  height, 
and  do  not  form  k thm, semi-transparent  pelli- 
cle upon  their  surface,  they  are  t<-  be  consi- 
dered as  weak  parts,  and  treated  according- 
ly. Sir  E.  Home  tlouks,  that  in  this  circum- 
stance, the  best  plan,  when  no  particularity 
of  constitution  forbids,  is  pressure,  made 
with  a thin  piece  of  lead  over  the  dressings, 
and  supported  with  a tight  bandage. 

OF  APPLICATIONS  TO  ULCERS  ATTENDED 
WITH  WEAKNESS. 

Although  strictly  we  have  no  topical  ap- 
plications which  can  directly  communicate 
strength  to  granulations,  there  are  certainly 
some  which  prevent  the  granulations  from 
exhausting  themselves  by  luxuriant  growth, 
and  stimulate  them  to  draw  more  blood  from 
the  arteries  ; which  effects,  as  Sir  E.  Home 
remarks,  render  such  granulations  stronger. 

1.  This  gentleman  very  properly  con- 
demns, as  applications  to  wreak  ulcers,  all 
relaxing  fomentations  commonly  employed  ; 
and  recommends,  instead  of  them,  the  use 
of  spirits  of  wine,  and  the  decoction  of  pop 
pies,  in  equal  proportions,  not,  however,  to 
be  applied  hot. 

2.  Wuh  regard  to  moist  applications,  the 
same  gentleman  expresses  his  disapprobation 
of  poultices,  and  mentions  a weak  solution 
of  the  argentum  nitratum.  as  the  most  eligi- 
ble application  in  an  aqueous  form. 

3.  On  the  subject  of  powdered  substances, 
as  applications  to  weak  ulcers,  SirE.  Home 
says,  be  has  often  tried  bark,  and  the  lapis  ca- 
laminaris,  without  perceiving  that  the  former 
had  any  power  of  strengthening  granulations, 
or  the  latter  any  virtue  in  disposing  them  to 
form  new7  skin  ; properties  commonly  im- 
puted to  these  applications. 

Sir  E.  Home  entertains  no  better  opinion 
of  plaster  of  Paris,  or  powdered  chalk,  em- 
ployed w ith  a view  of  promoting  the  forma- 
tion of  skin.  Powdered  carbon  he  speaks  of 
as  being  more  adapted  to  irritable,  than  weak 
ulcers.  He  praises  powdered  rhubarb,  as 
particularly  applicable  to  the  latter  kind  of 
ulcer,  because  it  represses  the  luxuriant 
growth  of  the  granulations,  renders  them 
small  and  compact,  and  disposes  them  to 
form  skin.  When,  however,  the  granulations 
have  arisen  above  the  level  of  the  skin,  it  is 
not  powerful  enough  to  reduce  them.  When 


the  rhubarb  is  too  stimulating,  it  is  to  be 
mixed  with  a fourth  part  of  crude  opium  in 
powder. 

A piece  of  lint,  a little  less  than  the  sore, 
is  always  to  be  put  over  the  powder,  and  co- 
vered with  a pledget  of  simple  ointment. 

4.  Ointments,  according  to  Sir  E Home, 
are  particularly  apt  to  disagree  with  weak 
ulcers.  When  other  applications  fail,  how- 
ever, greasy  ones  must  be  tried,  and  the 
above  gentleman  gives  a preference  to  the 
ung.  hydrarg.  nitrat.  mixed  with  hog’s  lard,, 
in  the  proportion  of  one  to  live,  or  else  to 
common  cerate,  blended  with  a small  quanti- 
ty of  the  hydrarg.  nitrat.  ruber. 

OF  ULCERS  IN  PARTS,  WHOSE  ACTIONS  ARE 
TOO  VIOLENT  TO  FORM  HEALTHY  GRANU- 
LATIONS, EITHER  FROM  TH1  STATE  OF 
THE  PARTS,  OR  THE  CONSTITUTION  : SIM- 
PLE VITIATED  ULCERS  OF  MR.  B.  BELL. 

There  are  three  states  of  the  constitution 
influencing  the  nature  of  ulcers  ; an  .irrita- 
ble state,  in  which  aJI  the  actions  of  the  ani- 
mal economy  are  more  rapid  than  in  health ; 
an  indolent  state,  in  which  they  are  unusual- 
ly languid  ; and,  lastly,  a diseased  state,  by 
which  they  are  affected. 

An  irritable  and  an  indolent  ulcer  cannot 
in  general  be  distinguished  from  each  other 
by  mere  appearances,  though  they  may  be 
so  in  a few  instanc  s.  Sir  E.  Home  informs 
us,  that  the  disposition  of  an  ulcer,  like  the 
disposition  of  a constitution,  can  only  be  ac- 
curately ascertained  by  determining  the  ac  - 
tions which  arise  from  the  different  impres- 
sions made  upon  it. 

The  same  gentleman  notices,  that  the  fol- 
lowing appearances  at  once  show  the  ulcer 
to  be  of  an  irritable  kind.  The  margin  of 
the  surrounding  skin  being  jagged,  and  ter- 
minating in  an  edge,  which  is  sharp  and  un- 
dermined. The  bottom  of  the  ulcers  being 
made  up  of  concavities  of  different  sizes 
There  being  no  distinct  appearance  of  gra- 
nulations, but  a whitish  spongy  substance, 
covered  with  a thin  ichorous  discharge. 
Every  thing  th»t  touches  the  surface  gives 
pain,  and  very  commonly  makes  it  bleed. 
The  discharge  is  altered  from  common  pus 
to  a thin  fluid,  in  proportion  to  the  degree  of 
irritability  communicated  to  the  sore  by  con- 
stitutional causes: 

The  pain  of  an  irritable  sore  in  general 
gradually  becomes  less.  When  it  is  not  con- 
stant, but  comes  on  in  paroxysms  chiefly  in 
the  evening,  or  night-time,  with  great  vio- 
lence, convulsive  motions  of  the  limb  arc 
apt  to  occur,  and  extend  to  various  other 
parts.  Sir  E.  Home  refers  this  symptom  to 
irritation,  communicated  along  the  course  of 
the  nerves,  and  producing  an  action  in  them, 
attended  with  a violent  contraction  of  the 
muscles,  which  they  supply. 

When  the  above-mentioned  signs  of  an  ir- 
ritable ulcer  are  not  present,  we  must  ionn 
a judgment,  of  the  nature  ot  the  sore  irorn 
listening  to  the  history  of  the  case,  the  effects 
of  various  applications.  &c.  When  this  kind 


ULCERS. 


of  information  cannot  be  obtained,  Sir  E. 
Home  recommends  the  treatment  to  begin 
on  the  supposition  of  the  ulcer  being  of  an 
irritable  nature. 

When  an  ulcer  occurs  just  over  the  mal 
leolus  externus,  it  is  generally  of  an  irritable 
kind,  in  consequence  of  the  nature  of  the 
part  on  which  it  is  situated,  quite  inde- 
pendently of  any  constitutional  or  local 
disposition  to  irritability.  Sir  E Home 
conceives,  that  the  periosteum,  which  here, 
lies  immediately  under  the  skin,  becomes  the 
seat  of  the  ulcer,  is  the  cause  of  its  being 
very  difficult  to  heal,  and  gives  it  the  irrita- 
ble appearance.  The  fact  that  sores,  situa- 
ted on  the  ligament  of  the  patella,  and  over 
the  periosteum  of  the  anterior  surface  of  the 
tibia,  assume  a similar  appearance,  and  are 
equally  difficult  to  heal,  made  the  above  gen- 
tleman more  confbmed  in  his  sentiment. 

In  treating  ulcers  in  general,  the  surgeon 
will  find  it  exceedingly  advantageous  to  be 
acquainted  with  the  effects  of  a great  many 
external  applications  ; lor  a very  few  cases 
will  continue  to  heal  beyond  a certain  time, 
without  some  alteration  in  the  treaunent. 
The  necessity  of  changing  the  applications, 
after  they  have  been  continued  for  a certain 
time,  is  strikingly  illustrated  by  the  fact,  (bat 
leaving  off  a powerful  application,  and  em- 
ploying one  which  at  first  would  have  had 
no  effect,  often  does  a great  deal  of  service. 
When  the  change  is  made  to  a medicine  of 
powers  equal  to  those  of  the  previous  one, 
the  benefit  will  be  more  lasting  than  in  the 
preceding  circumstance. 

Sir  E.  Home  compares  the  principle  of 
this  occurrence  with  that  by  which  change 
of  air,  even  of  a very  salubrious  air,  for  one 
that  is  less  so,  often  produces  an  infinite  im- 
provement of  the  health. 

OF  APPLICATIONS  TO  IRRITABLE  ULCERS. 

I.  SirE.  Home  recommends  applications 
in  the  form  of  vapour  as  being  particularly 
useful,  by  their  quality  of  allaying  irritation 
and  soothing  pain. 

The  steam  of  warm  water  is  productive 
of  benefit  in  this  way,  though  seldom  u>ed 
by  itself.  Its  good  effects  are  increased 
when  it  is  mixed  with  spirits. 

Sir  E.  Home  speaks  also  in  favour  of  the 
benefit  derived  from  fomentations  contain- 
ing opium  ; such  as  the  tincture  of  opium 
sprinkled  on  flannel,  wrung  <>ut  of  warm 
water ; or  the  application  of  flannels,  wet 
with  a warm  solution  of  the  extract  of  opi- 
um, or  with  a decoction  of  poppy  heads. 
A decoction  of  chamomile  flow  ers,  the  tops 
of  wormwood,  or  hemlock  leaves,  may  also 
be  employed  lor  the  same  purpose. 

Sir  E.  Home  points  out  particular  irrita- 
ble ulcers,  however,  which  are  rendered 
more  painful  by  warm  applications  ; and  he 
states,  that  the  sores  alluded  to  are  generally 
attended  with  a mottled  purple  discolora- 
tion of  the  limb  for  some  way  from  them, 
and  a coldness  of  the  low'er  part  of  the  leg, 
and  that  they  are  often  disposed  to  mortify, 
which  event  is  promoted  by  warmth. 


2.  As  for  moist  applications,  lb©  poultice 
made  of  linseed  meal  is  the  rnoSt  simple,  and 
most  easily  made  ; and  as  it  does  not  neces- 
sarily require  any  addition  of  oil,  is  to  be. 
preferred,  when  this  disagrees  with  the  sore. 

Sir  E.  Home  does  not  say  much  in  favour 
of  the  use  of  the  extract  of  lend  in  pouhices  ; 
for  though  he  allows  that  ii  often  answers  very 
well,  he  adds,  that  it  also  frequently  disa- 
grees with  the  ulcer,  and,  if  long  used,  is  apt 
to  bring  on  the  lead-colic. 

A decoction  of  poppy -heads  is  said  to  be 
a very  good  liquor  for  making  poultices. 

The  carrot  poultice  is  also  found  to  agree 
with  a great  many  irritable  sores. 

fhe  great  objection  to  poultices  in  these 
cases  being  the  weight  of  such  applications, 
the  limb  should  always,  if  possible,  rest  upon 
the  poultice,  and  not  the  poultice  upon  the 
limb.  When  the  weight  cannot  be  avoided, 
and  is  hurtful,  a lighter  application  should  be 
chosen. 

If  poultices  be  employed,  their  use  is  to 
be  continued  as  long  as  the  granulations  are 
small,  and  the  ulcer  is  rapidly  diminishing  in 
size,  and  this  even  till  the  cicatrization  is 
complete.  When  the  granulations  become 
large,  and  loose  in  their  texture,  poultice, 
should  be  left  off. 

When  the  weight  of  poultices  prohibits 
their  use,  Sir  E.  Home  advises  the  trial  of 
lint,  dipped  in  one  of  the  following  lotions, 
and  covered  w ith  a pledget  of  some  simple 
ointment  : a solution  of  the  extract  of  opi- 
um ; a decoction  of  poppies  ; the  tincture 
of  opium  ; a decoction  of  cicuta  ; the  liquor 
plumbi  acetatis  dilutis  ; or  a weak  solution 
of  the  argentum  nitratum. 

3.  Powdered  applications  are  generally 
too  stimulating  for  irritable  ulcers.  Carbon 
has  been  found  useful ; so  has  powdered  ex- 
tract of  opium,  mixed  w ith  an  equal  quantity 
of  carbon,  or  linseed  flour.  How  ever,  opium 
occasionally  affectsthe  constitution,  in  conse- 
quence of  absorption,  and  it  has  been  known 
to  excite  violent  inflammation,  ending  in 
mori  ideation. 

4.  Ointments  are  not  often  proper  appli- 
cations for  irritable  ulcers,  as  they  are  always 
more  or  less  rancid,  and  generally  disagree 
with  the  skin  of  persons  most  subject  to  such 
diseases. 

Sir  E.  Home  mentions  cream  as  being  a 
very  useful  application,  particularly  in  cases 
in  which  warmth  is  found  to  do  harm.  The 
same  gentleman  recommends,  as  a substitute 
for  it;  an  ointment  composed  of  hog’s  lard, 
purified  by  being  repeatedly  washed  in  spring 
water,  and  then  mixed  with  a small  quantity 
of  white  wax  and  rose  water. 

The  observations  made  respecting  the  so 
iutions  of  lead,  apply  to  the  unguentum  ce- 
russse  acetalaj. 

5.  The  pressure  of  bandages  is  generally 
hurtful  to  irritable  sores,  though  a slight  de 
gree  of  it  proves  serviceable  to  certain  ulcers, 
which  are  somewhat  less  irritable,  and  arise 
from  weakness. 

OF  ULCERS  IN  PARTS,  WHOSE  ACTIONS  ARE 

TOO  INDOLENT  TO  FORM  HEALTHY  CPA- 


ULCERS. 


m 

NULATIONS,  WHETHER  THIS  INDOLENCE 
ARIt.£g'  FROM  THE  STATE  OF  THE  PARTS, 
on  of  THE  constitution:  THE  callous 
ulcers  of  several  writers. 

Surii  is  the  next  division  of  ulcers  adopt- 
rd  by  Sir  C.  ilorne,  in  his  treatise  on  the 
subject  The  indolent  ulcer  terms  in  its 
apoearance'a  complete  contrast  to  the  ini- 
tlble  one.  Tiie  edges  of  Hie  surrounding 
ski,,  are  thick,  prominent, . smooth,  and 
rounded.  The  surface  of  tire  granulations 
is  smooth  and  glossy.  The  pus,  ...stead  of 
being  of  a perfect  kind,  is  thin  and  watery, 
being  composed  of  a mixture  of  pus  and 
coagulating  Ivinph.  The  lymph  consists  of 
flakes,  which  cannot  be  easily  separated 
from  the  surface  of  the  sore.  The  bottom 
cf  the  ulcer  forms  quite  a level,  or  nearly 
<o;  and,  as  Sir  E.  Home  very  accurately 
remarks,  the  general  aspect  conveys  an 
idea,  that  a portion  of  the  skill  and  p its 
underneath  has  been  for  some  removed, 
without  the  exposed  surface  haying  begun 
any  new  action  to  fill  up  the  cavity. 

When,  however,  the  indolence  of  the 
ulcer  is  not  so  strongly  marked,  the  sore 
does  not  correspond  to  the  preceding  de- 
scription; but  resembles  in  appearance  the 
ulcer,  which  possesses  an  inferior  degree  of 
irritability,  and  can  only  be  discriminated 
from  it  by  receiving  no  benefit  from  smooth- 

>n?fbo  odT circumstance  of  some  indolent 
sores  having,  the  appearance  of  irritable 
ones,  is,  in  some  degree,  explained  by  ul- 
cers always  being  influenced  by  changes  in 
the  constitution,  and  accidental  cncum- 
stances' affecting  the  parts 

Most  of  the  ulcers,  which  are  to  be  seen 
in  the  Londop  hospitals,  are  ot  the  undo  ept 
S ind  An  indolent  disposition  m the  ulcer 
may  proceed  altogether  from  the  long  ex- 
istence  of  the  disease;  and  hence,  >~ir  L. 
Home  very  justly  observes,  it  is  immaterial 
“Xer  atWh  was  healthy,  weak,  or 
irritable,  for,  if  not  cured  within  a ccitaiu 
. ; m P ;+  becomes  indolent,  with  the  excep- 
of  a few  of  the  irritable  kind,  which 

never  change  their  nature. 

Indolent  sores  do  form  granulations;  but 
tUf.se  Cverv  now  and  then,  are  all  on  a sud- 
wCbld,  and,  in  the  course  oi  four 
and  twenty  hours,  the  sore  becomes  as 
much  incieasc.i  in  size,  as  it  had  been  d - 
i finished  in  as  nnr.iiy  days,  or  weeks.  1 » 

ahsorptiou  of  the  granulat  ions  .arise*  princi- 
pally iro;n  their  not  being  o t a healthy 
biitd  : but  the  event  is  promoted  by  changes 
in  the  weather,  anxiety . fatigue,  fcc; 

The  object  in  the  tre.-ti.ucnt  ot  indolent 
v leers  is  nos  simply  to  produce  a cure,  but 
in  wider  such  erne  r,  permanent  as  po.‘- 
jujje*  This  cart  only  be  accomplished  by 
alterin0'  the  disposition  of  the  granulations^ 
and  rendering  them  strong  enough  to  stand 
their  mound  after  the  ulcer  is  tilled  up 
When  an  ulcer,,  wbu  n lms  existed  six 
months  is  dressed  with  poUH.ces  for  a vvee  , 
the  granulations,  at  the  end  of  tm.  In  ‘ , 
.vill  partfv  have  filled  up  the  hollow  of  tl- 


sore,  but  they  will  present  a large,  loose, 
and  glossy  appearance.  Should  the  poul 
tice  be  now  discontinued,  and  some  proper 
stimulating  application  used  for  another 
week,  the  granulations  will  be  found,  at  the 
expiration  of  this  time,  to  have  become 
smaller,  more  compact,  redder,  and  free 
from  the  glossy  appearance.  The  ulcer, 
when  healed  by  the  latter  application,  will 
not  be  so  likely  to  break  out  again,  as  when 
healed  with  large>  loose,  flabby,  glossy  gra- 
nulations. $ * 

Sir  E.  Home  states,  that  the  number  of 
indolent  sores,  which  heal  under  the  use  of 
stimulating  applications,  and  do  not  break 
out  agaju,  compared  with  similar  cases, 
treated  with  mild  dressings,  are  as  four  to 
one. 

AFFLIC  A.TIONS  TO  INDOLENT  ULCERS. 

1.  Medicines  in  the  form<of  vapour  can- 
not heal  indolent  sores,  so  as  to  accomplish 
a lasting  cure.  It  is  only  when  these  ulcers 
assume  a foul  appearance,  and  are  in  a tem- 
porary state  of  irritation,  that  such  applica- 
tions can  be  advantageously  employed. 

In  general,  patients,  on  their  first  admis- 
sion into  hospitals  with  sore  legs,  have  their 
ulcers  in  a temporary  state  of  irritation  from 
neglect,  exercise,  excesses,  Hence,  it 
is  generally  found  advantageous,  for  the 
first  few  days,  or  even  a week,  to  have  re- 
course to  poultices  and  fomentations. 

I believe,  that  any  common  fomentation., 
whether  of  chamomile,  poppy-heads,  or 
mere  warm  water,  answers  equally  well. 
The  time  for  using  it  is  while  a fresh  poul- 
tice is  preparing,  and  this  latter  application 
should  be  changed  twice  a day. 

2.  Moist  applications,  such  as  poultices, 
are  to  be  employed  when  fomentations  are 
proper,  and  they  may  be  made  of  bread, 
oatmeal,  or  linseed. 

‘Sir.  E.  Home  describes  a species  of  indo- 
lent ulcers,  which  occur  in  patients  of  de- 
bilitated constitutions  which  put  on  a 
sphacelated  appearance,  without  any  appa- 
rent cause,  even  after  they  have  made  some 
progress  towards  a cure,  and  in  this  way 
spread  to  a very  large  size.  Some  of  these 
ulcers,  if  judged  of  from  their  appearances, 
would  be  ranked  ns  irritable  ones;  but,  as 
soothing  applications  'do  not  agree  with 
them,  they  are  not  to  be--,  classed  with  the 
latter  kind  of  sores.  They  are  said  to  occur 
particularly  in  seamen  and  soldiers,  who 
have  been  long  at  sea,  and  have  been 
termed  scorbutic  ulcers.  Sir  E.  Home  re- 
presents them,  however,  as  not  being  ne- 
cessarily connected  with  the  scurvy,  and 
being  oTten  tncl  with  in  patients  wild  have 
not  been  on  the  sea.  He  states  that  they 
are  not  of  necessity  joined  with  any  specific 
disease  ; but  are  common  to  all  kinds  ol 
patients,  whose  constitutions  have  been  im- 
paired either  by  salt  provisions,  warm  cli- 
mates, or  drinking.  , . „ 

From  some  trials,  first  made  by  Di  Har- 
ness, and  afterward  by  Sir  E.  Home,  .1 
appears  that  these  particular  ulcers,  when 


LJLCERS. 


1 

in  a sphacelated  state,  are  benefited  by  em- 
ploying the  gastric  juice  of  ruminating 
animals,  as  an  external  application.  It 
makes  the  sloughs  fall  off,  and  the  sore  as- 
sume abetter  appearance.  Some  pain  fol- 
' lows  on  its  being  first  applied,  and  it  is  to 
tTfe  regarded  as  a stimulating  application. 

Sir  E.  Home  mentions,  that  in  the  West 
Indies  such  ulcers  are  advantageously 
dressed  with  the  fresh  root  of  the  cassada, 
grated  into  a pulp.  Lime-juice  has  also 
heen  found  a useful  application,  and  solu- 
tions of  vitriol  and  alum  have  been  recom- 
mended. 

When  indolent  ulcers  are  not  attended 
with  certain  peculiarities,  a solution  of  the 
argentum  nitratum  is  one  of  the  best  of  the 
watery  applications.  It  stimulates  the  gra- 
nulations, and  makes  them  put  on  a more 
healthy  appearance,  and  its  strength  may  be 
increased  according  to  circumstances.  An 
ulcer,  which  at  first  cannot  bear  this  solu- 
tion above  a certain  strength  without  pain, 
and  without  the  granulations  beingabsorbed, 
becomes  able,  after  the  application  has  been 
used,  about  ten  days  or  a fortnight,  to  bear 
it  twice  as  strong,  without  such  effects 
being  produced  : a proof  of  the  granulations 
having  acquired  strength. 

The  tincture  of  myrrh  is  often  employed 
as  an  application  to  indolent  ulcers.  Hune- 
zowsky  has  praised  a decoction  of  the 
walnut-tree  leaves,  and  soft  covering  of  the 
walnut,  for  the  same  purpose.  (Ada  Acad 
Med.  Chir.  Vindob.  T.  1, 1788.)  Sir  E.Home 
gives  his  testimony  in  favour  of  both  the 
latter  dressings. 

Diluted  sulphuric  acid,  aud  the  expressed 
juice  of  the  pod  of  different  species  of  pep- 
per in  a recent  state,  are  mentioned  by  Sir 
E.  Home  as  having  been  used  as  applica- 
tions to  indolent  ulcers : the  latter  one  in 
the  West  Indies. 

This  gentleman  recommends  also  a scru- 
ple of  nitrous  acid,  mixed  with  eight  ounces, 
of  water,  as  a very  useful  medicine  for  ex- 
ternal use.  The  strength  must  be  increased 
or  diminished,  according  to  circumstances. 
Sir  E.  Home  has  found  that  this  application 
promotes,  in  a very  uncommon  manner,  the 
. progress  of  the  cure. 

The  first . application  of  diluted  nitrous 
acid  gives  a good  deal  of  pain,  which  lasts 
about  half  an  hour,  and  then  goes  off. 

When  an  indolent  ulcer  heals  with  the 
diluted  nitrous  acid,  the  process  of  skinning 
is  accomplished  with  more  rapidity  than 
when  other  applications  are  employed  ; and 
the  new  skin  is  said  to  be  more  completely 
formed.  The  acid  coagulates  the  pus  as 
soon  as  it  is  secreted. 

Sir  E.  Home  states,  that  several  patients, 
who  had  ulcers  dressed  with  the  diluted 
nitrous  acid,  were  allowed  to  walk  about, 
without  finding  the  progress  of  the  cure  re- 
tarded, although  no  bandage  to  support  the 
limb  was  made  use  of.  This  gentleman  in- 
forms us,  also,  that  in  ulcers  of  the  leg,  at- 
tended with  an  exposure  of  a piece  of  bone, 
which  retards  the  cure,  because  it  does  not 
exfoliate,  and  come  a wav.  the  application 

VoL.Il,  ’ ' «<> 


521 

of  diluted  nitrous  acid  to  the  bone  removes, 
the  earthy  part,  and  excites  the  absorbents 
to  act  upon  the  remaining  animal  portion. 

3.  The  only  application,  in  the  form  of 
powder,  adapted  to  indolent  ulcers,  is,  ac- 
cording to  Sir  E.  Home,  the  hydrargyrum 
nitratus  ruber.  It  may  be  occasionally 
used  for  ulcers  of  the  most  indolent  kind. 

4.  Ointments  are  represented  as  being 
particularly  good  applications  for  indolent 
sores. 

Ihe  idea  of  the  air  having  bad  effects  on 
sores,  which  are  exposed  to  it,  is  now  dis- 
believed. That  air  lias  no  irritating  pro- 
perty of  this  kind  is  proved  by  the  fact, 
that,  when  the  abdomen  of  an  animal  is 
filled  with  it,  no  inflammation  is  excited. 
When  the  cellular  membrane  is  loaded  with 
it,  in  cases  of  emphysema,  the  parts  do  not 
afterward  inflame.  Nor  do  ulcers  in  the 
throat,  as  Sir  E.  Home  justly  remarks,  heal 
less  favourably  than  others,  although  they 
are  of  necessity  always  exposed  to  the  air. 

Whatever  ill  effects  arise,  may  probably 
be  explained  by  the  consequences  of  evapo- 
ration, which  converts  the  soft  pus  into  a 
scab.  The  granulations  are,  in  all  probabi- 
lity, most  favourably  circumstanced  when 
they  are  covered  with  their  own  matter, 
which  should  only  be  now  and  then  re- 
moved, in  order  that  such  applications  may 
be  made  as  will  stimulate  them  to  secrete  a 
more  perfect  pus.  F rom  what  has  been 
just  stated,  it  must  be  obvious  that  indolent 
ulcers  should  not  be  frequently  dressed,  and 
that  if  they  are  so,  and  the  dressings  are 
stimulating,  the  practice  will  do  harm. 
Changing  the  dressings  once  in  twenty-four 
hours  is  deemed  quite  sufficient,  unless  the 
quantity  of  matter  be  very  great,  which, 
seldom  happens. 

One  part  of  the  unguentum  hydrargyr’f 
nitrati,  mixed  with  three  of  hog’s  lard,  is 
one  of  the  best  applications.  Its  strength, 
however,  must  be  increased  after  being 
used  for  some  time,  as  a dressing  for  th& 
same  ulcer. 

The  unguentum  hydrargyri  nitrati  has  the- 
effect  of  quickly  removing  the  thickness  of 
the  edges  of  indolent  ulcers,  and  the  sur- 
rounding dark  red  colour  of  the  skin.  It 
seems  also  to  have  particularly  great  power 
in  making  the  granulations  become  small 
and  healthy,  and,  of  course,  the  ulcer  less 
likely  to  break  out  again. 

With  some  ulcers,  however  this  ointment 
is  found  to  disagree. 

The  unguentum  resinoe  flavae,  and  the  un- 
guentum elemi,  mixed  with  the  balsam  of 
turpentine,  or  that  of  copaiba,  are  other 
common  applications  to  indolent  sores  Sir 
E.  Horne  states,  that  the  resins  and  turpen- 
tines are  not  so  powerful  as  the  acids  and 
metallic  salts  in  giving  the  granulations  a 
healthy  appearance,  and  a disposition  to  re- 
sist being  absorbed. 

Cases,  attended  with  a degree  of  indolent 
thickening,  are  sucli  as  are  most  likely  to  be 
improved  by  camphorated  ointments. 

In  numerous  crises, the  applications,  what- 
ever they  are,  soon  lose  their  effect',  anil 


ULCERS. 


Sm- 


others should  then  he  substituted  for  them. 
The  past  and  present  states  of  the  sore  are 
always  to  be  considered.  Although  the  ulcer 
may  be  in  its  nature  indolent,  it  is  liable  to 
temporary  changes  from  constitutional 
causes;  and  hence  a temporary  alteration 
in  the  treatment  becomes  proper. 

5.  Bandages  are  undoubtedly  of  the  most 
essential  service  in  healing  many  hinds  of 
ulcers  ; but  their  efficacy  is  so  great  in  cur- 
ing numerous  indolent  sores,  that  they  are 
sometimes  considered  the  principal  means 
of  cure.  But  among  modern  advocates  tor 
rollers  Mr.  Whately  is  one  of  the  most  zea- 
lous. While  this  gentleman  acknowledges 
that  the  efficacy  of  pressure  in  counteract- 
ing the  effects  of  the  dependent  posture  was 
known  to  Wiseman,  who  recommended  the 
use  of  the  laced  stocking  for  this  purpose, 
he  conceives  that  the  effects  of  pressure,  in 
the  cure  of  ulcers  on  the  extremities,  pre- 
viously to  the  appearance  of  Dr.  Under- 
wood’s treatise,  were  not  duly  insisted  upon 
by  surgical  writers.  However,  he  confesses, 
that  there  always  have  been  practitioners, 
who  were  acquainted  with  the  importance 
of  this  mode  of  treatment,  and  adopted  it  in 
their  practice.  He  then  criticises  the  work 
of  Sir  Everard  Home,  in  which,  it  is  re- 
marked, that  the  effect  of  pressure  is  not 
much  relied  upon  for  the  cure  of  these  com- 
plaints. Indeed,  says  Mr.  Whately,  it  is 
stated  in  that  book,  not  only  that  no  benefit 
is  derived  from  compression  in  several  spe- 
cies of  these  ulcers,  but  that  many  ulcers 
are  rendered  worse,  more  painful,  and  more 
unhealthy  in  their  appearance  by  its  use  ; 
-truths  which  it  would  be  impossible  for  Mr. 
Whately  to  refute.  They  are,  1 conceive, 
admitted  by  himself,  when  he  observes  that 
there  are  certain  conditions  of  an  ulcer 
which  will  not  bear  compression.  Whether 
Sir  Everard  Home  has  not  given  a suffi- 
ciently favourable  account  of  the  effects  of 
pressure  in  the  cure  of  ulcers  of  the  leg,  ! 
will  not  presume  to  determine.  Perhaps  he 
may'  not  have  insisted  so  much  upon  this 
treatment  as  it  deserves ; but  I can  find  no 
fault  with  him  for  speaking  of  it  as  frequent- 
ly injurious,  because  the  fact  is  notorious. 

In  the  cases,  published  in  Mr.  Whately’s 
essay,  very  little  variety  of  dressing  was  used  ; 
pressure  being  the  principal  means  of  cure, 
with  some  exceptions  particularly  specified 
in  the  work. 

I cannot  doubt  (says  Mr.  Whately)  that 
the  practice  here  recommended  must  in  the 
end,  prevail,  notwithstanding  it  has  this 
great  obstacle  to  contend  with,  that  surgeons 
must  condescend,  for  the  most  part,  to  ap- 
ply the  bandages  with  their  own  hands.  The 
clumsy  and  ineffectual  manner,  in  which  this 
business  is  too  frequently  done,  can  never 
be  expected  to  produce  the  desired  effect.  1 
am  certain,  that  if  the  necessary  pains  be 
taken,  according  to  the  directions  here  laid 
dowu,  such  effects  will  uniformly  follow,  as 
must  convince  the  unprejudiced  mind,  that 
to  have  recourse  to  the  operation  of  tying 
varicose  veins,  and  the  application  of  a great 
variety  of  remedies,  can  be  i^ery  rarely,  most 


probably  never  necessary.  I can  safely  de* 
clare,  that  all  such  cases  as  are  described  by 
Sir  E.  Home  to  be  cured  by  this  operation^ 
have  readily  yielded  under  the  proper  ma 
n age  merit  of  pressure  alone.” 

With  respect  to  Mr.  Baynton’s  mode  of 
treatment,  while  Mr.  Whately  regards  it  as 
a confirmation  of  the  principles  insisted 
upon  in  his  own  tract,  he  considers  the  plan 
of  making  the  pressure  with  adhesive  plas- 
ter inconvenient,  and  on  several  accounts 
objectionable.  In  every  case  related  by 
Mr.  Baynton,  he  is  sure  that  the  proper  ap- 
plication of  compresses  and  fiannel  rollers, 
would  have  produced  similar  good  effects. 
The  instances  of  success  by  this  method, 
after  the  supposed  failure  by  the  roller,  he 
attributes  to  the  pressure  made  with  the 
plasters,  having  beer;  applied  with  Mr.  Bayn- 
ton’s own  hands,  whereas  that  with  the  roller 
was  probably  so  made,  that  the  effect  intend- 
ed by  it  could  not  possibly  be  obtained.  No 
surgeon,  he  observes,  who  will  not  be  at  the 
trouble  of  applying  the  roller  and  compres- 
ses himself,  can  be  a judge  of  what  maybe 
effected  by  the  proper  management  of  them. 

The  following  is  the  calamine  cerate, 
which  Mr.  Whately  has  usually  employed, 
f^.  Axung.  Porcin.  depur.  lib.  iij. 

Empl  PI umbi.  lib.  iss. 

Lap.  Calarn.  preep.  ap.  lib.  j.  M. 

“To  this  formula,  (says  Mr.  Whately)  I 
shall  add  another  for  making  a cerate,  which 
nearly  resembles  the  unguentum  tripharrai- 
emu  of  the  old  Dispensatory,  but  being  less 
oily,  it  makes  a much  more  adhesive  plas- 
ter. It  should  be  spread  on  rag,  or  silk,  as 
an  external  covering  to  the  dressing  on  lint, 
where  a tow  plaster  cannot  be  conveniently 
used,  as  in  wounds  of  the  face  or  hands,  a 
bubo,  or  any  other  sore,  where  an  external 
plaster  cannot  be  readily  retained  in  its  si- 
tuation by  a bandage.  This  plaster  is  like- 
wise so  mild,  that  it  never  irritates  the  skin. 
I have  found  it  also  a very  useful  plaster  in 
fractures.  The  following  is  the  formula  : 
j^.  Empl.  Plumbi  lib.  j . 

Axung.  Porcin  depur.  unc.  vj. 

Aceti  unc.  iv.  M.” 

With  respect  to  the  proper  method  of  ap- 
plying the  roller  and  compresses,  Mr. 
Whately  offers  the  following  remarks  : 

“ The  best  width  for  a Hannel  roller,  de- 
signed for  those  who  have  slender  legs,  is 
three  inches;  but  for  those  whose  legs  are 
of  a large  size,  they  should  always  be  three 
inches  and  a half  in  width.  They  must 
therefore  be  at  first  lorn  a little  wider,  that 
they  may  be  of  their  proper  width  when 
repeatedly  washed.  It  will  likewise  be 
found,  that  rollers  made  of  fine,  soft,  and 
open  flannel,  will  answer  much  better  than 
those  made  of  coarse  or  hard  fiannel. 

“ For  those  who  have  full-sized  legs,  the 
length  of  six  yards  is  but  just  sufficient  to 
answer  all  the  purposes  intended  by  a roller  ; 
but  in  those  who  have  very  small  legs,  five 
yards  is  a sufficient  length.  Care  should  he 
taken  that  the  rollers  be  washed  in  very  hot 
water,  and  they  should  be  hung  up  to  dry 
immediately  on  being  washed.  II  these  pre 


ULCERS. 


cautions  be  not  attended  to,  repeated  wash- 
ing them  will,  in  some  kinds  of  flannel,  make 
them  as  narrow  as  tape,  by  which  they  will 
be  rendered  almost  useless.  They  should  be 
often  washed,  as  they  are  much  softer,  and 
of  course  sit  easier,  when  quite  clean  than 
when  they  are  soiled. 

“ In  applying  a roller,  (says  this  gentle- 
man) the  first  circle  should  be  made  round 
the  lowest  part  of  the  ankle,  as  near  as 
possible  to  the  heel;  the  second  should  be 
formed  from  thence  round  the  foot;  the 
third  should  be  passed  again  round  the  foot 
quite  to  the  toes  The  roller  should  then  be 
passed  from  the  foot  round  the  ankle  and 
instep  a second  time  to  make  the  fourth  cir- 
cle. In  doing  this,  it  should  be  brought 
nearer  (but  not  over)  the  point  of  the  heel 
than  it  was  at  the  first  time  of  going  round 
this  part.  The  fifth  circle  should  pass  over 
the  ankle  again,  and  not  more  than  half  an 
inch  higher  up  (he  leg  than  the  fourth  cir- 
cle. The  sixth,  seventh,  eighth,  and  ninth 
circles  should  ascend  spirally  along  the  small 
of  the  leg,  at  the  exact  distance  of  three- 
fourths  of  an  inch  from  each  other.  Ha- 
ving proceeded  thus  far  up  the  leg,  we  may 
begin  to  increase  the  distances  of  the  circles 
from  each  other : they  may  succeed  each 
other  upward  to  the  knee  at  the  distance  of 
from  one  to  two  inches,  according  to  the 
size  and  shape  of  the  !e^.  At  that  part 
where  the  calf  of  the  leg  commences,  it  is 
generally  necessary  to  let  the  upper  edge  of 
the  roller  be  once,  twice, sor  thrice  turned 
downwards  for  about  half  the  circumference 
of  the  leg,  in  order  to  make  the  roller  lay 
smooth  between  the  middle  of  the  calf  and 
the  small  of  the  leg.  When  the  roller  has 
been  thus  applied  as  far  as  the  knee,  there 
will  be  a portion  of  it  to  spare,  of  perhaps 
a yard  in  length  ; this  remainder  should  be 
brought  down  by  spiral  windings,  at  greater 
distances  from  each  other  than  those  which 
were  made  on  the  ascent  of  the  roller.  The 
windings  should  in  general  be  completed  in 
the  small  of  the  leg,  where  the  roller  should 
lie  pinned. 

“In  many  cases,  it  is  necessary  to  apply 
the  roller  over  the  keel.  It  should  be  brought 
as  low  as  possible  round  the  ankle  ; as  in  the 
, former  description.  From  thence,  the  se- 
cond circle  of  the  roller  should  pass  from 
the  instep  over  one  side  of  the  heel,  and  be 
brought  over  the  other  side  of  the  heel  to 
the  instep  again.  The  third  circle  should 
be  passed  round  the  ankle  a second  time, 
but  stili  nearer  to  the  heel  than  the  first  cir- 
cle was.  The  roller  should  after  this  be 
brought  back  to  the  foot,  and  passed  round 
it  to  make  the  fourth  circle.  A fifth  circle 
should  be  again  made  (though  it  is  not  in  all 
cases  absolutely  necessary)  round  the  foot, 
to  the  toes.  To  make  the  sixth  circle,  the 
roller  should  be  brought  back,  and  passed 
round  the  ankle  again.  The  seventh,  eighth, 
ninth,  tenth,  and  eleventh  circles  should 
ascend  spirally  at  the  exact  distance  of  three- 
fourths  of  an  inch  from  each  other ; these 
distances  commencing  at  the  sixth  circle. 
The  roller  should  then  be  carried  to  the 


■m 

knee,  and  be  brought , flown  -again  to  the 
small  of  (he  leg,  as  described  in  the  former 
instruction. 

“ In  applying  the  compresses,  it  is  neces- 
sary in  every  instance  to  put  them  on  one 
by  one,  and  not  all  in  a mass,  though  they 
be  of  a proper  size  and  number.  They 
should  be  crossed  in  different  directions  ; the 
largest  ot  them  should  in  no  case  be  longer 
than  just  lo  meet  on  the  opposite  side  of  the 
leg  to  which  they  are  applied.  I have  in 
many  instances  seen  the  compresses  applied 
by  the  patients  of  such  a length  as  to  go 
round  the. leg  like  a roller,  and  be  fastened 
together  with  pins.  This  met  hod  generally 
wrinkles  and  blisters  the  skin;  and  by  no 
means  answers  tin1  purpose  of  making  a com- 
pression on  the  part  where  it  is  most  want- 
ed. I never  suffer  a pin  to  be  used  in  (he 
compresses.  If  the  same  compresses  in  a tty 
case  be  applied  two  days  together,  they 
should  always  be  turned  on  the  contrary 
side  at  each  reapplication,  in  order  to  pre- 
vent wrinkles  on  the  skin.” 

Mr.  Whately  notices  two  objections*  made 
by  Mr.  Baynton  to  rollers.  “ The  first  is, 
that  it  is  difficult  to  retain  the  roller  on  the 
parts  to  which  it  is  applied  ; the  second  is, 
that  it  gives  pain  to  the  patient.' ” Mr. 

Whately’s  experience,  however,  warrants 
him  in  saying,  that  a flannel  roller  will,  in 
almost  every  instance,  keep  the  exact  posi- 
tion in  which  it  was  first  placed,  for  a much 
longer  time  than  is  necessary.  “ I have 
seen  these  rollers  (says  Mr.  Whately)  many 
hundred  times  keep  their  situations  without 
any  variation  whatever  for  two  days ; and 
that  too  without  the  least  restraint  ujaon  ex- 
ercise. This  has  happened  in  those  cases 
where,  from  the  distance  of  the  patient,  or 
from  the  circumstance  of  his  being  nearly- 
cured,  l have  wished  to  dress  the  leg  only 
every  forty-eight  hours.  I must  go  a step 
further,  and  observe,  that  I have  seen  re- 
peated instances  in  which  these  rollers  have 
remained  in  their  situation  for  three  or  four 
days,  and  even  nearly  for  a week  without 
being  applied  afresh.  In  short,  it  is  one  of 
the  best  properties  of  a flannel  roller,  that  it. 
is  easily  retained  in  its  situation  when  well 
applied.  In  every  instance  in  which  it  is 
necessary  to  use  one,  I could  pledge  myself 
to  apply  it  in  such  a manner,  as  should  pre- 
vent its  altering  its  position  for  two  days. 
The  method  I should  use,  I have  already 
described  ; in  addition  to  which  nothing 
more  would  be  necessary,  even  in  those 
cases  where  the  shape  of  the  leg  is  peculi- 
arly unfavourable  to  the  retention  of  a ban- 
dage, than  the  insertion  of  a few  pins. 

“ In  answer  to  the  second  objection,  I 
observe,  that  I have  invariably  found,  that 
when  a flannel  roller  has  been  applied  in  the 
manner  here  described,  and  has  not  been 
drawn  unnecessarily  tight,  it  gives  no  pain. 
It  sits  nearly  as  easy  as  a common  stocking, 
and  allows  a very  free  motion  and  exercise 
of  the  limb.”  (See  Practical  Observations  on 
the  Cure  of  Wounds  and  Ulcers  on  the  Legst 
ivithout  rest ; by  Thomas  Whately , 1799.) 

6.  I shall  next  introdnee  an  account  of 


£24 


V)  LCKIi< 


Mr.  Baynton  s p*lau  of  curing  old  ulcers  of 
ihe  leg,  by  means  of  adhesive  plaster.  Were 
1 to  say,  that  any  particular  method  of 
dressing  such  sores  is  entitled  to  superior 
praise,  1 should  certainly  decide  in  favour 
of  this  gentleman’s  practice.  I have  seen  it 
most  successful  myself,  and  I h ins  it  highly 
spoken  of  by  numerous  professional  frie. ids, 
in  whose  unprejudiced  judgment  i place 
much  reliance. 

Mr.  Baynton  acquaints  us,  that  the  means 
proposed  by  him  will  be  found,  in  most  in- 
stances, sufficient  to  accomplish  cures  in 
the  worst  cases,  without  pain  or  confine- 
ment. After  having  been  repeatedly  disap- 
pointed in  the  cure  of  old  ulcers,  Mr. 
.Baynton  determined  on  bringing  their  edges 
' nearer  together  by  means  of  slips  of  adhesive 
plaster.  To  this  he  was  chiefly  led,  from 
having  frequently  observed,  that  the  proba- 
bility of  an  ulcer  continuing  sound,  depend- 
ed much  on  the  size  of  the  cicatrix  which 
remained  after  the  cure  appeared  to  be  ac- 
complished ; and  from  well  knowing  that 
the  true  skin  was  a much  more  substantial 
support  and  defence,  as  well  as  a better  co- 
vering than  the  frail  one,  which  is  obtained 
by  the  assistance  of  art.  But  when  he  had 
recourse  to  the  adhesive  plaster,  with  a view 
to  lessen  the  probability  of  those  ulcers 
breaking  out  again,  he  little  expected  that 
an  application  so  simple  would  prove  the 
easiest,  most  efficacious,  and  most  agreea- 
ble means  of  treating  ulcers. 

Although  the  first  cases  in  which  Mr. 
Baynton  tried  this  practice,  were  of  an  un- 
favourable nature,  yet  he  had  soon  the  sa- 
tisfaction to  perceive  that  it  occasioned  very 
little  pain,  and  materially  accelerated  the 
cure,  while  the  size  of  the  cicatrices  were 
much  less  than  they  would  have  been,  had 
the  cures  been  obtained  by  any  of  the  com- 
mon methods. 

At  first,  however,  the  success  was  not 
quite  perfect ; as,  in  many  instances,  he  was 
not  able  to  remove  the  slips  of  plaster,  with- 
out removing  some  portion  of  the  adjacent 
skin,  which,  by  occasioning  a new  wound, 
proved  a disagreeable  circumstance  in  a 
part  so  disposed  to  inflame  and  ulcerate,  as 
that  in  (he  vicinity  of  an  old  sore.  He 
therefore  endeavoured  to  obviate  that  in- 
convenience by  keeping  the  plasters  and 
bandages  well  moistened  with  spring-water, 
for  some  time,  before  they  were  removed 
from  the  limb.  He  had  soon  the  satisfaction 
to  observe,  that  the  inconvenience  was  not 
only  prevented,  but  that  every  succeeding 
case  justified  the  confidence  he  non'  began 
to  place  in  the  remedy.  He  also  discover- 
ed, that  moistening  the  bandages  was  attend- 
ed with  advantages  which  he  did  not  ex- 
pect : while  the  parts  were  wet  and  cool, 
the  patients  were  much  more  comfortable, 
and  the  surrounding  inflammation  was  soon- 
er removed,  than  he  had  before  observed  it 
to  be. 

By  the  mode  of  treatment  here  recom- 
mended, Mr.  Baynton  found  that  the  dis- 
charge was  lessened,  the  offensive  smell 
Ye  moved,  and  the  pain  abated  in  a very- 


short  time.  But,  besides  these  advantages, 
he  also  found  that  the  callous  edges  were 
in  a few  days  level  with  the  surface  of  the 
sore  ; that  the  growth  of  fungus  was  pre- 
vented, and  the  necessity  of  applying  pain  - 
ful escharotics  much  lessened,  if  not  entirely 
done  away.  Mr.  Baynton  gives  the  follow- 
ing description  of  his  method. 

The  parts  should  be  first  cleared  of  the 
hair,  sometimes  found  in  considerable  quan- 
tities upon  the  legs,  by  means  of  a razor, 
that  none  of  the  discharges,  by  being  retain- 
ed, may  become  acrid,  and  inflame  the 
skin,  and  that  the  dressings  may  be  remo- 
ved with  ease  at  each  time  of  their  renewal, 
which,  in  some  cases  where  the  discharges 
are  very  profuse,  and  the  ulcers  very  irrita- 
ble, may  perhaps  be  necessary  twice  in  the 
twenty-four  hours,  but  which  I have,  in 
every  instance,  been  only  under  the  neces- 
sity of  performing  once  in  that  space  of 
time. 

u The  plaster  should  be  prepared  by 
slowly  melting,  In  an  iron  ladle,  a sufficient 
quantity  of  litharge  plaster,  or  diachylon, 
which,  if  too  brittle  when  cold,  to  adhere, 
may  be  rendered  adhesive  by  melting  half 
a dram  of  resin  with  every  ounce  of  the 
plaster:  when  melted  it  should  be  stirred 
till  it  begins  to  cool,  and  then  spread  thinly 
upon  slips  of  smooth  porous  calico^  of  a 
convenient  length  and  breadth,  by  sweep- 
ing it  quickly  from  the  end  held  by  the 
left  hand  of  the  person  who  spreads  it,  to 
the  other,  held  firmly  by  Another  person, 
with  the  common  elastic  spatula  used  by 
apothecaries ; the  uneven  edges  must  be 
taken  ofF,  and  the  pieces  cut  into  slips  about 
two  inches  in  breadth,  and  of  a length  that 
will,  after  being  passed  round  the  limb, 
leave  an  end  of  about  four  or  five  inches. 
The  middle  of  the  piece  so  prepared  is  to 
be  applied  to  the  sound  part  of  the  limb, 
opposite  to  the  inferior  part  of  the  ulcer,  so 
that  the  lower  edge  of  the  plaster  may  be 
placed  about  an  inch  below  the  lower  edge 
of  the  sore,  and  the  ends  drawn  over  the 
ulcer  with  as  much  gradual  extension  as 
the  patient  can  well  bear;  other  slips  are 
to  be  secured  in  the  same  way,  each  above 
and  in  contact  with  the  other,  until  the 
whole  surface  of  the  sore  and  the  limb  are 
completely  covered,  at  least  one  inch  be- 
low, and  two  or  three  above  the  diseased 
part. 

il  The  whole  of  the  leg  should  then  be 
equally  defended  with  pieces  of  soft  calico, 
three  or  four  times  doubled,  and  a bandage- 
of  the  same,  about  three  inches  in  breadth, 
and  four  or  five  yards  in  length,  or  rather 
as  much  as  will  be  sufficient  to  support  the 
limb  from  (he  toes  to  the  knee,  should  be 
applied  as  smoothly  as  can  be  possibly  per- 
formed by  the  surgeon,  and  with  as  much 
firmness  as  can  be  borne  by  the  patient, 
being  first  passed  round  the  leg  at  the  ankle 
joint,  then  as  many  times  rotnid  the  foot  ns 
will  cover  and  support  every  part  of  it,  ex- 
cept the  toes,  and  afterward  up  the  limb  till 
it  reaches  the  knee,  observing  that  each 
turn  of  the  bandage  should  have  its  lower 


ULCERS 


edge  so  placed  as  to  be  about  an  inch  above 
the  lower  edge  of  the  fold  next  below. 

“ If  the  parts  be  much  inflamed,  or  the 
discharge  very  profuse,  they  should  be  well 
moistened,  and  kept  cool  with  cold  spring- 
water,  poured  upon  them  as  often  as  the 
heat  may  indicate  to  be  necessary,  or  per- 
haps at  least  once  every  hour.  The  patient 
may  take  what  exercise  he  pleases,  and  it 
will  be  always  found  that  an  alleviation  of 
his  pain  and  the  promotion  of  his  cure  will 
follow  as  its  consequence,  though  under 
other  modes  of  treating  the  disease,  it  aggra- 
vates the  pain,  and  prevents  the  cure. 

u These  means,  when  it  can  be  made 
convenient,  should  be  applied  soon  after 
rising  in  the  morning,  as  the  legs  of  persons 
affected  with  this  disease  are  then  found 
most  free  from  tumefaction,  and  the  advan- 
tages will  be  greater  than  when  they  are 
applied  to  limbs  in  a swollen  state.  But  at 
whatever  time  the  applications  be  made, 
or  in  whatever  condition  the  parts  be  found, 
I believe  it  will  always  happen  that  cures 
may  be  obtained  by  these  means  alone, 
except  in  one  species  of  the  disease  which 
seldom  occurs,  but  that  will  hereafter  be 
described.  The  first  application  will  some- 
times occasion  pain,  which,  however,  sub- 
sides in  a short  time,  and  is  felt  less  sensibly 
at  every  succeeding  dressing.  The  force 
with  w'hich  the  ends  are  drawn  over  the 
limb  must  then  be  gradually  increased,  and 
when  the  parts  are  restored”  to  their  natural 
state  of  ease  and  sensibility,  which  will  soon 
happen,  as  much  may  be  applied  as  the  ca- 
lico will  bear,  or  the  surgeon  can  exert ; 
especially  if  the  limb  be  in  that  enlarged 
and  compressible  state  which  has  been  de- 
nominated the  scorbutic,  or  if  the  edges  of 
the  wound  be  widely  separated  from  each 
other.” 

Mr.  Baynton  afterward  takes  notice  of 
the  breaking  of  the  skin  near  the  ulcers  ; a 
circumstance  which  sometimes  proved  trou- 
blesome, and  arose  partly  from  the  mecha- 
nical effect  of  the  adhesive  plasters,  and 
partly  from  the  irritating  quality  of  the 
plaster.  Mr.  Baynton,  however,  only  con- 
siders such  sores  of  serious  consequence 
when  they  are  situated  over  the  tendon  of 
Achilles,  in  which  situation  they  are  some- 
times several  weeks  in  getting  well.  This 
gentleman  recommends,  with  a view  of 
preventing  these  ulcers,  a small  shred  of 
soft  leather  to  be  put  under  the  adhesive 
plaster. 

Mr.  Baynton  next  adds,  “that  cures  will 
be  generally  obtained  without  difficulty  by 
the  mere  application  of  the  slips  and  band- 
age ; but  when  the  parts  are  much  inflamed, 
and  the  secretions  great,  or  the  season  hot, 
the  frequent  application  of  cold  water  will 
be  found  a valuable  auxiliary,  and  may 
be  always  safely  had  recourse  to  where  the 
heat  of  the  part  is  greater  than  is  natural, 
and  the  body  free  from  perspiration.”  (See 
•fl  Descriptive  Account  of  a new  Method  of 
treating  old  Ulcers  of  Ike  Legs.  Edit.  2, 
I;  1799.) 

ftne  circumstance,  strongly  in  favour  of 


520 

the  advantages  of  the  foregoing  mode  of 
treatment  deserves  particular  notice:  when 
M.  Roux  lately  visited  the  London  Hospi- 
tals, he  had  for  the  first  time  an  opportunity 
of  seeing  this  practice,  which  had  never 
been  tried  in  France.  The  plan  appeared 
to'  him  so  different  from  every  thing  which, 
he  had  been  accustomed  to  see  in  his  own 
country,  where  ulcers  were  almost  alwavs 
treated  by  rest  in  an  horizontal  posture,  and 
emollient  applications,  that  he  left  London 
somewhat  prejudiced  against  the  new  me- 
thod. Subsequently  to  his  return  to  Paris, 
however,  he  has  given  it  a fair  trial,  and 
experience  has  now  entirely  changed  his 
opinion,- as  he  has  had  the  candour  to  ac- 
knowledge. (See  Relation  d’un  Voyage  fait 
a Londres  en  1814,  ou  Par  allele  de  la  Chi - 
rurgie  Angloise  avec  la  Chirurgie  Francoisrit 
par  P.  J.  Roux,  p.  159.) 

OF  ULCERS  ATTENDED  WITH  SOME  SPECIFIC 

DISEASED  ACTION,  EITHER  CON5TITC- 

TIOSAL,  OR  LOCAL. 

1 . Ulcers  which  yield  to  Mercury. 

Here  we  shall  exclude  from  considera- 
tion venereal  ulcers,  as  this  subject  is  treat- 
ed of  in  the  article  Venereal  Disease.  At 
present  we  shall  only  notice  such  sores  as 
are  produced  by  other  diseases  of  the  gene- 
ral system,  or  of  the  parts,  aud  are  capable 
of  being  cured  by  mercury. 

Perhaps  there  is  no  greater  source  of 
error  in  the  whole  practice  of  surgery,  than 
the  supposition  that  a sore,  when  it  yields 
to  mercury,  must  be  of  a syphilitic  nature. 
Surgeons,  however,  who  run  into  this  ab- 
surdity. can  hardly  be  imagined  to  be  una- 
ware that  so  potent  a medicine  must  have 
effects  on  numerous  diseases  of  very  differ- 
ent descriptions.  Sir  E.  Home  accurately 
remarks,  that  many  ulcers  unconnected 
with  the  venereal  disease,  which  receive  no 
benefit  from  other  medicines,  heal  under  a 
mercurial  course,  or  yield  to  mercurial  ap- 
plications. Insome  cases, the  ulcer  remains 
in  the  same  state,  w hile  mercury  is  used  : 
but  begins  to  look  better  as  soon  as  the  me- 
dicine is  discontinued,  in  consequence  of 
the  beneficial  change  produced  in  the  sys- 
tem by  the  mercurial  course.  In  these 
cases  mercurial  frictions  are  the  best,  be- 
cause they  occasion  least  impairment  of 
the  constitution,  in  consequence  of  the 
stomach  continuing  undisturbed,  and  capa- 
ble of  digesting  welt. 

Another  description  of  ulcers,  noticed  by 
SirE.  Home  as  derivingbenefit  from  mercu- 
ry, occur  on  the  instep  and  foot,  have  a very 
thickened  edge,  and  are  attended  with  a dis- 
eased state  of  the  surrounding  skin,  so  as 
to  bear  some  resemblance  to  elephantiasis. 
They  are  frequently  observed  affecting  ser- 
vants who  live  in  opulent  families  in  an  in- 
dolent and  luxurious  way.  Sir  E.  Home 
states,  that  fumigations  with  hydrargyrus' 
sulphuratus  ruber  heal  these  ulcers,  and  re- 
solve in  a great  degree  the  swelling  of  the 
surrounding  parts.  In  some  instances,  an 
ointment  of  calomel  and  hog’s  lard  : In 


b26 


ULCERS. 


others,  the  camphorated  weak  mercurial 

ointment,  is  the  best  application. 

Many  diseased  ulcers,  particularly  those 
of  a superficial  kind,  with  a thickened  edge, 
may  be  healed  when  they  are  dressed  with 
a solution  of  one  grain  of  the  hydrargyrus 
muriatus  in  an  ounce  of  water  containing  a 
little  spirit. 


heals,  while  the  skin  beyond  is  in  a slate  of 
ulceration. 


2.  Ulcers  curable  by  Hemlock. 

Sir  E.  Home  places  more  reliance  on 
hemlock  as.  an  external  than  an  internal 
remedy  for  ulcers.  The  ulcers  which  usually 
receive  benefit  from  hemlock  applications, 
look  like  those  of  an  irritable  sort ; but  the 
surrounding  parts  are  thickened  in  conse- 
quence of  some  diseased  action.  Such 
sores  occur  near  the  ankle,  which  joint  is  at 
the  same  time  enlarged.  Spmetknes,  but 
not  so  often,  they  take  place  over  the  ligd* 
ments  of  the  knee.  On  account  of  their 
situation,  and  the  swelling  of  the  joint, 
they  may  be  suspected  to  be  scrofulous, 
though  they  are  more  sensible  than  stru- 
mous ulcers  usually  are.  The  sores  just 
described  are  rendered  less  painful,  their 
diseased  disposition  is  checked,  and  the 
swelling  of  the  joint  diminished,  by  hem- 
lock Several  irritable  scrofulous  ulcers 
are  also  particularly  benefited  by  this  me- 
dicine.” , . . * 

SirE.  Home  gives  the  preference  to  hem- 
lock poultices,  unless  their  weight  should 
be  objectionable,  in  which  case  he.  advises 
lint  to  be  dipped  in  a decoction  of  the  herb, 
and  put  on  the  s<»re.  . . 

Of  the  ointment  made  with  the  inspissa- 
ted juice,  Sir  E.  Home  says  but  little  in 
regard  to  its  efficacy. 


3.  Ulcers  curable  by  Sail- Water. 

Sir  E.  Home  takes  notice  of  other  specific 
ulcers  which  yield  to  this  application,  alter 
resisting  oilier  remedies.  Foultices,  made 
■with"  sea-water,  are  often  employed  ; but 
this  .gentleman  seems  to  prefer  keeping  the 
part  immersed  in  the  wafer  in  a tepid  state, 
about  a quarter  of. an  hour,  twice  a day. 

When  sea-water  poultices  bring  out  pim- 
ples in  cases  of  scrofulous  ulcers  on  the 
jeer/  and  feet,  Sir  E.  Home  informs  us  that 
this  disagreeable  circumstance  may  be  ob- 
viated by  diluting  such  water  with  an; equal 
quantity  of  a decoction  of  poppies.  After 
a time,  the  salt  water  may  be  tried  by  itself 
again.  While  each  fresh  poultice  is  prepa- 
ring, the  part  should  also  be  immersed  in 
such  water  wanned. 

When  there  is  a tendency  to  anasarca,  or 
when  there  is  an  unusual  coldness  in  the 
limb,  unattended  with  any  propensity  to 
mortification,  tepid  salt-water  may  be  used 
with  infinite  advantage. 


wane  uiv.  v' > " — - 

becomes  larger  and  larger.  Tne  discharge 
consists  of  a thin,  acrid  fluid,  which  seems 


CUiisiais  KJI  7.  , 

to  have  a great  share  in  making  the  disease 
spread. 

For  all  the  three  preceding  diseases,  a so- 
lution of  the  argentum  nitratum  is  strongly 
recommended  by  Sir  E.  Home. 


Of  this  description  are,  a leprous  eruption, 
mostly  seen  in  men  impressed  in  Ireland  ; 
a disease  of  the  skin  induced  by  buboes, 
which  have  continued  a great  while  after 
the  venereal  virus  has  been  destroyed  ; and 
the  ringworm. 

All  these  diseases  are  most  easily  cured 
by  applying  to  them  a solution  ot  the  argen- 
tum nitratum. 

The  leprous  eruption  is  communicated  by 
contact,  and  makes  its  appearance  in  the 
form  of  a boil.  This  is  converted  into  an 
ulcer,  which  discharges  a fetid  fluid,  by 
which  the  surrounding  skin  is  excoriated, 
and  the  ulceration  is  extended  over  a large 
surface.  The  pain  is  the  most  severe,  and 
the  discharge  greatest,  in  hot  weather.  The 
parts  first  diseased  heal,  while  others  are 
becoming  ulcerated,  and  the  disease  is 
always  rendered  worse  by  spirituous  liquors, 
salt  provisions,  and  catching  cold. 

Sir  E.  Home  remarks,  that  the  disease  in 
the  skin,  produced  by  the  effects  of  very  irri- 
table buboes,  in  constitutions  broken  down 
by  mercury,  is  attended  with  ulceration  of  a 
more  violent,  deep,  and  painful  kind,  than 
the  foregoing  distemper.  The  progress  of 
tli is  disorder  is,  in  other  respects,  very  simi- 
lar to  that  of  the  leprous  eruption. 

Although  the  ringworm  only  occurs  in  the 
form  of  an  ulcer  in  warm  climates,  a mild 
species  of  the  affection  takes  place  in  sum- 
mertime in  this  country.  It  seems  to  be 
infectious ; though  it  .often  occurs  without 
infection.  It  commences  with  an  efflores- 
cence, which  is  attended  with  very  trivial 
swelling,  and  spreads  from  a central  point. 
The  circumference  of  the  efflorescence  be- 
comes raised  into  a welt,  while  the  rest 
assumes  a scurfy  appearance.  The  welt  be- 
comes covered  with  a scab,  which  falls  off', 
and  leavef  an  ulcerated  ring,  in  general,  not 
more  thah  a quarter  of  an  inch  wide.  The 
outer  bargin  of  this  ring  continues  to  ulcerate, 
while  the  inner  one  heals,  so  that  the  circle 


4.  Ulcers  curable  by  Ike  Argentum  Mtrajum . 

SirE  Home  notices,  under  this  head,  an 

'ulcer  which  does  not  penetrate  more  deeply 
than  the  cutis,  hut  spreads  in  all  directions, 
producing  ulceration  on  the  surface  of  the 
skin,  and  often  extending  nearly  through  its 
whole  thickness.  The  part,  first  affected 


5.  Ulcers  which  yield  to  Arsenic. 

Thesores.  which  comeunderthe  definition 
of  noli  me  tangere  or  lupus,  derive  great 
benefit  from  this  powerful  remedy.  SirE. 
Home  observes,  that  they  are  nearly  allied 
to  cancer,  differing  from  it  in  not  contamina- 
ting'the  neighbouring  parts  by  absorption, 
and  only  spreading  by  immediate  contact. 

From  some  cases,  which  tell  under  Sir  E 
Home’s  observation,  he  discovered,  that  ar- 
senic was  not  only  efficacious  as  an  external,, 
but  also  as  an  internal  remedy.  1 shall  not 
unnecessarily  enlarge  upon  tins  subject  m 
the  present  place,  as  the  reader  may  refer  to 
the  articles  Arsenic , Cancer,  Lupus,  Hospital 
Gangrene.  &c.  for  additional  information  rc 


ULCEUS. 


Native  to  the  uses  of  this  mineral  in  the  prac- 
tice of  surgery. 

Sir  E.  Home  is  an  advocate  for  its  employ- 
ment, both  internally  and  externally,  tor 
ulcers  of  untoward  appearance  on  the  legs. 
The  fungated  ulcer  is  particularly  pointed 
out  by  this  gentleman  as  being  benefited  by 
arsenic.  This  ulcer  occurs  on  the  calf  of  the 
leg,  and  on  the  sole  of  the  foot.  From  its 
surface,  a fungus  shoots  out,  which  is  entire- 
ly different  from  common  granulations,  'lhe 
neo -formed  substance  is  radiated  in  its 
structure,  the  bottom  of  the  ulcer  being  lhe 
central  point, and  the  external  surface,  which 
is  continually  increasing,  the  circumference. 
The  substance  of  this  fungus  is  very  tender, 
and  readily  bleeds.  The  first  stage  of  the 
•disease  sometimes  has  the  appearance  of  a 
scrofulous  affection  of  the  metatarsal  bones; 
but  the  parts  seem  more  enlarged,  and,  when 
the  skin  ulcerates,  a fungus  shoots  out.  and 
betrays  the  nature  of  the  case. 

One  species  of  the  fungated  ulcer  is  capa- 
ble of  contaminating  the  lymphatic  glands  ; 
the  other  is  not  so.  The  first  is  represented 
by  Sir  E.  Home  as  being  incurable  by  arsenic, 
or  any  other  known  medicine. 

The  second  yields  to  this  remedy.  Sir  E. 
Home  uses  a saturated  solution  made  by 
boiling  white  arsenic  in  water,  for  several 
hours,  in  a sand  heat.  He  gives  from  three 
to  ten  drops  internally  ; and,  for  outward 
use,  dilutes  a dram  with  two  pints  of  water, 
making  it  afterward  gradually  stronger  and 
stronger,  till  it  is  of  double  strength.  The 
application  may  either  be  made  in  the  form 
of  a poultice,  or  of  lint  dipped  in  the  lotion. 

The  best  and  safest  preparation  of  ar- 
senic, both  for  internal  and  external  use,  is 
the  kali  arsenicatum  The  mode  of  em- 
ploying it  may  be  learnt  by  turning  to  the 
articles  Arsenic,  Cancer,  Potassa,  Lupus,  kc. 

6.  Ulcers  attended  with  Varicose  Veins. 

A certain  kind  of  ulcer  is  very  apt  to  oc- 
cur on  the  inside  of  the  leg,  and  is  equally 
difficult  to  cure,  and  liable  to  break  out 
, again.  It  has  the  look  of  a mild,  indolent 
sore;  but,  the  branches  and  trunk  of  the 
vena  saphena  are  enlarged,  and  this  varix  of 
the  veins  keeps  the  ulcer  from  healing.  The 
sore  is  seldom  deep,  usually  spreads  along 
the  surface,  and  has  an  oval  shape,  the  ends 
of  which  are  vertically  situated.  There  is  a 
pain  affecting  the  limb  rather  deeply,  extend- 
ing up  in  the  course  of  the  veins,  and  exas- 
perated by  keeping  the  leg  a long  while  in  an 
i erect  posture. 

This  is  a kind  of  ulcer,  which  derives 
immense  benefit  from  a light  roller,  applied 
from  the  toes  totbe  knee,  although  the  direct 
operation  of  the  pressure  of  the  bandage  on 
the  sore  is  itself  productive  of  no  particular 
good. 

Sir  E.  Home  found,  however,  that  many 
patients  could  not  bear  to  w'ear  laced  stock- 
ings, or  tight  bandages,  and  that  others 
received  no  relief  from  them.  Hence,  this 
gentleman  was  led  to  consider  what  else  could 
be  done  for  the  cure  of  the  varicose  state 
of  the  veins.  He  represent?,  that,  in  con- 


02? 

sequence  of  the  size  of  the  vena  saphena, 
and  its  numberless  convolutions,  the  return 
of  blood  from  the  smaller  branches  is  so  im- 
peded, as  to  retard  the  circulation  in  the. 
smaller  arteries,  and  to  interfere  with  their 
action  in  forming  healthy  granulations.  The 
coats,  and  valves  of  the  veins  also  become 
thickened,  so  that  the  latter  parts  (the  valves) 
do  not  do  their  office  of  supporting  the  weight 
ot  the  column  of  blood. 

These  reflections  induced  Sir.  E.  Home  to 
think,  that  some  benefit  might  be  obtained 
by  taking  off  a part  of  the  pressure  of  this 
column  of  blood,  by  making  a ligature  round 
the  vena  saphena,  where  this  vessel  passes 
over  the  knee  joint.  Thus  the  cavity  of  the 
vein  at  this  part  would  be  obliterated,  and  a 
kind  of  artificial  valve  formed. 

This  gentleman  recommended  the  follow- 
ing way  of  performing  the  operation  : “ As 
the  veins  are  only  turgid  in  the  erect  posture, 
the  operation  should  be  performed  while 
the  paiient  is  standing  ; and  if  placed  upon  a 
table,  on  which  there  is  a chair,  the  back  of 
the  chair  will  serve  him  to  rest  upon;  and  he 
will  have  the  knee-joint  at  a very  con- 
venient height  for  the  surgeon.  The*  leg  to 
be  operated  upon  must  stand  with  the  inner 
ankle  facing  the  light,  which  will  expose 
very  advantageously  the  enlarged  vena  sa- 
phena passing  over  the  knee-joint.  While 
the  patient  is  in  this  posture,  if  a fold  of  the 
skin,  which  is  very  loose  at  this  part,  is 
pinched  up  transversely,  and  kept  in  that 
position  by  the  finger  and  thumb  of  the  sur- 
geon, on  one  side,  and  of  an  assistant  on  the 
other,  this  fold  may  be  divided  by  a pointed 
scalpel,  pushed  through  with  the  back  of  the 
knife  toward  the  limb  to  prevent  the  vein 
being  wounded  ; much  in  the  same  way  as 
the  skin  is  divided  in  making  an  issue.  This 
will  expose  the  vein  sufficiently;  but,  there 
is  commonly  a thin  membranous  fascia  con- 
fining it  in  its  situalion  ; and,  when  that  is 
met  with,  the  vein  bad  better  be  laterally 
disengaged  by  the  point  of  the  knife.  This 
is  most  expeditiously  done  by  laying  hold  of 
the  fascia  with  a pair  of  dissecting  forceps, 
and  dividing  it;  for  it  is  difficult  to  cut  upon 
parts,  which  give  little  resistance,  and  there 
is  a risk  of  wounding  the  vein.  After  this  a 
silver  crooked  needle, with  the  pointrounded 
off,  will  readily  force  its  way  through  the 
cellular  membrane  connected  with  the  vein, 
without  any  danger  of  wounding  the  vessel, 
and  carry  a ligature  round  it.  This  part,  or,5 
indeed,  what  may  be  considered  as  the 
whole  of  the  operation,  being  finished,  the 
patient  had  better  be  put  to  bed,  so  as  to 
allow  the  vein  to  be  in  its  easiest  slate,  be- 
fore the  ligature  is  tied,  and  then  a knot  is  to 
be  made  upon  the  vein:  this  gives  some 
pain  ; but  it  is  by  no  means  severe.  The 
edges  of  the  wound  in  the  skin  are  now  to 
be  brought  together  by  sticking-plaster,  ex- 
cept where  the  ligature  passes  out,  and  a 
compress  and  bandage  applied,  so  as  to  keep 
up  a moderate  degree  of  pressure  on  the 
veins,  both  above  and  below  the  part  in- 
cluded in  the  ligature.”  (Home  on  Ulcers  o 
2J)f>.  Edit.  2.) 


lag 


LAG 


It  appears  that  A.  Parc  proposed  and  per- 
formed an  operation,  similar  to  that  des- 
cribed by  Sir  E.  Home.  (The  Works  of  A. 
Parti  translated  by  Johnson  ; folio , p.  319.) 
An  account  of  Mr.  Brodie’s  operation  for  the 
cure  of  varicose  veins,  and  some  additional 
remarks  on  the  treatment  of  ulcers  accom- 
panied with  varices,  will  be  found  in  a 
subsequent  article.  See  Varicose  Veins.  A 
description  of  what  has  sometimes  been 
called  the  hospital  sore , is  given  under  the 
head  of  Hospital  Gangrene. 

For  information  on  the  subject  of  ulcers, 
consult  Michael  Underwood' s Treatise  on  Ulcers 
of  the  Legs,  fyc.  8vo.  Lond.  1783,  and  Surgical 
Tracts:  3d  edit.  1799.  B.  Bell,  A Treatise 
on  the  Theory  and  Management  of  Ulcers , fyc. 
New  edit.  8 vo.  1791  ; and  his  System  of  Sur- 
gery. J.  Meric , Be  Curationibus  Ulcerum 
diffcilium  pretseriim  in  cruribus  obviorvm. 
4to.  Goett.  1776.  Baynton's  Descriptive  Ac- 
count of  a new  Method  of  Treating  Old  Ulcers 
of  the  Legs,  1799,  ed.  2.  8 vo.  Bristol,  1799. 
Whalely's  Practical  Observations  on  the  Cure 
of  Wounds  and  Ulcers  on  the  Legs , without 
rest,  St o.  Lond.  1799.  Practical  Obs.  on  the 
Treatment  of  Ulcers  on  the  Legs,  to  which  are 
ad^ed,  some  Observations  on  Varicose  Veins 
and  Piles,  by  Sir  Ererard  Home,  1801,  edit. 
2.  Principles  of  Surgery,  by  John  Bell,  Vol.  1. 
1801.  Hunter  on  the  Blood,  Inflammation,  fyc. 
C.  Curtis,  An  Account  of  the  Diseases  of  In- 
dia, fyc.  with  Observations  on  Ulcers  and  the 
Hospital  Sores  of  that  country,  fyc.  8 vo.  Edinb. 
1807.  Brodie  on  the  Treatment  of  Varicose 
Veins  of  the  Legs,  in  Med.  Chir.  Trans.  Vol. 
7,  P 195,  <U-  Bicker  and,  Nosographie  Ckir. 
T.  1,  p.  121,4 re.  ed.  4.  Boyer,  TraiU  des 
Maladies  Chir.  T.  2,  p.  365.  fyc.  Paris,  1S15. 
Roux,  Voyage  fait  a Londres  en  IS  14,  ou  Pa- 
rallelc de  la  Chirurgie  Angloise  avec  la  Chi- 
rurgie  Franqoise,  p.  142,  fyc.  Paris,  1815.  Dr. 
John  Thomson's  Lectures  on  Inflammation , p. 
423,  fyc.  Edinb.  1813.  Dr.  Dewar  on  the 
Treatment  of  Sinuous  Ulcers , in  Med.  Chir. 
Trans.  Vol.  7,  p.  482,  4 c-  The  stages  of  se- 
veral cutaneous  affections,  attended  with  ulcera- 
tion., have  been  excellently  described  by  Dr. 
Bateman  in  his  valuable  Synopsis  of  Cutane- 
ous Diseases. 

UNGUENTUM  ACIDI  SULPHURIC!. 
— R.  ’Acidi  Sulphurici  3j-  Adipis  Suillce 
pr separata}  j|j. — These  are  to  be  well  mixed 
together  in  a glass  mortar. 

This  ointment  has  been  used  by  Dr.  Dun- 
can, of  Edinburgh,  for  curing  the  itch.  It 
has  the  character  also  of  being  efficacious 
in  the  reduction  of  some  chronic  swellings 
of  the  joints;  and  when  mixed  with  a good 
deal  of  camphor,  it  was  rubbed  upon  the  tu- 
mour, in  cases  of  bronchoceie,  by  Mr.  Nay- 
Ipr,  of  Gloucester,  with  considerable  effect. 

As  the  sulphuric  acid  is  particularly  de- 
structive of  vegetable  substances,  the  parts, 
to  which  this  ointment  is  applied,  should 
always  be  covered  with  flannel,  instead  of 
linen. 

UNGUENTUM  ANTIMQNII  TARTA- 
RS Z ATI. — R,  Antim.  Tart.  3j.  Ung.Cetacei 
■ j.  Misce.  The  nntini.onial  ointment,  fre- 


quently used  for  exciting  irritation  of  the 
skin,  with  the  view  of  relieving  diseases  in 
the  vicinity  of  the  irritated  part,  as  is  exem- 
plified in  the  treatment  of  some  diseases  of 
the  eyes  and  joints,  and  a variety  of  indo- 
lent swellings. 

UNGUENTUM  CETACE1. — R.  Cetacei 
3vj.  Cerae  Albae  3>j-  Oliva?  Olei.  fluid  un- 
cias  tres.  These  are  to  be  melted  upon  a 
slow  fire,  and  then  briskly  stirred  till  cold. 
This  ointment,  spread  on  lint,  serves  as  a 
simple  dressing  for  wounds,  ulcers,  &c. 

UNGUENTUM  CER7E  CUM  ACETO. 
— R-  Cera;  Alba?  |iv.  Olei  Olivse  fbj.  Aceti 
Distillati  ^ij.  The  vinegar  is  to  be  gradu- 
ally mixed  with  the  two  first  ingredients, 
after  these  have  been  melted  together.  Dr. 
Cheston  recommends  this  ointment  for  su- 
perficial excoriations,  cutaneous  eruptions, 
&c. 

UNGUENTUM  CONTI— R.  Foiiorum 
Conii  recentium.  Adipis  Suiliae  praeparatae, 
sing.  ^iv.  The  hemlock  is  to  be  bruised 
in  a marble  mortar,  after  which  the  lard  is 
to  be  added,  and  the  two  ingredients  tho- 
roughly incorporated  by  beating.  Tbey  are 
then  to  be  gently  melted  over  the  fire,  and 
after  being  strained  through  a cloth,  and  the 
fibrous  part  of  the  hemlock  well  pressed, 
the  ointment  is  to  be  stirred  till  quite  cold. 
To  cancerous  Or  scrofulous  sores,  th'13  oint- 
ment may  be  applied'with  a prospect  of  ad 
vantage.  ( Pharm . Chirurg.) 

The  Pharmacopoeia  of  St.  Bartholomew's 
Hospital  directs  the  unguentum  conii,  vel 
cicutae,  to  be  made  as  follows: — R.  Foiio- 
rum Cicutae  fbj.  Adipis  Suiliae  ftjiss.  Boil 
the  leaves  in  the  melted  hog’s-Iarct  until  they 
become  crisp.  Then  strain  the  ointrnent- 
A similar  ointment  might  be  more  conve- 
niently made,  by  mixing  the  extraction  conii 
with  anv  common  salve. 

UNGUENTUM  DIGITALIS.— R.  Fo 

liorum  Digitalis  Purpureae  recentium.  Adi- 
pis Suiliae  praparatie,  sing.  ^iv.  This  oint- 
ment may  be  made  in  the  same  manner  as 
the  unguentum  conii,  and  tried  in  the  same 
cases. 

UNGUENTUM  ELEMI  COMPOSITUM. 
— R.  Elemifbj  Terebinthinae  ^x.  Sevi 
Ovilli  praeparati  ft>ij.  Olei  Olivae  ^ij.  Melt 
the  elemi  with  the  suet ; remove  them  from 
the  fire,  and  mix  them  immediately  with 
the  turpentine  and  oil.  Then  strain  the 
mixture. — Sometimes  employed  for  dressing 
ulcers,  which  stand  in  need  of  stimulating 
applications. 

UNGUENTUM  GALL/E  CAMPHORA- 
TUM. — R.  Gall  arum  Pulveris  Submission 
3 *j • Camphorae  3ss.  Adipis  Suilla?  prrnpii- 
ratae  ^ij.  Misce. — This  is  a very  good  ap- 
plication to  piles,  after  their  inflammatory 
state  has  been  diminished  by  the  liq.plumbi. 
acet.  dibit,  and  leeches. 

UNGUENTUM  HELLEBORl  ALBL— 
R.  Hellebore  Albi  pulv.  gj.  Adipis  Suiliae 
praeparata?  t-iv.  Olei  Limonis  3ss.  Misce. 
This  ointment  will  cure  the  itch,  and  several 
other  cutaneous  diseases.  Tinea  capitis  will 
sometimes  vield  to  it' 


UNO 


UNO 


629 


* UNGUENTUM  HYDRARGYRI  FOR- 
TIUS.— JJ,.  Hydrargyri  purificati  Jfoij.  Adi- 
pis  Suilla1  pracparafa?  gxxiij.  Sevi  Ovilli 
pfaeparati  !$j.  First  rub  the  quicksilver  with 
the  suet,  and  a little  of  the  hog’s-lard,  until 
the  globules  disappear ; then  add  the  remain- 
der of  the  lard,  and  make  an  ointment. — 
This  is  the  common  slrong  mercurial  oint- 
ment. Of  its  uses  we  need  say  nothing  in 
this  place. 

UNGUENTUM  HYDRARGYRI  CAM- 
PHORATUM. — R.  Unguent i Hydrargyri 

^j-  Camphorae  3SS-  Misce. — This  is  often 
recommended  to  be  rubbed  on  thickened, 
indurated  parts,  with  the  view  of  exciting 
the  action  of  the  absorbents.  Rubbed 
along  the  course  of  the  urethra,  it  is  very 
serviceable  Jn  diminishing  and  removing 
chordee. 

UNGUENTUM  HYDRARGYRI  MI- 
TIUS. — R.  Unguenti  Hvdrargyri  fort.  Rjj. 
Adipis  Suilla?  pra?parata?  ffoij.  Misce. — The 
weaker  mercurial  ointment  is  often  rubbed 
on  indurated,  thickened  parts  and  tumours, 
when  the  object  is  merely  to  promote  their 
absorption;  and  it- is  not  adviseable  to  em- 
ploy the  unguentum  hydrargyri  fort,  lest  a 
salivation  should  be  induced. 

UNGUENTUM  HYDRARGYRI  N1TRA- 
TCS. — R.  Hydrarg.  Purificati  Jj.  Acidi 

Nitrosi  Zij.  Adipis  praeparata?  ^ v j . Ole; 
Oliva?  ^iv.  Dissolve  the  quicksilver  in  the 
nitrous  acid  ; and  whilst  the  solution  is  yet 
hot,  mix  with  it  the  oil  and  hog’s  lard,  pre- 
viously melted,  but  beginning  to  concrete, 
by  being  exposed  to  the  air.  This  ointment 
is  a celebrated  application  to  the  inside  of  the 
eyelids,  in  cases  of  chronic  ophthalmy,  and 
also  to  specks  on  the  cornea?  When  blend- 
ed with  a little  olive  oil,  it  also  forms  a very 
eligible  stimulating  dressing  for  numerous 
kinds  of  sores.  It  is  particularly  efficacious 
in  curing  tinea  capitis,  and  many  other  cuta- 
neous diseases. 

UNGUENTUlM  HYDRARGYRI  NITKI- 
CO-OXYDI. — R.  Hydrargyri  nitrico-oxydi 
-p.  Cera?  Albas  ^ij.  Adipis  prrnpar.  ^vj. 
Misce. — This  is  a common  stimulating  ap- 
plication to  indolent  ulcers,  and  sores  in  ge- 
neral. 

UNGUENTUM  HYDRARGYRI  PRiC- 
CI  PIT  ATI  ALBI  — R.  Hvdrarg.  Prcemp. 
Albi  3j-  Adipis  prajparatae  ?iss.  Misce. — 
An  useful  application  in  certain  cases  of  por- 
rigo,  and  some  other  cutaneous  diseases. 
See  Porrigo. 

UNGUENTUM  LIQ.  PLUMBI  ACETA- 
TIS. — R.  Liquoris  Plumbi  Acetatis  ^v. 

Adipis  Suilla?  fbj-  Cerae  Aibae  Z\v.  Melt 
the  ingredients  together,  and  continue  to 
stir  them  till  cold. — This  ointment  is  em- 
ployed with  great  advantage  as  a simple 

*The  preparation  of  this  article  will  be  greatly  expe- 
dited by  rubbing  the  mercury  in  the  first  instance,  with 
a small  proportion  of  the  article  familiar  to  us  by  the 
appellation  of  goose-grease;  this  can  be  done  in  a glass 
mortar,  or  even  upon  a marble  slab,  by  a spatula;  it 
has  such  immediate  effect  upon  the  mercury.  One  ounce 
of  this  article  will  be  sufficient,  with  trituratiw  for  the 
space  of  one  minute,  to  make  the  globules  of  the  quirk- 
silver  entirely  disappear,  and  render  it  at  once  fit  for 
admixture  with  the  proper  proportion  of  lard. — Am. Ed, 

Vnj, . jr  ft? 


dressing.  According  to  Mr.  Dunn,  of  Scar- 
borough, it  is  much  improved  by  pouring 
the  liquified  mixture,  before  the  lead  has 
been  added  to  it,  into  cold  water.  It  is 
then  to  be  rubbed  in  a mortar,  or  on  a 
slab  with  the  liq.  plumbi  acet.  The  water 
occasions  a fine  white  cloudy  precipitation, 
which  gives  to  the  composition  abetter  ap- 
pearanc*1. 

UNGUENTUM  OPHTH  ALMICUM.— ft. 
Adipis  Suilla?  praeparatae  |s«.  Tutiae  praepa 
rata?,  Bol  Armen,  sing.  3'j-  Praecip.  Hy- 
drarg. Albi  3j.  Misce. — Janin’s  celebrated 
ophthalmic  ointment,  frequently  mentioned 
in  the  parts  of  this  work,  which  relate  to  dis- 
eases of  the  eye  and  eyelids. 

UNGUENTUM  OXYGENATUM,  vel 
ACIDI  NITROSI. — R.  Axungia?  Suillae  re 
cenlis;  non  salsa?  uneias  sedecim.  Leni 
calore  in  vase  vilreo  lente  liquefactis  ant  con- 
tiuua  a-itatione  instillentur,  Acidi  Nitrici 
unciae  dua?.  Massa  igni  exponatur,  donee 
ebullire  coepit ; tunc  ab  igne  removeatur,  fri- 
gefactaque  servelur. 

In  this  process  the  nitric  acid  is  decom- 
posed, the  nitrous  gas  escaping,  and  the  oxy- 
gen combining  with  the  lard.  This  oint- 
ment was  particularly  recommended  by  Aly- 
on,as  an  application  to  venereal  and  herpe- 
tic ulcers.  Its  virtues  are  said  to  vary  consi- 
derably, according  to  the  strength  of  the  acid 
employed,  and  it  is  not  generally  deemed  so 
efficacious  as  the  ointment  of  nitrate  of  mer- 
cury. 

UNGUENTUM  PICIS.— ft.  Picis,  Sevi 
Ovilli  prmparati,  sing.  ftss.  Melt,  and  then 
strain  them. 

UNGUENTUM  PICIS  COMPOSITUM, 
— R-  Unguenti  Picis,  Unguenti  Plumbi 

Superacetatis  sing.  Rjss.  Misce. 

The  two  preceding  ointments  are  applica- 
ble to  cases  of  tinea  capitis,  and  some  erup- 
tive complaints.  Also  to  some  kinds  of  irri- 
table ulcers. 

UNGUENTUM  PICIS  CUM  SULPHU- 
RE.— R.  Unguenti  Picis,  Unguenti  Sul- 
pburis,  sing,  ^iv,  Misce. — This  is  one  of  the 
most  common,  and,  I believe,  the  most  effi- 
cacious applications  for  curing  tinea  capitis, 
or  porrigo. 

UNGUENTUM  PLUMBI  SUPERACE- 
TATIS.— R.  Plumbi  Superacetatis  3»j*  Cera? 
Alba?  Zij.  Olei  fbss.  The  superacetate  of 
lend,  previously  powdered,  is  to  be  triturated 
with  part  of  the  olive  oil.  Th#  melted  wax 
and  rest  of  the.  oil  are  then  to  be  added.  This 
is  a good  dressing  for  cases  requiring  a mild 
astringent  application. 

UNGUENTUM  RESINiE.— R.  Resina? 
Flavee,  Cerae  Flavae  sing.  ft>j.  Olei  Oliva?  Jbj 
Melt  the  resin  and  wax  with  a slow  fire  ; 
then  add  the  oil,  and  strain  the  mixture  while 
hot. — This  is  a common  application  to  ul- 
cers, which  stand  in  need  of  being  gently  sti- 
mulated. 

UNGUENTUM  SAMBUCI, — ft.  Florum 
Sambuci,  Adipis  Suillae,  singulorum  ft>j. 
The  hag’s  lard  being  melted,  boil  the  elder 
flowers  in  it  till  they  become  crisp,  then 
strain  the  mixture. 

UNGUENTUM  SULPHURIS— R, 


URETHRA 


u&j 

pis  Suilla?  lt>ss.  Florutn  bulphuris  ?iv. 
Misce. 

UNGUENTUM  TUTIjE.— ft.  Tutiac  pnc- 
parata?,  Unguenti  Celacei  q.  s.  Misce.--- 
Used  for  smearing  the  borders  and  inside  of 
the  eyelids,  in  cases  of  chronic  ophtbalmy, 
&c. 

UNGUENUJM  TUTliE  COMPOS1TUM. 
— 15;.  Tuliae  prseparatae,  Lapidis  Cularriinaris 
pra;parati,  sing.  3vj.  Camphorae  3<j-  Un- 
guenti Sambuci  jftj.  Misce. 

This  formula  is  contained  in  the  Pharma- 
copoeia of  St.  Bartholomew’s  Hospital.  It 
is  occasionally  applied  to  the  inside  of  the 
eyelids,  piles,  ulcerations,  excoriations,  Sic. 

^ UNGUENTUM  ZINCl.— ft.  Zinci  oxyrii 
3J.  Adipis  prtepar.  fvj.  Misce. — An  astrin- 
gent application  in  very  common  use. 

UNGUIS.  (A  Nail.)  Some  surgical  au- 
thors apply  this  term  to  a collection  of  pus, 
or  matter  in  the  eye,  when  the  abscess  ap- 
pears, through  the  cornea,  to  be  shaped  like 
a finger  nail. 

UNION  BY  THE  FIRST  INTENTION. 

• — When  the  opposite  surfaces  of  a wound  are 
brought  into  contact,  and  grow  together  at 
once,  without  suppurating,  union  by  the  first 
intention  is  said  to  take  place.  When 
wounds  heal  by  suppurating,  granulating, 
Sic.  they  are  sometiipes  surgically  described 
as  getting  well  by  the  second  intention.  See 
Wounds. 

URETHRA,  DESTRUCTION  OF  PART 
OF  THE. — The  attempts  to  complete  the 
canal  by  operations, .performed  on  theTalia- 
eotian  principles,  will  be  noticed  in  the  arti- 
cle URINARY  FISTULA. 

URETHRA,  STRICTURES  OF.— A stric- 
ture of  the  urethra,  as  a modern  writer  ob- 
serves, “ consists  of  some  morbid  alteration 
of  action,  or  of  structure,  by  which  a part  of 
the  canal  is  rendered  narrower  than  the 
rest.”  ( Wilson  on  the  Malt  ' Urinary  and 
Genital  Organs,  p.  361.)  According  to  Mr. 
John  Hunter,  most  obstructions  to  the  pas- 
sage of  the  urine,  if  not  all,  are  attended 
with  nearly  the  same  symptoms.  Few  per- 
sons take  notice  of  the  first  symptoms  of  a 
stricture,  till  they  have  either  become  vio- 
lent, or  other  inconveniences  have  been  t he 
consequence.  A patient  may  have  a consi- 
derable stricture,  yet  be  unconscious  that  his 
Urine  does  not  freely  come  away;  and  in 
consequence  of  a stricture,  there  may  even 
be  a tendency  to  inflammation  and  suppura- 
tion in  the  perinaeum,  while  he  feels  no  ob- 
struction to  the  passage  of  his  urine,  and 
does  not  suspect  that  he  has  any  other  com- 
plaint. 

There  are  three  kinds  of  strictures  viz. 
the  true  permanent  one,  which  arises  from 
an  alteration  in  the  structure  of  a part  of  the 
urethra  ; the  mixed  case,  consisting  of  a per- 
manent stricture  and  a spasm  ; and,  thirdly, 
the  true  spasmodic  stricture. 

Whether  the  urethra  is  a truly  muscular 
canal,  and  whether  a variety  of  circumstan- 
ces, remarkable  in  its  healthy  and  dieased 
state,  can  be  accounted  for  by  its  elasticity, 
the  action  of  the  muscles  in  the  perinajutn, 
and  other  principles,  without  supposing  tue 


canal  to  be  ilseli  muscular,  are  questions  on 
which  the  writers  on  surgery  entertain  dif- 
ferent opinions.  However,  the  generality  of 
modern  practitioners  in  this  country  have 
inclined  to  that  view  of  the  subject,  which 
refers  the  property  of  muscularity  either  to 
the  membrane  of  the  urethra  itself,  or  to  the 
substance  immediately  surrounding  it.  The 
latter  is  now  alleged  to  be  the  real  case 
“ From  Mr.  Bauer’s  examinations  (says  Sir 
Everard  Home)  we  find  that  the  human 
urethra  is  made  up  of  two  parts,  an  internal 
membrane,  and  an  external  muscular  cover- 
ing. The  internal  membrane  is  exceedingly 
thin,  and  no  fibres  are  met  with  that  can 
give  it  a power  of  contraction.  When  it  is 
put  on  the  stretch  in  a transverse  direction 
the  circumference  of  the  canal  is  no  ways 
increased  ; but  when  stretched  longitudinal- 
ly a small  degree  of  elongation  is  produced 
When  a transverse  section  of  the  urethra  is 
made,  while  in  a collapsed  state,  the  inter- 
nal membrane  is  found  thrown  into  folds, 
pressed  together  by  the  surrounding  parts, 
it  is  afterward  explained,  that  “the  muscu- 
lar covering,  by  which  the  membrane  is 
surrounded  or  enclosed,  is  made  up  of  fasci- 
culi of  very  short  fibres,  which  appear  to  be 
interwoven  together,  and  to  be  connected  by 
their  origins  and  insertions  with  one  another 
They  all  have  a longitudinal  direction.  There 
is  a greater  thickness  of  this  muscular  struc- 
ture upon  the  upper,  than  the  under  surface 
of  the  urethra,  which  is  still  more  evident  as 
it  approaches  nearer  to  the  external  orifice 
The  fasciculi  are  united  together  by  an  elastic 
substance  of  the  consistence  of  mucus.  Im- 
mediately beyond  the  muscular  portion  of 
the  urethra,  is  the  cellular  structure  of  the 
corpus  spongiosum. 

Formerly  “ it  was  believed,  that  either  the 
lining  of  the  urethra  was  composed  of  circu- 
lar fibres,  possessed  of  a power  of  contrac 
tion,  or  that  it  was  immediately  surrounded 
by  such  fibres  ; and  therefore  that  the  dis 
ease,  commonly  known  by  the  name  of  a 
stricture  in  the  urethra,  was  produced  by  a 
contraction  of  some  of  these  circular  fibres  ; 
and  the  permanent  stricture  was  a term  ap- 
plied to  these  parts,  when  in  consequence 
of  inflammation  they  became  confined  to 
that  particular  state.  We  now  find,  that  the 
lining  of  the  urethra  is  never  ?net  with  in  a 
contracted  stale,  but  is  thrown  into  folds  by 
the  action  of  the  elastic  ligamentous  cover- 
ing of  the  corpus  spongiosum,  and  the  swell 
of  the  longitudinal  muscular  fibres  within  it; 
and  when  these  fibres  have,  by  acting 
through  their  whole  length,  reduced  the 
urethra  to  its  shortest  state,  the  pressure 
upon  the  internal  membrane  is  so  great,  that 
there  is  not  room  for  the  urine  to  pass,  till 
these  fibres  are  relaxed  by  elongating  the 
whole  canal. 

“ A spasmodic  stricture  is  in  reality  a con 
traction  of  a small  portion  of  the  longitudinal 
muscular  fibres,  while  the  rest  are  relaxed  , 
and  as  this  may  take  place  either  all  round  , 
or  upon  any  one  side,  it  explains  what  is 
met  with  in  practice,  and  could  not  before 
be  satisfactorily  accounted  for  ; the  mark, 
or  impression  of  a stricture  sometimes  form 


UUETHIU* 


mg  a circular  depression  upon  the  bougie 
at  other  times,  only  on  one  side. 

“ A permanent  stricture  is  that  contraction 
of  the  canal,  which  takes  place,  in  consequence 
of  coagulable  lymph  being  exuded  between  the 
fasciculi  of  muscular  fibres,  and  upon  the  in- 
ternal membrane , in  different  quantities,  ac- 
cording to  circumstances  ; and,  in  the  same 
proportion,  diminishing  the  passage  for  the 
urine  at  that  part,  or  completely  closing  it 
up.  (Sir  Everard  Home  in  Phil.  Trans.  1820, 
and  Pract.  Obs.  on  Strictures , Vol.  3,  p.  20, 
fyc.  Svo.Lond.  1821.) 

For  a particular  detail  of  the  arguments 
and  remarks,  urged  against  the  doctrine  of 
the  urethra  being  a tube,  capable  of  having 
its  diameter  suddenly  lessened  at  every  point 
by  the  contraction  of  muscular  fibres,  1 
must  refer  to  the  writings  of  Mr.  C.  Bell 
and  Mr.  Shaw,  whose  statements,  indeed, 
have  been  noticed  in  my  introductory  work. 
(See  First  Lines  of  the  Practice  of  Surgery, 
cd.  4,  Vol.  2.) 

In  all  obstructions  of  the  urethra,  Mr. 
Hunter  remarks,  that  the  stream  ot  water 
becomes  small  in  proportion  to  the  stop- 
page ; but,  though  this  symptom  is  probably 
the  first,  it  is  not  always  observed  by  the 
patient.  In  some  instances,  the  water  is 
voided  only  by  drops,  and  then  it  cannot 
escape  notice.  In  other  cases,  the  stream 
of  urine  is  forked,  or  scattered.  Under  such 
circumstances,  Mr.  Hunter  recommends  the 
passage  to  be  examined  with  a bougie  ; and, 
if  one  of  a common  size  can  be  readily  in- 
troduced, the  difficulty  of  voiding  the  urine 
is  likely  to  depend  on  a diseased  enlarge- 
ment of  the  prostate  gland,  which  should, 
therefore,  be  examined.  See  Prostate  Gland. 

The  spasmodic  stricture  may  be  known 
by  its  being  only  of  temporary  duration. 
This  kind  of  case,  and  more  particularly  the 
permanent  stricture,  are  generally  attended 
with  a gleet.  The  latter  complaint  is  often 
for  a long  while  suspected  as  being  the  only 
one,  and  the  surgeon  finds  all  his  efforts,  to 
effect  a cure,  fruitless. 

In  diseases  of  the  urethra,  and  also  of  the 
prostate  gland  and  bladder,  there  is  com- 
monly an  uneasiness  about  the  perinajum, 
anus,  and  lower  part  of  the  abdomen. 
(Hunter.) 

The  first  progress  of  the  contraction  is,  in 
general,  very  slow  ; but,  when  once  it  has 
so  far  increased,  that  the  longitudinal  fibres 
are  not  wholly  relaxed  by  the  force  of  the 
urine,  its  subsequent  advances  are  more 
rapid,  and  nevv  symptoms  are  perceived. 
The  urine  is  voided  more  frequently,  ^does 
not  pass  without  a considerable  effort,  at- 
tended with  pain,  and  a straining  sensation 
continues,  after  the  bladder  is  emptied.  If 
the  patient  accidentally  catches  cold,  drinks 
a glass  of  spirituous  liquor,  acid  beverage, 
or  punch,  commits  an  excess  in  drinking 
wine,  or  removes  quickly  from  a wrarm  to  a 
cold  temperature,  the  urine  will,  perhaps, 
pass  only  in  drops,  or  be  entirety  obstructed. 
These  causes  induce,  in  the  longitudinal 
fibres  at  the  contracted  part,  a spasmodic 
action,  by  which  it  fa  closed.  Cold,  exter- 


031 

nally  applied  to  the  body,  has  so  great  an 
effect  upon  a spasmodic  stricture,  that  a 
patient,  who  can  make  water  without  the 
smallest  difficulty  in  a warm  room,  is  often 
quite  unable  to  void  a drop,  on  making  the 
attempt  in  the  open  air.  However,  on  re- 
turning to  a warm  room,  and  sitting  down 
a little  while,  he  becomes  able  again  to 
expel  his  urine.  The  symptoms  of  a stric- 
ture are  more  frequent  in  persons  who  lead 
a sedentary  life,  than  in  those  whose  pur 
suits  are  active. 

Strictures  in  the  urethra,  being  attended 
with  a discharge  and  pain  in  making  water, 
especially  after  any  excess,  are  frequently 
regarded  and  treated  as  a gonorrhoea. 
These  two  symptoms  often  come  on  a few 
hours  after  connexion  w ith  women  ; the 
degree  of  inflammation  is  very  slight ; the 
discharge  is  the  first  symptom,  and  is  more 
violent  at  the  commencement,  than  at  any 
other  period.  The  inflammation  subsides 
in  a few  days,  leaving  only  the  discharge, 
which  also  frequently  disappears  in  five  or 
six  days,  whether  any  means  are  employed 
or  not  for  its  removal.  (Home.) 

What  renders*  a stricture  particularly  apt 
to  be  mistaken  for  a gonorrhoea,  is  the  cir- 
cumstance that,  in  both  diseases,  the  pain 
in  making  water  is  experienced  about  an 
inch  and  a half  from  the  orifice  of  the  glans 
penis. 

In  a more  advanced  stage,  the  part  of  the 
urethra  which  is  the  seat  of  stricture,  is 
always  much  narrower  than  the  rest  of  the 
canal.  The  stricture  is  permanent,  being 
combined  With  a thickening  of  structure, 
whereby  the  diameter  of  the  diseased  part 
of  the  passage  is  lessened.  However,  the 
diameter  of  the  affected  portion  of  the  canal 
even  now  varies,  according  as  the  spasm 
and  projection  of  the  longitudinal  fibres,  the 
spasmodic  action  of  the  muscles  about  the 
peri n am m,  and  the  effects  of  inflammation, 
contribute  more  or  less  1o  a temporary  in- 
crease of  the  obstruction.  In  the  language 
of  Sir  Everard  Home,  the  case  is  now  botli 
a permanent  stricture,  and  a spasmodic  one 
permanent,  because  the  diseased  part  of  the 
urethra  is  always  narrower  than  the  rest  of 
this  passage ; and  spasmodic,  inasmuch  as 
the  stricture  may  be  rendered  still  more 
contracted  by  spasm  affecting  the  muscular 
structure,  adjoining  the  disease.  In  the 
contracted  state  the  passage  is  closed  up 
iu  the  relaxed,  the  urine  can  passthrough  it 
in  a small  stream. 

The  spasmodic  contraction  must  act  with 
considerable  force,  sincQjtyhe  urine  cannot 
even  pass  in  a small  strehm,  and  a small 
bougie,  which,  in  a relaxed  state  of  the  ure- 
thra, met  with  no  resistance,  can  now  be 
scarcely  introduced  at  all.  Also,  if  the 
bougie  be  allowed  to  remain  for  a few  mi- 
nutes in  the  stricture,  it  is  not  unfrequently 
grasped  so  tightly  by  the  spasmodic  con- 
traction, that,  when  an  attempt  is  made  to 
withdraw  it,  some  force  is  requisite  to  suc- 
ceed. The  bougie,  when  examined,  seems 
as  if  it  had  had  an  impression  made  round  it 
by  a piece  of  packthread.  iHomCr.) 


URETHRA. 


in  old  cases  of  stricture*  the  muscular 
coat  of  the  bladder  becomes  thickened  and 
stronger  than  natural,  in  consequence  of 
more  force  being  necessary  to  propel  the 
uiine  through  the  obstructed  part.  The 
bladder,  in  this  thickened  state,  does  not 
admit  of  the  usual  dilatation,  so  that  the 
patient  is  obliged  to  make  water  very  fre- 
quently, and  he  is  unable  to  pass  the  whole 
night  without  making  this  evacuation  once 
or  twice.  (Home.) 

A nocturnal  emission  of  the  semen  is 
another  very  common  symptom  of  a stric- 
ture ; and  some  patients  seem  to  have  no 
other  complaint  attendant  on  the  disease  of 
the  urethra. 

A periodical  discharge  is  sometimes 
brought  on  by  cold,  or  other  occasional 
causes.  When  the  inflammation  extends  to 
the  bladder,  the  frequency  of  making  water 
is  considerably  increased,  and  the  urine  very 
turbid.  It  is  voided  for  twelve,  or  twenty- 
four  hours,  once  or  even  twice  every  hour; 
and,  when  allowed  to  stand,  it  deposits  a 
substance  in  the  form  of  powder,  consisting 
of  coagulable  lymph.  This  is  the  slightest 
kind  of  attack. 

Sometimes  the  bladder  is  inflamed  in  a 
greater  degree,  and  secretes  pus,  which  is 
discharged  with  the  urine.  In  a still  more 
violent  attack,  the  discharge  is  similar  to 
the  white  of  an  egg,  and  particularly  adhe- 
sive. Sir  Everard  Home  states,  that  it  has 
been  discovered  by  examinations  after  death, 
to  be  the  vitiated  secretion  of  the  prostate 
gland.  When  the  inflammation  of  the  blad- 
der becomes  still  worse,  the  afleetion  some- 
times extends  to  the  peritoneum,  and  the 
patient  dies. 

As  strictures  of  long  standing  always  im- 
pede the  passage  of  the  urine,  the  bladder 
acts  with  augmented  force  to  overcome  the 
resistance.  In  this  manner,  the  stricture  is 
kept  in  a continual  state  of  irritation,  and 
the  obstruction  becomes  more  and  more 
considerable. 

In  a few  cases,  indeed,  the  diseased  part 
of  the  urethra  is  rendered  quite  impervious  ; 
and  the  patient’s  life  is  preserved  by  the 
urethra  ulcerating,  at  some  point  within  the 
obstruction,  and  fistulous  openings  taking 
place  in  the  perinseum.  See  Fistula,  in  Pe- 
unao. 

Strictures  are  frequently  attended  with 
constitutional  symptoms,  one  of  the  most 
common  of  which,  in  warm  climates,  is  a 
complete  paroxysm  of  fever.  The  cold  tit 
is  very  severe  ; ***is  is  followed  by  a hot  fit, 
and  then  a very  profuse  perspiration.  Du- 
ring the  rigour,  nausea  and  vomiting  gene- 
rally occur,  and  at  this  period  the  "patient 
has  occasion  to  make  water  frequently,  sel- 
dom experiencing  at  the  same  time  any 
strangury.  When  the  fit  is  tolerably  com- 
plete, the  patient  suiters,  in  general,  only 
one;  in  the  opposite  circumstance,  two  ; 
but  a greater  number  rarely  happen.  Such 
febrile  paroxysms  are  not  frequent  in  cold 
countries  ; but  do  every  now  and  then  take 
place,  particularly  in  consequence  of  expo- 


sure to  cold,  excesses,  and  the  introduction 
both  of  common  and  armed  bougies. 

According  to  the  principles  of  Sir  Everard 
Home,  the  longitudinal  muscular  fibres  on 
the  outside  of  the  membrane  of  the  urethra, 
are  liable  to  a spasmodic  contraction,  in 
which  state  their  swell  lessens  the  diameter 
of  the  passage,  and  they  are  incapable  of 
becoming  relaxed  again,  until  the  spasm  is 
removed.  This  spasmodic  stricture  is  only 
a wrong  action  of  these  longitudinal  fibres; 
and,  if  the  parts  could  be  examined  in  their 
relaxed  state,  there  would  be  no  appearance 
of  disease. 

When  the  contraction  is  not  considerable, 
it  appears,  on  examination  after  death,  to 
be  merely  a narrowing  of  the  urethra  ; but  a 
permanent  stricture,  in  a more  advanced 
state,  usually  consists  of  a ridge,  which 
forms  a projection  in  the  passage.  (Home.) 

Mr.  Hunter  informs  us,  that  the  disease 
generally  occupies  no  great  length  of  the 
passage  ; at  least,  that  this  was  the  case  in 
most  of  the  instances  which  he  examined. 
In  these  cases,  the  contraction  was  not 
broader,  than  if  it  had  been  produced  by 
surrounding  the  urethra  with  a piece  of 
packthread ; and  in  many  it  had  a good 
deal  of  the  appearance,  which  one  may 
fancy  such  a cause  would  produce.  Mr. 
Hunter  states,  however,  that  he  had  seen 
the  urethra  contracted  for  above  an  inch  in 
length,  owing  to  its  coats,  or  internal  mem- 
brane being  irregularly  thickened,  and  form- 
ing a winding  canal. 

A stricture  does  not  always  arise  from  an 
equal  contraction  of  the  urethra  all  round  ; 
for,  in  some  instances,  the  contraction  is 
only  on  one  side  ; a fact,  which  appears  to 
me  to  be  better  accounted  for  by  the  con- 
sideration of  the  longitudinal  arrangement 
ot  the  muscular  fibres  in  packets,  on  the 
outside  of  the  membrane  of  the  urethra, 
than  the  circular  kind  of  stricture,  only  oc- 
cupying as  small  an  extent  of  the  passage, 
as  the  constriction  which  would  arise  from 
the  application  of  a piece  of  packthread 
round  it.  The  contraction  of  one  side  of 
the  canal  only  throws  the  passage  to  the 
opposite  side,  which  often  renders  the  in- 
troduction of  a bougie  difficult.  The  con- 
tracted part  is  whiter  than  the  rest  of  the 
urethra,  and  is  harder  in  its  consistence. 
In  some  cases  there*  are  several  strictures. 
Mr.  Hunter  mentions  his  having  seen  half 
a dozen  in  one  uiethra,  and  he  observes, 
that  a stricture  is  frequently  attended  with 
small  tightnesses  in  other  parts  of  the  pas- 
sage. 

Mr.  Hunter  remarks,  that  every  part  oi 
the  urethra  is  not  equally  subject  to  stric- 
tures, the  bulbous  portion  being  much  the 
most  subject  to  the  disease.  A stricture  is 
sometimes  situated  on  this  side  of  the  bulb, 
but  very  seldom  beyond  it,  that  is,  nearer 
the  bladder.  Mr.  Hunter  never  saw  a stric- 
ture in  that  part  of  the  urethra,  which  passes 
through  the  prostate  gland  ; and  the  bulb, 
besides  being  the  most  frequent  seat  of  this 
disease,  is  also  subject  to  it  in  its  worst 
forms.  ( Hunter.) 


URETHRA 


air  Everaid  Home  lias  measured  the 
iongth  of  the  urethra  in  different  subjects, 
and  examined  the  diameters  of  the  several 
parts  of  the  passage.  Strictures,  according 
fo  this  gentleman,  occur  most  commonly 
just  behind  the  bulb  of  the  urethra,  the  dis- 
tance from  the  external  orifice  being  6 1-2 
or  7 inches.  The  situation,  next  in  the  or- 
der of  frequency,  is  about  4 1-2  inches  from 
the  orifice  of  the  glans.  The  disease  does 
also  occur  at  3 1-2  inches,  and  sometimes 
almost  close  to  the  external  orifice.  The 
two  parts  of  the  urethra,  most  frequently 
affected  with  strictures,  are  naturally  the 
narrowest.  Sometimes  the  very  orifice  of 
the  urethra  is  contracted,  and  the  circum- 
stance often  leads  to  an  erroneous  supposi- 
tion, that  the  whole  canal  is  naturally  form- 
ed of  the  same  size.  The  prepuce  also  is 
observed  to  be  particularly  often  affected 
with  a natural  phymosis,  in  persons  who 
have  strictures  in  the  urethra. 

In  almost  all  the  cases  which  Sir  E. 
Home  has  met  with,  there  has  been  one 
stricture,  about  seven  inches  from  the  exter- 
nal orifice,  whether  there  wrere  any  others, 
or  not. 

With  respect  to  the  causes  of  strictures, 
some  writers  have  imputed  the  disorder  to 
the  effects  of  the  venereal  disease,  and 
often  to  the  method  of  cure.  Mr.  Hunter 
entertained  strong  doubts  however,  whether 
strictures  commonly,  or  ever  proceeded 
from  these  causes ; though  he  acknowledges, 
that  since  most  men  have  had  venereal 
complaints,  arefututionof  the  above  opinion 
is  very  difficult.  Mr.  Hunter  was  led  to 
think,  that  strictures  did  not  commonly 
arise  from  venereal  causes,  from  reflecting 
that  strictures  are  common  to  most  passages 
in  the  human  body.  They  often  take  place 
in  the  oesophagus  ; the  intestines,  particu- 
larly the  rectum  ; the  anus  ; the  prepuce  so 
as  to  produce  phymosis;  and  in  the  lachry- 
mal duct,  so  as  to  occasion  a fistula  lachry- 
malis.  Strictures  sometimes  take  place, 
when  there  have  been  no  previous  venereal 
complaints  Mr  Hunter  mentions  his  hav- 
ing seen  an  instance  of  this  kind  in  a young 
man,  nineteen  years  of  age,  who  had  had 
the  complaint  for  eight  years,  and  w hich 
therefore  began,  when  he  was  only  eleven 
years  old.  He  was  of  a weak  scrofulous 
habit.  Mr.  Hunter  had  also  seen  a stricture 
in  a boy  only  four  years  old,  and  a fistula 
in  perinaeo  in  consequence  of  it.  Strictures 
happen  as  frequently  in  persons,  who  have 
had  gonorrhoea  in  a slight  degree,  as  in 
others,  w ho  have  had  it  in  a severe  form 

It  is  not  an  uncommon  belief,  that  stric- 
tures arise  from  the  use  of  astringent  injec- 
tions in  the  treatment  of  the  gonorrhoea.  Sir 
Everaid  Home  is  of  this  sentiment,  and  so 
is  Mr.  Wilson.  (On  the  Male  Genilal  and 
Urinary  Organs,  p.  370.)  The  latter  gentle- 
man however,  mentions  some  circumstan- 
ces, calculated  to  raise  doubts  on  this  point, 
especially  the  fact,  that  wrhile  injections 
rarely  enter  far  into  the  urethra,  the  most 
common  seat  of  a stricture  is  where  the 
membranous  part  of  the  canal  joins  the 


033 

bulb.  Mr.  Hunter  himself  deemed  the  opin- 
ion founded  on  prejudice,  and  states  that  he 
had  seen  as  many  strictures  after  gonorrhoea, 
which  had  been  cured  without  injections, 
as  after  cases  which  had  been  treated  with 
these  latter  applications. 

He  rejected  also  the  old  doctrine,  that 
strictures  are  a consequence  of  ijcers  in 
the  urethra  ; for  ulcers  hardly  ever  occur  in 
this  passage,  except  when  there  are  stric- 
tures ; and  it  is  now  generally  admitted, 
that  in  gonorrhoea,  there  are  no  sores  in  the 
urethra.  Strictures  are  sometimes  produced 
by  external  violence,  though  the  passage 
would  appear  to  be  capable  of  frequently 
bearing  considerable  wounds  and  other  in- 
juries, without  this  consequence.  Thu- 
strictures  are  not  common  from  lithotomy, 
and  in  a modern  wrork,  we  read  the  case  of 
a serious  gunshot  wound  of  the  urethra, 
where  no  stricture,  ensued.  (See  Jlnnuairc 
Med.  Chir.  des  Hopitaux  de  Paris,  4to.  1819.) 

TREATMENT  OF  STRICTURES,  W'lTH  COMMON 

ROUGIES,  ON  THE  PRINCIPLE  OF  DILATA- 
TION. 

Mr.  Hunter  remarks,  that  the  cure  of  stric 
tures  may  be  accomplished,  either  by  a di- 
latation of  the  contracted  part,  or  a destruc- 
tion of  it  by  ulceration,  or  escharotics.  To 
these  methods  are  to  be  added,  first  the  plan 
of  forcing  a passage  through  the  stricture 
w ith  a conical  sound,  as  practised  by  the 
French  surgeons,  when  they  cannot  other- 
wise pass  the  stricture,  and  the  symptoms 
are  urgent.  (See  J.  Cross,  Sketches  of  the 
Medical  Schools  of  Paris,  Svo.  Lond.  1815,  p. 
Ill  ; and  First  Lines  of  the  Practice  of  Sur- 
gery, Vol.  2,  ed.  4;)  and  secondly,  the  me- 
thod of  cutting  down  to  obliterated  portions 
of  the  urethra,  and  attempting  to  cure  the 
obstruction  by  the  removal  of  the  diseased 
parts,  tracing  the  continuation  of  the  pas- 
sage, and  trying  to  heal  the  wound  over  a 
catheter.  Both  these  practices  are  attended 
with  such  difficulties  and  dangers,  as  should 
make  every  prudent  surgeon  very  reluctant 
to  adopt  them,  except  under  very  urgent 
circumstances,  in  which  every  milder  me- 
thod tails.  The  dilatation  is  accomplished 
by  means  of  bougies  or  catheters  ; but  Mr. 
Hunter  considered,  that  acure  thus  effected 
was  seldom  or  never  more  than  temporary 
The  removal  of  the  stricture  by  ulceration 
may  also  be  effected  with  bougies.  Its  de- 
struction w ith  caustic  used  formerly  to  be 
executed  through  a cannula,  contrived  for 
the  purpose ; but  is  now  performed  by 
means  of  caustic  or  armed  bougies. 

The  cure  by  dilatation  is  principally  me- 
chanical, when  effected  by  bougies,  the 
powers  of  which  are  generally  those  of  a 
wedge.  However,  Mr.  Hunter  conceived, 
that  their  ultimate  effect  was  not  always  so 
simple  as  that  of  a u edge  upon  inanimate 
matter:  tor  pressure  makes  living  parts 
either  adapt  themselves  to  their  new  posi- 
tion, or  else  recede  by  ulceration.  Bougies 
of  course,  either  dilate  strictures,  or  make 
them  ulcerate 


URETHRA 


i>34 

The  disease  has  generally  made  consider- 
able progress,  before  surgical  assistance  is 
required,  and  the  stricture  may  be  so  ad- 
vanced, that  a small  bougie  cannot  be  made 
to  pass,  without  a great  deal  of  trouble.  If 
the  end  of  a small  bougie,  let  it  be  ever  so 
small,  can  be  introduced  through  the  stric- 
ture, ih»t  cure  is  then  in  our  power.  How- 
ever, a small  bougie  frequently  cannot  pass 
in  the  first  instance,  and  even  not  after  re- 
peated trials. 

Often  when  the  stricture  is  very  consider- 
able, a great  deal  of  trouble  is  given  by 
occasional  spasms,  which  either  resist  the 
introduction  of  a bougie  altogether,  or  only 
allow  a very  small  one  to  pass.  At  other 
periods,  however,  a larger  one  may  be  in- 
troduced. In  these  circumstances  Mr. 
Hunter  mentions,  that  he  was  sometimes 
able  to  make  the  point  of  the  bougie  enter, 
by  rubbing  the  outside  of  the  perihasum 
with  the  finger  of  one  hand,  while  he  push- 
ed the  bougie  on  with  the  other.  The  same 
eminent  practitioner  often  succeeded  by. 
letting  the  bougie  remain  a little  while  close 
to  the  stricture,  and  then  pushing  it  on. 
Sometimes  the  spasm  may  also  be  taken  off 
•by  dipping  the  gians  penis  in  cold  water. 

Although  in  cases  of  permanent  stric- 
tures, the  bougie  may  not  pass  at  first,  yet 
after  repeated  trials,  it  will  every  now  and 
then  find  its  way.  In  this  manner  future 
attempts  become  more  certain  and  easy. 

However,  the  success  of  the  subsequent 
trials  to  introduce  a bougie  does  not  always 
depend  on  the  instrument  having  been  once 
or  twice  passed.  Sometimes  it  can  be  in 
produced  to-day,  but  not  to-morrow  ; and 
in  this  state,  the  case  may  continue  for 
weeks,  notwithstanding  every  trial  which 
can  be  made.  Mr.  Hunter  observes  how- 
ever, that  in  general,  the  introduction  of 
the  bougie  becomes  gradually  less  difficult, 
and  therefore,  that  we  ought  not  to  despair 
of  success  in  any  case. 

When  the  passage  is  very  small,  it  is  not 
easy  to  know  whether  the  bougie  has  enter- 
ed the  stricture  or  not ; for  bougies  as  slen- 
der as  those  which  must  be  at  first  employ- 
ed, bend  so  very  easily,  that  the  surgeon  is 
apt  to  fancy,  that  they  are  passing  along  the 
urethra,  while  they  are  only  bending.  Mr. 
Hunter  advises  the  surgeon  first  to  make 
himself  acquainted  with  the  situation  of  the 
stricture,  by  means  of  a common-sized 
bougie  ; and  then  to  take  a smaller  one, 
and  when  its  point  arrives  at  the  stricture, 
the  instrument  is  to  be  gently  pushed  for- 
ward, but  only  for  a short  time.  If  the 
bougie  has  passed  further  into  the  penis,  the 
surgeon  may  know  how  far  it  has  entered 
the  stricture,  by  taking  the  pressure  off  (he 
bougie.  For,  if  it  recoil , he  maybe  sure 
that  it  has  not  passed ; at  least,  has  not  pass- 
ed far,  but  only  bent.  On  the  contrary,  if 
it  remain  fixed , and  do  not  recoil,  it  has  cer- 
tainly entered  the  stricture. 

However,  the  preceding  remarks  are  said 
not  to  be  so  applicable  when  a very  small 
bougie  is  employed,  which  may  become 


bent,  without  our  being  aware  of  the  cir- 
cumstance,. 

A bougie  may  frequently  be  introduced  a 
very  little  way,  for  instance,  only  one-tenth 
of  an  inch,  and  then  it  bends,  and  cannot  be 
pushed  further.  To  determine  whether  this 
is  the  case,  Mr.  Hunter  says,  it  is  necessary 
to  withdraw  the  bougie  and  examine  its \ 
end.  If  the  end  be  blunted,  we  may  be 
sure,  that  the  bougie  has  not  entered  at  all ; 
but  if  it  be  flattened,  for  an  eighth,  or  tenth 
of  an  inch,  be  grooved,  or  have  its  outer 
waxen  coat  pushed  up  to  that  extent;  or  it 
there  be  a circular  impression  made  upon 
the  bougie,*  or  only  a dent  on  one  side, 
made  by  the  stricture  ; we  may  be  sure  that 
the  instrument  has  passed  ns  far  as  these 
appearances  extend.  It  then  becomes  ne- 
cessary to  introduce  another  of  exactlyr  the  ' 
same  size,  and  in  the  same  manner,  and  to 
let  it  remain  as  long  as  the  patient  can  bear 
it,  or  convenience  will  allow.  By  repeti 
tions  of  (his  plan,  the  stricture  will  be  over- 
come. 

Mr.  Hunter  remarks,  that  the  time  which 
each  bougie  ought  to  remain  in  the  passage 
must  be  determined  by  the  feelings  of  the 
patient ; for  if  possible,  no  pain  should  ever 
be  given.  If  the  patient  should  experience 
very  acute  pain  when  the  bougie  is  passing, 
it  ought  not  to  be  left  in  the  urethra  above 
five;  or  at  most,  ten  minutes  ; pr  not  so  long 
if  the  pain  be  exceedingly  severe.  Each 
time  of  application  should  afterward  be 
lengthened  so  gradually  as  to  be  impercep- 
tible to  the  feelings  of  the  patieql,  and  the 
irritability  of  the  parts.  Mr.  Hunter  affirms, 
that  he  has  known  many  patients,  who 
could  not  bear  a bougie  to  remain  In  the 
passage  ten,  or  even  five  minutes,  till  after 
several  days,  and  even  weeks,  but  who  in 
time  were  able  to  wear  the  instrument  for 
hours,  and  this,  at  last  without  any  diffi- 
culty. The  best  time  for  keeping  a bougie 
in  the  urethra,  is  when  the  patient  has  least 
to  do;  or  in  the  morning,  while  he  is  in 
bed,  if  he  can  introduce  the  instrument  him- 
self. 

Mr.  Hunter  next  observes,  that  the  bougie 
should  be  increased  in  size,  according  to  the 
facility  with  which  the  stricture  becomes  di- 
lated, and  the  case  with  which  the  patient 
bears  the  dilatation.  If  the  parts  are  very 
firm,  or  very  irritable,  the  increase  of  the 
size  of  the  bougie  should  be  very  slow,  so  as 
to  allow  them  to  become  gradually  adapted 
to  the  augmented  size  of  the  instrument. 
But  if  the  sensibility  of  the  parts  will  allow, 
the  increase  of  the  size  of  the  bougie  may 
be  somewhat  quicker,  but  never  more  siuR 
den  than  the  patient  can  easily  bear.  The 
surgeon  must  continue  to  increase  the  size 
of  the  bougie,  till  one  of  the  largest  size  can 
freely  pass  ; nor  should  the  use  of  this  be  dis- 
continued till  after  three  weeks,  ora  month, 
in  order  that  the  dilated  part  may  have  time 
to  become  habituated  to  its  new  position, 
and  lose  its  disposition  to  contract  again. 
However,  Mr.  Hunter  believed,  that  the 
permanency  of  a cure,  effected  on  the  pvin 


URETHRA 


• ipie  ol  mlataiiou,  could  seldom  be  depend- 
ed upon. 

At  the  present  day,  many  surgeons  prefer 
bougies  composed  of  metal,  flexible  enough 
to  allow  their  curvature  to  be  adapted  to  the 
bend  of  the  urethra,  yet  sufficiently  firm  to 
retain  the  figure  given  them,  while  they  are 
employed.  Others  very  commonly  use  iron 
sounds,  which,  in  cases  where  it  is  necessa- 
ry to  have  an  instrument  possessing  more 
firmness  than  a wax  bougie,  and  having  a 
point  more  unchangeably  turned  upwards 
than  that  of  the  latter  instrument,  may  have 
advantages.  But,  for  all  ordinary  cases,  1 
consider  a common  bougie  a safer  and  bet 
ter  instrument ; one  with  which  the  surgeon 
is  less  apt  to  exert  unwarrantable  force, 
so  as  to  occasion  a dangerous  degree  of  irri- 
tation, or,  what  is  worse,  a false  passage 

CURE  OF  STRICTURES  BY  ULCERATION. 

This  is  also  accomplished  by  means  of  a 
wax  or  metallic  bougie,  and  the  plan  may 
be  tried  both  when  the  instrument  can,  or 
cannot  be  introduced  through  the  stricture. 
In  the  first  instance,  the  method  is  less  pro- 
per, because  the  stricture  admits  of  being 
dilated. 

In  order  to  cure  a stricture  by  making  it 
ulcerate,  the  bougie  is  to  be  introduced  as 
far  through  the  contracted  part  as  possible, 
and  the  size  of  the  instrument  is  to  be  aug- 
mented, as  fast  as  the  sensations  of  the  pa- 
tient can  well  bear.  In  this  manner  ulcera- 
tion will  be  produced  in  the  part  which  is 
pressed;  and  Mr.  Hunter  remarks,  that  the 
cure  will  be  more  lasting,  because  more  of 
the  stricture  is  destroyed  than  when  the  parts 
are  simply  dilated.  This  eminent  surgeon 
notices,  however,  that  few  patients  w ill  sub- 
mit to  this  practice,  and  that  few  indeed 
would  be  able  to  bear  it,  since  it  is  apt  to 
bring  on  violent  spasms  in  the  part,  attend- 
ed with  a very  troublesome  retention  of 
urine 

If  the  smallest  bougie  cannot  be  made  to 
pass  a stricture,  by  using  some  degree  ot 
torce,  dilatation  becomes  impracticable ; 
and  as  the  stricture  must  be  destroyed, 
something  else  must  be  tried.  In  many 
cases,  says  Mr.  Hunter,  it  may  be  proper  to 
get  rid  ot  the  stricture,  by  making  it  ulce- 
rate, or,  in  other  w'ords,  be  absorbed.  Bou- 
gies,-intended  to  excite  ulceration,  need  not 
be  so  small  as  in  the  foregoing  cases,  as  they 
are  not  designed  to  be-passed  through  the 
stricture  ; and,  in  consequence  of  being  of 
the  common  size,  they  may  be  more  surely 
applied  to  the  parts  causing  the  obstruction. 
The  force  applied  to  a bougie,  in  this  case, 
should  not  be  great : for  a stricture  is  the 
hardest  part  of  the  urethra  ; and  it  a bougie 

forcibly  pushed  on,  its  end  may  slip  off 
the  stricture,  before  ulceration  has  com- 
menced, and  make  a false  passage  for  itself 
in  the  corpus  spongiosum  urethrae. 

In  trying  to  cure  strictures  by  ulceration.' 
the  utmost  attention  must  be  paid  ; and  if 
the  patient  does  not  make  wmter  better,  not- 
withstanding the  bougie  passes  further,  the 


surgeon  may  be  sure  be  Is  forcing  a false 
passage. 

When  the  stricture  has  so  far  yielded,  as 
to  allow  a small  bougie  to  be  introduced, 
the  treatment  is  then  to  be  conducted  on 
the  principle  of  dilatation. 

Mr.  Hunter  observes,  that  whenever  a 
bougie  ot  a tolerable  size  passes  with  ease, 
and  the  parts  and  the  patient  have  become 
accustomed  to  it,  the  surgeon  need  no  longer 
attend  for  the  purpose  of  introducing  it, 
1 he  patient  may  now  be  allowed  to  intro- 
duce bougies  himself;  and  when  he  can  do 
tins  with  ease,  the  business  may  be  trusted 
to  him,,  as  he  can  make  use  of  the  instru- 
ments at  the  most  convenient  times,  so  that 
they  may  be  more  frequently  and  longer 
applied.  In  the  mean  while,  the  surgeon 
should  only  pay  occasional  visits.  Mr.  Hun- 
ter adds,  that  this  practice  of  the  patient, 
under  the  surgeon’s  eye,  by  which  means 
the  former  learns  the  art  of  introducing  bo;  - 
gies,  is  the  more  necessary,  since  strictures 
are  diseases  which  commonly  recur  ; and, 
therefore,  no  man  w ho  has  ever  had  a stric 
ture,  and  is  cured  of  it,  should  rely  on  the 
cure  as  lasting  ; but  should  always  be  pre- 
pared for  a return,  and  always  have  some 
bougies  by  him.  He  should  not  go  a jour- 
ney, even  of  a week,  without  them  ; and  the 
number  should  be  according  to  the  time 
which  he  is  absent,  and  the  place  to  which 
he  is  going  , for  in  many  parts  of  the  world 
he  cannot  be  supplied  with  them. 

To  prevent  the  inconvenience  of  a bougie, 
slipping  out,  or  the  mischief  of  its  gliding 
intd  the  urethra,  a soft  cotton  thread  must 
be  tied  round  that  end  of  the  bougie  which 
is  out  of  the  urethra,  and  then  round  the 
root  of  the  glans.  This  last  part  of  the 
thread  should  be  verv  loose.  The  projecting 
portion  of  the  bougie  should  also  be  bent 
down  upon  the  penis,  by  which  means  it  is 
rendered  less  troublesome,  and  more  secure, 
(See  Hunter  on  the  Venereal  Disease.  When 
a considerable  part  of  the  bougie  remain, 
out  of  the  urethra,  surgeons  usually  clip  a 
piece  d{  it  off. 

In  many  examples, .in  which  a stricture  i 
accompanied  with  excessive  irritability  in 
the  urethra,  much  pain,  and  a tendency  to 
frequent  retentions  of  urine,  when  a com  - 
mon bougie  is  employed,  it  becomes  advisea 
ble  to  alter  the  plan  of  treatment,  and  use 
either  flexible  metallic,  or  elastic  gum  bon 
gies.  (See  Bougie.)  Desault  commonly  cured 
all  strictures  by  the  skilful  employment  of 
flexible  gum  catheters,  which  his  patients 
were  directed  to  wear  a certain  length  of 
time  every  day.  These  last  instruments 
produce  less  pain  and  irritation  than  any 
kind  of  bougie,  more  especially  when  thc( 
wires  are  withdrawn  ; and  were  I to  be  my 
self  altiicted  with  strictures,  I should  feel 
strongly  disposed  to  attempt  their  removal 
by  the  use  of  elastic  gum  catheters,  which 
are  unquestionably  the  mildest  and  least 
painful  means  of  cure.  I have  seen  cases, 
however,  in  which  the  flexible  metallic  bou- 
gie seemed  to  cause  much  less  irritation  than 
any  other  kind  of  bougie:  but  in  general. 


URETHRA 


fi3ti 


those  made  ot  elastic  gum  give  the  least 
pain.  Metallic  bougies  possess  the  advan- 
tage of  retaining  the  exact  curvature  of  the 
passage  better  than  others  ; and,  as  I have 
observed,  they  enable  the  surgeon  to  employ 
more  force,  and  this  with  more  precision 
than  can  be  done  with  a wax  bougie.  Yet, 
as  force  is  not  a principle  to  be  much  com- 
mended in  the  treatment  of  ordinary  stric- 
tures, I Uoubt  whether  such  instruments  will 
long  retain  as  many  employers  as  they  have 
now  acquired,  and  many  of  whom  use  them 
indiscriminately  in  all  cases.  Small  catgut 
bougies  are  chiefly  eligible,  when  the  cure 
by  dilatation  is  preferred,  and  the  smallest 
bougies  of  other  descriptions  cannot  be  in- 
troduced through  the  stricture. 

CORE  OP  STRICTURES  WITH  THE  ARGENTUM 
N1TRATUM. 

Wiseman  makes  mention  of  the  plan  of 
curing  strictures  in  the  urethra  by  means  of 
caustic.  He  observes,  that  when  the  ob- 
struction is  a caruncle,  and  you  cannot  pass 
it,  you  may  well  conclude  it  is  callous : 
•‘in  which  case,  you  may  pass  a cannula 
into  the  urethra  to  that  caruncle,  and,  whilst 
you  hold  it  there  steady,  you  may  convey  a 
grain  of  caustic  into  the  cannula,  and  press 
the  caustic  to  it  ; and  whilst  you  hold  it 
there,  you  will  perceive  its  operation,  by 
the  pressing  forward  of  the  cannula.” 

About  the  year  1752,  Mr.  Hunter  attended 
a chimney-sweeper,  who  had  a stricture. 
JNot  finding  that  any  benefit  was  derived 
from  the  use  of  common  bougies,  for  a space 
of  six  months,  Mr.  Hunter,  unaware  of  the 
above  passage  in  Wiseman,  conceived,  that 
the  stricture  might  be  destroyed  by  escharo- 
tics,  and  the  first  attempt,  which  he  made, 
was  with  red  precipitate.  He  put  some 
salve  on  the  end  of  a bougie,  and  then  dip- 
ped it  in  red  precipitate.  The  bougie  in  this 
state,  was  passed  down  to  the  stricture  ; but 
Mr  Hunter  found,  that  it  brought  on  con- 
siderable inflammation  all  along  the  inside 
of  the  passage,  as  he  thought,  in  conse- 
quence of  the  precipitate  being  rubbed  off, 
while  the  bougie  was  passing  to  the  stricture. 
He  then  introduced  a silver  cannula  down 
to  the  stricture,  and  again  passed  the  bougie 
with  precipitate  through  the  tube.  As  the 
patient,  however,  did  not  make  water  any 
better,  and  the  smallest  bougie  could  not 
be  introduced  through  the  stricture,  it  was 
suspected,  that  the  precipitate  had  sufficient 
power  to  destroy  the  obstruction.  Mr. 
Hunter  was  induced,  therefore,  to  fasten  a 
small  piece  of  the  argentum  nitratum  on  the 
end  of  a piece  of  wire  with  sealing-wax, 
and  introduce  the  caustic  through  the  can- 
nula to  the  stricture.  After  having  made 
the  application  ) three  times,  at  intervals  of 
two  days,  he  found  that  the  man  voided  his 
urine  much  more  freely,  and  on  applying 
the  caustic  a fourth  time,  the  cannula  went 
through  the  stricture.  A bougie  was  intro- 
duced for  a little  while  afterward,  till  the 
man  bad  completely  recovered. 

Having  experienced  this  success,  Mr.  Hun- 


ter was  encouraged  to  apply  his  mind  to  the 
invention  of  some  instrument,  better  suited 
to  the  purpose,  than  the  above  contrivance  ; 
and  an  improved  instrument  was  devised, 
although  he  acknowledges,  that  it  was  not 
perfectly  adapted  to  strictures  in  every  situ- 
ation in  the  urethra.  He  remarks  that  the 
caustic  should  be  prevented  from  hurting  the 
unaffected  part  of  the  urethra  by  introducing 
the  active  substance,  through  a cannula, 
down  to  the  stricture  ; and  that  it  should  be 
capable  of  protruding  a little  beyond  the  end 
of  the  cannula,  by  which  means  it  will  only 
act  upon  the  stricture.  The  caustic  should 
be  fixed  in  a small  portcrayon,  and  it  is  ne- 
cessary to  have  a piece  of  silver  of  the  length 
of  the  cannula,  with  a ring  at  one  end,  and 
a button  at  the  other,  of  the  same  diameter 
as  the  cannula.  The  button  forms  a kind  of 
plug,  which  should  project  beyond  the  end 
of  the  cannula  in  the  urethra,  so  as  to  make 
a rounded  end  ; or,  Mr.  Hunter  says,  the 
portcrayon  may  be  formed  with  this  button 
at  its  other  end.  The  cannula,  with  the 
button,  is  to  be  passed  into  the  urethra,  and 
when  it  reaches  the  stricture,  the  silver  plug 
should  be  withdrawn, and  the  portcrayon  with 
the  caustic  introduced  in  its  place  ; or,  if  the 
plug  and  portcrayon  are  on  the  same  instrn- 
ment,  then  it  is  only  necessary  to  withdraw  the 
plug,  and  introduce  the  portcrayon  with  the 
caustic.  The  plug,  besides  giving  a smooth 
rounded  end  to  the  cannula,  answers  ano- 
ther good  purpose,  by  preventing  the  tube 
from  being  filled  with  the  mucus  of  the  ure- 
thra, when  the  instrument  is  passing  in- 
ward, which  mucus  would  be  collected  iu 
the  end  of  the  cannula,  dissolve  the  caustic 
too  soon,  and  hinder  its  application  to  the 
stricture. 

When  the  stricture  was  beyond  the  straight 
pari  of  the  urethra,  Mr.  Hunter  owned,  that 
it  was  difficult  to  apply  caustic  to  the  disease 
through  a cannula. 

A better  mode  of  applying  lunar  caustic  lo 
strictures  was  afterward  devised  by  Hunter, 
and  has  since  been  extensively  introduced 
into  practice  by  Sir  E.  Home.  This  gentle- 
man directs  us  to  take  a bougie  of  a size 
that  can  be  readily  passed  down  to  the  stric- 
ture, and  to  insert  a small  piece  of  lunar 
caustic  into  the  end  of  it,  letting  the  caustic 
be  even  with  the  surface,  but  surrounded 
every  where  laterally  by  the  substance 
of  the  bougie.  This  should  be  done 
some  little  time  before  it  is  required  to  bo 
used;  for  the  materials  of  which  the  bou- 
gie is  composed,  become  warm  and  soft  by 
being  handled  in  inserting  the  caustic;  and. 
therefore,  the  hold  which  the  bougie  has  of 
the  caustic,  is  rendered  more  secure  after 
the  wax  has  been  allowed  to  cool  and  hard- 
en. The  bougie  thus  prepared,  is  to  be  oiled 
and  made  ready  for  use  ; but  before  passing 
it,  a common  bougie  of  the  same  size  is  to 
Or-  introduced  down  to  the  stricture,  in  or- 
der to  clear  the  canal,  and  to  measure  the 
exact  distance  of  tho  stricture  from  the  ori- 
fice of  the  urethra.  This  distance  being 
marked  upon  the  armed  bougie,  it  is  to  be 
passed  down  to  the  stricture,  a?  soon  ns  (hr 


URETHRA. 


037 

other  is  withdrawn.  The  caustic,  in  its  pas-  divided  parts  a flexible’ gum-cat lietcr  into 
sage,  is  scarcely  allowed  to  come  into  con-  the  bladder.  This  I have  done  myself,  and 
fact  with -any  part  of  the  membrane,  because  have  frequently  seen  it  performed  by  Mr. 
the  point  of  the  bougie,  of  which  the  argen-  Hunter,  and  it  always  succeeded  ; neither 
turn  nitratum  forms  the  central  part,  always  bringing  on  so  much  inflammation  as  was 
moves  in  the  middle  line  of  the  canal ; and,  expected,  nor  being  attended  with  any 
indeed,  the  quickness  with  which  it  is  con-  symptoms  of  irritation, 
vcyed  to  the  stricture,  prevents  any  injury  “ This  practice  has  by  othersurgeons  been 
of  the  membrane  lining  the  passage  when  carried  still  further ; the  portion  of  diseased 
the  caustic  accidentally  touches  it.  urethra  has  been  dissected  out,  and  entirely 

In  this  mode  the  caustic  is  passed  down  removed  ; nor  has  so  severe  an  operation 
with  little  or  no  irrilation  to  (he  lining  of  always  brought  chi  untoward  symptoms; 
the  urethra  ; it  is  applied  in  the  most  advan-  and  patients  have  recovered, 
tageems  manner  to  the  stricture,  and  can  be  “ If  the  membrane  of  the  urethra,  when 


retained  in  that  situation  sufficiently  long  to 
produce  the  desired  effect. 

The  reasons  urged  in  favour  of  the  em- 
ployment of  bougies  armed  with  the  lunar 
caustic,  arc,  that  a permanent  cure  is  effect- 
ed, which  common  bougies  cannot  accom- 
plish ; that  the  pain  arising  from  the  applica- 
tion of  the  argentum  nitratum  to  the  stric- 
ture, is  very  inconsiderable  ; and  that  nei- 
ther irritation  nor  inflammation  is  found  to 
ensue.  The  meaning  of  these  remarks, 
however,  is  to  be  received  as  a general  one, 
liable  to  exceptions.  Indeed,  SirE.  Home 
himself  has  candidly  acknowledged,  that 
some  inconveniences  occasionally  follow  the 
. use  of  armed  bougies.  But  w bat  practice, 
however  judicious  and  eligible,  is  altogether 
free  from  occasional  ill  consequences?  Sir 
E.  Home  remarks,  that  against  treating  stric- 
tures of  the  urethra  with  caustic  bougies, 
numerous  objections  have  been  adduced, 
and  many  bad  consequences  have  been  at- 
tributed to  the  practice,  without  any  real 
foundation  ; “for  whatever,  <1  priori,  might 
be  supposed  the  effects  of  so  violent  an  ap- 
{^icr.tion,  to  a membrane  so  sensible  and  ir- 
ritable as  the  urethra,  and  I will  admiit  tiiat 
it  is  very  natural  to  conceive  they  would  be 
very  severe,  (lie  result  of  experience,  the 
only  thing  to  be  relied  on,  evinces  the 
contrary.  The  pain  that  is  brought  on, 
is  by  no  means  violent  ; and  neither  irrita- 
tion nor  inflammation  is  found  to  take 
place. 

“ That  cases  do  occur,  in  which  strictures 
have  produced  so  much  mischief,  and  ren- 
dered so  great  an  extent  of  the  canal  dis- 
eased, that  the  use  of  the  caustic  has  proved 
unsuccessful,  is  certainly  true;  and  several  of 
these  cases  have  fallen  within  my  own  know- 
ledge. But  when  it  is  stated  that  none, 
even  of  these,  were  made  worse  by  its  use; 
that  no  bad  consequences  attend  it ; and 
that  no  other  mode,  at  present  known,  is 
equally  efficacious  ; «»y  occasional  want  of 
success  cannot  be  considered  as  an  objec- 
tion to  this  mode  of  practice. 

“ But  if  the  apprehension  of  violent 
effects  from  the  caustic,  however  ill-found- 
ed, cannot  be  removed,  let  the  alternative 
be  considered  ; namely,  the  only  operation 
previously  in  use,  where  a stricture  cannot 
be  dilated  by  the  bougie. . 

“ In  those  cases  we  are  obliged  to  have 
recourse  to  means  certainly  more  severe 
and  violent,  laying  open  with  a knife  the 
diseased  urethra,  and  passing  through  the 

Yol.  H 


diseased,  is  capable  of  suffering  so  much 
injury  without  any  consequent  symptoms 
of  irritation,  it  cannot  be  doubted  that  it 
will  bear  with  impunity  to  be  touched,  in 
a very  partial  manner,  several  different 
times  with  lunar  caustic.” 

Sir Everard afterward  proceeds:  “Having 
met  with  a number  of  facts,  from  which  a 
general  principle  appears  to  be  established, 
that  the  irritable  state  of  a stricture  is  kept 
up,  and  even  increased,  by  the  use  of  the 
bougie,  but  lessened  and  entirely  destroyed 
by  the  application  of  lunar  caustic  ; I am 
desirous  to  communicate  my  observations 
upon  these  facts,  and  to  recommend  the  use 
of  the  caustic  in  many  cases  of  irritable 
stricture,  in  preference  to  the  bougie. 

“ As  the  use  of  the  caustic  upon  this  prin- 
ciple is,  I believe,  entirely  new,  and  is  con- 
trary to  every  notion  that  has  been  formed 
upon  the  subject,  it  will  require  something 
more  than  general  assertion  to  gain  even 
the  attention  of  many  of  my  readers,  snil 
more  their  belief;  1 shall  therefore  detail 
the  circumstances  as 'they  occurred,  by 
which  I conceive  the  propriety  of  this  prac- 
tice to  be  established  : and  afterward  make 
some  observations  upon  the  principle  on 
which  it  depends. 

“ My  connexion  in  practice  with  Mr 
Hunter  afforded  me  opportunities  of  attend- 
ing to  cases  of  stricture  in  all  their  different 
stages;  many  of  them  brought  on  duringa 
long  residence  in  India,  attended  with  great 
irritability,  and  exceedingly  difficult  of 
cure. 

“ One  case  of  this  kind  admitted  the  pass- 
ing of  a small  bodgie ; but,  in  the  course  of 
three  years,  very  little  was  gained  hv  a 
steady  perseverance  in  the  use  of  that  in- 
strument, either  in  dilating  the  canal,  or 
palliating  the  symptoms  of  stricture  ; this 
made  me  look  upon  the  bougie  as  less  effi- 
cacious than  I had  always  been  taught  to 
believe  it.  I was  willing,  however,  to  con- 
sider this  as  an  uncommon  case,  depending 
more  on  the  peculiarities  of  the  patient’s 
constitution  than  on  the  nature  of  the  dis- 
ease: but  I found,  on  a particular  inquiry, 
that  several  other  gentlemen  from  Jntha 
were  under  circumstances  nearly  similar; 
the  bougie  only  preventing  the  increase  of 
the  stricture,  but  being  unable  to  dilate  it 
beyond  a certain  size  ; and  when  it  was  left 
off,  the  stricture  in  less  than  two  months 
returned  to  its  former  state  of  contrac- 
tion. • 


tJKETHRA. 


l{  What  plau  ought  to  be  followed  in  such 
cases,  I was  then  unable  to  determine  ; but, 
that  the  bougie  could  not  be  depended  on 
was  evident:  During  the  suspense,  the  fol- 

lowing case  came  under  my  care. 

“In  August,  1794,  a gentleman  consulted 
me  for  some  symptoms  which  had  been 
considered  as  indicating  the  presence  of 
gonorrhoea;  but,  as  they  did  not  yield  to 
the  common  treatment  in  the  usual  time, 
he  was  induced  to  take  my  advice  res- 
pecting the  nature  of  his  complaint  In  the 
necessary  inquiry,  to  obtain  a perfect  his- 
tory of  the  case,  among  other  things  it  was 
stated,  that,  nineteen  years  before,  there 
was  a stricture  which  became  very  trouble- 
some, and  that  Mr.  Hunter,  by  the  desire 
of  the  patient,  had  applied  the  caustic,  by 
which  the  stricture  was  removed,  and  never 
afterward  returned.  He  said  that  he  was 
one  of  the  first  persons  on  whom  the  caus 
tic  had  been  used.  From  this  account,  I 
was  naturally  led  to  believe  that  the  stric- 
ture had  gradually  returned,  and  was  now 
increased,  so  much  as  to  produce  the  pre- 
sent symptoms  ; a discharge  being  almost 
always  a symptom  of  stricture  when  it  is 
much  contracted  ; but,  upon  exaininingthe 
canal,  a bougie  of  full  size  passed  on  to  the 
bladder  without  the  smallest  impediment. 
I therefore  took  up  the  case  as  an  inflamma- 
tion in  the  urethra  ; and  large  doses  of  the 
balsam  of  copaiva,  given  internally,  effected 
a cure. 

11  The  circumstance  of  a stricture  having 
been  removed  nineteen  years  before,  and 
not  returning,  made  a strong  impression  on 
my  mind,  and  made,  me  desirous  to  ascer- 
tain whether  this  practice  could  be  employ- 
ed in  cases  of  stricture  in  general,  and  the 
cure  produced  by  it  equally  permanent.  A 
short  time  afterward,  I had  an  opportunity 
of  trying  it  in  the  following  case. 

“ A captain  in  the  East  India  Company’s 
service,  in  September,  1794,  applied  to  me 
for  assistance.  His  complaints  were,  great 
irritation  in  the  urethra  and  bladder,  con- 
stant desire  to  make  water,  and  an  inability 
to  void  it,  except  in  very  small  quantities. 
These  symptoms  had  been  at  first  supposed 
to  arise  from  gonorrhoea,  afterward  render- 
ed more  severe  by  catching  cold  ; but,  not 
yielding  to  the  usual  remedies  for  gonor- 
rhoea, they  were  investigated  more  minute- 
ly, and  a stricture  was  discovered  in  the 
urethra.  The  mode  of  treatment  was  now 
changed,  and  the  bougie  employed  ; but  its 
use  aggravated  all  the  symptoms,  and 
brought  on  so  great  a degree  of  irritability 
in  the  bladder  and  urethra,  that  there  was 
nn  alarm  for  the  patient’s  life,  which  was 
the  reason  for  applying  for  my  assistance. 

il  Besides  thejocal  symptoms,  this  patient 
had  those  of  quick  pulse,  white  tongue,  hot 
and  dry  skin,  loss  of  appetite,  and  total 
want  of  sleep,  with  frequent  attacks  of  spasm 
on  the  bladder  and  urethra.  A very  small 
flexible  gum-catheter  was  passed,  and  the 
water  drawn  off,  in  quantity  about  a pint, 
which  gave  him  great  Fefief : this  was  re- 
pe  ged  morniug  and  evening,  to  keep  the 


bladder  in  as  easy  a state  as  possible  ; but, 
in  other  respects,  he  continued  much  the 
same. 

“ As  the  present  symptoms  were  brought 
on  by  the  use  of  the  bougie,  little  good  was 
to  be  expected  from  that  instrument;  and 
where  the  urethra-  had  been  so  easily  irrita- 
ted, and  was  disposed  to  continue  in  that 
state,  there  was  no  prospect  of  the  use  of 
the  bougie  afterward  effecting  a cure.  These 
circumstances  I explained  to  the  patient; 
and  mentioned,  in  proof  of  my  opinion,  the 
case  in  which  so  little  had  been  effected  in 
three  years. 

“ I then  proposed  to  him  a trial  of  the 
caustic,  with  a view  to  deaden  the  edge  of 
the  stricture,  as  the  only  probable  means 
of  effecting  a cure.  The  degree  of  irritation 
was  already  great ; I was,  however,  led  to 
believe  that  the  application  of  the  caustic 
was  not  likely  to  increase  it ; since,  by 
destroying  the  irritable  part,  it  might  lessen 
and  even  remove  the  spasmodic  affection  ; 
but  if,  contrary  to  my  expectation,  the 
irritation  continued,  we  still  should  be  able 
to  draw  off' the  water,  as  the  slough  formed 
by  the  caustic  would  prevent  the  edge  of 
the  stricture  from  acting  and  obstructing  the 
instrument. 

“ The  application  of  the  caustic  was, 
upon  these  grounds,  determined  on  ; and  it 
was  applied  in  the  following  manner. 

“ I passed  a common  bougie,  nearly  the 
size  of  the  canal,  down  to  the  stricture,  to 
ascertain  its  exact  situation,  and  to  make 
the  canal  of  the  urethra  as  open  as  possible 
The  distance  was  then  marked  upon  a 
bougie  armed  with  caustic,  of  the  same 
size,  which  was  conveyed  down  as  quickjpr 
as  the  nature  of  the  operation  would  admit. 
It  was  retained  upon  the  stricture  with  a 
slight  degree  of  pressure  ; at  first  there  was 
no  pain  from  the  caustic,  but  a soreness 
from  pressure ; in  less  than  a minute  a 
change  was  felt  in  the  sensation  of  the  part, 
it  was  at  first  a heat,  succeeded  by  the 
burning  pain  peculiar  to  caustic ; as  soon 
as  this  was  distinctly  felt,  the  bougie  and 
caustic  were  withdrawn,  having  remained 
in  the  urethra  about  a minute  altogether. 
The  soreness,  he  said,  was  entirely  local, 
by  no  means  severe,  was  unaccompanied 
by  irritation  along  the  canal,  and  he  thought 
the  uneasiness  in  the  bladder  diminished 
by  it.  He  described  the  pain  as  resembling 
very  exactly  the  first  symptoms  of  gonor- 
rhoea. This  sensation  lasted  half  an  hour 
after  withdrawing  the  bougie. 

“ The  caustic  was  applied  about  one 
o’clock  in  the  forenoon,  and  he  passed 
the  day  more  free  from  irritation  than  he 
had  since  the  beginning  of  the  attack,  which 
had  lasted  six  days.  In  the  evgning,  the 
water  was  drawn  off  with  more  ease  than 
the  night  before.  He  passed  a tolerable 
night,  and,  the  next  day,  continued  free 
from  irritation.  On  the  third  day,  the  caus- 
tic was  again  applied  in  the  forenoon  ; the 
painful  sensation  was  less  than  on  the  for- 
mer application,  lasted  a shorter  time,  and 
in  an  hour  after  the  armed  bongio  was  with- 


btfETHKA. 


Orawn,  he  made  water  freely  tor  the  first 
time  since  the  commencement  of  his  indis- 
position. He  said  the  irritation  in  the  blad- 
der was  removed,  and  lie  felt  very  well,  his 
appetite  returned,  he  slept  very  well,  and 
continued  to  void  his  urine  with  ease. 

“ In  this  state,  nothing  was  done  till  the 
fifth  day,  leaving  always  a day  between  the 
applications  of  the  caustic. 

* “ Qn  this  day  a common-sized  bougie 
went  readily  into  the  bladder;  it  was  im- 
mediately withdrawn,  and  the  cure  was 
considered  as  complete  ; no  bougie  was 
afterward  passed,  lest  it  might  bring  back 
an  irritation  upon  the  passage.  I met  this 
gentleman  twelve  months  afterward,  and 
he  assured  me  he  had  continued  perfectly 
well,  and  1 have  since  learned  that,  in  three 
years,  there  has  been  no  return. 

“ From  the  result  of  this  case,  I was  en- 
couraged to  hope  that  the  caustic  might  be 
applied  to  strictures  in  the  urethra  with 
more  confidence  than  I had  hitherto  be- 
lieved, since  it  evidently  did  not  bring  on 
or  increase  the  general  irritation,  but,-  on 
the  contrary,  seemed  to  allay  it.” 

The  foregoing  case,  together  with  ano- 
ther which  Sir  E.  Home  has  related,  con- 
vinced this  gentleman  that  he  had  disco- 
vered an  effectual  mode  of  treating  such 
strictures  as  do  not  admit  of  being  relieved 
by  the  common  bougie.  Hence  he  adopted 
the  use  of  armed  bougies  as  a general  prac- 
tice ; but  he  has  not  concealed  the  circum- 
stances under  which  the  method  does  not 
prove  successful.  Sir  Everard  informs  us, 
that  “ in  some  constitutions,  where  the  pa- 
tients have  resided  long  in  warm  climates, 
every  time  the  caustic  is  applied  to  a stric- 
ture, a regular  paroxysm  of  fever,  called  by 
the  patient  an  ague,  takes  place ; and  this 
has  been  so  violent  as  to  render  it  impossi- 
ble to  pursue  this  mode  of  practice.  Of  this 
I have  met  with  two  instances.  I consider 
this  disposition  to  fever  as  the  effect  of  cli- 
mate, and  not  of  any  natural  peculiarity  of 
constitution;  for  the  brother  of  one  of  these 
patients  laboured  under  the  same  disease, 
but  as  he  had  not  been  in  warm  climates,  It 
was  removed  by  the  caustic  without  his  ex- 
periencing such  attacks.” 

In  gouty  constitution?,  attacks  of  the  gout 
have  in  two  instances  brought  on  spasmo- 
dic constrictions,  after  the  stricture  had 
been  removed  by  caustic.  This,  however, 
cannot  be  called  a failure  of  the  caustic.  It 
only  shows  that  gout  can  affect  strictures, 
and  reproduce  them. 

“In  some  patients  the  strictures  are  so 
obdurate,  that  the  use  of  the  caustic  is  ne- 
cessary to  be  continued  for  a longer  time, 
than  the  parts  can  bear  its  application,  or 
even  that  of  the  bougie  passing  along  the 
urethra;  irritation  therefore  comes  on,  and 
stops  the  progress  of  the  cure,  and  when  the 
same  means  are  resorted  to  again,  the  same 
thing  takes  place.  The  cases  of  failure  ot 
this  kind  that  I have  met  with,  some  of 
which  may  yet  ultimately  be  cured,  if  the 
patients  will  take  the  necessary  steps  for 
that  purpose,  amount  in  all  to  six 


539 

“ In  some  patients  the  stricture  is  readily 
removed  by  the  caustic,  but,  in  a few  weeks 
contracts  again.  The  stricture  being  wholly 
spasmodic,  the  caustic,  by  taking  off  the 
spasm,  is  allowed  to  pass  through,  and  can- 
not completely  destroy  the  stricture.  Of 
this  kind  I have  met  with  one  instance 
which  I must  consider  as  a failure,  as  I 
have  hitherto  been  unable  to  get  the  better 
of  it. 

“ In  those  cases  where  the  caustic  gradu- 
ally removes  the  stricture,  and  brings  the 
urethra  to  a size  that  allows  the  patient  to 
make  water  perfectly  well,  if  there  is  any 
return,  it  is  not  to  be  attributed  to  the  fail- 
ure of  the  caustic,  but  to  the  want  of  proper 
management,  either  from  the  caustic  being 
too  small,  or  its  use  left  off  too  soon  ; but 
all  such  cases  are,  I believe,  within  the  pow- 
er of  being  cured  by  the  caustic,  if  its  use 
is  recurred  to  when  that  is  found  ne- 
cessary.” 

For  the  generality  of  strictures  in  the 
urethra,  which  do  not  occupy  more  extent 
of  the  canal  than  if  caused  by  a piece  of 
packthread  being  tied  round  it,  bougies, 
armed  with  lunar  caustic,  answer  very  well, 
and  so,  I believe,  do  common  bougies,  to 
which  the  general  preference  ought  per- 
haps to  be  given.  For  cases,  also,  in  which 
the  urethra  is  diminished  in  diameter,  for  aa 
inch  or  more,  common  bougies  must  be 
most  advantageous,  that  is  to  say,  when 
they  can  be  introduced  through  the  stric- 
t re,  so  as  to  cure  it  on  the  principle  of 
dilatation. 

Whether,  in ‘certain  cases,  where  no  pro- 
gress can  be  made  with  common  bougies,  it 
is  better  to  try  caustic,  or  attempt  to  force 
the  obstruction  with  a sound,  is  a question  on 
which  there  is  a great  deal  of  difference  of 
opinion.  “ The  practice  of  pressing  firm 
bougies,  or  metallic  instruments,  so  as  to 
force  the  stricture,  or  to  produce  an  ulcera- 
tion of  it,  (says  a modern  writer,)  so  fre- 
quently has  been  found  to  form  false  pass- 
ages, fistula?,  and  gangrene,  that  I need  here 
make  no  further  observation  on  the  practice, 
or  its  consequences.  All  the  advantages  that 
can  be  gained  by  pressure,  tearing  through 
the  stricture,  or  producing  ulceration  of  it, 
may  be  obtained  by  a careful  and  judicious 
use  of  the  caustic,  which  will  be  found  on 
the  whole  a safer  application,  and  will  be  at- 
tended with  less  inflammation  and  pain.” 
( Wilson  on  the  Male  Urinary  and  Genital  Or- 
gans, p.  383.)  This  gentleman  is  not,  how- 
ever, an  advocate  for  the  caustic  in  every 
case.  “ I consider  it,”  says  he,  “ the  safest 
practice  in  cases  which  will  not  yield  to  the 
introduction  of  bougies,  and  which  require 
a portion  of  the  stricture  to  be  destroyed  ; 
but  the  symptoms  which  sometimes  attend 
its  use,  and  the  injury  which  may  be  done  by 
its  improper  application,  should  confine  it  to 
those  cases.”  ( p . 385.) 

I shall  conclude  this  part  of  the  subject  of 
strictures,  with  inserting  some  of  the  general 
directions  given  by  Sir  £.  Homeisovv  to  arm 
the  bougie,  and  apply  the  lunar  caustic  to- 
strictures. 


540 


URETHRA. 


In  arming  a bougie,  it  will  be  difficult  to 
get  a piece  of  caustic  of  a proper  shape  and 
aize  for  (he  purpose,  unless  it  be  cast  in  a 
small  cylindrical  mould.  “ If  these  pieces 
are  thicker  than  the  bougie  can  readily  en- 
close, by  putting  them  in  water  the  outside 
quickly  dissolves,  so  as  to  diminish  their  size 
as  much  as  is  required.  The  piece  of  caus- 
tic, so  prepared,  is  to  be  cut  into  small  por- 
tions, about  a quarter  of  an  inch  in  length, 
and  an  orifice  being  made  in  the  end  of  a 
bougie,  the  caustic  is  to  be  inserted  into  it, 
and  the  bougie  rolled  so  as  to  be  made  per- 
fectly smooth,  taking  care  that  the  sides  of 
the  caustic  are  every  where  covered,  and 
only  the  end  exposed. 

“ This  was  the  mode  (says  Sir  Everard)  in 
which  I armed  bougies,  when  I first  took  up 
this  practice ; but  it  happened,  that,  in  two 
or  three  instances,  the  caustic  was  left  in  the 
urethra  ; that  canal,  when  in  a very  irritable 
state,  grasped  the  bougie,  and  pulled  the 
caustic  out ; I was  therefore  led  to  consider 
how  such  an  accident  might  he  prevented, 
and  applied  to  the  makers  of  bougies  for  that 
purpose.  Mr.  Pass,  the  late  beadle  of  the 
Surgeon’s  Company,  who  dealt  in  bougies, 
discovered  a very  ingenious  and  effectual 
mode  of  securing  the  caustic.  In  forming 
the  bougie,  a piece  of  wire,  the  size  of  the 
caustic,  is  rolled  up  along  with  it,  passing 
into  the  substance  for  half  an  inch  ; when 
the  bougie  is  nearly  finished,  the  wire  i3 
withdrawn,  and  the  caustic  inserted  in  iis 
place  after  this,  the  bougie  is  rolled  again, 
so  that  the  sides  of  the  caustic  become  firmly 
cemented  to  the  linen,  by  means  of  the  com- 
position of  the  bougie,  and  when  cold,  can- 
not be  separated  by  any  force.  In  this  way 
bougies  are  now  generally  armed. 

“ After  the  bougie  has  been  thus  prepared, 
the  distance  of  the  stricture  from  the  exter- 
nal orifice  is  to  be  measured,  and  the  canal 
cleared  by  passing  a coramoft  bougie  fully  as 
large  as  that  which  is  armed.  The  armed 
bougie,  wiib  the  distance  marked  upon  it,  is 
then  to  be  introduced,  and  applied  to  the 
stricture;  when  it  is  brought  in  contact  with 
the  obstruction,  it  is  to  be  steadily  retained 
there,  with  a moderate  degree  of  pressure  at 
first,  and  less  as  it  is  longer  continued,  since 
the  bougie  becomes  soft  by  remaining  in  the 
urethra,  and  readily  bends  if  the  pressure  is 
too  great.  The  time  it  is  to  remain  depends 
a good  deal  upon  the  sensations  of  the  pa- 
tient, and  the  length  of  time  the  parts  have 
been  diseased  ; but  on  the  first  trial  it  should 
be  less  than  a minute,  as  it  then  commonly 
gives  greater  pain  than  on  any  subsequent 
application.  The  pain  produced  by  the 
caustic  Js  not  felt  so  immediately  as  it  would 
be  natural  to  expect;  the  first  sensation  arises 
from  the  pressure  of  the  bougie  on  the  stric- 
ture ; a little  afterward,  there  is  the  feeling 
of  heat  in  the  parts ; and  lastly,  that  of  pain. 

“ As  soon  as  the  caustic  begins  to  act,  the 
surgeon  who  makes  the  application  is  made 
sensible  of  it  by  the  smaller  arteries  of  the 
parts  beating  with  unusual  violence,  which 
is  very  distinctly  felt  by  the  finger  and  thumb 
dial  grasp  (be  penis 


4 The  pain  that  is  brought  on  by  the  caus- 
tic lasts  for  some  time  after  it  is  withdrawn  J 
but  this  period  differs  in  almost  every  patient, 
being  sometimes  extended  to  half  an  hour, 
and  sometimes  only  a few  miuutes. 

“ The  kind  of  pain  is  heat  and  soreness, 
which  is  not  severe,  not  being  accompanied 
with  the  peculiar  irritation,  upon  so  many  oc 
casions  experienced  by  patients  who  have 
strictures ; an  irritation  that  cannot  tfe  de- 
scribed, which  is  most  insupportable,  and  is 
too  often  brought  on  by  dilating  strictures 
with  the  bougie.”  In  the  vol  from  which 
the  above  directions  are  taken,  Sir  Everard 
Home  recommends  the  patient  to  make  wa- 
ter, as  soon  as  the  armed  bougie  is  with- 
drawn ; but  in  a subsequent  vol.  he  explains 
bis  change  of  opinion  upon  this  point : “ I 
not  only  have  no  wish  that  the  patient  should 
make  water  immediately  after  the  applica- 
tion, but  would  rather  that  it  be  retained 
some  time.”  (On  Strictures,  vol.  3,  p.  51 
8i;o.  Lond.  1821.) 

“ It  happens  not  unfrequently,”  says  Sir 
Everard  Home,  “ that  at  the  first  time  of 
making  water,  some  blood  passes  along  with 
it.  This  is  rather  favourable  ; as,  when  the 
parts  bleed,  the  stricture  usually  proves  to  be 
so  far  destroyed,  that  at  the  next  trial  the 
bougie  passes  through  it.  Every  other  day 
appears,  in  general,  to  be  as  often  as  it  is 
prudent  to  apply  the  caustic.  I have,  how'-, 
ever,  done  it  every  day  in  very  obstinate 
cases,  where  ihe  parts  are  less  sensible,  with- 
out any  detriment.” 

In  his  third  volume,  lately  published,  he 
states,  that  he  now  rarely  passes  the  bougie 
oftener  than  every  third  day,  and  never 
when  the  pain  from  the  last  application  has 
not  entirely  gone  off.  He  also  never  con- 
tinues any  one  application  beyond  the  time 
when  the  pain  begins  to  extend  further  than 
the  spot  to  which  the  armed  bougie  is  ap- 
plied. (Vol.  3, p.  51.) 

The  bougie  which  is  passed  down  to  pre 
pare  the  way  for  the  caustic,  and  measure 
the  distance  for  the  armed  bougie,  must  be 
made  of  soft  materials,  that  it  may  readily 
receive  an  impression  from  the  part  against 
which  it  is  pressed,  and  its  colour  should  be 
light,  so  as  to  admit  of  those  impressions 
being  more  distinctly  seen.  With  the  assis- 
tance ol  such  bougies,  I am  able  to  discover 
the  size  and  shape  of  the  orifice  of  the  stric- 
ture ; to  ascertain  with  accuracy  the  progress 
of  the  caastic  upon  it;  to  see  whether  it  is 
on  one  side  of  the  canal,  or  equally  nil  round 
and  to  apply  the  caustic  accordingly. 

“ When  the  soft  bougie  passes  through  the 
stricture,  by  leaving  it  in  the  canal  a few 
minutes,  it  can  be  kqown  whether  the  stric 
ture  is  completely  destroyed  or  only  relaxed ; 
in  the  last  case,  there  is  an  impression  on  the 
side  of  the  bougie.”  (Home  on  Strictures , 
vol.  1.) 

CURE  OF  STRICTURES  WITH  TIIE  POTASSA 
FUSA- 

Mr.  Whately,  in  his  publication  on  slric 
tures,  endeavours  to  convince  the  reader 


URETHRA- 


that  they  are  uot  merely  contracted  fibres  of 
the  urethra,  but  really  diseased  portions  of 
the  membrane  lining  that  canal,  with  a con- 
tinued disposition  to  increased  contraction. 
Hence  this  gentleman  seems  to  conceive, 
that  the  application  of  a remedy,  calculated 
both  to  remove,  the  diseased  affection,  and 
to  dilate  the  contracted  part,  might  perfectly 
cure  the  complaint,'  without  putting  the  pa- 
tient to  the  inconvenience  of  wearing  a bou 
gie.  Mr.  Whately  affirms,  that  such  a reme- 
dy is  caustic,  when  judiciously  used.  Hither- 
to the  lunar  caustic  has  been  chiefly  employ- 
ed ; but  this  gentleman  states,  that  it  has 
been  his  good  fortune  to  discover  a more  effi- 
cacious, and  at  the  same  time  a less  painful 
and  hazardous  remedy  for  the  disease  in  ques- 
tion. The  potassa^usa  is  the  application  al- 
luded to,  which  IVm  Whately  says,  if  used 
in  the  manner  and  with  the  precautions 
about  to  be  described,  will  be  found  to  pos- 
sess singular  efficacy  in  curing  the  complaint. 
He  avows,  that  he  has  already  had  so  much 
experience  of  it,  and  that  be  is  so  perfectly 
convinced  of  its  superiority  over  the  lunar 
caustic,  as  well  as  over  the  common  bougie, 
that  he  now  use3  it  in  a considerable  number 
of  the  cases  which  come  under  his  care.  Of 
its  safety  he  is  also  as  well  convinced  as  of 
its  efficacy  ; for  if  used  with  circumspection, 
experience  proves  that  there  is  little  danger 
of  its  producing  any  disagreeable  effect. 

However,  if  the  potassa  fusa  be  applied 
while  the  parts  are  in  a highly  inflamed,  or 
irritable  state,  or  (as  Mr.  Whately  expresses 
himself)  tending  to  gangrene  ; if  the  habit 
be  bad,  and  the  patient  very  far  advanced  in 
years,  the  most  mischievous  effects  may  be 
expected  from  the  application  ; and  the  U3e 
of  any  kind  of  caustic,  under  such  circum- 
stances, for  strictures  in  the  urethra,  is  cen- 
sured as  dangerous  in  the  extreme. 

Mr.  Whately  represents,  that  if  the  patient 
be  affected  with  fever,  or  any  other  acute 
disease  ; if  he  be  much  indisposed  from  any 
cause  ; if,  in  particular,  he  have  a gonorrhoea, 
attended  with  much  inflammation  and  irrita- 
tion in  th<  urethra;  if  the  prepuce,  glans,  or 
any  other  part  of  the  penis,  or  the  parts  ad- 
joining to  it,  be  swelled  and  inflamed  ; if  the 
urethra,  and  especially  the  strictured  part  of 
it,  be  so  irritable  as  uot  to  bear  the  touch  ot 
a bougie  ; the  use  of  the  caustic  is  for  the 
present  forbidden.  Mr.  Whately  also  en- 
joins great  caution  in  applying  this  remedy 
to  persons  advanced  in  years.  Even  when 
no  objections  of  the  above  kind  exist,  the 
caustic  should  not  be  resorted  to  in  the  first 
instance.  Mr.  Whately  maintains,  that  in 
every  case  of  stricture,  before  venturing  to 
employ  the  caustic,  we  ought  to  be  able  to 
pass  into  the  bladder  a bougie  of  at  least  a 
size  larger  than  one  of  the  finest  sort.  This 
is  necessary,  both  to  let  the  caustic^be  applied 
to  the  whole  surface  of  the  stricture,  and 
to  relieve  a retention  of  urine,  should  it  oc- 
cur during  the  use  of  the  caustic. 

When  a bougie  of  the  preceding  descrip- 
tion can  be  introduced,  without  occasioning 
pain,  faintness,  or  great  dejectiou  of  spirits, 
?he  use  of  caustic  may  commence  itnmedi- 


54A 

ately,  provided  none  of  the  above -described 
objections  exist. 

When  the  urethra  is  very  irritable,  Mr. 
Whately  recommends  a common  bougie  t© 
be  introduced  every  day,  and  kept  in  the 
urethra  ; at  first,  for  a few  minutes  only  ; 
but  by  degrees  for  a longer  time  ; til i the 
irritability  of  the  parts  has  been  sufficiently 
lessened. 

When  she  urethra  is  rendered  so  impervi- 
ous by  a stricture,  that  a small  bougie  cannot 
be  passed  into  the  bladder,  which  viscus  is 
also  in  a painful  inflamed  state,  Mr.  Whately 
asserts,  that  caustic,  in  any  form  or  quantity, 
must  not  be  immediately  employed ; but 
that  the  stricture  should  be  first  rendered  ca- 
pable of  allowing  a bougie  a little  larger  than 
one  of  the  finest  size,  to  be  introduced  into 
the  bladder.  When  this  is  done,  the  urine  is 
more  freely  evacuated,  and  the  consequent 
irritation  and  inflammation  of  the  bladder 
lessened,  if  not  removed,  together  with  the 
danger  of  • retention  of  urine.  Caustic  may 
then  be  advantageously  conveyed  into  the 
centre  of  the  stricture. 

Mr.  Whately  considers  'he  practice  of  at 
once  thrusting  down,  in  this  sort  of  case,  an 
armed  bougie  considerably  larger  than  the 
narrowest  part  of  the  contracted  canal,  as 
most  dangerous,  and  horridly  painful.  For, 
says  this  gentleman,  it  frequently  happens, 
that  nearly  the  vs  hide  of  the  urethra  anterior 
to  the  bulb  is  so  much  contracted  by  nume- 
rous, and  uncommonly  rigid  strictures,  that 
it  is  impossible,  by  any  art  whatever,  to  di- 
late the  passage  to  its  natural  size.  If,  there- 
fore, the  canal,  whilst  in  such  a slate,  be 
rudely  torn  open  by  a large  caustic  bougie, 
hemorrhage,  pain,  dangerous  suppressions  of 
urine,  inflammation,  mortification,  and  death 
itself,  must  sometimes  inevitably  ensue, — 
even  before  the  caustic  can  be  applied  to  the 
principal  seat  of  the  disease.  In  cases  like 
the  one  just  mentioned,  the  first  step  prepa 
ratory  to  the  use  of  the  caustic  should  be,  ac- 
cording to  Mr.  Whately,  to  dilate  the  strictu 
red  part  of  the  urethra;  for  which  purpose, 
he  advises  the  slow  and  gentle  introduction 
of  a fine  bougie,  with  its  point  inclined  to 
the  lower  side  of  the  canal,  in  order  to  avoid 
the  large  lacunce  situated  on  its  upper  part. 
When  the  surgeon,  by  steady  perseverance 
and  dexterity,  has  succeeded  in  getting  a fine 
bougie  through  the  worst  stricture  into  the 
bladder,  the  instrument  should  be  worn  for  a 
few  hours  every  day,  till  the  passage  is  suffi- 
ciently dilated  to  admit  a larger  one. 

Mr.  Whately,  after  explaining  that  caustic 
potassa  ought  not  to  be  applied  to  strictures 
of  the  urethra  till  a bougie  of  a proper  size 
can  be  passed  into  the  bladder,  pointing  out 
the  methods  to  be  taken  before  applying 
this  caustic,  and  enumerating  certain  cases 
and  circumstances  in  which  its  employment 
is  interdicted,  next  proceeds  to  describe  the 
mode  of  practice,  which  it  is  the  particular 
object  of  his  book  to  recommend. 

For  the  purpose  of  arming  a bougie,  Mr. 
Whately  advises  us  to  put  a small  quantity 
of  caustic  potassa  upon  a piece  of  strong 
paper,  and  to  break  the  bit  of  caustic  yvitii 


URETHRA. 


a hammer  into  small  pieces  of  about  the 
size  of  large  and  small  pins’  heads.  In  doing 
this,  care  should  be  taken  not  to  reduce  it 
to  powder.  Thus  broken,  it  should  be  kept 
for  use  in  a phial,  closed  with  a ground 
stopper.  The  bougie  should  have  a proper 
degree  of  curvature  given  to  it,  by  drawing 
it  several  times  between  the  finger  and 
thumb  of  the  left  hand. 

Mr.  Whately  next  acquaints  us,  that  be- 
fore the  caustic  is  inserted  into  the  bougie, 
it  is  necessary  to  ascertain  the  exact  dis- 
tance of  the  stricture  (to  which  the  caustic 
is  to  be  applied,)  from  the  extremity  of  the 
penis.  For  this  purpose,  the  bougie,  which 
should  be  just  large  enough  to  enter  the 
stricture  with  some  degree  of  tightness, 
ought  to  be  gently  introduced  into  the 
urethra;  and  when  its  point  stops  at  the 
stricture,  which  it  almost  always  does  be- 
fore it  will  enter  it,  a notch  is  to  be  made 
with  the  finger-nail  on  the  upper  or  curved 
portion  of  the  bougie,  on  the  outside  of  the 
urethra,  exactly  half  an  inch  from  the  ex- 
tremity of  the  penis.  When  the  bougie  is 
withdrawn,  a small  hole,  about  the  sixteenth 
part  of  an  inch  deep,  should  be  made  at  the 
extremity  of  its  rounded  end.  A large 
blanket-pin,  two  inches  and  a half  in  length, 
with  the  head  struck  off,  will  answer  the 
purpose ; the  hole  being  made  with  the 
point  of  the  pin.  The  extremity  of  ihe 
bougie  should  then  be  made  perfectly 
smooth  with  the  finger  and  thumb,  taking 
care  that,  in  doing  this,  the  hole  in  its 
centre  be  not  closed.  Some  of  the  broken 
caustic  should  then  be  put  on  a piece  of 
writing  paper,  and  a piece  less  in  size  than 
the  smallest  pin’s  head  should  be  selected  ; 
the  particle,  indeed,  says  Mr.  Whately,  can- 
not be  too  small  for  the  first  application. 
Let  this  be  inserted  into  the  hole  of  the 
bougie  with  a pocket-knife,  spatula,  or  some 
such  instrument ; and  pushed  into  it  with 
the  blunt  end  of  the  pin,  so  as  to  make  the 
caustic  sink  a very  little  below  the  margin 
of  the  hole.  To  prevent  the  potassa  fusa 
from  coming  out,  the  hole  should  then  be 
contracted  a little  with  the  finger,  and  the 
remaining  vacancy  in  it  is  to  be  filled  with 
bog’s  lard.  This  last  substance  (continues 
Mr  Whately)  will  prevent  the  caustic  from 
acting  on  the  sound  part  of  the  urethra,  as 
the  bougie  passes  to  the  stricture.  When 
the  bougie  is  quite  prepared,  let  it  be  first 
oiled,  arid  immediately  afterward  intro- 
duced, by  a very  gentie  motion,  with  the 
curvature  upwards  as  far  as  the  anterior 
part  of  the  stricture,  upon  which  the  caustic 
is  to  be  applied.  In  doing  this,  the  end  of 
the  bougie,  held  by  the  finger  and  thumb, 
should  be  a good  deal  inclined  towards  the 
abdomen,  on  the  first  introduction  of  the 
instrument,  in  order  to  prevent  its  curva- 
ture. After  it  has  passed  about  five  inches, 
this  end  should  be  gradually  brought  down- 
wards, as  the  bougie  passes  on,  till  it  forms 
a right  angle  with  the  body.  The  bougie  is 
known  to  have  arrived  at  the  stricture  by 
the  resistance  made  to  its  progress. 

As  «oou  as  the  bougie  lias  reached  the 


anterior  part  of  the  stricture,  it  should  rest 
there  for  a few  seconds,  that  the  caustic 
may  begin  to  dissolve.  It  should  then  be 
pushed  very  gently'  forward  about  one- 
eighth  of  an  inch  ; after  which,  there  should 
be  another  pause  for  a second  or  two.  The 
bougie  should  then  be  carried  forward  in 
the  same  gentle  manner  till  it  has  got 
through  the  stricture.  The  sense  of  feeling 
will  generally  inform  the  operator  when  the 
point  of  the  bougie  has  proceeded  so  far ; 
but  the  notch  in  the  bougie  is  to  be  an  ad- 
ditional guide,  by  becoming  very  near  the 
orifice  of  the  urethra  when  the  end  of  the 
instrument  has  just  got  through  the  stricture 

The  bougie  should  now  be  immediately 
withdrawn  by  a very  gentle  motion  to  the 
part  at  which  it  was  forst  made  to  rest 
awhile.  Then  it  shouV  be  very  slowly 
passed  through  the  stricture  a second  time; 
but  without  letting  the  bougie  stop  in  its 
passage.  If  the  patient  complain  of  pain, 
or  be  faint,  the  bougie  should  be  immedi- 
ately withdrawn  ; but,  if  these  effects  are 
not  produced,  we  may  repeat  the  operation 
of  passing  and  withdrawing  the  bougie 
through  the  stricture  once  or  twice  more 
before  we  finish  the  operation,  which  will 
take  up,  in  the  whole,  about  two  minutes. 

The  first  application  of  the  potassa  fusa, 
in  this  manner,  gives,  according  to  Mr. 
Whately’s  account,  a very  little  pain.  A 
slight  scalding  in  making  water,  and  a tri- 
fling discharge  during  the  first  day  or  two, 
however,  are  commonly  produced. 

At  the  end  of  seven  days  the  application 
of  the  caustic  is  to  be  repeated  in  the  same 
manner.  When  the  first  application  has 
enlarged  the  aperture  of  the  stricture,  which 
may  be  known  by  passing  a bougie  through 
it  of  the  same  size  as  that  by  which  the 
caustic  was  conveyed,  the  bougie  used  in 
the  second  operation  should  be  a size  larger 
than  the  one  used  in  the  first ; but  it  must 
not  be  too  large  to  pass  through  the  stric- 
ture. If  the  patient  had  no  pain  on  the  first 
application,  the  bit  of  potassa  fusa  may  also 
be  trivially  larger.  At  the  end  of  seven 
days  more,  the  armed  bougie  should  be  in- 
troduced a third  time.  At  this,  and  all  future 
applications,  the  bougie  should  be  increased 
in  size  in  proportion  as  the  aperture  in  the 
stricture  becomes  dilated.  The  quantity  of 
caustic,  however,  is  never  to  be  increased 
in  a ratio  to  the  size  of  the  bougie.  In  no 
cases  whatever  does  Mr.  Whately  apply 
more  of  the  potassa  fusa  at  a time  than  a 
piece  about  the  size  of  a common  pin’s 
head.  Twelve  bits  of  the  largest  size, 
which  this  gentleman  ever  uses,  weigh  one 
grain. 

When  there  are  several  strictures,  the 
potassa  fusa  should  be  generally  applied  to 
only  one  at  a time. 

An  interval  of  seven  days  is  what  Mr. 
Whately  generally  allows  to  elapse  between 
the  applications  of  the  caustic.  The  rule, 
however,  may  now  and  then  be  deviated 
from  ; but  the  potassa  fusa  ought  never  to 
be  reapplied  till  the  action  of  the  last  ap- 
plication has  completely  ceased.  In  a few 


URETHRA 


S4M 


instances,  the  interval  may  only  be  five 
days  ; in  some  others,  it  may  be  eight,  nine, 
or  even  a longer  space. 

In  the  above  method  of  using  the  potassa 
fusa,  Mr.  YVhately  represents  that  this  sub 
stance  is  equally  diffused  over  every  part  of 
the  strictured  surface,  and  only  abrades  the 
membrane  of  the  stricture,  without  produ- 
cing a slough.  The  degree  of  this  abrasion, 
he  says,  may  be  increased  or  lessened  as 
circumstances  dictate,  by  paying  attention 
to  the  quantity  of  the  caustic. 

The  foregoing  account  will  suffice  for 
conveying  an  adequate  idea  of  Mr.  Whate- 
ly’s  method.  I am  sorry  I cannot  add  my 
favourable  opinion  of  the  practice.  To 
abrade,  without  destroying,  is  rather  too 
nice  a distinction  for  a practical  man,  doing 
business  as  it  were  in  the  dark.  Nor  can  1 
conceive,  that  a liquid  caustic  (for  so  it  is 
represented  as  becoming)  can  be  applied 
with  the  accuracy  to  strictures,  which  Mr. 
Whately  seems  to  suppose  happens.  This, 
however,  is  merely  my  own  sentiment ; 
and  I do  not  wish  to  conceal  that  there  are 
yet  a few  surgeons  who  believe  that  Mr. 
Whately’s  plan  is  the  most  eligible. for  all' 
cases,  in  which  the  stricture  is  irritable,  or 
far  advanced.  (See  Howship's  Pract.  Obs. 
on  the  Urinary  Organs,  p,  207.)  On  the 
other  hand,  I know  some  very  eminent 
surgeons,  who  formerly  took  up  this  prac- 
tice with  great  zeal,  yet  now  have  entirely 
abandoned  it.  I consider  it  myself  the 
worst  and  most  random  mode  of  applying 
caustic  to  strictures,  and  more  likely  to  act 
on  the  sound  than  the  diseased  portion  of 
the  urethra. 

Upon  the  whole,  I may  safely  declare, 
that  caustic  bougies  are  now  much  less 
frequently  used  by  the  best  surgeons  in 
London  than  they  were  about  fifteen  years 
ago;  Several  distinguished  practitioners, 
who  to  my  knowledge  were  then  accus- 
tomed to  recommend  and  employ  them, 
have  at  present  returned  either  to  the  use 
of  common  bougies,  or  those  made  of  me- 
tal, or  elastic  gum,  to  which,  after  many 
comparative  trials,  I acknowledge,  a gene- 
ral, but  not  universal,  preference  seems  to 
me  to  be  due.  We  learn  from  M.  Roux, 
that  caustic  bougies  never  had  many  advo- 
cates in  France  ; and  the  inquiries  which 
he  made  when  he  was  in  London  autho- 
rized him  to  announce  to  his  countrymen 
after  his  return,  that  such  instruments  are 
at  present  not  more  in  general  favour  here 
than  they  are  at  Paris.  (See  Voyage  fait  a 
Londres  en  1814,  ou  Par  allele  de  la  Chirur- 
gie  Angloise,  tye.p.  315.) 

Cases  of  stricture,  however,  where  the 
disease  is  far  advanced,  of  long  standing, 
and  attended  with  such  obstruction  that  no 
kind  of  common  bougie  can  be  introduced, 
appear  to  me  to  be  the  examples  in  which 
the  employment  of  bougies,  armed  with  the 
nitrate  of  silver,  ought  principally  to  be  con- 
tinued. This  mode  seems  to  me  less  vio- 
lent than  that  of  employing  a common 
bougie,  or  iron  sound,  with  sufficient  force 
to  make  it?  wav  through  the  stricture  by 


laceration.  It  must  also  be  attended  with 
less  risk  of  rupturing  the  urethra,  and  pro  - 
ducing a false  passage.  At  the  same  time, 
if  the  stricture  occupy  some  length  of  the 
passage,  and  a common  bougie,  which  is 
the  best  instrument  in  this  circumstance, 
cannot  be  introduced  through  the  obstruc  - 
tion so  as  to  dilate  it,  1 believe  a passage 
through  it  must  often  be  attempted  on  the 
principle  of  exciting  ulceration,  and  that 
for  this  purpose  a sound  or  metallic  catheter 
should  be  employed.  In  the  first  instance, 
however,  1 would  try  the  armed  bougie. 

1 have  already  explained  that  the  armed 
bougie  has  likewise  been  particularly  re- 
commended for  what  has  been  termed  the 
irritable  stricture  ; and  it  is  even  declared, 
in  Sir  Everard’s  third  volume,  that  lunar 
caustic  has  a greater  power  of  removing 
spasm  than  any  other  kind  of  caustic. 

A Treatise  on  the  Venereal  Disease,  by 
John  Hunter,  2 d Edit.  Practical  Obs.  on 
the  Treatment  of  Strictures  in  the  'Urethra 
and  (Esophagus,  by  Sir  Everard  Home,  in  3 
Vols.  8 vo.  bond.  An  Improved  Method  of 
Treating  Strictures  in  the  Urethra,  by  Tho- 
mas Whately,  Edit.  2, 1806.  M.  W.  Andrews's 
Obs.  on  the  Application  of  Lunar  Caustic  to 
Strictures  in  the  Urethra  and  (Esophagus, 
8r o.  Lond.  1807.  T.  Luxmore's  Practical- 
Observations  on  Strictures , fyc.  8i o.  Lond. 
1800.  Howship's  Practical  Obs.  on  the  Dis- 
eases of  the  Urinary  Organs,  8 vo.  Lond.  1816. 
Soemmering  Abhandlvng  fiber  die  schnell 
und  langsam  todtlichen  Krankheitcn  der 
Harnblase  und  Harnrohre  bey  Mannern  im 
hohen  Alter.  4 to.  Frankf.  1800.  Letters  con- 
cerning the  Diseases  of  the  Urethra,  by  C. 
Bell , 1810  ; subsequently  republished  with  ad- 
ditions by  Mr.  Shaw.  James  Wilson,  Lectures 
on  the  Structure  and  Physiology  of  the  Male 
Urinary  and  Genital  Organs,  and  their  Dis- 
eases, Svo.  Lond.  1821.'  James  Arnott,  a 
Treatise  on  Stricture  of  the  Urethra,  8r c. 
Lond.  1819.  Having  given  an  account  of 
this  gentleman's  dilator,  and  his  method  of 
treatment, .in  the  2d  Vol.  of  the  last<cdition  of 
the  First  Lines  of  the  Practice  of  Surgery,  I 
have  not  considered  it  necessary  to  repeat  the 
statement  in  the  present  work.  J.  Cross, 
Sketches  of  the  Medical  Schools  of  Paris,  p. 
Ill,  fyc.  Svo.  Lond.  1815. 

URETHRA,  FALSE  PASSAGE  IN. 
One  of  the  worst  consequences  of  using 
catheters  and  bougies  in  an  improper  man- 
ner, is  the  rupture  of  the  urethra,  or  the  for- 
mation of  a false  passage  by  ulceration. 
With  bougies,  this  accident  is  generally  oc- 
casioned by  trials  to  excite  ulceration  by  the 
application  of  the  end  of  the  bougie  to  the 
stricture,  when  this  instrument  cannot  be 
passed  through  it.  When  once  the  new  pas- 
sage has  been  formed,  whenever  the  bougie 
is  introduced,  it  cannot  be  hindered  from 
going  into  the  false  track,  and  its  action  on 
the  stricture  is  altogether  frustrated. 

In  this  kind  of  case  Mr.  Hunter  has  ad- 
vised the  following  operation  to  be  practised. 
Pass  a staff,  or  any  such  instrument  into  the 
urethra  as  far  as  it  will  go,  which  will  pro- 
bably be  to  the  bottom  of  the  new  passage. 


URINARY  ABSCESSES. 


644 


and  this,  we  may  be  certain,  is  beyond  the 
stricture.  Feel  for  the  end  of  the  instru- 
ment externally,  and  cut  upon  it,  making 
the  wound  about  an  inch  long,  if  the  disease 
be  before  the  scrotum  ; and  an  inch  and  a 
half,  or  more,  if  in  the  perineum.  If  the 
new  passage  be  between  the  urethra  and 
body  of  the  penis,  you  will  most  probably 
get  into  the  sound  urethra,  before  you  come 
to  the  instrument,  or  new  passsage.  If%so, 
introduce  a probe  into  the  urethra,  through 
the  wound,  and  pass  it  towards  the  glans 
penis,  or,  in  other  words,  towards  the 
stricture.  When  it  meets  with  an  obstruc- 
tion, this  must  be  the  stricture,  which  is 
now  to  be  got  through,  and  afterward  dila- 
ted. To  complete  the  operation,  withdraw 
the  probe,  and,  instead  of  it  introduce  a 
hollow  cannula  forwards  to  the  stricture. 
Then  introduce  another  cannula  from  the 
glans  downward,  till  the  two  tubes  are  oppo- 
site each  other,  having  the  stricture  between 
them.  An  assistant  is  now  to  take  hold  of 
the  urethra  on  the  outside,  with  his  finger 
and  thumb,  just  where  the  two  cannulse 
meet,  in  order  to  keep  them  in  their  places. 
Through  the  upper  cannula  next  introduce  a 
piercing  instrument,  which  is  to  perforate 
the  stricture,  and  enter  the  lower  cannula. 
The  piercing  instrument  is  now  to  be 
withdrawn,  and  a bougie  introduced  through 
the  first  cannula  and  stricture,  into  the 
second  cannula.  The  tubes  are  to  be 
withdrawn,  and  the  end  of  the  bougie, 
in  the  wound,  directed  into  the  bladder, 
through  the  further  portion  of  the  urethra. 
It  may  also  be  necessary  to  lay  the  whole  of 
the  false  passage  open,  in  order  to  make  it 
heal;  for  otherwise  it  might  still  obstruct  the 
future  passage  of  bougies  into  the  proper 
canal. 

When  the  new  passage  is  between  the 
skin  and  urethra,  the  surgeon  must  extend 
his  incision  more  deeply,  for  the  purpose  of 
finding  out  the  natural  passage.  Then  he  is 
to  proceed  as  above  explained. 

The  longer  the  first  bougie  is  allowed  to 
remain  in  the  canal,  the  more  readily  will 
the  second  pass.  The  bougies  must  be  gra- 
dually increased  in  size,  and  used  til!  the 
wound  is  healed.  The  only  improvement 
wliicli  seems  proper  to  be  made  in  this  plan, 
is  to  employ  flexible  gum-catheters,  which 
might  be  worn  longer  than  common  bougies, 
as  the  patient  could  void  his  urine  through 
them.  (See  Hunter  on  the  Venereal  Disease.) 
Additional  Observations  on  this  subject  are 
contained  in  the  2dvol.  of  the  First  Lines  of 
Surgery. 

URINARY  ABSCESSES  Extravasations 
of  urine  may  be  in  three  different  states. 
This  fluid  may  be  collected  in  a particular 
pouch  ; it  may  be  widely  diffused  in  the 
cellular  membrane  : or,  lastly,  it  may  pre- 
sent itself  in  a purulent  form,  after  having 
excited  inflammation  and  suppuration  in  the 
parts,  among  which  it  is  situated.  This  case 
is  termed  an  urinary  abscess. 

Such  extravasations  of  urine  always  im- 
ply a rupture,  either  in  the  kidneys  or  ure- 
ters, the  bladder  or  the  urethra.  The  solu 
I ■ 


lion  of  continuity  may  be  produced  by  a. 
variety  of  causes.  It  is  most  frequently  the 
effect  of  a forcible  distention  of  these  pas- 
sages, in  consequence  of  a retention  of 
urine.  The  bursting  of  phlegmonous  ab- 
scesses into  the  same  passages,  may  occasion 
the  breach.  It  may  also  be  produced  by 
the  penetration  of  the  parts  with  a sword, 
or'other  foreign  body:  there  are  likewise  ex- 
amples of  effusion  of  urine  from  the  displace- 
ment of  the  cannula  of  the  trocar,  after  the 
operation  of  puncturing  the  bladder.  Others 
are  caused  by  false  passages  in  the  urethra  ; 
or  by  violent  contusions  of  the  perineum, 
attended  with  laceration  of  the  urethra. 

In  Desault's  Surgical  Works,  ( T . 3.)  it  is 
observed,  that  the  ravages,  which  extravasa- 
ted  urine  makes,  are  usually  greater  and 
more  extensive,  when  it  enters  the  cellular 
membrane,  than  when  it  is  confined  in  a 
particular  cyst.  The  mischief  is  also  less 
when  the  excretory  passage  is  free,  than 
when  it  is  closed  by  any  obstacle,  as  in  cases 
of  retention.  The  more  or  less  loose  tex- 
ture of  the  parts  in  which  such  effusions 
happen,  likewise  makes  a considerable  dif- 
ference in  their  progress  and  formation. 
When  the  pelvis,  or  infundibulum  of  the 
kidney,  or  the  upper  part  of  the  ureter,  gives 
way,  the  urine  is  commonly  effused  in  the 
loins  and  the  fossae  iliacae,  between  the  pe- 
ritoneum and  the  adjacent  parts.  When  the 
lower  part  of  the  ureter,  or  the  bladder,  near 
its  lower  portion,  gives  way,  the  extravasa- 
tion is  generally  included  within  the  pelvis. 

But  when  the  rupture  occurs  in  the  ante- 
rior parietes  of  the  bladder,  near  its  upper 
part,  and  especially  when  it  takes  place  at. 
a time  w hen  this  organ  is  extremely  distend- 
ed and  dilated,  the  urine  becomes  effused 
behind  and  above  the  pubes,  sometimes  as- 
cends to  the  epigastric  region,  between  the 
peritoneum  and  the  abdominal  muscles, 
and  after  having  followed  the  course  of  the 
spermatic  vessels,  it  often  makes  its  exit  at 
the  ring,  and  is  extravasated  in  the  groins 
and  scrotum.  If  (he  rupture  has  happened 
in  the  urethra,  the  most  common  situation 
of  the  effusion  is  in  the  perineum  and  scro- 
tum. The  extravasation  frequently  extends 
to  the  penis  and  upper  part  of  the  thighs, 
and  even  sometimes  propagates  itself  under 
the  skin  of  the  abdomen,  up  to  the  hypo- 
chondria and  sides  of  the  chest. 

There  is  no  fluid,  the  extravasation  of 
which  is  so  fatal,  as  that  of  the  urine.  If  it 
is  not  promptly  discharged,  it  soon  excites 
suppuration  and  sloughing  of  the  cellular 
membrane,  a gangrenous  inflammation  of 
the  skin,  and  almost  always  a mortification 
of  the  parts  among  which  it  flows. 

WThi!e  the  extravasation  of  urine  is  con- 
fined to  t lie  interior  of  the  pelvis,  and  lum- 
bar and  iliac  regions,  without  manifesting 
itself  externally,  there  is  no  certain  sign  oi’ 
its  existence.  The  circumstances  which 
may  be  recollected,  however,  joined  with 
the  symptoms  which  the  patient  complains 
of,  may  lead  to  a suspicion  of  the  extrava- 
sation. Thus,  when  in  consequence  of  a 
retention  of  urine  in  the  ureters  or  bladder^ 


UKijNARl  ABaCES'SEt1 


Uie  patient  has  suddenly  experienced  great 
relief,  without  any  of  the  urine  having  been 
discharged  the  natural  way  ; when  he  lias  at 
the  same  instant  felt  a kind  of  pricking  in  the 
loins,  or  pelvis  ; when  to  the  ease,  which 
lasted  only  a few  hours,  symptoms,  more 
severe  than  the  former  ones,  have  succeed- 
ed, such  as  violent  fever,  hiccough,  vomit- 
ing, &c.  an  internal  extravasation  is  to  be 
suspected. 

As  soon  as  the  extravasation  is  apparent 
externally,; the  case  is  announced  by  symp- 
toms which  hardly  ever  deceive.  The  pre- 
ceding retention  of  urine  ; the  sudden  ap- 
pearance of  the  swelling  caused  by  this 
fluid  ; the  rapid  progress  of  the  tumour  ; 
the  kind  of  crepitation  perceptible  in  it,  like 
that  which  occurs  in  emphysema  ; the  shi- 
ning tension  and  cedema  of  the  skin  ; the 
diminution  of  sueh  symptoms  as  depended 
entirely  upon  the  retention  ; are  the  first 
changes  which  are  observable,  when  the  ex- 
travasation is  somew  hat  considerable. 

If  the  patient  is  not  speedily  assisted,  and 
the  urine  continues  to  be  extravasated,  the 
tumour  spreads  more  and  more  ; the  skin 
assumes  a red  violet  colour;  gangrenous 
eschars  are  formed,  the  separation  of  which 
gives  issue  to  a very  fetid  sanies,  in  which 
the  smell  of  urine  is  readily  distinguishable. 
Portions  of  dead  cellular  membrane  are  pre- 
sently discharged  together  with  the  sanies  ; 
the  ulcer  grows  larger;  and  the  dressings 
are  continually  wet  with  the  urine. 

When  one  of  the  ureters  has  given  way, 
and  an  urinary  abscess  is  formed  in  the 
loins,  the  aid  to  be  derived  from  surgery  is 
limited  to  making  an  opening  in  the  extra- 
vasation, as  soon  as  it  can  be  felt  external- 
ly. It  is  then  not  in  the  power  of  art  to  re- 
establish the  natural  course  of  the  urine,  or 
to  hinder  this  fluid  from  passing  through 
the  wound,  and  rendering  it  fistulous.  How- 
ever, there  are  some  circumstances  in  which 
a radical  cure  maybe  attempted.  Tor  ex- 
ample, if  the  abscess  were  produced  by  a 
calculus  lodged  in  the  infundibulum,  or  ure- 
ter, and  it  could  be  felt  and  taken  hold  of 
with  a pair  of  forceps,  introduced  into  the 
opening,  the  extraction  of  the  foreign  body 
might  promote  the  healing  of  the  ulcer,  by 
rendering  the  natural  channel  for  the  urine 
free. 

When  the  opening,  by  which  the  urine 
has  become  extravasated,  exists  in  the  blad- 
der or  urethra,  one  indication  that  does 
not  present  itself  in  the  foregoing  case,  may- 
be fulfilled,  viz.  the  urine  maybe  drawn  off 
by  means  of  a catheter  passed  into  the  blad- 
der, and  kept  there.  By  this  means,  we  not 
only  immediately  stop  the  progress  of  the 
extravasation,  but  attack  the  very  cause  of 
the  malady,  by  removing  the  obstacles 
which  oppose  the  natural  course  of  the 
urine.  The  introduction  of  the  catheter 
then  becomes  a matter  of  the  most  urgent 
necessity.  This  operation  is  often  attended 
with  the  greatest  difficulties.  Besides  the 
ordinary  obstruction  of  the  canal,  we  have 
also  to  surmount  the  obstacles  which  the 
urinary  swellings  situated  in  the  course  of 

Vot  JI  <59. 


the  urethra,  create  to  the  passage  of  the  in 
strument.  When  these  tumours  are  consi- 
derable, they  ought  to  be  opened  before 
the  catheter  is  employed.  The  subsidence 
of  the  swellings  would  render  catheterism 
more  easy.  Besides,  Desault  was  assured 
by  daily  experience,  that  with  a little  skill, 
exercise,  and  patience,  the  catheter  might 
always  he  got  into  the  bladder.  If,  how- 
ever, the  thing  could  not  be  done,  ought  we 
to  puncture  the  bladder,  or  have,  recourse 
to  the  operation  termed  by  the  French  bou  - 
tonniere ? 

Desault  was  an  advocate  for  neither  of 
these  proceedings : he  thought  it  was  a more 
simple  and  beneficial  practice  merely  to 
make  an  external  opening  in  the  collection 
of  effused  urine.  This  measure  would  both 
afford  an  outlet  for  the  urine,  and  arrest 
the  extension  of  the  extravasation.  Besides, 
such  an  opening  is  often  indispensably  re  - 
quisite for  the  purpose  of  putting  a stop  to 
the  symptoms  depending  upon  the  effusion 
and  stagnation  of  the  urine.  But  if  the  ca- 
theter can  be  introduced, there  maybe  cases 
in  which  an  opening  would  not  only  be  use- 
less, but  hurtful  ; for  instance,  when  the 
swelling  caused  by  the  urine  is  of  little  ex- 
tent, or  when  it  is  situated  in  the  thickness 
of  the  parietes  of  the  passage,  or  along  its 
track,  it  almost  always  admits  of  dispersion 
by  the  simple  employment  of  the  catheter 
But  it  seldom  happens,  that  this  swelling* 
however  small,  ends  in  resolution  ; it  al- 
most always  suppurates  ; yet,  as  it  breaks 
into  the  urethra,  the  matter  escapes  between 
this  canal  and  the  catheter,  and  renders 
the  making  of  an  external  opening  needless. 
Experience  teaches  us,  also,  that  when  the 
tumour  is  situated  in  the  scrotum,  or  be- 
tween the  root  of  the  penis  and  the  symphy^ 
sis  pubis,  even  after  the  healing  of  the  inci 
sions  made  in  these  situations,  a fistula  will 
often  remain,  which  is  very  difficult  of  cure. 
With  the  exception  of  these  particular  cases, 
Desault  was  an  advocate  for  opening  all 
urinary  abscesses. 

The  manner  of  opening  such  collections 
varies  according  as  the  urine  may  be  in  one 
cavity,,  or  widely  effused  in  the  cellular 
membrane  In  the  first  case,  a simple  inci- 
sion, the  whole  length  of  the  cavity,  will 
suffice  for  emptying  and  healing  it.  In  the 
second,  if  the  extravasation  is  extensive, 
the  incisions  must  be  multiplied.  It  would 
be  absurd  to  spare  the  parts  ; for  all  those, 
with  which  the  urine  has  come  into  con- 
tact. seldom  escape  mortification.  The  in- 
cisions which  are  made,  hardly  ever  have 
the  effect  of  saving  them  ; but  by  accelera- 
ting the  discharge  of  putrid  sanies  and  stag- 
nant urine,  they  prevent  mischief,  which 
would  originate  from  a further  lodgment. 
At  all  events,  when  the  operation  is  at  all 
delayed,  the  destruction  of  all  the  parts  in 
contact  with  this  irritating  fluid,  is  inevita- 
ble. The  approach  of  mortification  is  indi- 
cated by  the  crepitation  under  the  bistoury, 
resembling  the  kind  of  noise  produced  by 
tearing  parchment.  The  extent  and  depth 
of  the  incisions  must  be  proportioned  l.o 


URINARY  CALCULI 


U>lt> 


those  of  the  abscess.  When  the  extravasa- 
tion occupies  the  scrotum,  long  deep  scarifi- 
cations should  be  made  in  that  part,  as  well 
as  in  the  skin  of  the  penis,  and  in  every 
place  where  the  urine  is  effused. 

Practitioners,  unaccustomed  to  see  such 
diseases,  would  be  alarmed  at  the  extent  of 
the  sore  produced  by  the  separation  of  the 
eschars.  Sometimes  the  whole  scrotum, 
skin  of  the  penis,  and  that  of  the  groins, 
perinseum,  and  upper  part  of  the  thigh,  mor- 
tify, and  the  naked  testicles  hang  by  the  sper- 
matic chords,  in  the  midst  of  t his  enormous 
ulcer.  It  is  hardly  conceivable  how  cica- 
trization could  take  place  over  the  exposed 
testicles;  but  the  resources  of  nature  are 
unlimited.  She  unites  the  testicles  and  the 
chords  to  the  subjacent  parts,  and  drawing 
the  skin  from  the  circumference  to  the 
centre  of  the  ulcer,  she  covers  these  organs 
again,  and  furnishes  them  with  a sort  of 
new  scrotum.  This  statement  is  founded 
upon  numerous  cases,  in  which  nature  al- 
ways followed  this  course.  The  cicatriza- 
tion of  the  ulcer  is  even  more  expeditious 
than  might  be  apprehended,  considering  its 
extent.  In  all  this  business,  what  does  art 
do?  If  the  introduction  of  the  catheter  is 
excepted,  which  indeed  is  absolutely  neces- 
sary for  the  radical  cure,  her  assistance  is 
very  limited,  and  almost  nothing,  in  the  ge- 
nerality of  instances  ; for,  when  patients  are 
not  exhausted  by  the  tediousuess  of  the 
disorder,  when  they  are  of  a good  constitu- 
tion, and  in  the  prime  of  life,  they  get  well 
as  quickly  and  certainly  with  the  aid  of  a 
good  diet  and  simple  dressings,  as  when 
they  take  internal  medicines,  and  use  a 
multiplicity  of  compound  topical  applica- 
tions. The  practice  of  Desault  at  the  Hotel- 
Dieu,  consisted  in  applying  emollient  poul- 
tices, until  the  sloughs  were  detached.  The 
ulcer  was  then  sometimes  dressed  with 
pledgets  charged  with  styrax  ; but  frequent- 
ly mere  dry  lint  was  used,  and  continued 
till  the  cure  was  completed.  If  any  com- 
plication occurred  in  the  course  of  the 
treatment,  suitable  remedies  were  prescri- 
bed for  it.  Thus,  when  prostration  of  strength 
and  tendency  to  sloughing  existed,  bark, 
cordials,  and  antiseptics  were  ordered.  But 
iu  every  case,  the  catheter  is  the  essential 
means  of  cure  ; without  it,  the  treatment  is 
almost  always  imperfect,  and  the  ulcer  will 
not  heal  without  leaving  several  urinary 
fistulae.  (See  CEuvres  Chir.  de  Default,  par 
Bichat , T.  3, p.277— 287.) 

URINARY  CALCULL  A true  explana- 
tion of  the  nature  of  urinary  calculi  was 
quite  impossible,  before  chymistry  had  made 
considerable  progress,  and  the  methods  of 
analysis  had  advanced  a great  way  towards 
perfection  ; and  as  will  appear  in  the  course 
of  this  article,  all  the  valuable  knowledge 
which  now  exists  upon  this  subject,  is  in 
reality  the  fruit  of  modern  investigations. 
It  is  to  be  regretted,  however,  that  our  in- 
formation on  many  points  is  far  from  being 
settled,  or  complete,  as  any  impartial  and 
judicious  reader  may  soon  convince  himself 
bv  a reference  to  the  able  and  scientific 


views,  lately  taken  by  Dr.  Prout,  of  various 
questions,  relative  to  the  formation  of  gra- 
vel and  calculi,  and  the  treatment  of  such 
cases  in  all  their  varieties.  (See  An  Inqui- 
ry into  the  Nature  and  Treatment  of  Grave . 
and  Calculus , and  other  Diseases  connected 
with  a deranged  operation  of  the  Urinary  Or- 
gans, 8 vo.  Lond.  1821.) 

Mechanical  deposites  from  the  urine  are 
divided  by  Dr.  Prout  into  three  classes.  1. 
Pulverulent,  or  amorphous  sediments.  2. 
Crystalline  sediments,  usually  denominated 
gravel.  3.  S'olid  concretions,  or  calculi, 
formed  by  the  aggregation  of  these  sedi- 
ments. 

Pulverulent,  or  amorphous  sediments , are 
described  by  Dr.  Prout,  as  almost  always 
existing  in  a state  of  solution  in  the  urine 
before  it  is  discharged,  and  even  afterward 
until  it  begins  to  cool,  when  they  are  depo- 
sited in  the  State  of  a fine  powder,  the  parti  - 
cles  of  which  do  not  appear  to  be  crystal- 
line. Their  colour js  for  the  most  part  brown, 
or  yellow,  and  generally  speaking,  they  con- 
sist of  two  specie's  of  neutral  saline  com- 
pounds ; viz.  the  lithates  of  ammonia,  soda, 
and  lime,  tinged  more  or  less  with  the  co- 
louring principle  of  the  urine,  and  with  the 
purpurates  of  the  same  bases,  and  consti- 
tuting what  are  usually  denominated  pink 
and  laleritious  sediments;  and,  secondly, 
the  earthy  phosphates,  namely,  the  phos- 
phate of  lime,  and  the  triple  phosphate  of 
magnesia  and  ammonia,  constituting  for  the 
most  part  sediments  nearly  white.  The 
two  species  of  sediments  are  frequently 
mixed  together;  though  the  lithates  general- 
ly prevail. 

Crystalline  Sediments,  or  Gravel,  ore  com- 
monly voided  in  the  form  of  minute  angular 
grains  or  crystals,  composed,  1.  Of  lit  hie 
acid,  nearly  pure.  2.  Of  triple  phos- 
phate of  magnesia  and  ammonia  ; and,  3.  Of 
oxalate  of  lime.  The  crystals  of  1 it  hie  acid, 
which  are  by  far  the  most  frequent,  are  al- 
ways more  or  less  of  a red  colour.  Those 
composed  of  the  triple  phosphate  of  mag- 
nesia and  ammonia  are  nearly  white;  while 
others,  composed  of  the  oxalate  of  lime,u  hich 
are  extremely  rare,  are  of  a dark,  blackish, 
green  colour.  It  is  further  remarked  by  Dr 
Prout,  that  ’these  different  varieties  of  crys- 
talline deposites  are  never  voided  together, 
though  they  not  unfrequently  occur  with 
amorphous  sediments.  {Prout,  Op.  cit.  p.  79, 

Solid  Concretions,  or  Urinary  Calculi,  ari  - 
sing trorn  the  precipitation  arid  consolidation 
of  the  urinary  sediments,  may  be  formed  in 
any  of  the  cavities  10  which  the  urine  has 
access;  and  hence,  they  are  met  with  in  the 
kidneys,  meters,  bladder,  and  urethra 
Their  various  appearances,  and  chymical 
properties,  will  be  presently  described. 
Most  of  them  are  believed  to  be  originally 
produced  in  the  kidneys,  from  which  they 
afterward  descend  with  the  urine.  To  this 
statement,  however,  the  cases  in  which  cal- 
culi are  formed  upon  foreign  bodies  intro- 
duced into  the  bladder  through  the  urethra, 
an  accidental  wound,  or  some  ulcerated 


URINARY  CALCULI 


communication  between  the  intestines  and 
the  bladder,  are  manifest  exceptions.  In  the 
centre  jdi  urinary  calculi,  bullets,  splinters 
of  bone,  pieces  of  bougies,  and  wood,  pins, 
needles,  nuts,  &lc.  are  frequently  observed  ; 
and  it  would  appear,  that  a very  minute 
substance  is  capable  of  becoming  a nucleus  ; 
a mere  clot  ef  blood,  ora  little  bit  of  chaff, 
if  not  soon  voided,  being  sufficient  to  lead 
to  the  formation  of  a stone  in  the  bladder 
The  litbic  acid  itself  is  a common  nucleus, 
even  where  the  whole  calculus  is  not  of  the 
same  material. 

That  many  urinary  calculi  ore  originally 
produced  in  the  kidney,  is  certain  ; first, 
from  (he  severe  pain,  which  the  passage  of 
such  foreign  bodies  down  the  ureter  always 
excites  ; and,  secondly,  from  their  being  of- 
ten discovered  in  the  infundibula  and  pelvis 
of  that  viscus  after  death.  This  last  fact  is 
well  illustrated  in  the  first  plate  of  Dr.  Mar- 
cel’s interesting  “ Essay  on  the  Chymical 
History  and  Medical  Treatment  of  Calculous 
Disorders ,”  8 vo.  1817.  The  engraving  is 
taken  from  a preparation  in  the  Museum  of 
Guy’s  Hospital.  In  this  instance,  there 
were  several  calculi  closely  pressed  against 
each  other  ; but  in  another  example,  drawn 
from  a specimen  in  Mr.  Abernethy’s  muse- 
um, the  renal  concretion  was  composed  of  a 
single  mass,  which  represented  a complete 
cast  of  the  pelvis  and  part  of  the  infundibula 
of  the  kidney.  In  this  form  of  the  disease, 
the  kidney  loses  at  last  all  vestiges  of  its 
natural  structure,  and  is  converted  into  a 
kind  of  cyst,  filled  with  the  extraneous  sub- 
stance. As  Dr.  Marcet  observes,  when  such 
a complete  alteration  of  the  structure  takes 
place,  th«  secretion  of  urine,  must  of  course 
be  entirely  carried  on  by  the  other  kidney. 
However,  in  some  instances,  the  inconve 
nience  thus  produced  is  so  slight,  that  it  al- 
most escapes  notice;  and  sometimes  even 
both  kidneys  are  diseased  in  a very  great 
degree,  and  yet  life  is  preserved  for  a con- 
siderable time.  (Op.  cit.  p.  3,  4.) 

Calculi  are  sometimes  found  in  the  ureters, 
especially  at  the  upper  part ; but  it  is  not 
supposed  that  they  are  originally  formed  there; 
an  event  not  likely  to  happen,  unless  there 
were  some  cause  retarding  the  descent 
of  the  urine  through  those  tubes.  The 
common  belief  is,  that  all  calculi,  found  in 
the  ureter,  are  first  produced  in  the  infun- 
dibula and  pelvis  of  the  kidney,  from  which 
they  afterward  descend  with  the  urine. 

The  generality  of  calculi,  however,  which 
leave  the  kidney,  are  of  small  size,  and 
consequently,  after  a time,  and  exciting 
some  pain  and  inconvenience,  they  usually 
pass  into  the  cavity  of  the  bladder.  Indeed, 
as  Dr.  Marcet  remarks,  the  bladder  is  the 
most  frequent  seat  of  calculi ; not  only  be- 
cause all  urinary  concretions,  or  their  nuclei, 
formed  in  the  kidneys,  tend  to  fall  into  that 
organ  ; but  also  because  a stone  may  be,  and 
probably  often  is,  originally  formed  in  the 
bladder  itself. 

Rena!  concretions  vary  considerably  in 
their  number,  size,  and  shape.  In  some 
eases,  a single  small  calculus  has  been 


547 

found  occupying  one  of  the  foregoing  situa- 
tions; while  in  other  instances,  an  innume- 
rable collection  of  calculous  substances  are 
observed  filling  the  whole  of  the  cavity  of 
the  pelvis  and  infundibula  of  the  kidney, 
distending  its  parietes,  and  even  obstructing 
the  passage  of  the  urine  out  of  this  viscus. 
which  is  converted  into  a sort  of  membra- 
nous cyst.  Lastly,  a single  stone  in  the  kid 
ney  tnay  acquire  a very  large  size  there  ; or 
a great  number  of  small  caiculi,  in  the  same 
situation,  may  become  cemented  together, so 
as  to  form  one  mass  of  enormous  dimensions, 
and  the  shape  of  which  invariably  corres 
ponds  to  the  space  in  which  it  is,  as  it  were, 
moulded.  Hence,  renal  calculi  often  present 
a variety  of  odd,  irregular  figures,  resembling 
those  commonly  observed  in  specimens  of 
coral. 

It  has  been  already  remarked,  that  urina- 
ry concretions  of  large  size  very  often  exist 
in  the  kidney,  without  their  presence  being 
indicated  by  any  external  circumstances,  or 
attended  with  any  symptoms,  sufficiently 
unequivocal  to  constitute  a ground  for  sus- 
pecting the  importance  of  their  cause.  On 
the  other  hand,  it  is  very  usual  for  renal  ca! 
culi,  of  middling  dimensions,  to  excite  seri 
ous  and  alarming  complaints.  The  reason 
of  this  difference  becomes  obvious,  when 
it  is  recollecied,  that  smallish  concretions 
are  readily  carried  with  the  urine  into  the 
ureter,  and  become  fixed  in  the  narrow  por 
tion  of  the  tube.  But  very  large  calculi  can 
he  contained  only  in  the  upper  part  of  this 
canal,  where  its  parietes  are  more  yielding, 
and  the  space  in  them  more  capacious. 

Calculi,  of  middling  size,  in  their  passage 
through  the  ureter,  cause  at  first,  a feeling 
of  heaviness,  or  an  indeterminate  sense  of 
uneasiness,  and  an  obtuse  pain  in  the  region 
of  the  corresponding  kidney.  These  com- 
plaints occur  at  intervals  of  greater  or  less 
duration.  At  length  the  pain  grows  more 
urgent  and  annoying,  attended  with  flatu 
lence,  heart-burn,  frequent  vomiting,  pain- 
ful retraction  of, the  testicle,  and  sometimes 
acute  fever.  The  patient  makes  water  fre- 
quently, and  in  small  quantities  at  a time  ; 
and  the  urine  is  high-coloured  and  bloody 
The  patient  cannot  sit  upright,  his  body  being 
bent  forwards  towards  the  affected  side. 
These  symptoms  may  have  more  or  less  du- 
ration, and  then  suddenly  cease.  They  may 
also  subside,  and  recur  several  times  suc- 
cessively, with  intervals  of  some  day3.  In 
the  latter  case,  the  pain  is  fell  at  each  at 
tack  to  be  situated  lower  in  the  track  of  the 
ureter.  Lastly,  when  the  symptoms  have 
entirely  disappeared,  the  urine  is  more 
abundant,  not  so  high-coloured,  and  easily 
discharged,  the  stream  sometimes  bringing 
out  with  it  the  urinary  concretion,  after  its 
entrance  into  the  bladder. 

Suppuration  of  the  kidney,  and  an  abscess 
in  the  lumbar  region,  in  consequence  of  re- 
nal calculi,  are  not  very  common  events 
However,  these  are  the  only  cases  of  the  kind, 
in  which  the  interposition  of  surgery  can  be 
useful.  By  adverting  to  previous  cireum 
stances,  and  irregularity  of  the  pain  about 


URINARY  CALCULI 


•>'18 

The  kidney,  tiie  pracl  it ioner  may  suspect  the 
nature  of  a phlegmonous  tumour  in  the 
situation  of  this  viscus.  Whatever  may  be 
his  conjectures,  however,  he  must  carefully 
abstain  from  the  use  of  his  lancet,  until  pu- 
rulent matter  is  plainly  under  the  integu- 
ments. He  may  then  safely  make  an  open- 
ing, from  which  urine  and  pus  will  be  dis- 
charged, and  through  which  the  calculi 
themselves  may  sometimes  be  felt  and  ex- 
tracted. If  they  should  not  be  readily 
touched  with  a probe,  let  not  the  surgeon 
rashly  conceive,  that  he  is  justified  in  en- 
deavouring to  discover  them  with  his  knife. 
Their  situation  may  be  such  as  to  baffle  all 
his  endeavours,  and  the  operation  itself 
might  cause  a most  dangerous  hemorrhage, 
and  other  fatal  mischief.  The  opening  of 
an  abscess  of  the  kidney  may  remain  a long 
while  fistulous,  and  the  circumstance  indeed 
warrant  the  conclusion,  that  the  fiealing  is 
prevented  by  the  presence  of  some  extrane- 
ous substances  ; but  a prudent  practitioner 
will  never  think  of  performing  any  opera- 
tion for  their  extraction,  unless  they  can  be 
distinctly  felt,  and  nature  has  brought  them 
tolerably  near  to  the  surface.  (See  Nephro- 
tomy.) 

Urinary  calculi,  which  form  upon  foreign 
bodies,  accidentally  introduced  into  the  blad- 
der, and  acting  as  nuclei,  are  a!-.\  ays  single, 
unless  the  number  of  foreign  bodies  them- 
selves happen  to  be  greater.  It  is  curious 
also  to  find,  from  the  observations  of  Mr. 
Murray  Forbes,  (On  Gravel  and  Gout,  p.  74, 
8 ro.  Lond.  1793,)  and  Dr.  Marcet,  that  in 
such  instances  the  deposition  most  frequent- 
ly, if  not  always,  consists  of  the  earthy  phos- 
phates, and  especially  of  the  fusibie  calculus. 
Thus,  in  the  collection  of  Mr.  R.  Smith,  of 
Bristol,  there  is  a pin,  a piece  of  bougie,  and 
four  pieces  of  stick,  coated  with  fusible  mat- 
ter. (See  Med.  Chir.  Trans.  Vol  11,  jo.  11.) 
But  when  calculi  originate  from  a particular 
diathesis,  there  may  be  many  of  litem  lodged 
in  the  bladder  at  the  same  time.  Several 
distinct  nuclei  may  descend  successively 
from  the  kidneys,  and  each  may  increase  in 
a separate  manner.  Sometimes,  however, 
calculi  in  the  bladder,  which  are  at 'first  dis- 
tinct and  unconnected,  become  afterward 
cemented  together,  so  as  to  make  only  one 
mass. 

The  magnitude  of  calculi  in  the  bladder 
is  generally  in  an  inverse  ratio  to  their  num- 
ber. Sortie  hundreds  have  been  found  in 
one  bladder;  but  they  were  not  larger  than 
a pea.  It  is  observed  Uy  Sir  AstUjy  Cooper, 
that  when  a great  number  of  calculi  are 
found  in  the  bladdery  the  circumstance  is  ge- 
nerally attended  vvitn  an  enlargement  of  the 
prostate  gland,  directly  behind  which  a cal- 
culus is  formed.  In  cases  of  diseased  pros- 
tate gland,  the  bladder  can  seldom  be  com- 
pletely emptied,  and  this  partial  stagnation 
of  the  urine  in  the  sac,  here  alluded  to,  is 
supposed  to  facilitate  the  production  of  cal- 
culi. From  their  number  and  collision 
against  each  other,  their  surfaces  are  gene- 
rally smooth,  and  their  shape  is  commonly 
roundish,  (bjee  Med.  > Chir.  Trans.  Vo!  11, 


p.  359,  and  art.  Prostate  Gland.)  Other  cal- 
culi have  been  met  with  of  so  large  a size, 
that  they  were  more  than  six  inches  in  dia 
meter.  In  Fourcroy’s  museum,  and  in  that 
of  the  Ecole  de  Medeeine,  at  Paris,  may  be 
seen  some  calculi,  which  filled  the  whole  ca- 
vity of  the  bladder  ; and  in  the  Phil.  Trans, 
fur  18G9.  the  late  Sir  James  Earle  described 
an  enormous  stone,  which  he  extracted  after 
death  from  the  bladder  of  the  late  Sir  David 
Ogilvie,  who  had  been  unsuccessfully  cut  for 
it.  This  calculus,  which  was  of  the  fusible 
kind,  weighed  forty-four  ounces,  and  was 
of  an  oval  shape,  its  long  axis  measuring 
sixteen  inches,  and  the  shorter  fourteen. 
The  average  size  of  vesical  calculi  may  be 
compared  with  that  of  a chesnut,  walnut, 
or  a small  hen’s  egg.  The  size  depends 
very  much  upon  their  composition,  the 
largest  being  of  the  fusible  kind.  Their 
weight  differs  from  a few  grains  to  upwards 
of  fifty  ounces  ; but  on  an  average,  it  is 
from  two  to  six  ounces.  Their  weight  is 
not  always  proportioned  to  their  size;  for 
substances  of  different  qualities  enter  into 
their  composition,  and  diversify  their  hea- 
viness. 

The  urinary  salts,  in  calculous  patients, 
are  not  continually  precipitated  in  the  same 
quantities:  in  some  cases,  indeed,  the  pro- 
cess appears  to  be  even  suspended  for  a 
considerable  time.  Hence  a stone  of  mid- 
dling size,  already  formed,  may  increase  but 
very  slowly,  and  it  has  actually  happened, 
that  a calculus,  which  could  be  plainly  felt 
with  a sound,  has  remained  more  than  ten 
years  in  the  bladder,  and  yet,  after  all  this 
time,  been  only  of  a moderate  size. 

According  to  Dr.  Marcet,  the  form  of 
urinary  calculi  is  mostly  spheroidal,  some- 
times egg-shaped,  but  often  (lattened  on  two 
sides,  like  an  almond.  (P.  50.)  Sometimes 
the  calculous  matter,  which  descends  from 
the  kidneys,  is  in  the  form  of  minute  sphe- 
rical grains,  which  have  a singular  tendency 
to  unite  either  to  each  other,  or  to  calculi 
already  lodged  in  the  bladder. 

When  there  are  several  loose  calculi  in 
the  bladder  together,  they  seldom  lie  long 
in  contact  with  each  other,  while  their  size 
is  diminutive,  but  are  incessantly  changing 
their  situation  as  the  patient  moves  about, 
or  alters  the  position  of  bis  body.  Hence 
their  increase  is  at  first  regular  and  uniform  : 
but  when  they  have  attained  a more  consi- 
derable size,  or  by  their  numbers  compose 
a large  mass,  their  relative  situation  is  more 
permanent,  and  many  of  their  surfaces  be- 
ing in  this  manner  usually  covered,  no 
longer  receive  any  additional  depositions. 
Every  other  part  of  these  calculi,  however, 
goes  on  increasing.  It  is  thus  that  stones, 
with  surfaces  corresponding  to  those  oi 
other  stones,  are  produced,  and  which  are 
aptly  denominated  by  the  French  writers, 
“ pier  res  h face  lies." 

Dr.  Marcet  lias  likewise  taken  notice  oi 
the  angular  shape  of  certain  calculi,  and  re- 
marked the  rare  occurrence  ot  their  being 
sometimes  almost  cubic.  His  work  con 
tains  the  engraving  of  a species  of  calculus. 


URINARY  CALCULI 


549 


which  somewhat  resembles  a pear,  with  a 
circular  protuberance  at  its  broader  end, 
apparently  moulded  in  the  neck  of  the  blad- 
der. 

The  same  intelligent  writer  has  also  par- 
ticularly considered  the  variety  in  the  co- 
lours and  surfaces  of  calculi,  which  often 
alford  indications  of  their  chymical  nature. 
“ When  they  have  a brownish,  or  fawn 
colour,  somewhat  like  mahogany  wood, 
with  a smooth,  though  sometimes  finely  tu- 
berculated  surface,  they  almost  always  con- 
sist of  lithic  acid.  When  cut  open,  they 
appear  to  be  formed  of  concentric  layers, 
sometimes  homogeneous,  sometimes  alter- 
nating with  other  substances.  The  colour, 
however,  cannot  be  considered  as  a .certain 
criterion,  since  other  kinds  of  calculi  may 
often  be  coloured  in  the  bladder,  in  a simi- 
lar manner,  by  bloody  mucus,  or  other  vi- 
tiated seerelions. 

:i  When  calculi  are  white,  or  gravish- 
white,  they  always  consist  of  earthy  phos- 
phates. This  is  particularly  the  case  with 
the  species  called  fusible.  And  when  they 
are  dark  brown,  or  almost  black,  hard  in 
their  texture,  and  covered  with  tubercles, 
or  protuberances,  they  are  generally  of  the 
species  which  has  been  distinguished  by  the 
name  of  mulberry , and  consists  of  oxalate  of 
lime. 

“ Calculi  have  sometimes  an  uneven, 
crystalline  surface,  studded  with  shining, 
transparent  particles.  This  appearance  al- 
ways denotes  the  presence  of  the  ammo- 
niaco-magnesian  phosphate.”  ( Marcet , p. 
52.) 

A large  calculus,  especially  when  it  has  a 
rough  irregular  surface,  produces  a great 
deai  of  irritation  of  the  bladder,  which  con- 
tracts more  clasely  round  it.  The  contact, 
however,  is  remarked  to  be  particularly  ex- 
act at  the  transverse  line,  which  extends 
between  the  terminations  of  the  two  ureters 
in  the  bladder ; a part  of  this  organ  which 
generally  becomes  more  thickened  than  the 
rest.  Sometimes,  indeed,  the  cavity  of  the 
bladder  is  nearly  effaced,  and  the  urine  can 
be  retained  only  a very  short  time,  or  if  it 
be  not  evacuated,  it  spreads  uniformly  round 
the  calculus,  especially  above  and  below 
the  above-described  transverse  projection, 
which  is  less  yielding  than  other  parts  of 
this  organ.  Hence,  the  surface  of  the  stone, 
towards  the  orifices  of  the  ureters,  does  not 
enlarge  so  fast  as  the  other  sides  of  it,  and 
a circular  groove  is  produced,  giving  the 
foreign  body  the  shape  of  a calabash.  Such 
calculi  are  generally  very  large,  and  some- 
times even  of  enormous  size.  In  the  latter 
circumstance,  the  foreign  body  fills  the  ca- 
vity of  the  bladder  so  completely,  that  there 
is  no  space  left  for  the  lodgement  of  t lie 
urine  there,  which  fluid  then  generally  passes 
along  a sort  of  groove,  situated  in  a line 
reaching  from  the  lower  termination  of  the 
ureter  to  the  neck  of  the  bladder.  This' 
state  is  of  course  accompanied  with  a com- 
plete incontinence. 

Urinary  calculi  are  not  always  loose  and 
moveable  in  the  cavity  of  the  bladder  : be- 


ing sometimes  fixed  in  various  ways  to  cer- 
tain points  of  the  circumference  of  this 
organ  ; a subject,  w hich  has  been  noticed  in 
the  article  Lithotomy . 

When  the  bladder  protrudes  from  the  ab- 
domen, so  as  to  form  a hernia,  a stone  is 
occasionally  situated  in  the  displaced  por- 
tion of  it.  This  circumstance  has  the  same 
effect  as  the  encysted  state  of  a calculus  : 
for  the  foreign  body  is  thereby  fixed,  and  it 
cannot  be  propelled  towards  the  neck  of  the 
bladder  at  the  period  when  the  urine  is  dis- 
charged. Also,  in  cases  of  prolapsus  uteri T 
when  the  bladder  is  drawn  downwards,  a 
stone  has  sometimes  been  found  lodged  at 
the  low  est  part  of  it.  The  possibility  of  the 
complication  of  a calculus,  with  such  dis- 
placements of  the  bladder,  ought  to  be  well 
remembered,  since,  if  the  nature  of  the  case 
be  detected,  its  treatment  becomes  mate- 
rially simplified. 

The  symptoms  of  a stone  in  the  bladder 
have  been  detailed  in  the  article  Lithotomy ? 
and  therefore  need  not  here  be  repeated. 
They  are  all  so  equivocal,  and  bear  so  great 
a resemblance  to  the  effects  of  several 
other  disorders,  that  they  cannot  be  depend- 
ed upon,  and  consequently  no  well-informed 
surgeon  will  venture  to  pronounce  positive- 
ly, that  there  is  a calculus  in  the  bladder, 
unless  he  can  distinctly  feel  it  with  a sound. 
(See  Lithotomy  and  Sounding.)  As  for  the 
operation,  if  the  surgeon  cannot  plainly  feel 
the  calculus  immediately  before  he  com- 
mences the  incisions,  it  ought  to  be  post- 
poned. 

Notwithstanding  the  laudable  zeal,  With 
which  various  distinguished  physicians  and 
surgeons  of  the  present  day,  have  applied 
themselves  to  the  consideration  of  the 
causes  of  urinary  calculi,  the  subject  is  yet 
in  great  obscurity.  The  conjectures  which 
have  been  started,  respecting  the  influence 
of  particular  kinds  of  food,  drink,  air,  and 
habits  of  life,  are  all  Of  them  liable  to  such 
objections,  as  throw"  considerable  doubts  on 
their  correctness,  and  sometimes  amount  to 
a decided  refutation  of  them. 

If  a foreign  body  be  introduced  into  a 
cavity,  to  which  the  urine  has  access,  what- 
ever may  be  the  nature  of  the  immersed 
substance,  it  always  becomes  after  a time 
incrusted  with  calculous  matter,  though  it 
undergoes  no  chymical  change  in  its  com 
position.  In  such  cases,  it  is  found  (See 
Forbes  on  Gravel  and  Gout,  8 vo  Lond.  1793, 
and  Marcet  on  the  Chymical  Hist.,  tyc.  of 
Calculous  Disorders,  8 vo.  Lond.  IS  1 7.)  that 
the  concretion  mostly,  if  not  always,  con- 
sists of  the  earthy  phosphates.  Mere,  the 
operation  of  any  particular  diathesis  is  be- 
yond all  suspicion,  because  theforeign  body  , 
which  forms  the  nucleus,  would  lead  to  the 
production  of  a calculus  in  all  descriptions 
of  patients. 

There  are  some  countries,  where  patients 
with  calculi  are  tolerably  numerous;  and 
other  parts  of  the  world,  where  the  disease 
is  rare,  or  never  met  with  ; and  yet  the  dif- 
ference cannot  always  be  accounted  for  by 
any  geographical  circumstance,  which  is 


URINARY  CALCULI, 


550 

constant,  ov  any  definable  peculiarity  of 
constitution,  climate,  diet,  or  mode  of  life. 
One  fact,  however,  I believe  is  certain,  viz. 
tiie  uniform  rarity  of  the  disease  in  very  hot 
countries.  In  tropical  climates,  urinary  cal- 
culi are  almost  unknown,  and,  as  Dr.  Mar- 
cet  observes,  the  testimony  of  Dr.  Scott  on 
this  point,  who  long  resided  in  India,  must 
be  considered  valuable.  Dr.  Scott  affirms* 
that,  between  the  tropics,  he  never  met 
with  a single  instance  of  the  formation  of  a 
stone  in  the  urinary  bladder,  although  he 
knew  of  some  cases  which  had  been  im- 
ported, and  were  not  cured  by  climate. 
(See  Marcel  on  the  Chymical  History  and 
Med.  Treatment  of  Calculous  Disorders,  Chap. 
2,  8t’o.  Load.  1817.)  Yet,  as  calculi  fre- 
quently form  on  various  nuclei,  bullets, 
pieces  of  bougies  &c.  I conceive,  that,  even 
in  India,  calculi  will  some  day  or  another 
be  found  to  originate  from  this  cause, though 
not  perhaps  from  diathesis. 

Urinary  calculi  are  said  also  to  be  very  un- 
common in  Spain  and  Africa,  though  pa- 
tients with  gravel  are  numerous  in  Majorca, 
which  lies  between  them.  ( Magendie . Re- 
cherces  sur  les  Causes,  fyc.  de  la  Gravelle,  p. 
31,  8vo.  Paris , 1818.)  The  usual  belief  is, 
that  calculi  are  most  frequent  in  damp,  cold 
countries,  like  England  and  Holland,  but, 
that  in  such  other  parts  of  the.  world,  as  are 
either  very  hot  or  cold,  the  disease  is  rare. 
However,  in  every  estimate  of  this  kind,  the 
number  of  the  inhabitants  of  the  countries, 
or  districts  in  question,  is  always  an  essential 
thing  for  consideration,  because  the  propor- 
tion of  stone-patients,  in  a given  number  of 
individuals,  is  invariably  rather  small ; and, 
therefore,  in  referring  to  the  rarity  of  such 
patients  in  very  cold  countries,  it  is  to  be 
considered,  whether  the  fact  may  not  be,  in 
some  measure,  ascribable  to  the  fewness  of 
the  inhabitants.  The  state  of  medicine  and 
surgery,  in  the  countries  from  which  the  in- 
formation is  transmitted,  is  likewise  another 
thing  for  contemplation,  inasmuch  as  pa- 
tients are  not  likely  to  be  reported  as  suf- 
fering from,  or  dying  of  stone,  where  the 
nature  of  diseases  is  not  scientifically  ob- 
served, morbid  anatomy  is  uncultivated,  and 
the  operation  of  sounding  never  attempted 
However,  as  our  East  India  native  regi 
meats  are  furnished  with  excellent  surgeons, 
I consider  it  well  proved  that  in  those  regi- 
ments the  disease  is  uncommon,  for  other- 
wise the  statement  would  no  doubt  have 
been  contradicted  by  them.  The  fact  seems 
therefore  well  established,  in  relation  to  the 
East  Indies.  At  the  same  time,  the  ages  of 
the  individuals,  to  whom  any  calculation 
applies,  is  always  to  be  taken  into  consider- 
ation, before  any  inference  be  drawn  re- 
specting tile  cause  of  the  rarity  of  calcuii, 
because,  if  the  disease  be  rare  among  sol- 
diers in  India,  it  is  also  rare  among  soldiers 
xn  Europe,  and  therefore  climate  would  not 
explain  the  fact  in  both  parts  of  the  world. 
But,  probably,  the  recollection,  that  com- 
mon soldiers  are  neither  children,  nor  men, 
above  the  middle  period  of  life,  and  that  the 
first,  formation  of  stone  in  yoylhs,  adults. 


and  middle-aged  persons,  is  uncommon, 
unless  some  extraneous  substance  happen 
to  enter  the  bladder  and  form  the  nucleus, 
may  furnish  a reason  for  the  infrequency  of 
the  disease  among  soldiers,  applicable  per- 
haps to  siich  individuals  in  every  country. 
And  that  the  children  of  soldiers,  like  those 
of  other  persons,  are  not  exempt  from  the 
disease,  I know  very  well,  having  had  oc- 
casion myself  to  operate  upon  a patient  of 
this  kind  during  my  service  with  the  army 
The  preceding  consideration  also  of  the 
general  age  of  sailors  in  the  royal  navy,  and 
of  the  little  chance  there  must  be  of  a boy 
with  s'one  beii.g  sent  to  sea,  or  of  any  sailor 
being  admitted  on  board  of  a King’s  ship 
with  that  disorder,  unless  it  be  wilfully  con- 
cealed by  the  man  himself,  furnish  to  my 
mind  a better  explanation  of  the  cause  of 
so  few  cases  of  stone  having  been  met  with 
among  seafaring  persons,  than  any  of  the 
references  to  the  habits  or  mode  of  life  of  a 
sailor,  made  by  Mr.  C.  Hutchison  in  his  in- 
genious paper.  (See  Med.  Chir.  Trans  Vol 
9,  p.  448,  fyr.)  From  this  gentleman’s  ac- 
count it  seems,  that  out  of  86,00<  patients, 
admitted  into  the  Naval  Hospital  at  Haslar. 
Plymouth,  and  Deal,  in  the  space  of  sixteen 
years,  there  has  only  been  eight  calculous 
cases,  or  one  in  10,750  patients.  Two  of 
these  cases  were  boys,  about  fourtten  years  of 
age,  “ who  had  laboured  under  symptoms  of 
stone  for  some  years  previously  to  their  admis 
sion  into  the  service,  and  into  which  they  had 
recently  entered , expressly  for  the  purpose  of 
deriving  benefit  from  our  magnificent  institu- 
tions; one  was  a marine  who  had  been  at 
sea  a few  months  only  ; three  were  adult 
seamen,  and  the  seventh  a marine  ; but  tlieir 
length  of  service  afloat  could  not  be  at  all  as- 
cer tamed  .-  the  eighth,  and  last  case,  was  a 
warrant  officer,  advanced  in  years , who  had 
been  serving  in  ordinary,  that  is,  in  a ship 
in  harbour  for  a considerable  time  previ- 
ously to  the  operation.”  Subsequently  to 
the  period,  embraced  by  the  returns  col- 
lected by  Mr.  C Hutchison,  a boy  has  also 
been  operated  upon  in  Haslar  Hospital. 
( Vol.  cit.  p.  449.)  Mr.  R.  Smith,  of  Bristol, 
has  published  an  interesting  statistical  in- 
quiry into  the  frequency  of  stone  in  the 
bladder  in  Great  Britain  and  Ireland,  though 
strictly  it  is  a comparative  estimate  of  the 
number  of  operations  for  stone  in  different 
parts  of  the  kingdom  in  given  spaces  of 
time,  and  not  of  the  number  of  calculous 
patients.  (See  Med.  Chir.  Trans.  Vol.  11.) 
As  far  as  I can  judge  from  the  facts  sta- 
ted in  Mr.  Smith’s  paper,  and  from  what 
I know  about  the  average  number  of  ope- 
rations for  stone  in  London,  not  more 
than  180  can  be  fairly  reckoned  as  the  an 
iiu ah  total  in  Great  Britain  and  Ireland, 
which  is  about  1 for  each  100,000  of  the 
population,  taken  at  18  millions.  Now,  if 
this  fact  be  recollected,  in  computing  the 
rarity  of  stone  operations  in  the  navy,  and 
the  other  circumstances  of  there  being  few 
children  and  old  men  in  that  service,  and 
of  every  man  btiing  examined  by  a surgeon, 
to  the  state  of  his  health,  before,  be  is  rn 


i;kinaky  calculi 


tered,  1 think  the  reason  of  the  infrequency 
of  stone  in  the  navy  will  be  tolerably  clear. 
However,  as  sailors  live  partly  in  very  hot 
and  partly  in  very  cold  climates,  even  if 
they  were  of  the  ages  most  subject  to  cal- 
culi. they  may  perhaps  be  rather  less  dis 
posed  to  the  complaint,  than  individuals  of 
the  same  periods  of  life,  constantly  resident 
in  England  In  the  cold  country  of  Swe- 
den, urinary  calculi  are  said  to  be  infre- 
quent. (Riche rand,  Nosogr.  Chir  T.  8,  p. 
528,  Ed.  4. ;)  and,  as  surgery  is  there  highly 
cultivated,  the  uncontradicted  statement 
weighs  considerably  in  favour  of  the  truth 
of  the  general  belief  in  the  rarity  of  this 
disorder  in  very  cold  countries.  But,  as  I 
have  already  said,  the  number  of  inhabit- 
ants, to  which  any  particular  evidence  on 
this  point  relates,  is  an  essential  inquiry, 
before  a safe  inference  can  be  drawn. 

It  is  perfectly  well  ascertained,  that  the 
greater  number  of  urinary  calculi  are  com- 
posed chiefly  of  lithic,  or  uric  acid,  which  is 
naturally  contained  either  in  a free  or  com- 
bined state  in  the  urine  of  man,  and  all 
other  animals,  which  consume  a great  deal 
of  food  abounding  in  azote,  as  flesh  ojf  every 
kind,  fish,  shellfish,  eggs,  &ic.  Whenever 
the  urine  will  redden  the  tincture  ot  turnsol, 
Magendie  infers  with  the  generality  of  chy- 
mists,  that  it  contains  lithic  acid,  the  pro- 
portion of  which,  he  says,  varies  according 
to  the  quantity  of  substances  abounding  in 
azote,  taken  as  food.  And  Magendie  further 
observes,  that  when  animals  live  altogether 
on  flesh,  their  urine  is  full  of  uric  acid,  and 
even  may  be  entirely  composed  of  it,  as  is 
proved  with  respect  to  birds,  by  the  experi- 
ments both  of  Dr.  Wollaston  and  Vauquelin. 
Here  Magendie  cannot  mean  free  uric  acid, 
but  this  acid  in  a state  of  combination  ; for, 
as  Dr.  Prout  has  observed,  there  is  no  in- 
stance known,  in  which  lithic,  or  uric  acid 
is  secreted  in  a pure  state  ; birds,  serpents, 
&,c.  always  secrete  it  in  combination  with 
ammonia ; in  the  gouty  chalk-stone,  it  is 
secreted  in  combination  with  soda.  (On  the 
Nature,  fyc.  of  Gravel  and  Calculus,  p.  13.) 
On  the  contrary,  if  animals  live  on  vegeta- 
bles, as  is  the  case  with  the  herbivorous 
class,  Magendie  states  that  there  is  no  ap- 
pearance of  lithic  acid  in  their  urine.  In  a 
series  of  experiments,  communicated  by 
Magendie  to  the  Academy  of  Sciences  in 
1816,  this  distinguished  physiologist  exem- 
plified, that  if  a carnivorous  animal  be  de- 
prived of  all  nutriment,  containing  azote, 
and  be  fed  with  sugar,  gum,  oil,  and  other 
substances  considered  to  be  nutritious,  and 
having  no  azote  in  their  composition,  the 
urine,  in  three  or  four  weeks,  will  contain 
no  lithic  acid.  (See  Mem.  sur  les  Proprteles 
nutritives  des  Substances,  qui  nc  contiennent 
pas  d'azote.  Paris,  1817.)  A dog,  allow-ed 
only  sugar,  and  distilled  water,  soon  began 
to  grow  lean,  and  died  apparently  starved 
on  the  32d  day  from  the  commencement  of 
his  diet.  The  inference  which  Magendie 
draws  from  his  experiments,  aud  from  some 
cases  which  he  has  detailed,  is,  that  the 
quantity  of  uric  acid  in  the  urine,  and  of 


«i51 

course,  the  tendency  to  gravel  and  calculous 
disorders,  depend  very  much  upon  the  kind 
of  food.  However,  he  takes  into  consider- 
ation the  relative  propoition  of  the  uric  acid 
to  the  urine  itself,  because  if  this  be  also 
abundant,  the  liability  to  calculi  is  counter 
.acted.  It  would  appear  also  from  his  obser- 
vations, that  the  urine  not  only  becomes 
impregnated  with  a great  proportion  of  uric 
acid  in  animals,  which  eat  a large  quantity 
of  flesh,  but  is  also  scanty  ; arid  that,  on  the 
other  band,  a vegetable  diet  always  pro- 
motes the  secretion  of  a large  quantity  of 
fluid  from  the  kindneys,  as  well  as  check- 
tbe  formation  of  the  acid  in  question.  Ma- 
gendie is  also  disposed  to  believe,  that  the 
rarity  of  calculi  in  hot  climates  may  be 
partly  traced  to  the  kind  of  food  employed. 
In  fact,  it  is  well  known,  that,  in  a consider- 
able part  of  Asia,  many  millions  of  the  inha- 
bitants never  eat  flesh.  But,  though  this 
circumstance  must  be  allowed  to  have  full 
weight,  with  respect  to  the  sects  which  re- 
ligiously decline  animal  food,  the  influence 
ot  climate  cannot  be  rejected,  because  cal- 
culi are  rare  in  all  hot  countries,  wrhethev 
meat  be  freely  eaten  or  not.  At  the  same 
time,  the  tenor  of  this  gentleman’s  reason- 
ing may  be  true,  that,  setting  out  of  the 
question  the  influence  of  climate,  a vege 
table  diet  tends  to  prevent  the  formation  of 
lithic  acid  calculi,  while  eating  large  quan- 
tities of  such  food  as  contains  a greal  deal 
of  azote,  has  the  opposite  effect. 

However,  Magendie  himself  is  not  so  par 
tiat  to  his  theory,  as  not  to  confess  that  it  is 
liable  to  objections  ; for,  says  he,  individu- 
als are  met  with  every  day,  who  from  their 
age,  manner  of  living,  and  habits,  appear  to 
be  subjected  to  every  condition,  calculated 
to  produce  the  gravel,  and  yet  they  remain 
free  from  it.  Hence  he  infers,  that  there 
must  be  some  unknown  causes  which  some 
times  keep  the  uric  acid  dissolved,  even 
where  its  quantity  in  the  urine  is  copious. 
On  the  other  hand,  he  admits  that  certain 
persons  are  met  with,  whose  regimen  and 
mode  of  life  ought  to  exempt  them  from 
gravel,  and  still  they  are  afflicted.  In  proof 
of  this  fact,  he  adverts  to^  the  poor  inhabit- 
ants of  a district  in  Sussex,  mentioned  by 
Dr.  Scudamore,  (On  the  Nature  and  Cure  of 
Gout,  fy-c.  Svo.  Land.  1817.)  who  live  almost 
entirely  on  vegetable  matter  and  hard  beer, 
aud  many  of  whom  are  much  troubled  with 
gravel.  Magendie  might  also  have  recol 
lected,  that  some  birds  which  live  entirely  on 
vegetable  matter,  as  several  singing  birds 
kept  in  cages,  void  a good  deal  of  the  lithate 
of  ammonia.  Magendie  refers  to  examples 
of  gravel  being  always  produced  in  certain 
individuals  after  any  unusual  exertion,  and 
in  other  apparently  healthy  subjects,  after 
any  difficulty  of  digestion,  flatulence,  the 
eating  of  salad,  raw  fruit,  &c.  With  regard 
to  the  dyspepsia,  frequently  attendant  on 
calculous  disorders,  and  other  chronic  dis- 
eases, Magendie  sets  down  the  complaints 
of  the  stomach  and  of  the  urinary  organs,  as 
probably  only  two  effects  of  the  same  cause, 
and  not.  mutually  productive  of  each  other 


URINARY  CALCULI 


(See  Rechercius , «V"  • sar  'es  Causes,  fye.  dc  la 
Gravelle ■ 8 to.  Paris,  1818.) 

It  should  he  observed,  that  Mageudie’s 
observations  are  meant  to  apply  only  to  ca- 
ses of  gravel,  and  where  the  substance  void- 
ed is  1 it  hie  acid.  And  as  for  other  instances, 
in  which  the  calculous  matter  is  formed  of 
phosphate  of  lime,  oxalate  of  lime,  cystic 
oxide,  &x.  he  deems  the  causes  entirely  un- 
known. One  thing  is  certain,  that  Magen- 
die’s  theory  will  not  account  for  the  origin 
of  calculi,  unless  a predisposition  to  the  dis- 
ease from  other  unknown  or  conjectured 
causes  be  taken  as  a matter  of  fact.  Indeed, 
this  admission  he  makes  himself;  and  he 
enumerates  various  circumstances  conducive 
to  gravel,  besides  a diet  of  food  abounding 
in  azote  ; as  advanced  age,  a sedentary  life, 
and  hard  study,  long  retention  of  the  urine 
in  the  bladder,  strong  wines  and  liquors.  In 
fact,  without  the  predisposition,  arising  from 
unknown  causes,  and  particular  periods  of 
life,  a meat  diet  will  not  render  the  occur- 
rence of  calculi  frequent,  as  is  exemplified 
in  sailors,  who  eat  a great  deal  of  salt  beef 
and  pork.  And,  on  the  contrary,  that  the 
eatmg  of  little.' or  no  animal  food  will  not 
always  prevent  the  formation  of  calculi, 
when  there  is  tendency  to  it  from  time  of 
life,  diathesis,  or  other  causes,  is  sufficiently 
proved  by  the  frequency  of  the  disease  in 
infants,  in  whose  food  there  is  a much 
smaller  proportion  of  meat  and  azotic  sub- 
stances than  in  the  usual. diet  of  an  adult. 

With  respect  to  amorfdious  sediments,  the 
circumstances  which  Dr.  Prout  has  observed 
to  produce  a lithic  acid  diathesis  in  per- 
sons, subject  to  slight  dyspepsia,  but  in  other 
respects  healthy,  are,  1,  Simple  errors  in 
diet.  2,  Unusual,  or  unnatural  exercise, 
either  bodily  Or  mental,  particularly  after 
eating,  and  the  want  of  proper  exercise  at 
all  other  times.  3,  Debilitating  circumstan- 
ces. (On  Gravel , Calculus,  tyc.  p.  113.)  An 
unusually  heavy  meal,  especially  of  animal 
food,  or  bread,  he  says,  is  invariably  follow- 
ed by  a deposition  of  the  lithate  of  ammo 
nia  from  the  urine.  Heavy,  unfermented 
bread,  and  compact,  hard  boiled,  fat  dump- 
lings, or  puddings,  he  finds  particularly  apt 
to  produce  such  an  effect. 

Crystallized  sediments,  or  gravel,  consist- 
ing of  nearly  pure  lithic  acid,  Dr.  Prout  as- 
cribes to  a free  acid  being  sometimes  gene- 
rated in  the  kidneys,  and  combining  with 
the  ammonia,  with  which  the  lithic  acid  is 
previously  united,  so  as  to  precipitate  the 
latter  in  a pure  crystallized  state.  Accord- 
ing to  the  investigations  of  Dr.  Prout,  the 
precipitating  acid  is  not  constantly  the 
same,  though  generally  the  phosphoric,  and 
sometimes  the  sulphuric.  (P.  1 :7,  128.) 

The  same  intelligent  writer  represents, the 
circumstances,  which  promote  the  formation 
of  urinary  sediments  in  general,  as  being 
either  natural  or  acquired.  -£  With  respect 
to  those  of  the  first  description,  (says  he) 
it  cannot  « think  be  doubtmi,  that  certain 
individuals  are  much  more  liable  to  these 
sediments  than  others.  This  tendency  is 
not  infrequently  inherited  'thus,  I know  a 


family,  where  the  grandfather  ;fnd  father 
have  actually  lithic  calculi  in  the  bladder  ; 
and  where  the  grandson,  a youth  of  twelve, 
or  thirteen  years  of  age,  has  a very  strong 
tendency  to  the  same  disease  ; his  urine  de 
positing  frequently  very  large  quantities  of 
lithic  acid,  both  in  the  form  of  amorphous 
and  crystalline  sediments.  On  the  other 
hand,  the  disposition  to  generate  these  sedi- 
ments in  excess  is,  like  gout,  or  rather  si- 
multaneously with  gout,  but  too  frequently 
acquired  by  indolent  habits,  and  excess  in 
eating  and  drinking.  Most  frequently,  how- 
ever, the  tendency  to  these  diseases  is  con 
nected  with  some  unknown  causes,  peculiar 
to  certain  districts  or  countries,”  as,  for  ex- 
ample, the  district,  of  which  Norwich  may 
be  considered  as  the  centre  ; in  which  more 
calculous  cases  occur  than  in  the  whole  of 
Ireland  or  Scotland.  In  such  instances  the 
water,  diet,  temperature,  &c.  of  the  district 
has  been  each  accused,  in  its  turn,  of  being 
the  exciting  cause  ; bnt,  (says  Dr.  Prout) 
the  circumstance,  I believe,  still  remains 
unexplained.  I have  in  one  or  two  instan- 
ces seen  a fit  of  lithic  gravel  iuduced  in  the 
predisposed  by  sitting  on  a damp  cold  seat 
for  some  hours.  Sometimes  also  a tenden- 
cy to  lithic  calculus  is  evidently  connected 
with  lo.^al  injury,  or  disease  of  the  kidney.” 
(P.  133.) 

The  difficulty  of  tracing  the  causes  of  the 
formation  of  calculi  is  rather  increased,  than 
facilitated,  by  the  fact,  that,  except  when  the 
urinary  organs  are  much  diseased,  the  pa- 
tient may  appear  to  be  in  perfect  health. 
Indeed,  persons  of  the  strongest  constitu 
tions  are  often  troubled  with  the  stone, 
quite  independently  of  the  entrance  of  any 
foreign  body,  as  a nucleus,  into  the  bladder ; 
and  if  is  now  universally  admitted,  that  lithic 
acid  itself  constitutes  by  far  the  most  com  - 
mon nucleus,  even  when  other  calculou; 
matter  is  deposited  round  it.  (See  Prout  on 
Grarcl,  p.  95.)  It  is  sometimes  conjectured 
that  the  female  is  less  liable  than  the  male 
sex,  to  calculi ; but  whether  this  is  the  fact, 
or  whether  the  circumstance  can  be  satis- 
factorily explained  on  another  " principle, 
viz.  the  facility  with  which  any  calculi  of 
moderate  size  are  generally  discharged 
through  the  short  and  capacious  meatus 
urinarius,are  questions  perhaps  not  yet  com- 
pletely settled 

Infants  and  children  to  the  age  of  twelve, 
or  fourteen,  are  very  liable  to  stone.  How- 
ever, it  is  asserted  by  Delpech,  that  at  this 
period  of  life,  relapses  are  infrequent;  that 
is  to  say,  an  entirely  fresh  stone  is  hardly 
ever  formed  again  ; arid,  if  a return  of  the 
complaint  happens,  the  quickness  of  its  re- 
currence, and  an  attentive  examination  of 
the  calculus,  will  mostly' prove,  either  that 
the  second  stone  has  formed  round  a frag- 
ment of  the  first  left  behind,  or  that  it  ex- 
isted when  the  former  one  was  taken  out, 
but  was  not  discovered.  I am  not  inclined 
myself  to  put  much  faith  in  this  statement, 
because  it  is  hardly  credible,  that  the  calcu- 
lous diathesis  of  childhood  can  be  at  all 
diminished  bv  the  circumstance  of  there 


UKINAItV  CALCULI 


having  already  been  one  calculus,  and  of 
the  patient  having  had  the  bladder  opened 
for  its  removal. 

Dr.  Marcet  thinks,  that  the  disorder  is 
frequent  only  among  the  children  of  the 
poor  classes;  and  that  in  those  of  the  high- 
er ranks,  or  even  of  the  lowest  classes,  pro- 
vided they  arc  well  fed , the  same  frequency 
is  not  observed.  “ In  the  Foundling  Hos- 
pital, for  instance,  within  the  last  27  years, 
during  which  1151  children  have  been  ad- 
mitted, only  3 cases  of  stone  have  occurred, 
all  of  which  were  among  children  while  at 
nurse  in  the  country.  And,  in  the  Military 
Asylum  at  Chelsea,  which  contains  about 
1250  children,  and  into  which  upwards  of 
6000  of  them  have  been  already  admitted, 
no  more  than  one  single  case  of  stone  has 
occurred  ” (See  MarceVs  Essay  on  Calcu- 
lous Disorders,  p.  36  ) However,  supposing 
that  the  foregoing  statement  refers  to  ope- 
rations for  stone,  and  that  the  average 
number  of  operations  for  the  population  oi 
Great  Britain  and  Ireland,  is  annually  about 
1 for  each  100,000  inhabitants,  the  inference 
drawn  by  Dr.  Marcet,  which  also  does  not 
agree  with  later  statistical  reports,  cannot  be 
received,  because  in  the  total  number  of 
children,  specified  as  having  been  admitted 
into  the  above  charities,  even  when  every 
allowance  is  made  for  the  time  comprised 
in  the  calculation,  the  proportion  of  opera- 
tions is  far  beyond  the  average,  with  refer- 
ence to  the  population  in  general.  And, 
that  stone  cases  are  more  numerous  in  the 
children  of  the  poor,  than  in  those  of  the 
higher  classes,  is  a fact,  which  perhaps  may 
be  explained  by  the  recollection,  that  the 
mass  of  the  population  consists  of  the  poor 
and  laborious  classes. 

In  the  period  of  life,  between  the  age  of 
twelve,  or  fourteen,  and  that  of  forty,  the 
liability  to  stone  in  the  bladder,  is  much  less 
than  in  infancy,  childhood,  or  old  age. 
And  no  doubt,  many  of  the  cases,  which  do 
present  themselves  in  adults,  or  middle  aged 
individuals,  either  began  at  an  earlier  period 
of  life,  or  are  owing  to  some  extraneous 
nucleus. 

According  to  Delpech,  in  old  men,  who 
are  particularly  subject  to  calculi,  the  dispo- 
sition to  the  return  of  the  disease  always 
continues  during  life  ; and  hence  in  them, 
relapses  are  frequent.  {Pricisdts  Mai.  Chir. 
T.  2,  p.  193,  fyc.) 

The  following  table,  collected  by  Dr. 
Prout,  exhibits  the  proportion  of  stone  cases 
before  and  after  puberty,  and  of  their  occur- 
rence in  the  different  sexes : 


isting  of. 
|Females 

44 

C/l  , 

a m 

o o 

u ^ 

o 

5 

O)  Ox 

© 

H 

i C iO 

-d 

a 

U3  — 1 

. ©> 

03  f' 

o 

o 

Cl  Cl 

o 

'Z. 

©>  -1 

r~- 

O 

Oi  © 

Cj 

— ; 

CO  i'- 

to 

i - r- 

to 

03 

23 

o 

,c  ~ 

3 tft 

—l  * 

m — « 

a o 
cj  > 


Thus,  nearly  one  half  of  the  whole  number 
of  stone  cases  occur  before  the  completion  of 
the  14 th  year  ; and  it  appears  also  from  Mr. 
Smith’s  valuable  reports,  that  there  is  an 
evident  increase  in  the  number  of  cases,  about 
the  age  of  40  years.  (See  Prout  on  Gravel, 
tyc.  p.  210;  and  R.  Smith , in  Med.  Chir. 
Trans.  Vol.  10.) 

Dr.  Marcet  has  estimated  the  comparative 
frequency  of  the  disease  in  various  coun- 
tries, and  in  the  different  stations  of  life, 
and  tried  to  ascertain,  w'bether  its  frequency 
be  influenced  by  varieties  of  climate,  or 
situation,  or  by  peculiarities  in  our  habits 
and  occupations.  He  instituted  inquiries  at 
all  the  great  hospitals  of  the  metropolis,  in 
the  hope  of  getting  at  some  useful  records 
concerning  the  vast  number  of  patients,  on 
whom  lithotomy  had  been  performed  in 
those  establishments.  In  London,  he  found 
it  impossible  to  obtain  all  the  particulars  of 
such  cases,  as  no  entry  of  them  had  been 
preserved.  The  Norwuch  hospital,  however, 
afforded  him  some  details,  udiich  are  inter- 
esting. All  the  calculi,  w'hich  have  been 
exracted  in  that  hospital  for  44  years,  viz. 
from  1772,  to  1816,  and  which  amount  to 
506,  have  been  carefully  preserved,  with 
the  circumstances  annexed  to  each  stone, 
and  the  event  of  the  operation  distinctly 
recorded.  Dr.  Marcet  has  given  the  results 
of  these  records  in  the  following  table  : 


Vofc,  II 


0 


URINARY  CALCULI. 


CO  00 
f-  Gl 


— o 

Oi 

Ci 


tr 1X1 

CJ 


2fa 

It  appears,  says  Dr.  Marcet.  from  the 
above  table,  that  the  mean  annual  number 
of  cases  of  lithotomy  in  the  Norwich  Hos- 
pital, during  the  last  44  years,  has  been 
11  1-2,  or  23  in  every  two  years  ; and  that 
the  total  number  of  fatal  cases,  in  the  506 
operations-  is  70,  or  1 in  7 1-4,  or  4 in  29. 
The  proportion  of  females,  who  have  under- 
gone the  operation,  is  to  that  of  males,  as 
58  to  1000,  or  about  1 to  17  ; that  the  mor- 
tality from  the  operation  in  children  was 
oniy  about  1 in  18;  while,  in  adults,  it  was 
4 in  19,  or  nearly  quadruple. 

According  to  Mr.  Smith,,  the  mortality 
from  lithotomy  at  the  Bristol  Infirmary,  has 
been  in  the  following  proportions: 


Age. 

10  years  of  age  and  under 

Between  10  and  20  

20 
30 
40 
50 
60 
70 


30 

40 

50 

60 

70 

SO 


Mean  at  all  Ages 


Rate  of  Mor- 
tality. 

1 in  4 1-2 
1 — 5 
1 — 7 
1 — 5 
1-3  1-8 
1 — 4 2-3 
1-2  1-2 
1 —2 

I in  4 1-4 


The  following  table  is  also  from  Mr. 
Smith’s  paper,  and  refers  to  the  Leeds  Hos- 
pital. (See  Med.  Chir.  Trans.  Vol.  10.) 


] Cases  of 
| Lithotomy. 
From  1767  to  1777124  of  whicli 
1777  1787162 

1787  1797123 

1797  1807  42 

1807  1817146 

Mean  at  all  ages, 


died 


>r  I in  12 
1 7 3-4 

1 7 2-3 

1 6 
1 5 3-4 


1 in  7 4-5 


In  the  Norfolk  Infirmary  the  mortality  has 
been  much  less  in  children,  than  in  adults. 
But  at  St.  Bartholomew’s,  the  proportion  of 
deaths  in  children,  during  the  20  years  that 
I frequently  attended  operations  for  stone 
there,  was  very  great.  In  the  Bristol  Infir- 
mary, the  risk  in  children  seems  to  have 
been  about  equal  to  what  it  has  been  in 
adults.  In  all  calculations  of  this  kind,  how- 
ever, it  is  to  be  recollected,  that  as  opera- 
tions for  the  stone  are  done,  not  oniy  by 
surgeons  of  various  degrees  of  skill,  but  in 
dilferent  ways,  and  even  with  instruments 
of  great  diversity,  such  computations  do  not 
give  the  fair  average  of  any  one  method  of 
operating. 

Now,  where  the  patients  are  equally 
favourable,  but  the  results  of  any  given 
number  of  operations  on  them  are  consider- 
ably dilferent,  the  skill  of  the  surgeons,  the 
particular  methods  of  operating  pursued,  the 
kinds  of  instruments  used,  the  general  health- 
iness of  the  hospital  itself,  and  the  treatment 
after  the  patients  are  put  to  bed,  are  consi- 
derations, by  which  questions,  apparently  in- 
explicable, might  sometimes  he  solved. 

From  the  year  1772  !o  1816,  the  Norwich 
Hospital  received  18,859  patients  of  all 
kinds,  making  an  average  of  428  annual  ad- 
missions ; and  Dr.  Marcet  observes,  that 
the  proportion  of  50.6  operations  of  lithoto- 
my, out  of  18,859  patients,  which  corres- 
ponds to  about  1 in  38,  exceeds  in  an  as- 
tonishing degree,  that  obtained  from  any  of 
the  other  public  institutions,  whose  records 
he  examined. 

Next  to  the  records  of  the  Norwich  Hos- 
pital, Dr.  Marcet  derived  the  most  distinct 
information  of  this  kind  from  Cheselden, 
who  mentions  in  his  work  on  anatomy,  that 
during  the  course  of  his  public  practice  in 
St.  Thomas’s  Hospital,  a period  of  about  20 
years,  he  had  performed  th’e  operation  of 
the  stone  213  times,  and  lost  only  20  patients. 
This  was  about  2 cases  in  21,  which  is  much 
less  than  the  common  average. 

In  St.  Thomas’s  Hospital,  during  the  last 
ten  years,  the  operation  of  lithotomy  seems 
to  have  been  done,  on  an  average,  11  times 
in  each  two  years  ; and  one  case  of  stone 
has  occurred  in  eacli  528  patients  admitted. 

In  St.  Bartholomew’s,  lithotomy  was  per- 
formed 56  times  in  the  years  1812,  1813, 
1814,  1815,  and  1816  The  annual  average 
about  11,  or  1 in  each  340  patients  of  all 
descriptions. 

In  Guy’s  Hospital,  lithotomy  has  been 
performed,  on  an  average,  about  9 or  10 
times  annually,  during  the  last  20,  or  30 
years.  The  proportion  of  calculous  patients 
there  is  also  estimated  as  1 in  about  300 
cases  of  all  kinds. 

Dr.  Marcet’s  inquiries  incline  him  to  think, 
that  on  the  whole,  lithotomy  in  the  London 
Hospitals  for  some  years,  has  been  gradually 
becoming  less  frequent ; and  this  lie  con- 
ceives may  be  owing,  partly  to  a real  reduc- 
tion in  the  frequency  of  the  stone,  from 
some  . Iteration  in  the  diet,  or  habits  of  the 
people  ; partly  to* the  use  of  appropriate 
medicines ; and  partly  to  the  circumstance 


URINARY  CALCULI. 


t>5  6 


of  calculous  patients  not  resorting  so  exclu- 
sively, as  was  formerly  the  case,  to  the 
great  London  hospitals  for -the  operation. 

In  the  Royal  Infirmary  at  Edinburgh,  the 
average  number  of  stone  cases  annually, 
during  the  last  six  years,  is  said  not  to  have 
exceeded  2,  although  about  2000  patients 
are  admitted  there  every  year. 

Dr.  Marcet  has  been  informed  by  M. 
Roux,  that,  in  La  Charite  at  Paris,  ten  or 
twelve  cases  of  stone  occur  every  year,  out 
of  about  2600  patients,  and  that  the  propor- 
tion of  deaths  from  the  operation  there  is  1 
in  6 or  6. 

In  the  HOpital  des  Enfans  Malades,  in 
the  same  city.  Dr.  Marcet.  states,  on  the 
authority  of  Dr.  Biett,  that  about  6 cases 
of  stone  are  received  every  year  into  that 
establishment,  where  about  3000  children 
of  both  sexes  are  annually  admitted.  There 
have  been  only  3 cases  in  females,  and 
what  is  remarkable,  only  two  deaths  from 
the  operation  in  the  course  of  the  last  se- 
ven years. 

Dr.  Marcet  was  acquainted,  that  lithotomy 
is  comparatively  rare  at  Vienna,  not  on  ac- 
count of  the  want. of  good  surgeons,  or  the 
unfrequent  occurrence  of  stone  cases  in  that 
part  of  the  continent ; but  in  consequence  of 
the  little  attention  paidjo  this  disease  by  the 
most  eminentsurgeonsofthe Austrian  capital. 

At  Geneva,  says  Dr  Marcet,  in  a popula- 
tion of  30,000,  lithotomy  has  been  perform- 
ed only  thirteen  times  in  the  last  twenty 
years,  though  good  surgeons  are  never 
wanting  in  that  town  to  perform  the  opera- 
tion whenever  an  opportunity  presents 
itself.  Out  of  these  thirteen  patients,  seven 
were  not  strictly  Genevese,  though  belong- 
ing to  the  neighbouring  districts,  and  one 
was  an  Englishman  ; so  that  the  disease 
would,  at  first  sight,  appear  to^be  a rare  oc- 
currence at  Geneva.  But,  continues  Dr. 
Marcet,  if  the  smallness  of  the  Genevese  po- 
pulation be  taken  into  account,  this  propor- 
tion of  calculous  cases  may  not  fall  very 
short  of  that  observed  in  other  places.  At 
Lyons,  a populous  town,  not  more  than 
eighty  miles  distant  from  Geneva,  the  dis- 
ease is  stated  to  be  rather  frequent. 

With  regard  to  the  chymical  nature  of 
urinary  calculi,  there  was  nothing  known 
until  1776,  when  Sc'neele  published  on  the 
subject  in  the  Stockholm  Transactions.  He 
there  stated,  that  all  the  urinary  calculi, 
which  he  had  examined,  consisted  of  a pe- 
culiar concrete  substance,  now  well  known 
by  the  name  of  lithic,  or  uric  acid,  which 
he  also  showed  was  soluble  in  alkaline  lixi- 
via. Scheele  further  discovered,  that  the 
lithic  matter  was,  in  some  degree,  capable 
of  being  dissolved  in  cold  water;  that  this 
solution  possessed  acid  properties,  and,  in 
particular,  that  of  reddening  litmus;  that  it 
was  acted  upon  in  a peculiar  manner  when 
boiled  in  nitric  acid  ; and  lastly,  that  hu- 
man urine  always  contained  this  substance 
in  greater  or  less  quantity,  and  often  let  it 
separate  in  the  form  of  a brick-coloured 
sediment,  by  the  mere,  effect  of  cooling. 

The  disooverv  made  by  Scheele  was  con- 


firmed by  Bergmann  and  Morveau,and  the 
investigation  of  the  subject  was  afterward 
prosecuted  by  others  with  redoubled  ardour 
As  Professor  Murray  observes,  experiments 
continued  to  be  repeated  and  diversified  on 
these  concretions,  anti  on  their  solvents. 
At  length  it  was  fully  ascertained,  that 
there  existed  others,  besides  those  compo- 
sed of  uric  acid;  and,  latterly,  our  know- 
ledge of  them  has  been  much  extended  by 
the  researches  of  Pearson,  Wollaston, Four- 
croy,  and  Vauquelin.  Several  important 
facts  have  also  been- established  by  the  ta- 
lents and  industry  of  some  other  distinguish- 
ed men  ; viz.  Dr.  Henry,  of  Manchester  ; 
Professor  Brande,  of  the  Royal  Institution 
of  London  ; Dr.  Marcet  late  of  Guy’s  Hos- 
pital ; and  Dr.  Proul,  of  London.  The  facts 
and  considerations  of  the  latter  writer  ren- 
der it  probable,  however,  that,  the  common 
opinion  of  pure  lithic  acid  being  contained 
in  the  urine  is  not  exactly  correct ; but  that 
this  acid  <£  in  healthy  urine  exists  in  a state 
of  combination  with  ammonia,  and  that,  in 
reality,  this  fluid  contains  no  uncombined 
acid  at  all.”  (On  the  jYaturc,  fyc.  of  Gravel 
and  Calculus , c.  13.) 

The  credit  which  is  due  to  Dr.  Wollaston 
for  his  valuable  and  original  discoveries, 
respecting  urinary  calculi,  is  very  consider- 
able; a truth  which  I have  particular  plea- 
sure in  recording  here,  since  his  merits  have 
not  been  faifiy  appreciated  by  the  French 
ehvmists.  Indeed,  as  Dr.  Marcet  observes, 
it  is  the  more  desirable  that  his  claims 
should  be  placed  in  the  clearest  point  oi 
view,  as  the  late  celebrated  M.  Fourcror, 
both  in  his  “ Systerae  des  Connoissances 
Chimiques,”  and  in  his  various  papers  on 
this  particular  subject,  has,  in  a most  unac- 
countable manner,  overlooked  Dr.  Wollas- 
ton's labours,  and,  in  describing  results,  ex- 
actly similar  to  those  previously  obtained 
and  published  by  the  English  chymist,  has 
claimed  them  as  his  own  discoveries.  Yet. 
Dr.  Wollaston’s  was  printed  in  our  Philoso 
phical  Transactions,  two  years  before  Four- 
croy  published  his  Memoir  in  the  w Annales 
de  Chimie.”  and  three  years  before  he  gave 
to  the  world  his  “ Systeme  des  Connoissan- 
ces  Chimiques;”  and  he  discussed  in  these 
works  a paper  of  Dr.  Pearson  on  the  lithic 
acid,  published  in  a volume  of  the  Philoso- 
phical Transactions  (for  171)8)  subsequent- 
to  that  which  contained  the  account  of  Dr. 
Wollaston’s  discoveries!  (See  Marcel's 
Essay  on  Calculous  Disorders,  p 60.  Also 
Murray’s  Syst.  of  Chyw . vol.  4,  p.  6)6,  edit, 
of  1S09.) 

It  would  appear  then,  that  Scheele  fir. 
discovered  the  nature  of  those  urinary  cal- 
culi which  consist  of  lithic  acid  ; but  that 
Dr.  Wollaston  first  ascertained  the  nature 
of  several  other  kinds,  some  of  which  have 
also  been  described  at  a later  period  by 
Fourcroy  and  Vauquelin.  On  the  whole, 
there  are  five  species  of  concretions,  whose 
chymical  properties  were  first  pointed  out. 
by  Dr.  Wollaston,  and  no  less  than  four  be- 
long to  the  urinary  organs.  These  are,  1st. 
Gouty  concretions.  2dly.  The  fusible  (■■■'■ 


cuius.  3dly.  The  mulberry  calculus.  4thly. 
•The  calculus  of  the  prostate  gland.  Gthly. 
The  cystic  oxide,  discovered  in  1810. 

1.  Lithic  Acid  Calculus.  Dr.  Front  be- 
lieves that,  at  least  two-thirds  of  the  whole 
number  of  calculi  originate  from  lithic  acid ; 
for,  as  it  forms  by  far  the  most  common  nu- 
cleus, round  which  other  calculous  matter 
is  subsequently  deposited,  if  such  huclei  had 
not  been  formed  and  detained,  two  persons 
at  least  out  of  three  who  suffer  from  stone, 
would  never  have  been  troubled  with  the 
disorder.  (On  Gravely  Calculus,  fyc.  p.  95.) 

Lithic  Acid  forms  a hard,  inodorous  con- 
cretion, of  a yellowish,  or  brown  colour, 
similar  to  that  of  wood  of  various  shades. 
According  to  Professor  Murray,  calculi  of 
th  is  kind  are  in  fine,  close  layers,  fibrous, 
or  radiated,  (and  generally  smooth  on  their 
surface,  though  sometimes  a little  rough. 
They  arc  rather  brittle,  and  have  a specific 
gravity,  varying  from  1,276  to  1,786,  but 
usually  above  1,500.  One  part  of  lithic 
acid  is  said  to  dissolve  in  1720  parts  of  cold 
water,  and  1150  parts  of  boiling  water; 
( Marcel , p.  65.)  and  this  solution  turns  ve- 
getable blues  to  a red  colour.  When  it  has 
been  dissolved  in  boiling  water,  small  yel- 
lowish ((crystals  are  deposited  as  the  fluid 
becomes  cold.  Lithic  acid  calculi  blacken, 
but  are  not  melted  by  the  blowpipe,  emit- 
ting a peculiar  animal  smell,  and  gradually 
evaporating,  until  a small  quantity  of  white 
ash  remains,  which  is  alkaline.  By  distilla- 
tion, they  yield  ammonia  and  prussic  acid. 
They  are  soluble  in  the  cold,  in  a solution 
of  pure  potassa,  ovsoda,  and  from  the  solu- 
tion a precipitate  of  a fine  white  powder  is 
thrown  down  by  the  acid.  Lime-water 
likewise  dissolves  them,  but  more  sparingly. 
According  to  Scheele  they  remain  unchan- 
ged in  solutions  of  the  alkaline  carbonates  ; 
a statement  which  agrees  with  that  of  Dr. 
Prout,  who  accounts  for  the  effect  said  to 
be  produced  by  the  alkaline  carbonates 
upon  calculi  in  the  bladder,  by  their  pro- 
perty of  dissolving  the  lithate  of  ammonia. 
(Egan  in  Trans,  of  Irish  Acad.  1805,  Prout 
on  Gravel,  tyc.  p.  84.)  They  are  not  much 
acted  upon  by  ammonia.  They  are  not 
soluble  either  in  the  muriatic  or  sulphuric 
acid  ; though  they  are  so  in  the  nitric  when 
assisted  by  heat,  and  the  residue  of  this  so- 
lution, when  evaporated  to  dryness,  as- 
sumes a remarkably  bright  pink  colour, 
which  disappears  on  adding  either  an  acid 
or  an  alkali.  In  many  of  these  calculi,  the 
lithic  acid  is  nearly  pure  ; in  others,  there 
is  an  intermixture  of  other  ingredients,  par- 
ticularly of  phosphate  of  lime,  and  phosphate 
of  ammonia  and  magnesia  ; and,  in  almost 
all  of  them,  there  is  a portion  of  animal 
matter,  which  occasions  the  smell  when 
they  are  burnt,  and  the  loss  in  their  analy- 
sis. (See  Murray's  Chymisiry,  vol.  4,  p. 
640  ; and  Marcel  s Essay  on  the  Chym.  and 
Med.  Hist.  »f  Calculous  Disorders,  Svo.  Load. 
1817.) 

A great  quantity  of  uric  acid  is  formed  in 
gpiiiy  constitutions,  and  deposited  in  the 
joints,  or  soft  parts,  in  the  state  of  lithate  of 


ammonia.  Sir  Everard  Home  removed  a 
tumour  weighing  four  ounces  from  the 
heel  of  a gentleman,  a martyr  to  the  gout  ; 
and  when  anatysed  by  Professor  Brande,  it 
was  found  to  be  principally  composed  of 
uric  acid.  (On  Strictures,  vol.  3,  p.  313.) 

2.  Lithate  of  Ammonia  Calculus,  accord- 
ing to  Dr.  Prout,  is  generally  of  the  colour 
of  clay,  f ts  surface  is  sometimes  smooth  ; 
sometimes  tuberculated.  If  is  composed  of 
concentric  layers,  and  its  fracture  resem- 
bles that  of  compact  limestone.  It  is  ge- 
nerally of  small  size,  and  rather  uncom- 
mon ; but  the  lithate  of  ammonia  very  fre- 
quently occurs,  mixed  with  lithic  acid, 
forming  a mixed  variety  of  calculus.  Under 
the  flame  of  the  blowpipe  it  usually  decre- 
pitates strongly.  It  is  much  more  soluble 
in  water  than  the  lithic  acid  calculus  ; and 
always  gives  off  a strong  smell  of  ammonia 
on  being  heated  with  caustic  potash.  The 
liihale  of  ammonia  is  also  readily  soluble  in 
the  alkaline  subcarbonates,  which  pure  lithic 
acid  is  not.  (Prout  on  Gravel , fyc.  p.  83.) 

3.  Bone  Earth,  Phosphate  of  Lime  Calcu- 
lus. The  presence  of  phosphate  of  limp  in 
urinary  calculi  had  been  mentioned  by 
Bergmaun  and  others,  when  Dr.  Wollaston 
first  ascertained,  that  some  calculi  are  en- 
tirely composed  of  it.  From  the  investiga- 
tions of  Dr.  Wollaston,  it  appears  that  this 
substance  sometimes,  though  rarely,  com- 
poses the  entire  calculus,  but  that  in  general 
it  is  mixed  with  other  ingredients,  particu- 
larly with  uric  acid,  and  phosphate  of  mag- 
nesia and  ammonia.  In  the  first  case,  the 
calculus  is  described  as  being  of  a pale 
brown  colour,  and  so  smooth  as  to  appear 
polished.  When  sawn  through,  it  is  found 
very  regularly  laminated,  and  the  laminae  in 
general,  adhere  so  slightly  to  each  other,  as 
to  separate  with  ease  into  concentric  crusts. 
It  dissolves  entirely,  though  slowly,  in  mu- 
riatic or  nitric  acid.  Exposed  to  the  flame 
of  the  blowpipe,  it  is  at  first  slightly  char- 
red, but  soon  becomes  perfectly  white,  re- 
taining its  form,  until  urged  with  the  utmost 
heat  from  a common  blowpipe,  when  it 
:nav  be  completely  fused.  It  appears  to  be 
more  fusible  than  the  phosphate  of  lime, 
which  forms  the  basis  of  bone;  a circum- 
stance which  Dr.  Wollaston  ascribes  to  the 
latter  containing  a larger  quantity  of  lime. 
(Phil.  Trans.  1797.) 

4.  Triple  Phosphate  of  Magnesia  and  Am- 
monia Calculus . The  existence  of  this  cal- 
culus in  the  intestines  of. animals  was  first 
pointed  out  byFourcroy;  but  its  being  a 
constituent  part  of  some  urinary  calculi  of 
the  human  subject,  was  originally  discover- 
ed by  Dr.  Wollaston.  (Phil.  Trans.  1797.) 
According  to  Dr.  Prout,  t his  species  of  cal- 
culus is  always  nearly  white  : its  surface  is 
commonly  uneven,  and  covered  with  minute 
shining  crystals.  Its  texture  is  not  lamina- 
ted, and  it  is  easily  broken  and  reduced  to 
powder.  In  some  rare  instances,  however, 
it  is  hard  and  compact,  and  when  broken, 
exhibits  a crystalline  texture,  and  is  more  or 
less  transparent.  Calculi  composed  entire- 
ly of  the  phosphate  of  magnesia  and  ammo. 


URINARY  CALCULI 


uia  are  rare,  but  specimens,  m which  they 
constitute  the  predominant  ingredient  are 
by  no  means  uncommon.  ( Prout , p.  S6.) 
When  the  blow-pipe  is  applied,  an  ammonia- 
cal  smell  is  perceived,  the  fragment  dimi- 
nishes in  size,  and  it  the  heat  be  strongly 
urged,  it  ultimately  undergoes  an  imperfect 
fusion,  being  reduced  to  the  state  ot  phos- 
phate of  magnesia.  ( P . 69.)  Ur.  Wollaston 
describes  the  form  of  the  crystals  of  this  salt, 
as  being  a short  trilateral  prism,  having  one 
angle  a right  angle,  and  the  other  two  equal, 
terminated  by  a pyramid  of  three  or  six 
sides.  These  crystals,  as  Dr.  Marcet  has  ex- 
plained, are  but  very  sparingly  soluble  in 
water,  but  very  readily  in  most,  if  not  all 
the  acids,  and  on  precipitation,  they  reas- 
sume the  crystalline  form.  From  the  solu- 
tions of  these  crystals  in  muriatic  acid,  sal 
ammoniac  may  be  obtained  by  sublimation. 
Solutions  of  caustic  alkalies  disengage  am- 
monia from  the  triple  salt,  the  alkali  com- 
bining with  a portion  of  the  phosphoric 
acid. 

5.  Fusible  Calculus.  Mr.  Tennant  first 
discovered,  that  this  substance  was  different 
from  the  lithic  acid,  and  that,  when  urged 
by  the  blowpipe,  instead  of  being  nearly 
consumed,  a large  part  of  it  melted  into  a 
white  vitreous  globule.  The  nature  of  the 
fusible  calculus  was  afterward  more  fully 
investigated  and  explained  by  Dr.  Wollas- 
ton. {Phil.  Trans.  1797.)  According  to 
the  excellent  description  lately  given  ot  this 
calculus  by  Dr.  Marcet,  it  is  commonly 
whiter  and  more  friable  than  any  other  spe- 
cies. It  sometimes  resembles  a mass  of 
chalk,  leaving  a white  dust  on  the  fingers, 
and  separates  easily  into  layers,  or  laminae, 
the  interstices  of  which  are  often  studded 
with  sparkling  crystals  of  the  triple  phos- 
phate. At  other  times  it  appears  in  the 
form  of  a spongy  and  very  friable  whitish 
mass,  in  which  the  laminated  structure  is 
not  obvious.  Calculi  of  this  kind  often  ac- 
quire a very  large  size,  and  they  are  apt  to 
mould  themselves  in  the  contracted  cavity 
of  the  bladder,  assuming  a peculiarity  of 
form  which  Dr.  Marcet  has  never  observed 
in  any  of  the  other  species  of  calculi,  and 
which  consists  in  the  stone  terminating,  at 
its  broader  end,  in  a kind  of  peduncle,  cor- 
responding to  the  neck  of  the  bladder.  The 
chymical  composition  of  the  fusible  calcu- 
lus is  a mixture  of  the  triple  phosphate  of 
magnesia  and  ammonia,  and  of  the  phos- 
phate of  lime.  These  two  salts,  which, 
when  separate,  are  infusible,  or  nearly  so, 
xvhen  mixed  together  and  urged  by  the 
blowpipe,  easily  run  into  a vitreous  globule. 
The  composition  ot  this  substance,  says  Dr. 
Marcet,  may  be  shown  in  various  ways. 
Thus,  if  it  be  pulverized,  and  acetic  acid 
poured  upon  it,  the  triple  crystals  will  be 
readily  dissolved,  while  the  phosphate  of 
lime  will  scarcely  be  acted  upon  ; after 
which  the  muriatic  acid  will  readily  dissolve 
the  latter  phosphate,  leaving  a small  resi- 
due, consisting  of  lithic  acid,  a portion  of 
which  is  always  found  mixed  with  the  fusi- 
ble calculus 


5 At 

It  is  also  remarked  [by  Dr.  Marcet,  that 
many  of  the  calculi,  which  form  round  ex- 
traneous bodies  in  the  bladder,  are  of  the 
fusible  kind.  And  the  calculous  matter 
sometimes  deposited  between  the  prepuce 
and  glans  is  found  to  be  of  the  same  nature. 

6.  Mulberry  Calculus , or  Oxalate  of  Lime 
is  mostly  of  a dark  brown  colour,  its  inte- 
rior being  often  gray.  Its  surface  is  usually 
uneven,  presenting  tubercles  more  or  less 
prominent,  frequently  rounded,  sometimes 
pointed,  and  either  rough  or  polished.  It  is 
very  hard,  difficult  to  saw,  and  appears  to 
consist  of  successive  unequal  layers : ex- 
cepting the  few  stones,  which  contain  a 
proportion  of  silica,  it  is  the  heaviest  of  the 
urinary  concretions.  Though  this  calculus 
has  been  named  mulberry  from  its  resem- 
blance to  that  fruit,  yet,  as  Dr.  Marcet  has 
observed,  there  are  many  concretions  of 
this  class,  which,  far  from  having  the  mul- 
berry appearance,  are  remarkably  smooth 
and  pale-coloured,  as  may  be  seen  in  plate 
8,  fig.  6,  of  that  gentleman’s  essay.  Accor- 
ding to  Mr.  Brande.  persons  who  have  void- 
ed this  species  of  calculus,  are  much  less 
liable  to  a return  of  the  complaint,  than 
other  patients,  who  discharge  lithic  calculi. 
{Phil.  Trans.  1808.) 

With  regard  to  chymical  characters  (says 
Professor  Murray,)  it  is  less  affected  by  the 
application  of  the  usual  reagents,  than  any 
other  calculus.  The  pure  alkaline  solutions 
have  no  effect  upon  it,  and  the  acids  dissolve 
it  with  great  difficulty.  When  it  is  reduced 
however  to  fine  powder,  both  muriatic  and 
nitric  acid  dissolve  it  slowly.  The  solutions 
of  the  alkaline  carbonates  decompose  it,  as 
Fourcroy  and  Vauquelin  have  observed  ; 
and  this  affords  us  the  easiest  method  of 
analysing  it.  The  calculus  in  powder  being- 
digested  in  the  solution,  carbonate  of  lime 
is  soon  formed,  which  remains  insoluble, 
and  is  easily  distinguished  by  the  efferves- 
cence produced  by  the  addition  of  weak 
acetic  acid,  while  there  is  obtained  in  solu- 
tion the  compound  of  oxalic  acid  with  the 
alkali  of  the  alkaline  carbonate.  From  this 
the  oxalic  acid  may  be  precipitated  by  the 
acetate  of  lead,  or  of  barytes ; and  this 
oxalate,  thus  formed,  may  be  afterward  de- 
composed by  sulphuric  acid.  Another  me- 
thod of  analysing  this  calculus  is  by  expo- 
sure to  heat : its  acid  is  decomposed,  and  by- 
raising  the  heat  sufficiently,  pure  lime  is 
obtained,  amounting  to  about  a third  of  the 
weight  of  the  calculus.  According  to  Four- 
croy and  Vauquelin,  the  oxalate  of  lime 
calculus  contains  more  animal  matter,  than 
any  other.  This  animal  matter  appeared  to 
them  to  be  a mixture  of  albumen  and  uree. 
'1  he  composition  of  a calculus  of  this  species 
analysed  by  Mr.  Brande,  was;  oxalate  of 
lime  65  grains;  uric  acid  16  grains  ; phos- 
phate ot  lime  15  grains;  animal  matter  lour 
grains. 

7.  The  Cystic  Oxide  Calculus  is  small,  and 
very  rare.  It  was  first  described  by  Dr. 
Wollaston.  {Phil.  Trans,  for  1810.)  In 
external  appearance,  it  bears  a greater  re- 
semblance lo  the  triple  phosphate  of  ma?- 


558 


URINARY  CALCULI. 


nesia,  than  any  other  sort  of  calculus. 
However,  it  is  more  compact,  and  does  not 
consist  of  distinct  lamina?,  but  appears  as 
one  mas»<;onfusedly  crystallized  throughout 
its  substance.  It  has  a yellowish  semi- 
transparency,  and  a peculiar  glistening  lus- 
tre. Under  the  blowpipe,  it  gives  a singu- 
larly fetid  smell,  quite  different  from  that  of 
lithic  acid,  or  the  smell  of  prussic  acid.  In 
consequence  of  the  readiness,  with  which 
this  species  of  calculus  unites  both  with  acids 
and  alkalies,  in  common  with  other  oxides, 
and  the  fact  of  its  also  containing  oxygen  (as 
is  proved  by  the  formation  of  carbonic  acid 
by  distillation,)  Dr.  Wollaston  named  it  an 
oxide,  and  the  term  cystic  was  added  from 
its  having  been  originally  found  only  in  the 
bladder  in  two  examples.  Dr.  Marqet, 
however,  has  subsequently  met  with  no  less 
than  three  instances  of  calculi  formed  of 
cystic  oxide,  all  of  which  were  unquestiona- 
bly of  renal  origin. 

8.  Alternating  Calculus.  Lithic  strata  fre- 
quently alternate  wkh  layers  of  oxalate  of 
lime,  or  with  the  phosphates.  Sometimes 
also  the  mulberry  alternates  with  the  phos- 
phates, and  in  a few'  instances,  three,  or 
even  four  species  of  calculi  occur  in  the 
same  stone,  disposed  in  distinct  concentric 
laminae.  On  the  comparative  frequency 
of  these  and  other  varieties  of  calculi. 
Dr.  Prout’s  work  contains  valuable  infor- 
mation. 

9.  Compound  Calculi , with  their  Ingredients 
intimately  mixed.  Under  this  title  Dr.  Mar- 
cet  comprehends  certain  calculi,  which  have 
no  characteristic  feature,  by  which  they  can 
be  considered  as  distinctly  belonging  to  any 
of  the  other  classes.  He  observes,  that 
they  may  sometimes  be  recognized  by  their 
more  or  less  irregular  figure,  and  their  less 
determinate  colour;  by  their  being  less  dis- 
tinctly, if  at  all  divisible  into  strata  ; and 
by  their  often  possessing  a considerable 
hardness.  By  chvmical  analysis  confused 
results  are  obtained.  (See  Essay  on  the 
Ckym.  and  Med.  Hist,  of  Calculous  Disorders, 
p.  90.) 

10.  Calculi  of  the  Prostate  Gland.  The 
composition  of  those  calculi  is  said  to  have 
been  first  explained  by  Dr.  Wollaston.  (See 
Phil.  Trans,  for  1797.)  They  all  consist  ot 
ohospbate  of  lime,  the  earth  not  being  re- 
dundant as  in  bones.  Their  size  varies  from 
that  of  a pin’s  head  to  that  of  a hazel  nut. 
Their  form  is  more  or  less  spheroidal ; and 
they  are  of  a yellowish  brown  colour. 

Fourcroy  has  described  a species  of  uri- 
nary calculus,  which  is  characterized  by  its 
being  composed  of  the  urate  or  lit  hate  of 
ammonia.  Dr.  Wollaston,  Mr.  Brande,  and 
Dr.  Marcet  did  not,  however,  satisfactorily 
ascertain  the  presence  of  this  substance  in 
any  of  the  concretions,  which  they  examin- 
ed. As  also  urea  and  the  triple  phosphate, 
both  of  which  afford  ammonia,  are  frequent- 
ly present  in  lithic  calculi,  it  is  conjectured, 
that  these  circumstances  may  have  given 
rise  to  the  analytical  results,  from  which  the 
existence  of  nratex>f  ammonia  has  been  in- 


ferred. {Brande  in  Phil.  Trans.  1808.  Mar- 
cet’s  Essay,  p.  93.) 

The  recent  investigations  of  Dr.  Prout, 
however,  tend  to  establish  the  reality  of  the 
lithate  of  ammonia  calculus. 

Dr.  Marcet  has  met  with  two  specimens 
of  urinary  calculi  entirely  different  from  any 
which  have  hitherto  been  noticed.  One  of 
these  he  proposes  to  name  Xanlhic  oxide, 
from  gavBoe,  yellow , because  one  of  its  most 
characteristic  properties  is  that  of  forming 
a lemon-coloured  compound,  when  acted 
upon  by  nitric  acid.  The  chymical  proper- 
ties of  the  other  new  calculus,  mentioned 
by  Dr.  Marcet,  correspond  to  those  of  fibrine, 
and  he  therefore  suggests  the  propriety  of 
distinguishing  it  by  the  term  fibrinous.  For 
a particular  description  of  these  new  sub- 
stances, I must  refer  to  this  gentleman’s  Es- 
say. 

11.  Carbonate  of  Lime  Calculus.  This 
substance  is  not  enumerated  by  Dr.  Marcet, 
as  entering  into  the  composition  of  urinary 
calculi.  But,  according  to  Mr.  R.  Smith, 
there  can  be  no  doubt  of  the  fact.  Dr.  W. 
H.  Gilby  of  Clifton,  he  says,  detected  it  de- 
cidedly in  four  instances.  “ A notice  of  it 
will  be  found  in  Mr.  Tillock’s  Journ.  for 
1817,  vol.  49,  p.  188,  in  the  account  of  a 
curious  calculus,  given  to  me  by  Mr.  G.  M. 
Burroughs,  of  Clifton ; the  nucleus  of  which 
is  a common  cinder,  an  inch  and  a half 
long,  and  one  broad.  Since  the  publication 
of  that  paper  (continues  Mr.  Smith,)  Mr. 
H.  Sully,  of  Wiveliscombe,  sent  me  three 
oddly  shaped  calculi,  which  he  removed 
from  a lad,  together  with  15  pea-sized  ones 
previously  voided  by  the  urethra,  which  are 
entirely  carbonate  of  lime,  held  together 
by  animal  mucus.”  (See  Med.  Chir.  Trans, 
vol.  l\,p.  14.)  Dr.  Prout  has  also  seen  some 
small  calculi,  composed  almost  entirely  of 
carbonate  of  lime.  {On  Gravel , fyc.  p.  89.) 

Dr.  Prout  has  investigated  with  considera- 
ble talent  the  comparative  prevalency  of  the 
different  forms  of  urinary  deposite,  and  the 
order  of  their  succession.  His  data  are 
taken  from  the  examinations,  made  by  Pro- 
fessor Brande,  of  the  calculi  in  the  Hunterian 
Collection  ; by  Dr.  Marcet,  of  those  at  Nor- 
wich and  Guy’s  Hospital ; by  Dr.  Henry,  of 
those  at  Manchester ; and  by  Mr.  Smith,  of 
others  preserved  at  the  Bristol  Infirmary. 
The  whole  number  of  calculi  examined  was 
S23  ; of  these,  294  were  classed  under  the 
name  of  lithic  acid.  98  of  which  were  nearly 
pure;  151  were  mixed  with  a little  of  the 
oxalate  of  lime  ; and  45  with  a little  of  the 
phosphates.  113  consisted  of  oxalate  of 
lime.  Three  were  of  cystic  oxide.  202 
were  phosphates ; of  which  16  were  nearly 
pure  ; 84  mixed  with  a small  proportion  of 
lithic  acid  ; eight  consisted  of  phosphate 
of  lime  nearly  pure  ; three  of  triple  phos- 
phate nearly  pure  ; and  91  of  the  tusible  or 
mixed  calculi  186  were  alternating  calculi, 
or  those  whose  lamina?  varied,  but  consisted 
of  lithic  acid,  oxalate  of  lime,  and  phos- 
phates: of  these.  15  consisted  of  lithic  acid 
and  oxalate  of  lime,  the  first  being  in  the 
creates t proportion  : 40  of  the  oxalate  of 


URINARY  CALCULI 


inne  in  the  greatest  proportion,  and  lithic 
acid  in  the  least ; 51  of  the  litbic  acid  and 
the  phosphates ; 49  of  the  oxalate  of  lime, 
and  the  phosphates  ; 12  of  the  oxalate  of 
lime,  litbic  acid,  and  the  phosphates ; one 
of  fusible  and  litbic  ; two  of  fusible,  and 
oxalate  of  lime  ; and  16,  the  composition 
of  which  was  not  mentioned. 

Of  compound  calculi,  whose  composition 
was  not  specified,  there  were  25.  (See  W. 
Front's  Inquiry  into  the  JVature  and  Treat- 
ment of  Gravel  and  Calculus,  p.  94.) 

The  proportion  of  Hi  hie  acid  calculi  is 
somewhat  more  than  one-third  of  the  whole 
number.  But  as  this  acid  is  the  common 
nucleus,  round  which  other  calculous  matter 
is  deposited,  Dr.  Prout  computes  the  pro- 
portion of  calculi  originating  from  it,  to  be 
at  least  two-thirds  of  the  whole  number. 
According  to  the  experiments  of  the  same 
physician,  the  red  crystalline  calculus  is 
composed  of  nearly  pure  lithic  acid  ; and 
the  earthy,  amorphous  one,  consists  of  lithic 
acid,  more  or  less  ammonia,  generally  a lit- 
tle of  the  phosphates,  and  sometimes  a small 
portion  of  the  oxalate  of  lime.  The  lighter 
the  colour,  the  greater  in  geheral  the  pro- 
portion of  lithate  of  ammonia  and  the  phos- 
phates. (P.  97.) 

Oxalate  of  lime  calculi  form  one-seventh 
of  the  whole  number,  without  any  regularity, 
however,  in  different  museums. 

Cystic  oxide  calculi  are  so  rare,  that  the 
proportion  found  was  only  one  in  274. 

Calculi  composed  of  the  phosphates , made 
about  one-fourth  of  the  whole  number. 

Alternating  Calculi  amounted  to  between 
one-fourth  and  one-fifth ; but,  Dr.  Prout 
oilers  good  reasons  for  believing,  that  the 
data,  from  which  the  estimate  is  drawn, 
cannot  be  depended  upon.  For  additional 
information  on  this  branch  of  the  subject, 
I must  refer  to  Dr.  Prout’s  valuable  work. 

The  stone  being  a severe  affliction,  and 
the  operation  extremely  hazardous  and  pain- 
ful, a variety  of  experiments  have  been  in- 
stituted for  the  purpose,  of  discovering  a 
solvent  for  urinary  calculi.  Hitherto,  how- 
ever, all  the  remedies  and  plans  which  have 
been  tried,  have  been  attended  with  very 
limited,  and  by  no  means,  unequivocal 
•'iiccess,  notwithstanding  many  persons  may 
have  been  deceived  into  a contrary  opinion. 

The  dissolution  of  stones  in  the  bladder 
has  been  attempted  by  lilhontriptic  medicines, 
as  they  are  termed,  and  by  fluids  injected 
into  this  viscus.  At  the  present  day,  prac- 
titioners direct  their  endeavours  very  much 
to  the  correction  of  those  particular  diathe- 
ses, or  states  of  the  constitution,  on  which 
the  formation  of  various  calculi  depend,  and 
more  confidence  seems  to  be  placed  in  this 
aim,  than  in  any  schemes  for  the  dissolution 
of  urinary  concretions.  It  is  certain,  that 
in  the  latter  project  many  difficulties  present 
themselves,  and  among  these,  some  of  the 
most  serious  are  the  great  variety  in  the 
composition  of  calculi ; the  impossibility  of 
knowing  tbe  exact  ingredients  of  a stone, 
while  it  is  concealed  in  the  bladder,  though 
many  useful  suggestions  for  assisting  the 
judgment  on  this  point  have  been  recently 


559 

.otFered  by  Dr.  Prout ; and  lastly,  if  the  right 
solvent  were  ascertained,  as  calculated  upon 
chymical  principles  applied  to  urinary  con- 
cretions out  of  the  body,  it  is  obvious,  that 
any  medicines,  taken  by  the  mouth,  are  lia- 
ble to  so  many  changes  in  the  alimentary 
canal,  and  in  the  lymphatic  and  vascular 
systems,  that  it  must  be  exceedingly  difficult 
to  get  them  in  an  unaltered  state  and  effect- 
ive quantity  into  the  bladder;  while,  if  this 
were  possible  (as  it  is  in  the  way  of  injection 
through  a catheter,)  the  bladder  itself  might 
be  incapable  of  bearing  the  application,  and 
the  patient  lose  his  life  in  the  experiment. 

As  Dr.  Prout  well  observes,  a calculus  in 
the  bladder  may  be  considered  a substance 
placed  in  a solution  of  various  principles  in 
a certain  quantity  of  water.  If  any  of  the 
more  insoluble  of  these  principles  exist  in 
this  solution  in  a state  of  supersaturation  , 
the  calculus  will  afford  a nucleus,  round 
which  the  excess  will  be  deposited.  But,  if 
none  exist  in  a state  of  excess,  of  course 
none  can  be  deposited,  and  the  calculus 
will  not  increase  in  bulk. 

Whoever  studies  the  chymical  properties 
of  the  urine,  says  Dr.  Marcet,  will  learn, 
that  “ if  any  alkali  (a  few  drops  of  ammonia 
for  instance.)  be  added  to  recent  urine,  a 
white  cloud  appears,  and  a sediment,  con- 
sisting of  phosphate  of  lime,  with  some  am- 
moniaco-magnesian  phosphate,  subsidesln 
the  proportion  of  about  two  grains  of  the 
precipitate  from  four  ounces  of  urine.  Lime 
water  produces  a precipitate  of  a similar 
kind,  which  is  still  more  copious  ; for  the 
lime,  in  combining  with  the  excess  of  phos- 
phoric, and  perhaps  also  of  lactic  acid,  not 
only  precipitates  tbe  phosphate  of  lime, 
which  these  aeids  held  in  solution,  but  it 
decomposes  the  other  phosphates,  thus  ge- 
nerating an  additional  quantity  of  the  phos- 
phate of  lime,  which  is  also  deposited. 

“ It,  on  the  contrary  (observes  the  same 
author,)  a small  quantity  of  any  acid,  either 
the  phosphoric,  the  muriatic,  or  indeed 
even  common  vinegar,  be  added  to  recent 
healthy  urine,  and  the  mixture  be  allowed 
to  stand  for  one  or  two  .ays,  small  reddish 
crystalline  particles  of  lithic  acid  will  be 
gradually  deposited  on  the  inner  surface  of 
the  vessel. 

‘ It  is  on  these  two  general  facts  that  our 
principles  of  chymical  treatment  ultimately 
rest.  Whenever  the  litbic  secretion  predo- 
minates, the  alkalies  are  the  appropriate 
remedies  ; and  the  acids,  particularly  the 
muriatic,  are  the  agents  to  be  resorted  to 
when  the  calcareous  or  magnesian  salts 
prevail  in  the  deposite.”  ( P . 147, 148.) 

The  alkalies  taken  into  the  stomach  cer 
tainly  reach  the  urinary  passages  through 
the  medium  of  the  circulation  ; and  it  is 
aiso  strongly  suspected  that  the  acids  like- 
wise do  so,  though  this  circumstance  is  still 
a question.  Unfortunately,  the  quantity  of 
either  alkalies  or  acids,  which  thus  mixes 
with  the  urine,  is  so  small,  that  no  impres- 
sion is  made  upon  calculi  of  magnitude. 
The  experience  of  Dr.  Marcet,  Dr.  Prout, 
and  others,  however,  has  clearly  ascer- 
tained that  such  medicines  are  often  capable 


UIUJNAKY  CALCULI. 


' »jbU 


of  checking  a tendency  to  the  formation  of 
stone,  and  sometimes  of  bringiug  on  a cal- 
culous deposite  depending  upon  the  altered 
state  of  the  system.  Indeed  Dr.  Marcet  ex- 
presses his  decided  opinion,  that,  even  sup- 
posing not  an  atom  of  alkali  or  acid  ever 
reached  the  bladder,  still  it  would  not  be 
unreasonable  to  expect  that  these  remedies 
may  respectively  produce  the  desired 
changes  during  the  first  stages  of  assimila- 
tion ; in  one  case,  by  neutralizing  any  mor- 
bid excess  of  acid  in  the  primte  vi<e  ; and  in 
the  other,  by  checking  a tendency  to  alka- 
lescence, or  otherwise  disturbing  those 
affinities,  which,  in  the  subsequent  processes 
of  assimilation  and  secretion,  give  rise  to 
calculous  affections.  (P.  153.) 

When  muriatic  acid  is  prescribed,  from  6 
to  25  drops  may  be  given  two  or  three 
times  a day,  diluted  with  a sufficient  quan- 
tity of  water. 

The  best  way  of  taking  the  alkalies  is  by 
drinking  soda  water  as  a common  beve- 
rage. It  is  asserted,  however,  on  the  au- 
thority of  Sir  G.  Blane,  that  when  the 
alkalies  are  combined  with  nitric  acid,  as 
in  the  ordinary  saline  draught,  they  also 
have  the  effect  of  depriving  the  urine  of  its 
acid  properties. 

Dr.  Marcet,  with  every  appearance  of 
probability,  refers  to  carbonic  acid  itself  no 
solvent  power;  and  he  does  not  even  adopt 
Mr.  Brande’s  opinion,  that  this  acid  passes 
into  the  urine,  when  patients  drink  fluids 
impregnated  with  it. 

. But,  it  may  be  inquired,  if  no  known  in- 
ternal medicine  will  dissolve  a stone  already 
formed,  what  is  the  good  of  merely  altering 
the  diathesis,  and  checking  the  increase  of 
the  calculus,  as  lithotomy  must  still  be  ne- 
cessary? The  reasons  for  persevering  in 
the  aim  of  correcting  any  particular  state  of 
the  system,  and  the  urinary  secretion,  on 
which  state  the  increase  of  a calculus  de- 
pends, are  very  important;  for  it  is  found, 
that,  though  medicines  may  be  quite  inca- 
pable of  dissolving  a calculus,  they  relieve 
a great  deal  of  the  distress  and  suffering 
apparently  the  effect  of  the  diathesis  itself, 
as  will  be  presently  noticed,  and  sometimes 
afford  such  ease  that  the  operation  may  be 
postponed  until  the  health  is  improved,  or, 
in  a very  old  subject,  even  be  dispensed 
with  altogether.  The  aim  is  also  of  high 
importance,  with  the  view  of  preventing 
relapses. 

As  the  lithic  acid  diathesis  seems  to  be 
concerned  in  the  production  of  about  two- 
thirds  of  the  whole  number  of  the  urinary 
calculi,  the  correction  of  it  has  been  a chief 
aim  among  modern  practitioners.  For 
this  purpose,  Magendie,  whose  experiments 
tend  to  prove  that  the  lithic  acid  diathesis 
maybe  lessened  and  removed  by  abstinence 
from  animal  food,  arid  other  nutriments 
abounding  in  azote,  founds  his  practice  very 
much  upon  this  alleged  fact.  His  indica- 
ions,  however,  are  four  in  number,  viz.  1. 
ro  lessen  the  quantity  of  uric  acid  produced 
by  the  kidneys;  2.  to  augment  the  secretiori 
,->f  urine  ;.  a maxim,  which  leads  iiim  to  con- 


sider cutaneous  perspiration  injurious ; a 
statement  which  I think  must  be  rejected, 
considering  the  rarity  of  calculi  in  hot  cli- 
mates, independently  of  the  sentiments  of 
Dr.  Wilson  Philip,  that  the  precipitating 
acid  (if  such  be  the  cause)  is  thrown  off  by 
the  skin,  and  consequently  that  insuring  a 
due  performance  of  the  cutaneous  func- 
tions, must,  in  these  cases,  be  beneficial 
(See  Medical  Trans,  of  the  College  of  Phy- 
sicians, Vol.  6.)  3.  To  prevent  the  lithic 

acid  from  assuming  a solid  form,  by  satu- 
rating it.  4.  When  gravel  and  calculi  are 
formed,  to  promote  their  discharge  and  at- 
tempt their  dissolution.  ( Richerches , fyc.  sur 
la  Gravelle,  p.  42.) 

For  correcting  the  lithic  acid  diathesis, 
Dr.  Prout  particularly  enjoins  the  avoidance 
of  errors  in  diet,  exercise,  kc.  The  error  of 
quantity  of  food,  he  deems  worse  than  the 
error  of  quality.  Patients,  he  say9,  should 
abstain  altogether  from  things  which  mani- 
festly disagree  with  them,  and  which  must 
be  unwholesome  to  all,  such  as  heavy  un- 
fermented bread,  hard  boiled  and  fat  pud- 
dings, salted  and  dried  meats,  acescent 
fruits,  and  (if  the  digestive  organs  be  debili- 
tated) soups  of  every  kind.  In  general  also 
wine,  and  particularly  those  of  an  acescent 
quality,  should  be  avoided.  The  wearing  of 
flannel,  the  preserving  a regular  state  of  the 
bowels,  and  the  occasional  use  of  alterative 
medicines, are  likewise  commended.  (Prout 
on  Gravel,  <^c.  p.  135.) 

According  to  the  same  author,  the  treat- 
ment of  calculous  affections  is  either  of  a 
local  or  general  description.  The  local 
treatment  is  nearly  the  same  in  all  the  spe- 
cies; the  general  treatment  wall" depend 
upon  the  nature  of  the  calculous  diathesis. 

What  Dr.  Prout  calls  the  local  treatment 
consists  chiefly  in  prescribing  hyosciamus 
and  opium,  either  alone  or  combined  with, 
uva  ursi.  The  hyosciamus,  he  says,  is  ge- 
nerally preferable  in  the  lithic  acid  diathe- 
sis, and  opium  in  the  phosphatic.  He  also 
recommends  the  use  of  opium  in  the  form 
of  injection  and  embrocation,  andespecially 
in  that  of  a suppository.  The  warm  bath, 
fomentations,  and  sitting  over  hot  water, 
are  spoken  of  as  other  means  of  relief. 

According  to  the  observations  of  the  same 
well-informed  writer,  the  distressing  symp- 
toms produced  by  lithic  aci4  calculi  have  a 
very  constant  relation  to  the  severity  of  the 
diathesis  present ; a circumstance,  which 
he  says  is  also  more  or  less  true  with  re- 
spect to  all  the  other  kinds  of  calculi : that 
is  to  say,  in  proportion  as  the  urine  is  unna- 
tural, and  loaded  with  gravel  and  amor- 
phous sediments,  in  the  same  proportion, 
are  the  patient’s  sufferings.  Hence  our  first 
object  should  be  to  restore  the  urine  to  its 
natural  state.  The  first  means  to  be  recom- 
mended, in  ordinary  cases,  is  usually  a dose 
of  calomel  and  antimonial  powder,  the 
Plummer’s  pill,  or  some  other  alterative 
purgative,  taken  at  night,  to  be  followed  up 
the  next  morning  by  an  alkaline  diuretic 
purgative,  composed,  for  example,  ot  Bo 
chelle  salts  and  magnesia,  or  subcarbona'e 


URINARY  CALCULI 


oi  soda  During  the  day,  a strong  infusion 
of  uva  ursi.  combined  with  hyosciamus  and 
the  liquor  potassae,  may  be  taken.  These 
means  ere  to  be  persisted  in  for  a greater  or 
less  time,  according  to  the  circumstances, 
and  till  the  urine  begins  to  be  natural : they 
may  then  be  gradually  left  off  or  varied,  as 
occasion  may  require  ; and,  under  this  plan, 
it  will  be  found,  that,  in  the  majority  of 
cases,  not  only  the  urine  will  assume  its  natu- 
ral state,  but  most,  or  all  the  distressing  symp- 
toms of  calculus  in  the  bladder,  will  be  very 
ihitch  diminished,  and  in  many  instances  dis- 
appear. It  is  obvious  also  that,  while  the 
urine  is  in  its  natural  state,  the  calculus 
cannot  increase  in  size. 

“ After  the  diathesis  is  once  fairly  broken 
by  these  means,  it  may  in  general  be  easily 
prevented  from  recurring  by  attention  to 
the  diet,  and  other  circumstances,  formerly 
mentioned  as  inducing  this  diathesis,  and 
by  the  occasional  use  of  medicines  ; and  the 
patient  will  scarcely  know  that  he  has  a 
calculus  in  the  bladder,  at  least  from  the 
pain  that  it  gives  him.  I state  this  with 
confidence  ; but  at  the  same  time,  I wish  to 
be  understood  to  mean,  that  the  freedom 
from  pain,  &c.  depend,  in  no  inconsiderable 
degree,  upon  the  size  of  the  calculus,  its 
smoothness,  upon  the  exercise  a patient  is 
•obliged  to  take,  &,c.  all  of  which  are  pre- 
sumed to  be  favourable  ; for  it  must  be  suf- 
ficiently obvious  that  a foreign  substance  in 
the  bladder  cannot  be  prevented  from  act- 
ing mechanically,  and  from  occasionally 
producing  bloody  urine,  or  a temporary 
stoppage  of  the  discharge  of  that  secretion 
from  the  bladder,  and  similar  symptoms,  if 
the  patient  is  obliged  to  take  severe  exer- 
cise.” ( Prout  on  Gravel,  fyc.  p.  202 — 204.) 

At  the  beginning  of  the  eighteenth  cen- 
tury, lime  and  the  alkalies  were  known  to 
be  frequently  productive  of  relief  in  cases  of 
stone,  and  in  particular  the  nostrum  of  a 
Mrs.  Steevens,  the  active  ingredients  of 
which  were  calcined  egg-shells  and  soap, 
acquired  such  celebrity  for  the  cures  which 
it  effected,  that  much  anxiety  was  expressed 
that  her  formula  should  be  made  public. 
The  consequence  was,  that,  in  the  year 
1739,  parliament  appointed  a committee  of 
22  respectable  men  to  investigate  the  merits 
of  the  remedy  in  question  ; and,  on  their 
very  favourable  report,  the  secret  was  pur- 
chased for  the  sum  of  5000/.  These  pro 
ceedings  naturally  interested  our  neigh- 
bours, and  in  the  year  1740  and  1741,  Mo- 
rand  communicated  to  the  Academy  of 
Sciences  two  memoirs,  in  which  are  report- 
ed numerous  cases  where  the  new  remedy 
was  tried,  and  mostly  with  success ; the 
greater  number  of  the  patients  being  de- 
scribed as  either  benefited  or  actually 
cured. 

In  many  instances,  stones  which  had  been 
unquestionably  felt,  were  no  longer  to  be 
discovered  ; and  as  the  same  persons  w^ere 
examined  by  surgeons  of  the  greatest  skill 
an  i eminence,  both  before  and  after  the  ex- 
hibition of  the  medicines,  it  is  no  wonder 
that  the  conclusion  was  drawn  that  the 
Vor,.  II  71 


oO  J 

stones  had  .been  really  • dissolved.  Front 
the  cessation  of  this  success,  however,  and 
from  its  now  being  known  that-stones occa- 
sionally become  lodged  in  a kind  of  cyst, 
on  the  outside  of  the  general  cavity  of  the 
bladder,  so  as  to  cause  no  longer  any  mate- 
rial suffering,  surgeons  of  the  present  da) 
are  inclined  to  suspect,  that  this  must  have 
happened  in  Mrs.  Stevens’s  cases.  Ihis 
was  certainly  what  happened  to  one  of  the 
persons,  on  whom  the  above  medicine  was 
tried,  as  Dr.  W.  Hunter  informs  us.  It  is 
evident,  that  a stone,  so  situated,  would 
not  in  general  produce  a great  deal  ol 
irritation,  nor  admit  of  being  felt  with  a 
sound  ; though,  as  l have  stated  in  the 
article  Lithotomy,  there  have  been  a tew 
exceptions  to  this  observation. 

Mrs.  Steevens  first  gave  calcined  egg-shell  • 
alone;  but,  finding  costiveness  produced, 
she  added  soap.  In  time,,  she  rendered  her 
process  more  complicated,  adding  snails 
burnt  to  blackness,  a decoction  of  camomile 
flowers,  parsley,  sweet  fennel,  and  the 
greater  burdock. 

That,  in  the  lithic  acid  diathesis,  the  car- 
bonated fixed  alkalies,  taken  in  large  doses, 
have  the  effect  of  passing  into  the  urine,  and 
saturating  the  redundant  lithic  acid  in  the 
unhealthy  state  of  that  fluid,  is  a'  fact  deci- 
dedly proved.  If  there  were  any  doub 
yet  remaining  upon  this  point,  it  would  be 
immediately  removed  by  the  perusal  oi  the 
case  of  the  celebrated  Mascagni  as  detailed, 
by  himself.  (See  Mem.  della  Soc.  Ital.  1804.y 
This  eminent  anatomist  being  much  afflicted 
with  gravel,  derived  benefit  from  drinking 
the  aqua  alcalina  mephitica,  or  Selzer  Water , 
but,  conceiving,  that  more  good  might  result 
from  a trial  of  carbonate  of  potash,  he  took, 
at  first  half  a dram  of  this  substance  in  the 
morning,  and  as  much  in  the  evening,  dis- 
solved in  ten  ounces  of  water.  The  second 
dav,  the  dose  was  augmented  to  two  drains, 
and  on  the  third  to  three,  which  quantity  dis- 
solved in  20  ounces  of  water,  was  continued 
for  ten  days.  “ Before  taking  the  carbonate 
of  potash  (says  Mascagni)  my  urine  was 
very  acid,  arid  immediately  reddened  litmus 
paper:  as  soon  as  the  medicine  was  begun, 
I made  the  same  experiment  with  the  urine, 
then  voided,  and  found  the  intensity  o.u 
the  colour  of  the  paper  less.  The  second  day, 
the  paper  was  very  little  altered,  and  on  le 
third,  the  urine  did  not  redden  it  at  all . -tup 
acid  in  my  urine,  therefore,  was  saturated, 
and,  at  the  same  time,  the  pain  in  my  loins 
diminished,  and  no  more  gravel  was  voided 
with  my  urine.  Afterward  the  pain  ceased 
entirely,  the  urine  became  dearer,  and  I per- 
ceived that  it  contained  an  excess  of  potash. 
Being  attacked  again  at  a subsequent  period 
with  the  gravel,  Mascagni  adopted  the  same 
treatment,  and  experienced  equal  benefit 
from  it. 

In  the  lithic  acid  diathesis,  the  cauatic 
alkali,  in  the  form  of  the  liquor  potassae.  has 
sometimes  been  thought  to  have  more  em- 
cacy,  than  the  carbonate. 

Sir  E.  Home  and  Mr.  Hatchet  first  suggest- 
ed the  utility  of  giving  magnesia  in  cases 


f KLNARJfc  CALCULI. 


of  stone  : aim  ihe  proposal  was  communica- 
led  to  the  public  by  Mr.  Brande  (Phil.  Trans . 
1810.)  As  Dr.  Marcet  observes,  magnesia  is 
often  found  advantageous  in  long-protracted 
cases,  in  which  the  constant  use  of  the  sub- 
carbonated,  or  caustic  alkalies,  would  injure 
t he  stomach.  But,  he  properly  remarks,  that, 
if  magnesia  is  sometimes  beneficial,  it  has 
of  late  years  often  done  harm.  For,  as  this 
earth  is  the  base  of  one  of  the  most  common 
species  of  calculi,  viz.  that  containing  the 
phosphate  of  ammonia  and  magnesia,  there 
is  nearly  an  even  chance,  when  magnesia  is 
prescribed,  without  any  previous  knowledge 
of  the  nature  of  the  calculus,  that  it  will 
prove  injurious.  Magnesia,  also,  when  long 
and  profusely  administered,  sometimes  forms 
large  masses  in  the  intestinal  canal,  causing 
serious  distress,  and  even  fatal  consequences. 

According  to  Dr.  Prout,  purgatives  wiil 
sometimes  stop  calculous  depositions,  espe- 
cially in  children ; and  Dr.  Henry,  of  Man- 
chester, has  observed  that  a quack  medicine, 
composed  of  turpentine  and  opium,  will  oc- 
casionally produce  a plentiful  discharge  of 
lithic  acid  from  the  bladder. 

On  the  whole,  I believe,  reason  and  expe- 
rience will  aliow  us  to  consider  lirnewater, 
soap,  acidulous  soda  water,  the  carbonate  of 
potassa,  the  liquor  potassa?,  and  magnesia, 
only  as  palliative  remedies,  by  which  the 
pain  of  the  disorder  may  sometimes  be 
diminished,  and  the  urinary  secretion  im- 
proved, it  being  more  rational  to  impute 
the  few  supposed  instances  of  greater  suc- 
cess to  the  calculi  becoming  encysted. 

As  medicines,  taken  into  the  stomach, 
wiil  not  dissolve  urinary  calculi,  solvent  in- 
jections have  been  introduced  through  a ca- 
theter directly  into  the  bladder.  Fourcroy 
and  Vauquelin  ascertained,  that  a ley  of 
potassa,  or  soda,  not  too  strong  to  be  swal- 
lowed, softens  and  dissolves  small  calculi* 
composed  of  the  uric  acid  and  urate  of  am- 
monia, when  they  are  left  in  the  liquid  a 
few  days.  They  proved,  that  a beverage, 
merely  acidulated  with  nitric  or  muriatic 
acid,  dissolves  with  still  greater  quickness, 
calculi,,  formed  of  the  phosphate  of  lime, 
and  of  the  triple  phosphate  of  ammonia  and 
magnesia.  They  also  ascertained,  that  cal- 
culi, composed  of  the  oxalate  of  time,  which 
are  the  most  difficult  of  solution,  may  be 
softened,  and  almost  quite  dissolved,  in  nitric  ■ 
acid,  greatly  diluted,  provided  they  are  kept 
in  the  mixture  a sufficient  time. 

Liquids  are  then  known  which  will  dissolve 
calculi  of  various  compositions  ; but,  as  I 
have  already  hinted,  much  difficulty  occurs 
in  employing,  tliem  effectually  in  practice, 
-.'or,  although  they  can  be  easily  injected 
into  the  bladder,  this  organ  is  so  extremely 
tender  and  irritable,  that  the  action  of  such 
liquidsupon  it,  as  would  be  requisite  for  dis- 
solving a stone,  would  produce  sufferings 
which  no  man  could  endure,  and  the  most 
dangerous  and  fatal  effects  on  the  bladder 
i i self.  Another  objection  to  this  practice  also 
arises  from  the  surgeon  never  knowing  what 
il  e exact  composition  of  a calculus-is,  be- 
ar this  body  is  extracted,  and  his  conse- 


quent inability  to  determine  what  solvent 
ought  to  be  tried. 

Until  the  complete  success  of  lithontriptics 
is  established,  therefore,  the  operation  of 
lithotomy,  severe  and  hazardous  as  it  is, 
must  continue  an  indispensable  practice, 
whenever  the  patient  s sufferings  are  great, 
and  the  calculus  too  large  to  be  voided,  or 
extracted  through  the  urethra.  In  the  early 
stage,  however,  before  calculi  have  exceed- 
ed a certain  size,  if  they  cannot  be  expelled 
with  the  urine,  they  may  sometimes  be  taken 
out  by  means  of  an  instrument,  invented  by 
Mr.  Weiss,  of  the  Strand,  shaped  like  a 
sound,  but  the  end  of  which,  after  its  introduc- 
tion into  the  bladder,  admits  of  being  opened 
and  rnaife  to  grasp  the  calculus,  which  is 
then  to  be  drawn  through  the  urethra.  The 
urine  is  first  to  be  discharged  through  a ca- 
theter. (See  an  Account  of  a Case , in  which 
numerous  Calculi  were  extracted,  without  cut- 
ting Instruments , by  Sir.  A.  Cooper,  in  Med- 
Chir.  Trans.  Vol.  11,  p.349.) 

Consult  T.  Lobb,  a Treatise  on  Dissolvents 
of  the  Stone,  8 vo.  Loud.  1/39.  Stephen  Hales , 
Experiments  and  Observations  on  Mrs.  Stee 
veils' s Medicines , 8 vo.  Lond.  1741.  Morand , 
■in  Mem.  de  l’ Acad,  des  Sciences,  1740,  and 
1741.  J.  Rutty,  New  Experiments  on  Joanna, 
Sieevens's  Medicines , 8 vo.  Loud  1742  R 
Why  It,  an  Essay  on  the  Virtues  of  Lime  Wa-% 
ter  and  Soap,  in  the  Cure  of  Stone,  8 vo 
Edinb.  1761.  D.  Hartley,  a Vieiv  of  tliepre 
sent  Evidence  for  and  against  Mrs.  Sieevens's 
Medicine,  8 vo.  Lond.  1739  ; and  Supplement . 
1740.  N.  Hulme,  a safe  and  easy  Remedy  for 
the  Stone,  fyc.Ato.  Lond.  1778  Wm.  Butler , 
Method  of  Cure  for  the  Stone,  chiefly  by  injec- 
tions, 12 mo.  Edinb.  1754.  B.  Langrisk,  Phy- 
sical Experiments  upon  Brutes,  in  order  to 
discover  a safe  Method  of  dissolving  Stones  in 
the. Bladder  by  Injections,  8vo.  Lond.  1746.  J 
Jurin , Effects  of  Soap-ley,  taken  internal hj 
for  the  Stone,  ‘Id  Edit,  with  an  Appendix . 
12 mo.  Ixmd.  1745.  J.  F.  Schreiber,  De  Me  - 
dicamentosa J.  Stcevens , contra calculum  divul- 
gato  inefficaci  et  noxio,  Gi)tt.  1744.  Murray 
Forbes,  a Treatise  upon  Gravel  and  Gout , 
with  an  Examination  of  Dr.  Austin's  Theory  of 
Stone,  an  Inquiry  into  the  Operation  of  Sol- 
vents, fyc.  8 vo.  Lond.  1793.  W.  Austin,  a 
Treatise  on  the  origin  and  component  Parts  of 
the  Stone,  fyc.  8 vo.  Lond.  1791.  T.  Beddoes , 
on  the  Nature  and  Cure  of  Calculus , fyc.  8 vo. 
Loud.  1793.  J.  S.  Dorsey,  an  Essay  on  the 
Lithontriplic  Virtues  of  the  Gastric  Liquor. 

8 vo.  Philadelphia , 1802.  M.  Girardi,  Dr. 
Ur  a Ursina,  ejusque  el  aqiue  calcis  vi  lilhon - 
triplica,  fyc.  Patav.  1764.  Schbele,  in  Stock- 
holm Trans.  Fourcroy,  in  Systeme  des  Con- 
noissanccs.  Ciiimiques . Wollaston,  Pearson , 
and  Brande,  in  Phil.  Trans,  and  Journal  of 
Science  and  Arts,  Vols.  6 and  8,  fyc.  A.  Marcet, 
on  Vie  Chymical  History  and  Medical  Treat  - 
menl  of  Calculous  Disorders,  8vo.  Lond.  1 S 1 7 
a work  full  of  valuable  information.  Wilson 
Philip,  in  Medical  Trans.  Vol.  6.  Dr.  Henry , 
in  Med.  Chir.  Trans.  Vol.  10.  C.  Scudamore , 
on  Gout,  fyc.  Edit.  3.  F.  Magcndie,  Recher- 
ches  Physiologiqucs  et  Medicates  sur  les  Causes . 
fyc.  dr  la  GraveV-r,  8vo,  Paris,  I^IK,  A 


URINARY  li'lSTUL/L 


Upland  Hutchison,  on  the  Comparative  In- 
frequency of  Urinary  Calculi  among  Seafaring 
People , vid.  Med.  Chir.  Trans.  Vol.  9.  A*. 

Smith , a Statistical  Inquiry  into  the  Frequency 
of  Stone  in  the  Bladder,  in  Great- Britain  and 
Ireland,  vid.  Med.  Chir.  Trans.  Pol.  11.  IV. 
Front , an  Inquiry  into  the  Nature  and  Treat- 
ment. of  Gravel,  Calculus,  fyc.  8 vo.  Loud.  1821 ; 
a work  abounding  in  original  valuable  observa- 
tions J.  Wilson , on  the  Structure  and  Physio- 
logy  of  the  Male  Urinary  and  Genital  Organ  , 
and  the  Nature  and  Treatment  of  their  Dis- 
eases, 8 vo.  Loud.  1S21  ; this  publication  con- 
tains an  excellent  summary  of  the  latest 
observations  on  the  subject. 

URINARY  FISTULiE.  By  an  urinary 
fistula,  strictly  speaking,  is  implied  a deep, 
narrow  ulcer,  which  leads  into  some  of  the 
urinary  passages  : but,  this  name  is  likewise 
applied  to  sinuses,  which,  without  having  any 
communication  with  these  passages,  termi- 
nate near  some  point  of  their  course.  Thus, 
in  Desault’s  works,  T.  3,  p.  287,)  three  kinds 
of  fistula?,  in  respect  to  the  urinary  passages, 
are  noticed.  The  first  Sort  is  called  a blind 
external  fistula,  because  it  opens  only  exter- 
nally ; the  second  plind  internal,  because  it 
has  only  one  opening  into  the  urinary  pas- 
sages ; the  third,  is  termed  complete,  being 
attended  both  with  an  internal  opening  into 
the  urinary  organs,  and  one  or  more  external 
apertures. 

Among  the  blind  external  fistula?,  only 
such  as  terminate  near  the  canal  of  the  ure- 
thra are  particularly  noticed  in  Desault’s 
works.  All  fistulas  of  this  kind  are  originally 
owing  to  an  abscess,  that  has  formed  in 
the  vicinity  of  the  urethra  ; and.  in  the  arti- 
cle Urinary  abscesses,  it  has  been  explained, 
that  these  suppurations  frequently  originate 
from  disease  of  that  canal.  Whatever  may 
be  the  cause  of  these  fistulas,  however,  it 
is  not  unusual  to  find,  that,  after  the  pus 
has  made  its  way  towards  the  scrotum  or 
perineum,  and  discharged  itself  outwardly, 
the  ulcer  is  converted  into  a sinus,  which 
resists  all  the  efforts  of  nature  to  heal  it. 
One  of  the  chief  circumstances,  tending  to 
evince,  that  the  sinus  has  no  communication 
with  the  urethra,  is,  that  no  urine  has  ever 
escaped  through  the  opening  ; for,  with  re- 
spect to  the' judgment  formed  from  the  im- 
possibility of  making  a probe  touch  a catheter 
in  the  passage,  it  must  be  exceedingly  falla- 
cious, because  the  winding  course  of  the 
sinus,  or  the  small  size  of  its  communication 
with  the  urethra,  may  prevent  the  instru- 
ments from  touching  each  other. 

According  to  Desault,  the  indications  in 
the  treatment  of  these  blind  fistula?  depend 
upon  the  nature  of  their  complications. 
When  the  sinuses  are  kept  up  by  a separa- 
tion of  the  scrotum. from  the  parie  es  of  the 
urethra,  Desault  recommends  exact  com- 
pression to  be  made  over  the  part,  which 
method,  he  says,  is  sometimes  sufficient  to 
accomplish  a cure.  When  this  plan  fails, 
he  states,  that  the  healing  ot  the  sinus  may 
be  promoted  by  practising  an  incision  on 
one  side  of  the  scrotum,  and  carrying  it  as 
far  as  the  denuded  portion  of  the  urethra. 


When  sinuses  exist,  and  they  depend  upon 
the  smallness  of  the  opening,  or  its  un- 
favourable situation  for  the  discharge  of  the 
matter,  the  aperture  should  be  enlarged,  by 
making  an  incision  into  the  main  collection 
of  pus.  When  there  are  callosities,  which 
resist  cataplasms,  and  the  most  active  re- 
solvents, Desault  advises  us  to  introduce  into 
the  fistula,  trochees  of  minium,  for  the  pur- 
pose of  destroying  the  indurated  parts. 
When  the  bones  are  diseased,  exfoliation 
must  be  awaited  ; and,  in  every  instance, 
the  treatment  should  vary,  according  to  the 
cause,  upon  which  the  fistula  depends. 

Blind  internal  fistulae,  or  such  as  communi 
cate  with  the  urethra,  but  have  no  external 
opening,  are  sometimes  produced  in  conse- 
quence of  the  bursting  of  an  abscess  into 
this  canal ; the  ulceration,  from  a retention 
of  urine  ; a false  passage  . and  the  healing  of 
the  external  part  of  the  wound  made  in 
lithotomy,  while  the  internal  part  is  not 
united. 

In  these  cases,  there  is  a discharge  of  pus 
from  the  urethra,  before,  and  sometimes 
after,  the  issue  of  the  urine  ; and  one  may 
feel,  in  the  ^ourse  of  the  urethra,  a tumour, 
which  increases  while  the  patient  is  making 
water,  and  afterward  disappears  on  pressure 
attended  with  a fresh  discharge  from  the 
penis  of  a mixture  of  pus  and  urine. 

These  internal  urinary  fistulae  cannot  be 
cured,  except  by  preventing  the  urine  from 
passing  into  them  and  lodging  there.  The 
catheters  employed  should  be  neither  too 
large  nor  too  small.  If  too  large,  they  would 
exactly  fill  the  canal,  and  the  pus  and  urine 
contained  in  the  fistula?  could  not  be  dis- 
charged. If  too  small,  the  urine  would  in- 
sinuate itself  between  them  and  the  sides  ot 
the  urethra,  and  enter  the  fistula?.  Their  use 
must  be  continued  till  the  ulcef  is  entirely 
healed. 

The  most  frequent  urinary  fistula?  are  those 
which  are  termed  complete.  Their  origin 
may  be  in  the  ureters,  bladder,  or  urethra. 
Those  which  arise  in  the  ureters,  sometimes 
terminate  in  the  colon,  and  the  urine  is  dis- 
charged per  ahum  mixed  with  the  feces. 
But  most  commonly,  these  fistula?  make 
their  appearance*  externally,  either  in  the 
lumbar  or  inguinal  regions.  Those  whicii 
communicate  with  the  bladder,  have  also  dif- 
ferent terminations.  When  they  proceed 
from  the  upper  and  interior  part  of  this  or- 
gan, they  ordinarily  pierce  the  parietes  of  the 
abdomen  above  the  pubes,  and  towards  the 
navel.  They  also  sometimes  terminate  in  the 
groins.  When  they  originate  in  the  poste- 
rior parietes  of  the  bladder^  they  sometimes 
tend  into  the  cavity  of  the  abdomen,  where 
they  almost  always  prove  mortal ; and  some- 
times into  the  intestines,  if  there  should  be 
adhesions  between  these  and  the  bladder,  so 
as  to  favour  this  communication.  When  the 
opening  in  the  bladder  is  near  the  bottom  of 
this  viscus,  the  fistula  sometimes  terminates 
in  the  rectum  of  ihe  male,  and  the  vagina  of 
the  female  subject;  but  most  frequently  it 
ends  in  the  perineum,  in  both  sexes.  With 
regard  to  the  fistula?  which  originate  in  the 


564 


URINARY  FISTULA. 


urethra,  they  usually  open  externally  in  the 
perimnurn,  the  scrotum,  or  the  penis,  and 
sometimes  alsto  in  the  rectum.  It  is  not  un- 
common to  see  the  external  opening  of  these 
fistula?  at  a great  distance  from  the  internal 
one,  and  to  find  it  in  the  middle,  and  even 
the  lower  part  of  the  thighs,  the  groins,  pa- 
rietes  of  the  abdomen,  and  as  high  as  the 
sides  of  the  chest.  Often  there  is  only  one 
opening  in  the  urethra,  while  there  are  seve- 
ral situated  externally,  more  or  less  distant 
from  one  another. 

Most  of  these  fistula?  are  the  consequences 
of  a retention  ot  urine,  and  are  owing  to 
the  same  causes  as  the  diseases  of  Which 
they  are  a symptom.  Those  which  cornvnu- 
ni<  ate  with  the  rectum,  in  the  male  subject, 
sometimes  depend  upon  this  intestine  having 
been  wounded  in  the  operation  ot  lithoto- 
my ; and  those  which  open  into  the  vagina 
are  often  the  effect  of  a violent  contusion, 
caused  by  the  head  of  the  child  in  difficult 
labours,  or  of  ulceration  produced  by  pessa- 
ries, which  are  too  large,  and  ihe  margins  of 
which  are  too  sharp  and  irregular.  Carcino- 
ma of  the  rectum  aud  vagina  also  give  rise 
to  fistula?,  by  extending  into  the  bladder. 

The  discharge  of  urine  from  the  external 
orifice  of  the  fistula,  is  an  unequivocal  proof 
of  its  communication  with  the  urinary  pas- 
sage ; when  the  fistula  is  narrow,  arid  there  is 
no  obstruction  in  the  urethra,  the  urine  some- 
times escapes  more  readily  the  latter  way 
than  through  the  fistula.  It  may  also  be  dif- 
ficult, or  even  impossible,  to  find  out  the  in- 
ternal orifice  of  the  fistula  with  a probe. 
When  the  fistula  communicates  with  the  rec- 
tum or  vagina,  a staff  introduced  through 
the  urethra  may  sometimes  be  fell  in  those 
parts. 

When  fistula  of  the  bladder  or  urethra  are 
the  consequences  of  a retention  of  urine, 
produced  by  strictures,  which  still  exist,  or 
have  even  increased  since  the  formation  of 
the  fistula,  the  circumstance  may  render  the 
introduction  of  the  catheter  difficult.  In  this 
sort  of  case,  if  the  catheter  cannot  be  pass- 
ed, the  surgeon  must  endeavour  to  remove 
the  stricture  with  bougies,  on  the  principles) 
explained  in  the  article  Urethra , Strictures 
of.  “ In  general,  (as  Sir  Everard  Home  ob- 
serves,) where  fistula?  take  place  in  perina?o, 
in  consequence  of  a stricture,  the  removal 
of  the  stricture  is  sufficient  to  give  the  fistula 
a disposition  to  heal.  There  are,  however, 
cases  which  require  more  being  done  for  that 
purpose,  and  simply  laying  them  open  is  not 
sufficient.”  (See  Fistula  in  Perinceo.)  Un- 
der such  circumstances,  Sir  Everard  Home 
finds  the  actual  cautery  the  surest  means  of 
making  the  part  heal  In  one  case,  he  pass- 
ed a bougie  into  the  urethra,  and  seared  the 
edge  of  the  fistula  with  a hot  wire,  introdu- 
ced as  far  as  to  touch  the  bougie.  In  another 
instance,  a full-sized  silver  sound  was  passed 
into  the  bladder,  and  the  direction  of  the 
fistula  having  been  ascertained  with  a probe, 
a female  steel  sound  was  heated  to  redness, 
and  “ at  the  moment  at  which  it  passed  from 
a red  to.  a black  heat,  it  was  hurried  down 
through  the  fistula  (about  two  inches  and  a 


half)  to  the  sound  in  the  urethra.  In  both 
these  cases  a cure  was  effected.  ( Home  on 
Strictures , Vol.  3 , p.  262,  fyc.)  ■ 

When  fistulae  terminate  in  the  lower  part 
of  the  bladder,  Desault  advises  the  utmost 
care  to  be  taken  to  prevent  the  catheter  from 
being  stopped  up,  and  to  hinder  the  instru- 
ment from  becoming  displaced,  or  slipping 
out  of  the  bladder  ; for  which  last  purpose, 
the  catheter  bracelet  described  by  Sir  E. 
Home  seems  well  calculated.  However, 
when  the  fistula  communicates  with  the  ure- 
thra, Desault  believes  that  no  advantage 
would  be  derived  from  keeping  the  catheter 
open.  In  both  cases,  Desault  recommends 
us  to  continue  the  catheter,  not  only  until 
the  fistula  is  cured,  but  also  until  the  obsta- 
cles which  binder  the  urine  from  passing  the 
natural  way  are  removed. 

Fistulae  of  the  bladder,  communicating 
with  the  vagina,  and  produced  by  difficult 
labours,  are  almost  always  attended  with  loss 
of  substance.  The  forcible  contusion,  occa- 
sioned by  the  child’s  head,  on  the  anterior 
parietes  of  the  vagina  and  bottom  of  the 
bladder,  gives  rise  to  the  formation  of  sloughs, 
the  separation  of  which  • sometimes  ieaves 
apertures  large  enough  to  admit  the  finger, 
and  hence  the  difficulty  of  the  cure.  In 
treating  such  fistulae,  there  are  two  indica- 
tions to  be  fulfilled  : 1st,  to  hinder  the  urine 
from  passing  into  the  vagina  : 2dly,  to  keep 
the  edges  of  the  division  as  closely  as  possi- 
ble together,  so  as  to  give  them  an  opportu- 
nity of  uniting. 

In  women,  the  introduction  of  the  cathe- 
ter is  easy  ; but  the  instrument  is  more  diffi- 
cult to  be  fixed  than  in  men.  Desault  con- 
tends, however,  that  it  is  very  essential  to 
have  it  so  fixed  in  the  bladder  that  the  urine 
may  escape.  He  found  that  the  only  effect- 
ual plan  was  to  fasten  the  catheter  to  a point 
that  always  retained  the  same  position,  with 
respect  to  the  meatus  urinarius.  He  used  a 
kind  of  machine,  made  after  the  manner  of 
a truss,  the  circle  of  which  was  long  enough 
to  embrace  the  upper  part  of  the  pelvis,  and 
had  in  its  middle  an  oval  plate,  intended  to 
be  placed  upon  the  pubes.  In  the  centre  of 
this  plate  was  a groove,  to  which  a piece  of 
silver  was  fitted,  curved  so  that  one  of  its 
ends,  with  an  aperture  in  it,  came  over  the 
vulva,  on  a level  with  the  meatus  urinarius. 
This  piece  of  silver  admitted  of  being  fas- 
tened to  the  plate  with  a screw.  After  the 
catheter  had  been  introduced  and  arranged 
in  the  bladder,  so  that  its  beak  and  eyes  were 
situated  at  the  lowest  part  of  tin's  viscus,  the 
end  of  the  instrument  was  put  through  the 
aperture  of  the  piece  of  silver  which  slided 
into  the  groove  of  the  plate,  and  it  was  af- 
terward fixed  in  the  way  already  explained 
By  means  of  this  machine,  the  catheter  was 
securely  fixed,  without  incommoding  the  pa- 
tient, even  when  she  was  walking. 

In  these  last  cases,  large  catheters,  with 
full-sized  apertures,  should  be  employed,  so 
that  the  urine  may  more  readily  escape 
through  the  instrument,  than  tall  into  the 
vagina.  In  the  early  part  of  the  treatment, 


URINARY  FISTULA:. 


otio 


the  catheters  should  also  be  left  constantly 
open. 

In  order  to  keep  the  edges  of  the  division 
as  near  together  as  possible,  Desault  intro- 
duced into  the  vagina  a soft  kind  of  pessary, 
large  enough  to  fill  the  vagina,  without  dis- 
tending it.  By  this  means,  the  form  of  the 
fistula  was  changed  from  round  to  oval, 
whichis  the  most  favourable  to  its  reunion; 
and  the  advantage  was  gained  of  closing  the 
fistula,  and  hindering  the  urine  from  falling 
into  the  vagina. 

When  the  rectum  is  wounded  in  lithotomy, 
Desault  advised  dividing  the  parts  compre- 
hended between  the  wound  of  the  operation, 
the  opening  in  the  rectum,  and  the  margin 
of  the  anus.  That  such  an  operation  may 
become  necessary  in  some  instances.  I will 
not  say  ; but  it  can  never  be  proper  until  it 
is  seen  whether  the  wound  of  the  rectum 
will  hot  heal  up  favourably  without  such 
treatment.  I have  seen  two  cases,  in  which 
the  rectum  was  cut  in  lithotomy,  yet  no  fis- 
tula ensued  ; and  other  similar  facts  iiave 
been  mentioned  to  me  by  professional  friends. 
The  success  also  with  which  the  wound  has 
generally  been  healed  after  lithotomy,  done 
through  the  rectum,  is  another  fact  tending 
to  prove,  that  the  inconveniences  of  a wound 
of  the  latter  bowel  in  the  operation  have 
been  rather  exaggerated. 

In  a case  of  urinary  fistula,  co  nmuni- 
cating  with  the  rectum,  and  which  could 
not  be  healed  with  the  catheter.  Sir  A. 
Cooper  introduced  a catheter  into  the  blad- 
der, and  his  finger  into  the  rectum,  and  then 
made  an  incision,  as  in  the  operation  for  the 
stone,  in  the  left  side  of  the  raphe,  until  he 
felt  the  staff  through  the  bulb.  He  then  di- 
rected a double-edged  knife  across  the  peri- 
neum, between  the  prostate  gland  and  the 
rectum,  with  the  intension  of  dividing  the 
fistulous  communication  between  the  urethra 
and  the  bowel.  A piece  of  lint  was  intro- 
duced into  the  wound,  and  a poultice  applied. 
When  the  lint  was  removed,  the  urine  was 
found  to  take  its  course  through  the  opening 
in  periiujeo  ; the  aperture  in  the  rectum  gra- 
dually healed  ; and  that  in  the  perineum 
quickly  closed  ; the  urine  being  all  now  dis- 
charged in  she  natural  way  {A.  Cooper , 
Surgical  Essays,  Part  1 ,p.  215.) 

As  the  same  gentleman  has  observed,  aper- 
tures in  the  urethra,  attended  with  loss  of 
substance,  are  extremely  difficult  to  heal. 
He  relates  a case  where  the  urethra  had 
sloughed  at  the  junction  of  the  scrotum  with 
the  penis;  the  opening  healed  at  its  margin, 
but  a large  fistulous  orifice  still  remained. 
Bougies,  the  plans  ol  excoriating  the  edges 
of  the  opening  with  blistering  plaster,  and 
even  paring  them  off,  and  bringing  the  fresh 
cut  surfaces  together  with  the  twisted  »u;ure, 
had  all  been  tried  in  vain.  In  this  example 
a cure  was  affected  by  applying  the  nitrous 
acid  to  the  edge  of  the  fistulous  orifice,  and 
to  the  skin,  three  quarters  of  an  inch  around 
it,  the  principle  on  which  Sir  A.  Cooper  rest- 
ed his  hopes  ot  success,  being  the  contrac- 
tion of  the  skin  in  cicatrization.  The  fir.-t 
application  having  produced  considerable 


amendment,  the  plan  was  repeated  several 
times  in  the  course  of  about  nine  months,  ai 
the  end  of  which  time  the  fistula  was  closed 
But  Sir  A.  Cooper  is  ol  opinion,  that  such 
practice  will  only  succeed  in  cases  where 
the  skin  is  very  loose,  and  the  scrotum  forms 
a part  of  the  fistulous  orifice.  If  the  skin  be 
much  confined,  he  suggests  raising  a piece  of 
skin  from  the  scrotum,  paring  off  tiie  edges 
of  the  fistulous  orifice,  and  removing  the 
skin  to  a small  extent  around  it.  The  skin 
thu  - raised  is  to  be  turned  half  round,  so  that 
its  raw  surface  may  be  .applied  to  the  open- 
ing. and  unite.  An  elastic  catheter  is  first 
to  be  introduced.  In  the  successful  opera 
tion  of  this  kind,  which  was  actually  done, 
the  flap  was  held  by  four  sutures;  and  small 
slips  of  adhesive  plaster,  and  a bandage  to 
support  the  scrotum,  were  employed.  In 
the  course  of  the  treatment,  pressure  Was 
found  necessary  to  prevent  the  occasional 
passage  of  urine  through  the  wound.  (A 
Cooper , Surgical  Essays , Part  2 ,p.  221,  fyc.) 

Mr.  Earle  met  with  a case,  in  which  the 
integuments  in  the  perineum,  and  above  an 
inch  of  the  canal  of  the  urethra,  had  slough 
ed  away  in  consequence  of  external  violence. 
At  the  man’s  entrance  into  St.  Bartholomew’s 
Hospital,  a large  smooth  cicatrix  occupied 
the  place  of  the  urethra,  no  vestige  of  which 
remained  in  that  part.  The  integuments  on 
the  right  side  had  suffered  less  extensively 
than  those  on  the  left ; so  that  when  the 
catheter  was  introduced,  that  portion  of  the 
instrument  which  pass.-d  over  the  cicatrix 
could  be  about  half  covered,  by  drawing 
the  skin  and  healed  part  from  the  right  to 
wards  the  opposite  side.  The  treatment  was 
therefore  begun  by  confining  the  knees  to- 
gether over  a pillow,  a.m  applying  a kind  of 
truss,  which  kept  the  skin  constantly  pressed 
towards  the  left  side.  While  these  measures 
were  going  on,  the  opportunity  was  taken  of 
dilating  the  anterior  portion  of  the  urethra 
with  bougies.  Afterward  the  following  ope- 
ration, which  I had  the  pleasure  of  seeing, 
was  performed  ; a portion  of  the  integuments 
was  removed,  about  an  inch  and  a half  long, 
and  one-third  of  an  inch  in  width,  on  the 
left  side  of  the  cicatrix.  The  groove  thus 
formed  was  intended  for  the  reception  of 
the  edge  ot  the  skin  to  be  detached  from  ihe 
opposite  side.  An  i.  eision  was  then  made 
across  the  perineum,  above  and  below,  so  as 
to  pare  away  the  callous  edges  of  the  ure- 
thra. The  skin  was  next  dis-ected  off  from 
a portion  of  integument  on  the  riglu  side  of 
the  perineum,  about  an  inch  and  - halt  in 
length,  and  half  an  inch  broad,  leaving  a 
smooth  space  of  rather  more  than  an  inch  be 
tween  the  cut  surfaces.  Ihe  integuments  on 
the  right  ^-ide  were  now  dissected  up,  turned 
over  a catheter,  arid  brought  in  contact  with 
the  opposite  groove.  The  detached  portion 
of  cicatrix  bled  little  during  the  operation, 
and  before  it  could  be  applied  to  the  groove, 
its  edge  bad  so  iivid  an  appearance,  as  to 
create  an  apprehension  that  it  must  perish. 
Two  sutures  were  employed  to  assist  in  re- 
taining it  in  the  desired  position,  and  some 
straps  of  adhesive  plaster  and  a bandage 


URINE,  INCONTINENCE  Ui 


>00‘ 


completed  the  dressings.  The  day  after  the 
operation,  it  was  evident  that  some  urine 
had  escaped  by  the  side  of  the  catheter;  and 
on  the  third  day,  when  the  dressings  were 
removed,  it  was  found  that  the  portion  of 
flesh  which  had  been  deprived  of  skin,  had 
sloughed,  but  that  a sufficient  quantity  had 
united  above  and  below  to  form  a canal, 
open  at  one  side,  and  large  enough  to  in- 
clude the  whole  catheter.  After  the  parts 
had  healed,  some  urine  could  be  made  to 
passthrough  the  urethra,  when  pressure  was 
applied  to  the  left  sicie  of  the  remaining  fis- 
tula. Various  attempts  were  afterward  made 
to  excoriate  its  edges,  and  unite  them,  but 
without  success. 

A second  operation  was  therefore  done 
in  the  summer  of  1820,  and  integuments 
were  now  borrowed  from  the  opposite  side 
to  that  from  which  they  had  been  taken  in 
the  first  operation.  A deep  groove  was. 
made  on  the  right  side,  the  surface  was  de- 
nuded of  its  cutis  to  some  extent,  a consi- 
derable portion  of  integument  was  then  de- 
tached from  the  left  side:  and  in  order  to 
obtain  healthy  skin  (says  Mr.  Earle)  I en- 
croached a little  on  the  thigh,  and  laid  bare 
the  edge  of  the  fascia  lata.  Instead  of  pass- 
ing any  ligature  through  the  detached  por- 
tion, the  "old  quill-suture  was  employed, 
which  was  passed  from  the  two  outer  cut 
surfaces.  A pad  of  adhesive  plaster  was  in- 
terposed between  the  ligatures  and  the  llap 
of  skin.5’  The  catheter  was  not  left  in  the 
urethra,  but  introduced  about  three  times  in 
24  hours.  By  this  operation  much  more 
was  gained,  and  about  two-thirds  of  the  de- 
ficient part  of  the  canal  were  restored  ; but 
still  a small  aperture  remained  at  the  upper 
part.  This  opening  could  not  be  closed  by 
touching  it  with  escharotics,  and  conse- 
quently, a third  operation  on  a smaller  scale 
was  done,  which  so  nearly  completed  the 
cure,  as  to  leave  only  an  orifice  large  enough 
to  admit  a bristle,  and  this  opening  subse- 
quently closed,  arid  the  patient  remained 
quite  well  in  March  1821.  (S ee  Phil  Trans, 
for  1821.) 

Here  we  see  the  same  art  by  which  new 
noses  and  under-lips  are  formed,  extending 
itself  to  cases  where  it  may  be  the  means  of 
extricating  some  individuals  from  a state  in 
which  life  is  hardly  desirable,  i'he  surgeon 
of  judgment,  however,  will  never  forget, 
that  such  an  operation  is  only  indicated 
where  the  fistula  is  large,  the  urethra  lree 
from  obstruction,  and  bougies  ancl  the  ca- 
theter insufficient. 

URINE,  INCONTINENC  E OF.  This 
complaint  is  quite  the  reverse  of  retention 
of  urine  ; for,  as  in  the  latter  affection,  the 
urine  is  continually  flowing  into  the  blad- 
der, without  the  patient  having  the  power 
to  expel  it;  so,  in  the  former  it  Hows  out, 
without  the  patient  being  able  to  retain  it. 

According  to  Desault,  children  are  parti- 
cularly liable  to  the  disorder  ; adults  are  less 
frequently  afflicted  with  it  ; and  persons  of 
advanced  years  appear  to  be  still  less  liable 
to  it.  The  last  observation  may  seem  an 
error  to  such  practitioners  as  have  met  with 


numerous  examples,  where  patients,  advan- 
ced in  years,  were  incapable  of  retaining 
their  urine.  The  fact  is,  that  the  overflow 
of  this  fluid,  or,  in  other  words,  its  dribbling 
away  through  the  urethra, in  somecasesof  re- 
tention, of  which  it  is  only  a symptom,  has 
been  too  commonly  confounded  with  an 
incontinence  of  urine,  though  the  cases  are 
as  different  in  their  nature  as  possible,  and 
require  very  opposite  modes  of  treatment. 
In  retentions , depending  upon  weakness  and 
paralysis  of  the  bladder , the  involuntary  drib- 
bling of  the  urine  is  generally  only  an  effect 
of  the  other  disease,  and  they  prevail  to- 
gether. The  distended  bladder  reacts  upon 
the  urine,  and  forces  some  of  it  out  of  the 
urethra,  until  the  resistance  of  the  sphincter 
and  of  the  urethra  are  precisely  equal  to  the 
expelling  power.  Sometimes  the  urine  even 
dribbles  away  incessantly,  as  is  found  to 
happen  when  the  action  of  the  bladder  is 
entirely  destroyed;  for  being  then  con- 
stantly full,  it  cannot  hold  any  more  of  the 
urine  descending  to  it  through  the  ureters, 
unless  as  much  be  voided  through  the  ure- 
thra as  is  received  from  the  kidneys,  and  as 
unremittingly  as  the  addition  from  the  lat- 
ter organs  continues  to  be  made.  Such  case 
rather  belongs  to  the  article  Urine , Reten- 
tion of  than  the  present  subject.  v 

It  is  correctly  remarked  by  Desault,  that 
the  causes  of  an  incontinence  of  urine,  strict- 
ly so  called,  are  the  very  reverse  of  those 
of  a retention.  The  latter  case -happens 
whenever  the  action  of  the  bladder  is  weak- 
ened, and  the  resistance  in  the  urethra  in- 
creased. On  the  contrary,  an  incontinence 
originates,  either  from  the  expelling  power 
of  the  bladder  being  augmented,  while  the 
resistance  in  the  urethra  is  not  proportion- 
ately increased  ; or  from  the  resistance  be- 
ing lessened,  while  the  expelling  force 
continues  the  same.  On  these  principles, 
Desault  thought  it  easy  to  explain  why  the 
disorder  should  be  most  common  in  chil 
dren  ; and  one  reason  which  he  gives  for 
the  circumstance  is,  that  in  childhood  there 
is  more  irritability  than  at  any  other  period 
of  life.  The  expulsion  of  . the  urine,  he  ob- 
serves, is  entirely  effected  by  muscular  ac- 
tion while  the  resistance  is  merely  owing 
to  the  sphincter  vesicoe,  the  levatores  ani, 
and  perhaps  to  a few  other  inconsiderable 
fasciculi  of  muscular  fibres  ; for  the  different 
curvatures  of  the  urethra,  and  the  contrac- 
tile power  of  this  tube  itself,  he  thought, 
could  make  only  a feeble  resistance  to  the 
discharge  of  the  urine.  An  incontinence 
happens  in  children,  because  the  bladder 
contracts  so  suddenly  and  forcibly,  that  its 
contents  are  voided  almost  before  these 
young  subjects  are  aware  of  the  occasion  to 
make  water,  and  without  their  being  able  to 
restrain  the  evacuation.  There  are  also  ma- 
ny children,  who,  from  indolence,  or  care- 
lessness, do  not  make  water  immediately 
the  first  calls  of  nature  invite  them,  and  who 
afterward,  beingurgently  pressed,  wet  their 
clothes.  In  other  young  subjects,  the  sen- 
sation which  makes  the  bladder  contract 
and  accompanies  the  expulsion  of  the  urine. 


URINE,  INCONTINENCE  01  oi>7 


t*  so  slight,  that  the  lu notion  is  performed 
without  any  formal  act  of  the  will, — with- 
out even  exciting  an  impression  sufficiently 
strong  to  disturb  sleep.  This  is  the  case 
wit  h such  children  as  are  troubled  only  with 
an  incontinence  of  urine  in  the  night-time. 
Increasing  years,  by  diminishing  the  irrita- 
bility of  tile  bladder,  and  making  man  more 
attentive  to  his  necessities,  usually  bring 
about  a cure  of  the  infirmity,  w hich  seldom 
continues  till  the  patient  has  attained  the 
adult  state. 

It  was  not,  however,  the  doctrine  of  De- 
sault, that  no  period  of  life,  excepting  child- 
hood, is  subject  to  incontinence  of  urfne.. 
On  the  contrary,  he  admits,  that  other  ages 
are  subject  to  it but  then  it  depends  almost 
alw'ays  upon  a want  of  resistance  to  the  es- 
cape of  the  urine.  Thus,  it  may  be  occa- 
sioned by  weakness,  or  paralysis  of  the 
sphincter  vesica?,  or  levatores  ani : some- 
times also  by  a forcible  dilatation  of  the 
urethra,  and  loss  of  its  elasticity,  and,  las 
Desault  might  have  added)  its  muscular 
powrer  of  contraction,  since  the  microscopi- 
cal observations  of  Mr.  Bauer,  tend  to  con- 
firm the  existence  of  muscular  fibres  on  the 
outside  of  the  membrane  of  the  canal, 
though,  as  is  elsew  here  mentioned,  their  ar- 
rangement and  mode  of  action  are  now'  re- 
presented to  be  quite  different  from  w hat 
was  formerly  supposed.  (See  Urethra , Stric- 
tures of  the.) 

A calculus,  a fungus,  or  any  other  extra- 
neous body  of  an  irregular  shape,  may  lodge 
in  the  neck  of  the  bladder,  but  not  accu- 
rately filling  it,  may  allow  the  urine  to  es- 
cape at  the  sides  ; or  there  may  even  be  in 
the  calculhs  grooves  through  which  the 
urine  may  pass  into  the  urethra. 

A violent  contusion,  or  forcible  distention 
of  the  sphincter,  is  often  follow  ed  by  an  in- 
continence of  urihe.  F ormerly , the  complaint 
used  to  be  very  common  after  the  mode  of 
lithotomy  called  the  apparatus  major,  and 
it  is  even  at  present  not  an  unusual  conse- 
quence of  the  extraction  of  calculi  from  fe 
males,  either  by  dilatation  or  division  of  the 
meatus  urinarius,  and  neck  of  the  bladder. 

Women,  after  difficult  labours,  and  in 
"whom  the  child’s  head  has  seriously  contu- 
sed and  weakened  the  neck  of  the  bladder, 
are  also  subject  to  a species  of  incontinence 
of  urine  ; which,  however,  is  in  general  ex- 
perienced only  when  they  laugh,  or  make 
exertions. 

Incontinence  of  urine  is  stated  by  many 
writers  to  be  an  attendant  on  paisy  and 
apoplexy.  Here  they  mistake,  what  the 
French  surgeons  aptly  call  the  “ retention 
d'urinc  avec  regorgeme?it ,”  for  an  inconti 
nence.  In  such  cases,  the  involuntary  dis- 
charge of  urine  has  been  referred  to  paraly- 
sis of  the  sphincter  of  the  bladder;  but  it 
is  forgot,  that  the  bladder  itself  aiso  partici- 
pates in  the  paralytic  affection  ; for  the 
sphincter  now  being  a particular  muscle, 
but  only  a fasciculus  of  fleshy  fibres,  form- 
ed, as  Desault  observes,  by  the  junction  of 
those  which  compose  the  inner  layer  of 
the  muscular  coat  of  the  bladder,  if  can  only 


be  weakened  in  the  same  degree,  and  at  the 
same  time,  as  the  rest  of  this  organ.  Be- 
sides, says  Desault,  it  is  proved,  and  all  phy  - 
siologists admit  the  fact,  that  the  action  of 
the  bladder  is  absolutely  necessary  for  the 
expulsion  of  the  urine,  and  that  when  this 
organ  cannot  act,  a retention  alw  ays  ensues 
Although  much  less  danger  attends  an  in- 
continence than  a retention  of  urine,  the  in- 
firmity is  a serious  affliction  ; for  as  the  pa- 
tient’s clothes  are  continually  wet  with  a 
fluid  that  readily  putrefies,  the  stench  which 
he  carries  about  w?ith  him,  is  offensive  to 
himself,  and  every  body  who  approaches 
him. 

In  children,  the  disorder  usually  gets  well 
of  itself,  as  they  grow  up  and  acquire 
strength.  When  they  wet  their  beds  really 
from  idleness  and  carelessness,  moderate 
chastisement  may  be  proper,  inasmuch  as 
the  fear  of  correction  w ill  make  them  pay 
more  attention  to  the  earliest  call  to  make 
make  water.  However,  it  has  always  been 
my  own  belief,  that  this  doctrine  is  carried 
to  an  unjustifiable  extent  particularly  in 
schools,  and  been  a pretext  for  the  most  ab  - 
surd kind  of  severity.  Nor  is  it  doubted  by 
any  man  who  understands  the  subject,  that 
in  almost  all  cases,  the  disorder  is  a true  in- 
firmity, arising  from  the  causes  already  in  • 
dicated,  and  not  from  indolence  ; the  sup  - 
posed crime  taking  place,  in  fact,  w hen  the 
child  is  asleep,  and  unconscious  of  what  i? 
happening. 

If  excessive  irritability,  and  constitutional 
weakness,  be  the  cause  of  incontinence  of 
urine,  and  a very  small  quantity  of  urine 
forces  the  bladder  to  contract,  the  resist- 
ance of  the  urethra  being  involuntarily 
overcome,  an  endeavour  should  be  made  to 
lessen  such  irritability  by  the  use  of  the 
warm,  or  cold  bath,  sea-batbing,  tonics, 
chalybeates,  good  air  &c.  And  in  order 
to  prevent  the  accident  from  taking  place 
in  the  night-time,  the  child  should  not  lake 
any  drink  for  some  time  before  being  put 
to  bed  ; the  bladder  should  be  always  emp- 
tied before  sleep  and  if  necessary,  the 
child  ought  to  be  taken  up  in  the  night  for 
the  same  purpose. 

li  the  infirmity  arises  from  a want  of  ac- 
tion in  the  parts,  causing  the  resistance  in 
the  urethra,  tonics  may  be  externally  and 
internally  employed.  However,  when  tho 
disorder  has  been  "of  long  standing,  Desault 
found  that  they  rarely  succeeded. 

Palliative  means  are  then  the  only  re- 
source ; viz.  instruments  calculated  either 
to  compress  the  urethra,  and  intercept  the 
passage  of  the  urine,  or  to  receive  the  fluid 
immediately  it  ss  voided.  The  first  of  these 
plans  is  more  difficult  to  accomplish  in  wo- 
men than  men  ; but  if  may  be  executed  by 
means  of  an  elastic  hoop,  which  goes  round 
the  pelvis,  and  from  the  middle  of  which, 
in  front,  a curved  elastic  piece  of  steel  de- 
scends, and  terminates  in  a small  compress, 
which  is  contrived  to  cover  accurately  the 
meatus  urinarius.  (See  CUvvres  Chir.  uc  De- 
sault par  Bichat  T 3,  p.  95,  ) 

Large  blisters:  applied  over  the  os  sacrum? 


URINE;  RETENTION  Oi 


&G8 

Ixavc  often  cured  an  incontinence  of  urine, 
both  when  the  complaint  seemingly  arose 
from  excessive  irritability  of  the  bladder, 
and  from  paralysis  and  loss  of  tone  in  this 
organ  and  the  parts,  which  naturally  resist 
the  expulsion  of  the  urine  from  it,  the  case 
being  in  fact  a retention  “ par  regorge  me  nt,” 
or,  as  one  might  call  it  in  plain  English,  a 
retention,  combined  with  incontinence  of 
urine.  (See  Med.  Obs.  and  Inq.)  As,  in 
some  of  these  cases,  the  blisters  removed 
also  a paralysis  of  the  lower  extremities, 
they  might  have  furnished  a hint  to  the  prac- 
tice of  making  issues  for  the  relief  of  the 
palsy  of  the  legs,  connected  with  the  dis- 
eased vertebrae 

URINE,  RETENTION  OF.  It  is  ob- 
served by  the  experienced  Mr.  Hey,  that  a 
retention  of  urine  in  the  bladder,  when  the 
natural  efforts,  are  incapable  of  affording 
relief,  is,  in  male  subjects,  a disease  of  great 
urgency  and  danger.  Persons  advanced  in 
years,  re  more  subject  to  this  complaint, 
than  she  young  or  nii> idle-aged.  Is  is  of- 
ten brought  on  by  an  incautious  resistance 
to  the  calls  of  nature  ; and  if  not  speedily 
relieved,  generally  excites  some  degree  of 
fever. 

The  distinction,  says  Mr.  Hev,  which  has 
sometimes  been  made  between  a suppression 
and  retention  of  urine,  is  practical  and  judi- 
cious Tue.  former  most  properly  points  out. 
a defect  in  the  secretion  of  the  kidneys  ; the 
latter,  an  inability  of  expelling  the  urine 
when  secreted. 

The  retention  of  urine  is  an  inability, 
whether  total  or  partial,  of  expelling,  by  the 
natural  efforts,  the  urine  contained  in  the 
bladder.  The  characteristic  symptom  of 
Ibis  disease,  previous  to  the  introduction  of 
the  catheter,  is  a distention  of  the  bladder 
(to  be  perceived  by  an  examination  of  the 
hypogastrium,)  after  the  patient  has  dis- 
charged all  the  urine,  which  he  is  capable  of 
expelling. 

As  this  complaint  may  subsist,  when  the 
flow  of  urine  from  the  bladder  is  by  no  means 
totally  suppressed,  great  caution  is  required 
to  avoid  mistakes. 

Violent  efforts  to  make  water  are  often 
excited  at  intervals,  and  during  these  strain 
ings,  small  quantities  of  urine  are  expelled. 
Such  a case  may  be  mistaken  for  strangury. 

At  other  times  a morbid  retention  of  urine 
subsists,  when  the  palient  can  make  water 
with  a stream,  and  discharge  a quantity 
equal  to  that  which  is  commonly  discharged 
by  a person  in  health.  Under  this  circum- 
stance, Mr.  Hey  has  k own  the  pain  in  the 
hypogastrium,  and  distention  of  the  bladder, 
continue  till  the  patient  was  relieved  by  the 
catheter. 

And  lastly,  it  sometimes  happens,  that 
when  the  bladder  has  offered  its  utmost 
distention,  the  urine  runs  off  by  the  urethra, 
as  ta>t  as  it  is  brought  into  the  blad- 
der by  the  ureters.  Mr.  Hey  has  repeat- 
edly known  this  circumstance  cause  a seri- 
ous misapprehension  of  the  true  nature  of 
the  disease. 

In  forming  a correct  judgment  of  all 


these  cases,  it  is  very  necessary  to  recollect 
the  important  division  of  retentions  of 
urine  into  the  complete  and  incomplete 
forms;  a distinction  which  will  at  once  put 
the  surgeon  on  his  guard  against  a variety  of 
errors. 


In  every  case  of  retention  of  urine  which 
'he  iate  Mr.  Hey  attended,  the  disease  could 
be  ascertained  by  an  examination  of  the  hy- 
pogastrium,  taken  in  connexion  with  the 
other  symptoms.  The  distended  bladder 
torms  there  a hard  and  circumscribed  tumour, 
giving  pain  to  the  patient  when  pressed  with 
the  hand.  Some  obscurity  may  arise  upon 
the«exarnination  of  a very  corpulent  person  ; 
but  in  all  doubtful  cases,  the  catheter  should 
be  introduced. 


Mr.  Hey  has  not  adverted  to  the  swelling 
in  the  rectum,  or  vagina;  nor  to  cases  of 
contracted  bladder,  where,  of  course,  the 
information,  derived  in  ordinary  instances 
from  the  tumour  above  the  pubes,  cannot 
be  had;  but  in  other  respects,  his  observa- 
tions on  the  diagnosis  are  practical  and 
correct. 

Mr  Hey  had  seen  only  a few  cases  of  is- 
churia reualis,  or  complete  suppression  of 
the  secretion  of  urine.  The  disease  proved 
faial  in  all  his  patients  except  one,  in  whom 
it  was  brought  on  by  the  effect  of  lead, 
taken  into  the  body  by  working  in  a pottery. 
It  subsisted  three  days,  during  a violent  at- 
tack ot  the  colica  pictonum,  and  was  then 
removed,  together  with  the  original  disease. 
Mr.  Hey  tound  no  difficulty  in  distinguish- 
ing this  disorder,  in  any  of  the  cases,  from 
the  ischuria  vesicalis,  though,  for  the  satisfac- 
tion ot  some  ot  his  patients,  he  introduced 
the  catheter.  ( Practical  Obs.  in  Surzery,  p. 
374,  fyc.) 

Re  tention  of  urine,  may  be  the  effect  of  a 
great  many  different  causes;  as  paralysis  of 
the  bladder;  inflammation  of  its  neck;  the 
presence  of  foreign  bodies  in  it  ; pressure 
made  on  its  cervix  by  the  gravid  uterus  ; en 
largemerit  of  the  prostate  gland;  strictures  in 
the  urethra;  fee.  . 

Every  case  of  retention  of  urine  demands 
prompt  assistance,  but  where  the  disorder 
presents  Itself  in  its  complete  form,  the  mis 
chief  of  delay  is  of  the  most  serious  nature  ; 
for  if  the  bladder  remain  preternaturally  dis- 
tended, it  not  only  loses  its  contractile  pow- 
er, but  is  quickly  attacked  with  inflammation 
and  sloughing.  At  length  some  (joint  of  it 
bursts,  and  the  urine  is  extravasated  in  the 
cellular  membrane  of  the  pelvis ; spreading 
behind  the  peritoneum  as  far  up  as  the  loins, 
and  in  other  directions,  into  the  perineum, 
scrotum,  and  the  integuments  of  the  penis, 
and  upper  part  ot  the  tiiigbs.  The  common 
result  then  of  the  rupture  of  the  bladder,  and 
the  effusion  of  its  contents,  is  the  speedy 
death  » f the  patient,  from  the  effects  of  this 
irritating  fluid  upo  all  the  parts  with  which 
it  comes  in  contact,  among  which  effects 
is  inflammation  ot  the  peritoneum  und  bowels. 
It  appears  also  from  '.he  observations,  both  of 
Desault  and  Sir  Evrard  Home,  that  a com- 
plete retention  ot  urine  alter  a lime  basilic 
effect  of  putting  a mechanical  stoppage  to 


URINE,  RETENTION  OF 


u69 


the  further  secretion  of  this  fluid  in  the  kid- 
neys ; a circumstance  which  sometimes  has 
a principal  share  in  producing  death,  parti- 
cularly where  this  event  happens  before  the 
urine  becomes  extravasated. 

In  all  cases  of  retention  of  urine,  the  indi- 
cations are  sufficiently  manifest;  viz.  1st,  to 
adopt  such  treatment  as  seems  best  calcula- 
ted to  procure  a discharge  of  the  urine 
through  the  natural  passage,  which  object  is 
performed,  sometimes  by  means  of  fomenta- 
tions, the  warm  bath,  bleeding,  opium, 
and  other  medicines  : sometimes  bv  the 
removal  of  mechanical  obstacles  to  the 
flow  of  the  urine  ; hut  more  frequently  b}' 
the  use  of  the  catheter,  than  any  other 
means.  When  ell  these  plans  fail,  it  then 
becomes  necessary  to  puncture  the  bladder. 
2dly.  The  second  indication,  or  that  which 
presents  itself  after  the  immediate  dangers 
of  the  distention  of  the  bladder,  are  thus 
guarded  against,  is  to  remove  whatever  dis- 
ease, or  other  circumstance,  constitutes  the 
still  existing  impediment  to  the  natural  ex- 
pulsion of  the  urine. 

With  respect  to  the  fit  manner  and  time  of 
employing  the  several  means  for  fulfilling 
the  above  indications,  and  the  selection 
which  should  be  made  of  them,  these  are 
important  considerations,  which  vary  in  dif- 
ferent cases,  and  actually  cannot  be  under- 
stood, without  due  reference  to  the  causes 
and  circumstances  of  each  individual  case. 
A part  of  this  subject  belongs  also  to  other 
parts  of  this  work,  to  which,  in  order  to  avoid 
the  necessity  of  repetition,  I here  refer.  (See 
. Catheter  ; Bladder , Puncture  of;  Prostate 
Gland,  Diseases  of;  Urethra , Strictures  of; 
*?c.) 

With  respect  to  catheters,  we  shall  find 
that  some  cases  require  the  urine  to  be 
drawn  off  two  or  three  times  a day,  and  the 
instrument  to  be  taken  out  after  each  evacua- 
tion ; while  in  other  instances,  it  is  prudent 
to  keep  the  tube  continually  introduced. 
Here  one  general  caution  may  be  conveni- 
ently offered,  which  is,  never  to  let  a 
silver  catheter  remain  in  the  passage  more 
than  a week  or  ten  days,  without  taking  it 
out  and  cleaning  it  ; for  if  this  he  not  done, 
the  instrument  becomes  coated  with  deposits 
from  the  urine,  so  as  afterward  not  to  admit 
of  being  withdrawn  through  the  urethra, 
without  great  suffering  and  irritation.  The 
eye  in  the  beak  is  also  apt  to  become  com- 
pletely blocked  up  ; and  sometimes  the  pres- 
sure which  the  catheter  makes  on  the  part  of 
the  urethra,  corresponding  to  the  root  of  the 
penis,  in  front  of  the  scrotum,  causes  in  this 
situation  inflammation,  followed  by  a slough 
as  large  as  a crown  piece,  and  an  opening, 
formed  by  the  loss  of  substance  is  left,  which 
may  even  continue  fistulous  during  the  pa- 
tient’s life.  These  remarks  particularly  ap- 
ply to  metalic  catheters  ; but  such  as  are 
supposed  to  be  made  of  elastic  gum,  espe- 
cially those  ordinarily  met  with  in  the  shops, 
are  apt  to  spoil  and  become  blocked  up  with 
mucus,  if  not  taken  out  and  cleaned,  or 
changed,  every  five  or  six  days.  However, 
as  I have  mentioned  in  the  article  Prostate 
Vol.  If.  73 


Gland , Diseases  of,  Mr.  Weiss  lias  succeeded 
in  constructing  elastic  catheters,  which  will 
bear  being  retained  more  than  a fortnight  in 
the  urethra,  without  becoming  obstructed, 
besides  having  the  advantage  of  always  re- 
taining a due  curve. 

1.  Of  the  Retention  of  Urine,  to  which  per 
sons  of  advanced  age  are  liable.  -- This  disor- 
der is  so  common  in  elderly  persons,  that  it 
is  generally  allowed  to  be  "one  of  the  grie- 
vances to  which  their  period  of  life  is  par- 
ticularly exposed.  In  them  the  bladder  is 
less  irritable  than  in  younger  subjects,  and 
hence,  it  is  not  so  soon  stimulated  by  the 
presence  of  the  urine.  In  fact,  it  is  notun- 
til  a painful  sensation  arises  from  the  disten- 
tion of  the  coats  of  the  bladder,  that  the  pa- 
tient is  aware  of  the  occasion  to  discharge 
the  urine.  The  bladder  then  contracts;  but 
still  would  not  be  able  to  expel  its  contents, 
were  it  not  for  the  powerful  action  of  the 
abdominal  muscles-  Nor  is  the  expulsion  of 
the  urine  even  now  complete  : since  the 
bladder  no  longer  retains  the  power  of  effa- 
cing the  whole  of  its  cavity.  On  the  con- 
trary, alter  each  evacuation,  some  urine  is 
still  left  undischarged,  and  already  consti- 
tutes an  incipient  retention.  The  quantity 
daily  augments,  and  at  length,  not  more  than 
half  the  fluid  contained  in  the  bladder  is 
voided  at  each  evacuation. 

According  to  Desault,  the  complaint  par- 
ticularly attacks  old  subjects  of  a plethoric 
state  of  body,  and  of  sedentary  and  studi- 
ous habits.  It  also  especially  afflicts  those 
who,  from  carelessness  or  indolence,  do  not 
take  time  enough  to  expel  the  last  drops  of 
urine  ; and  others,  who  are  accustomed  to 
discharge  their  urine  into  a pot,  as  they  lie 
in  bed,  instead  of  rising  for  the  purpose. 

In  these  cases,  the  urethra  and  neighbour- 
ing parts  seem  to  be  free  from  every  disease, 
capable  of  preventing  the  issue  of  the  urine  ; 
which  has  always  come  awray  freely,  and  in 
a full  stream,  although  it  could  not  be  dis- 
charged with  the  same  force,  nor  to  the 
same  distance,  as  formerly.  At  length,  in- 
stead of  describing  an  arch  as  it  flows  out, 
it  falls  down  perpendicularly  between  the 
legs.  Towards  the  close  of  the  evacuation, 
the  patient  is  also  not  sensible  of  the  final 
contractile  effort  of  the  badder,  of  which 
he  used  to  be  conscious  in  his  younger  days. 
When  he  is  about  to  make  water,  he  is 
obliged  to  wait  some  time  before  the  eva- 
cuation commences;  and  as  the  disorder 
increases,  he  cannot  make  water  without 
considerable  efforts  ; the  quantity  of  urine, 
voided  each  time,  manifestly  decreases ; 
the  desire  to  empty  the  bladder  becomes 
more  and  more  frequent ; and  lastly,  the 
urine  only  comes  away  by  drops,  and  an 
incontinence  succeeds  a retention. 

In  this  state,  the  patient’s  sufferings  are 
not  very  great.  The  tumour,  formed  by 
the  bladder  above  the  pubes,  is  indolent, 
and,  if  it  be  pressed  upon  with  some  force, 
a certain  quantity  of  urine  is  discharged 
from  the  urethra. 

The  retention  of  urine  arising  from  old 
age  is  seldom  complete  the  urine,  after 


UKLNE,  RETENTION  01 


5.70' 

having  filled  anti  distended  the  bladder, 
dribbles  oat  of  the  urethra,  so  that  the  pa- 
tient voids  as  much  of  this  fluid  in  a given 
lime,  as  he  does  in  a state  of  health.  Nor 
is  this  species  of  retention  of  urine  com- 
monly attended  with  very  urgent  symp- 
toms. It  does  not  occasion,  like  complete 
intention,  a suppression  of  the  urinary  se- 
cretion in  the  kidneys  ; and  as  the  urine 
escapes  through  the  urethra,  after  the  blad- 
der is  distended  to  a certain  degree,  the 
disorder  is  less  apt  to  produce  a rupture  of 
this  organ,  and  dangerous  extravasations  of 
the  urine.  The  swelling  of  the  bladder 
then  continues  without  any  particular  suf- 
fering, except  a sense  of  weight  about  the 
pubes  and  perineum.  These  circumstances 
have  often  led  to  serious  mistakes,  and  the 
disease  has  been  set  down  as  an  abscess  or 
dropsy. 

The  indications  are  to  evacuate  the  urine, 
and  restore  the  tone  of  the  bladder.  When 
the  retention  is  incipient,  the  proper  action 
of  the  bladder  will  sometimes  return  after 
cold  applications  are  made  to  the  hypogas- 
tric region,  or  thighs,  and  the  patient  goes 
from  a warm  into  a cool  place. in  order  to 
make  water. 

The  patient  must  also  be  strictly  careful 
to  make  water  immediately  the  least  incli- 
nation to  do  so  is  felt ; for,  if  this  precau- 
tion be  neglected,  the  bladder  grows  more 
and  more  inert ; the  desire  to  make  water 
subsides;  and  the  retention,  which  at  first 
consisted  of  only  a few  drops,  very  soon 
becomes  complete.  It  would  then  be  in 
vain,  as  Desault  observes,  to  try  the  expe- 
dients above  recommended.  No  stimulus 
will  now  make  the  bladder  contract  suffi- 
ciently to  expel  the  whole  of  the  urine,  and 
the  catheter  is  the  only  thing,  by  which  this 
fluid  can  be  discharged.  This  artificial 
mode  of  evacuation,  however,  only  affords 
temporary  relief;  for  as  the  bladder  is  slow 
in  recovering  its  tone,  a relapse  would  be 
inevitable,  if  the  employment  of  the  cathe- 
ter were  not  continued.  Hence  this  instru- 
ment must  either  be  left  in  the  bladder,  or  in- 
troduced as  often  as  the  patient  lias  occa- 
ion  to  make  water.  When  a skilful  surgeon 
is  constantly  at  hand,  or  when  the  patient 
knows  how  to  pass  the  catheter  himself, 
Desault  thinks  it  better  to  introduce  the  in- 
strument only  when  the  bladder  is  to  be 
emptied,  by  which  means  the  inconvenience 
arising  from  the  continual  presence  of  a fo- 
reign body,  will  be  avoided.  In  this  case, 
either  a silver  catheter,  or  an  elastic  gum 
one,  may  be  used  with  equal  advantage  ; 
Hut  if  the  instrument  is  to-be  kept  in  tiie 
bladder,  one  made  of  elastic  gum,  and  pro- 
vided with  a curved  stilet,  is  to  be  prefered. 
As  in  old  subjects,  the  urethra  is  flaccid,  a 
large  catheter  is  generally  found  to  enter 
more  easily,  than  one  of  smaller  diameter. 

As  the  treatment  must  be  continued  for  a 
long  while,  and  the  bladder  seldom  perfectly 
regains  its  tone  in  old  age,  the  patient  should 
be  instructed  how  to  introduce  the  catheter 
himself,  and  he  is  to  pass  it  whenever  lie 
wants  to  make  wafer.  After  a certain  time. 


however,  he  may  try  if  tie  can  empty  ike 
bladder  without  this  instrument.  When  he 
finds  that  he  can  expel  the  urine,  he  should 
certify  himself  by  means  of  the  catheter, 
that  the  last  drops  of  this  fluid  are  duly 
voided.  Should  they  not  be  so,  he  must 
persevere  in  the  use  of  the  instrument. 

In  this  sort  of  retention  of  urine,  it  has 
been  proposed  to  throw  into  the  bladder  as- 
tringent injections : Desault  tried  them  ; but, 
he  does  not  give  a favourable  report  of  the 
practice. 

Warm  balsamic,  diuretic  medicines;  cold 
bathing  ; and  liniments  containing  the  tinc- 
tura  lyttee  ; have  likewise  been  praised  ; but 
according  to  Desault,  these  means  frequent- 
ly prove  hurtful  to  persons  of  advanced 
years,  and  are  seldom  useful.  He  restricted 
his  own  practice  to  the  use  of  the  catheter 
which,  when  skilfully  employed,  often  re- 
stored the  tone  of  the  bladder,  and  when  it 
failed,  other  means  also  were  ineffectual. 
A blister  over  the  sacrum  may  deserve  a 
trial. 

Passing  over  (he  cases  of  retention  of 
urine,  referred  by  Desault  to  the  effects  of 
intemperance  with  .women,  and  the  immo- 
derate use  of  diuretic  drinks ; cases  which 
considerably  resemble  in  their  nature  and 
treatment  the  retention,  from  the  weakened 
state  of  the  bladder  in  elderly  persons,  I 
proceed  to  another  example  of  the  disorder 
still  more  interesting  to  the  practical  sur- 
geon. 

2.  Retention  of  Urine  from  an  Affection  oj' 
the  Nerves  of  the  Bladder. — These  nerves 
may  be  affected  either  at  their  origin,  or  in 
the  course  of  their  distribution.  Injuries  of 
the  brain  are  seldom  followed  by  a retention 
of  urine,  but  the  complaint  often  aceom 
panies  those  of  the  spinal  marrow.  A con 
cussion  of  this  medullary  substance,  from 
blows,  or  falls  upon  the  vertebral  column  ; 
the  injury  which  it  suffers  in  fractures  and 
dislocations  of  the  vertebra?,  or  from  a vio- 
lent strain  of  the  back  ; its  compression  by 
blood,  purulent  matter,  or  other  fluid  effu- 
sed in  the  vertebral  canal,  and  the  effects, 
which  a caries  of  the  spine  has  upon  it ; 
may  all  operate  as  so  many  causes  of  a re  - 
tention of  urine.  This  form  of  the  com- 
plaint may  also  be  the  consequence  of  tu 
mours  situated  in  the  track  of  the  nerves, 
which  are  distributed  to  the  bladder. 
Whether  the  retention  of  urine,  common  in 
typhus  fever,  arises  from  an  affection  of  the 
nerves  of  the  bladder,  or  from  the  general 
debility  extending  itself  to  the  expelling 
powers,  may  be  a question  ; but  the  liabili- 
ty of  patients  in  fevers  to  this  disorder 
should  never  be  out  of  the  practitioner’s 
recollection. 

When  a retention  of  m ine  arises  from  in- 
jury or  disease  of  the  spinal  marrow,  an  in- 
sensibility and  weakness  of  the  lower  ex- 
tremities are  almost  always  concomitant 
symptoms.  The  patients  suffer  very  little  ; 
most  of  them  are  ignorant  of  their  condi- 
tion ; and  do  not  complain  of  any  thing 
being  wrong  in  the  functions  of  the  urinary 
organs.  The  surgeon,  aware  that  a r©teu- 


URINE,  RETENTION  OF 


vioii  of  urine  is  common  in  these  cases, 
shoulil  examine,  whether  there  is  any  inter- 
ruption of  the  evacuation,  either  by  feeling 
the  state  of  the  abdomen  just  above  the 
pubes,  or  by.  introducing  a catheter. 

As  this  species  of  retention  of  urine  is 
only  symptomatic,  and  not  dependent  upon 
any  prev  ious  defect  in  the  bladder,  it  is  not 
in  itself  alarming;  but  with  reference  to  its 
cause,  it  is  exceedingly  dangerous.  Affec- 
tions of  the  spine,  complicated  with  injury 
of  the  spinal  marrow,  are  often  fatal.  By 
means  of  a catheter,  it  is  always  easy  to  re- 
lieve the  inconveniences,  arising  from  the 
bladder  not  contracting,  and  thus  fulfil  the 
only  indication,  which  this  sort  of  retention 
of  urine  presents ; viz.  the  evacuation  of 
the  urine.  But  this  proceeding  is  merely 
palliative  ; and  the  bladder  will  not  recover 
ifs  contractile  power,  until  the  causes  of  its 
x weakness  are  removed.  The  last  then  is 
the  main  object  in  the  treatment,  which 
must  vary  according  to  the  nature  and  ex- 
tent of  the  disorder. 

The  consideration  in  detail  of  all  the 
means,  which  may  be  requisite  for  the  relief 
of  the  different  accidents  and  diseases  of 
the  spine,  belongs  to  other  parts  of  this 
work.  (See  Dislocations  and  Fractures  of 
the  Vertebrae;  Vertebrae , Disease  of.)  In 
shocks  and  concussions  of  the  spinal  mar- 
row, Desault  had  a high  opinion  of  the  be- 
nefit resulting  from  cupping.  This  was  done 
on,  or  near  the  part  of  the  back,  which  had 
been  struck,  and  the  number  of  scarifica 
lions  was  proportioned  to  the  strength  of 
the  patient.  The  plan  was  sometimes  re- 
peated the  same  day,  and  for  several  days  in 
succession  ; and  when  the  patient  could  not 
bear  the  loss  of  more  blood,  dry  cupping 
was  employed,  which  in  this  country,  would 
be  deemed  less  efficacious,  than  stimulating 
liniments  or  blisters.  In  diseases  of  the 
spine,  Desault  also  preferred  the  moxa,  to 
caustic  issues. 

3.  Retention  of  Urine  from  Distention  of 
the  Bladder. — Desault  thought  that  this  form 
of  the  disorder  might  very  properly  be  call- 
ed secondary , because  it  is  invariably  pre- 
ceded and  produced  by  a 'primary  retention. 
Of  course,  its  remote  causes  are  all  those  cir- 
cumstances, which  may  bring  on  the  other 
forms  of  the  complaint;  but  its  immediate 
cause  depends  altogether  upon  the  weakness 
and  loss  of  irritability  in  the  bladder,  occa-* 
sioned  by  the  immoderate  distention  of  its 
coats.  The  disorder  frequently  occurs  in 
persons,  who  from  bashfulness,  indolence, 
or  intense  occupation,  neglect  to  make 
water,  when  they  first  have  the  desire  ; or 
who  cannot  fora  time  empty  the  bladder, 
in  consequence  of  some  temporary  obstruc- 
tion in  the  urethra  Although  the  impedi- 
ment to  the  escape  of  the  urine  no  longer 
exists,  and  the  bladder  is  in  other  respects 
sound,  yet  as  this  organ  has  been  weakened 
by  the  excessive  distention  of  its  coats,  it 
cannot  now  contract  sufficiently  to  oblite- 
rate the  whole  of  its  cavity,  and  expel  the 
last  portion  of  urine. 

The  indication  is  simple  : for  there  is  not 


here,  as  in  other  retentions  of  urine,  another 
disease  to  be  remedied.  The  catheter, 
when  left  in  the  bladder,  generally  proves 
adequate  to  the  restoration  of  the  tone  of 
this  viscus.  I do.  not  conceive,  however, 
that  English  surgeons  will  place  any  confi- 
dence in  warm  diuretics  which  were  com- 
mended by  Desault,  though  they  may  join 
him  in  the  approval  of  a tonic  plan  of  treat- 
ment in  general.  When  the  urine  flows 
from  the  catheter  in  a rapid  stream,  and  is 
projected  to  some  distance,  and  when  it  also 
passes  out  between  the  catheter  and  the 
urethra,  it  is  a sign  that  the  bladder  has  re- 
gained its  power  of  contraction,  and  that 
it  can  empty  itself,  without  the  aid  of  the 
instrument.  In  this  circumstance,  the  ca- 
theter is  to  be  discontinued,  and  the  patient; 
may  gradually  resume  his  usual  mode  of 
life.  But  When  the  urine  passes  through  the 
catheter  only  in  a slow  stream,  the  catheter 
cannot  be  m>id  aside,  without  the  bladder 
becoming  distended  again,  and  losing 
whatever  degree  of  tone  it  may  have  re- 
covered. , 

The  time  which  the  badder  takes  to  re- 
gain its  power  of  contracting,  varies  consi- 
derably in  different  cases.  When  the  dis- 
ease is  accidental  and  sudden,  it  frequently 
goes  off  in  a few  days.  When  it  has  come 
on  in  a slow  manner,  it  usually  lasts  about 
six  weeks.  However,  the  cure  is  not  to  be 
despaired  of,  if  the  paralytic  affection  of  the 
bladder  should  continue  much  longer. 
Sabatier  says  that  he  has  seen  patients 
wear  a catheter  upwards  of  ninety  days, 
and  yet  ultimately  get  completely  well. 
When  there  is  reason  for  believing,  that  the 
urine  will  come  away  of  itself,  the  use  ot 
the  catheter  may  be  discontinued.  When 
he  makes  water  very  slowly;  when  he  is 
obliged  to  make  frequent  attempts:  and 
when  he  feels  a sense  of  weight  about  the 
neck  of  the  bladder ; this  organ  lias  not- 
completeiy  recovered  its  tone,  and  the  em- 
ployment of  the  catheter  is  still  necessary. 
When  the  patient  could  make  water  tolera- 
bly well  in  the  day,  but  not  during.the  rest 
of  the  24  hours,  Sabatier  has  often  seen  be- 
nefit arise  from  the  catheter  being  worn 
only  in  the  night-time. 

When  three  or  four  months  elapse  with- 
out amendment,  Sabatier  states  bis  convic- 
tion, that  the  tone  of  the  bladder  is  lost  for 
ever.  In  this  unfortunate  case,  the  patient 
should  continue  the  flexible  catheter,  which 
he  should  be  taught  to  introduce  himself,  as 
often  as  necessary.  (See  De  la  Mcdecine 
Operatoirc.  T.  2.) 

Among  the  means  deserving  of  trial, 
when  the  contractile  power  of  the  bladder 
does  not  return  with  the  use  of  the  catheter. 
I have  to  mention  the  tincture  of  cantha- 
rides ; blisters  applied  to  the  sacrum,  and 
kept  open  with  the  savine  ointment ; and 
cold  washes  to  the  hypogastric  region. 

In  all  cases,  where  the  incapacity  of  the 
bladder  to  contract,  whether  from  weakness, 
or  paralysis,  is  the  cause  of  retention,  arid 
where,  though  the  bladder  continues  dis 
tended,  a certain  quantity  of  urine  feFmde’d 


URINE.  RETENTION  OF. 


f>  72 

daily,  mistakes  are  particularly  liable  to  be 
made.  Thus,  besides  the  chance  of  the 
disease  being  mistaken  for  an  abscess,  as 
Colot  states  was  not  uncommon  in  his  time, 
other  errors  may  take  place.  Sabatier  was' 
consulted  about  a woman,  who  had  been 
advised  to  repair  to  some  distant  mineral 
waters,  with  the  view  of  dispersing  a tumour, 
which  remained  after  a difficult  labour,  and 
was  supposed  to  be  in  the  uterus  itself. 
However,  the  swelling  turned  out  to  be 
only  a retention  of  urine,  as  it  disappeared 
as  soon  as  the  catheter  was  introduced. 
Here  no  suspicion  had  been  entertained  pf 
the  real  nature  of  the  case,  because  the  pa- 
tient had  voided  her  urine  in  a voluntary 
manner,  and  in  reasonable  quantity,  for  the 
live,  or  six  weeks,  during  which  the  swelling 
existed. 

In  a thesis  by  Murray,  a case  is  recorded, 
in  which  the  swelling  of  the  bladder  was  so 
considerable,  that  it  was  mistaken  for  drop- 
sy. The  abdomen  of  a delicate  woman 
began  to  enlarge,  without  any  particular 
pain,  and  the  cause  was  at  first  supposed  to 
be  pregnancy.  This  idea  however,  was  re- 
moved by  the  enlargement  increasing  too 
rapidly,  attended  with  a great  deal  of  ana- 
sarca of  the  lower  extremities,  arms,  and 
face.  The  patient  was  now  considered  to 
be  dropsical ; and  a surgeon  was  sent  for  to 
tap  the  abdomen.  The  fluctuation  in  the 
belly  was  quite  evident.  Fortunately,  be- 
fore the  operation  was  done,  atrial  of  diu- 
retic medicines  was  determined  upon  ; and 
while  this  plan  was  going  on,  the  patient 
was  attacked  with  a total  retention  of  urine 
for  three  days  ; a symptom,  which  she  had 
not  previously  suffered.  It  was  now  judged 
prudent  to  pass  a catheter,  before  the  tro- 
car was  employed.  Eighteen  pints  of  urine 
were  drawn  olF,  and  the  swelling  of  the  abdo- 
men subsided.  The  next  day,  twelve  more 
pints  of  urine  were  drawn  off.  The  anasarca, 
which  was  entirely  symptomatic,  disappear- 
ed. The  application  of  cold  water  re-esta- 
blished the  tone  of  the  bladder,  so  that  when 
three  pints  of  urine  had  been  drawn  oft’  by 
means  of  the  catheter,  the  patient  herself 
could  spontaneously  expel  three  or  four 
others,  with  the  aid  of  pressure  on  the  hy- 
pogastric region. 

The  retention  of  urine  caused  by  weak- 
ness, or  paralysis  of  the  bladder,  and  the 
swelling  above  the  pubes,  may  continue  a 
long  while,  without  any  inconvenience,  ex- 
cepting a sense  of  weight  about  the  hypo- 
gastric region,  and  frequent  inclination  to 
make  water  Sabatier  has  known  patients 
labour  under  the  complaint  more  than  six 
months. 

4.  Retention  of  Urine  from  Inflammation 
of  the  Bladder. — According  to  Desault, 
writers  have  ascribed  different  effects  to  an 
inflammation  of  the  neck  of  the  bladder, 
and  to  the  same  affection  of  the  body  of 
this  viscus.  They  have  in  fact  regarded  the 
first  case  as  a cause  of  retention  ; and  the 
tyst  as  a cause  of  incontinence  of  urine. 
An  inflamed,  highly  sensible  bladder,  instead 
of  being  weakened,  has  been  supposed  to 


acquire  an  increase  of  energy,  and  to  con- 
tract with  greater  vigour.  But  if  there  had 
not  been  retentions  of  urine,  which  could 
be  referred  to  nothing  but  inflammation  o 
the  bladder,  still  analogy  might  have  unde- 
ceived us ; for  an  inflamed  muscle  is  never 
found  disposed  to  contract,  and  if  it  be 
compelled  to  act,  its  action  is  always  fee- 
ble. 

Plethoric,  bilious  subjects,  are  said  to  be 
particularly  liable  to  this  species  of  reten- 
tion. It  is  also  frequently  occasioned  by 
the  abuse  of  wine,  or  other  spirituous  liquors, 
heating  diuretic  drinks,  or  the  external,  or 
internal  employment  of  lyttae.  This  form 
of  the  complaint  makes  its  attack  suddenly, 
and  may  be  known  by  the  frequent  desire 
to  make  water  ; the  acute  .pain,  in  the  re- 
gion of  the  bladder;  pain,  which  is  increased 
by  the  efforts  to  make  water,  and  which 
shoots  up  to  the  loins,  and  along  the  urethra 
to  the  end  of  the  glans ; by  the  frequency 
and  hardness  of  the  pulse,  and  other  symp- 
toms of  fever ; by  the  aggravation  of  the 
pain,  when  the  hypogastric  region  is  press- 
ed ; by  the  easy  passage  of  a catheter  into 
the  bladder;  by  the  acute  pain,  which  is 
excited  by  the  instrument  touching  the  in 
side  of  this  organ  ; and  by  the  red,  inflam 
matory  colour  of  (he  urine. 

In  this  case,  the  most  prompt  assistance 
is  necessary.  The  urine,  which  is  a source 
of  additional  irritation,  should  be  drawn  oft’. 
The  catheter  should  be  introduced  with 
great  gentleness,  and  merely  far  enough  to 
let  its  eye  pass  beyond  the  neck  of  the  blad- 
der. 

The  inflammation  itself  is  to  be  counter- 
acted by  the  most  powerful  antiphlogistic 
remedies,  large  and  repeated  venesections  ; 
the  application  of  leeches  to  the  perineum 
and  hypogastric  regions;  the  warm  bath 
glysters;  fomentations  on  the  abdomen; 
and  cold  mucilaginous  beverages.  When 
the  inflammation  extends  to  the  other  ab- 
dominal viscera,  attended  with  hiccough, 
and  vomiting,  and  continues  beyond  the 
sixth  day,  the  patient’s  life  is  in  extreme 
danger. 

5.  Retention  of  Urine  from  Hernia  of  the 
Bladder. — An  inability  to  discharge  the 
urine  is  a symptom  generally  attending  her- 
nia of  the  bladder.  But  the  weakness  of 
this  organ  is  not  always  the  sole  cause  of 
the  infirmity  ; for  the  urethra  itself  makes 
greater  resistance  than  natural  to  the  issue 
of  the  urine.  As  the  neck  of  the  bladder  is 
drawn  out  of  its  right  position  by  the  por- 
tion of  this  organ  which  actually  protrudes, 
the  beginning  of  the  urethra  also  undergoes 
an  elongation,  and  a change  of  its  curvature, 
by  being  pressed  towards  the  symphysis  of 
the  pubes,  and  its  diameter  is  likewise  di- 
minished. ’fhe  urine  may  also  be  detained 
in  the  pouch  composing  the  hernia,  in  con 
sequence  of  the  communication  'between 
this  and  the  rest  of  the  bladder  being  too 
small,  or  indirect,  or  perhaps  from  the  her- 
nial portion  not  being  compressed  byr  tho 
action  of  the  abdominal  muscle,  or  capable 
of  any  contraction  itself.  However,  the 


URINE,  RETENTION  OF. 


oT4 


rest  of  this  organ,  within  the  pelvis,  can  it- 
self rarely  expel  the  last  drops  of  the  urine. 
Its  complete  contraction  cannot  be  accom- 
plished without  great  difficulty  ; and  in  the 
end  it  almost  invariably  follows,  that  the 
urine  is  retained  both  in  the  protruded  and 
unprotruded  portions. 

When  a retention,  arising  from  a hernia 
of  the  bladder,  is  complete,  and  occurs  in 
both  parts  of  this  organ,  there  is,  in  addition 
to  the  symptoms  common  to  other  reten- 
tions produced  by  weakness  of  the  bladder, 
a more  or  less  considerable  swelling  in  the 
situation  of  the  hernia.  Ihe  tumour  is  un- 
attended with  any  change  of  the  colour  of 
the  skin  ; is  not  very  tender;  and  it  presents 
a feeling  of  fluctuation,  sometimes  obscure, 
sometimes  very  distinct.  When  the  swell- 
ing is  pressed  upon,  the  desire  to  make  wa- 
ter is  excited,  or  increased,  and  occasionally 
a few.  drops  escape  from  the  urethra.  As 
soon  as  the  urine  has  been  drawn  off  with 
a catheter,  and  the  patient  is  put  in  a pos- 
ture in  which  the  protruded  portion  of  the 
bladder  is  higher  than  the  rest  of  this  organ 
within  the  pelvis,  the  tumour  subsides,  and 
it  is  some  time  before  it  becomes  large 
again. 

When  the  hernia  is  recent,  and  the  pro- 
truded portion  of  the  bladder  small  and  re- 
ducible, the  part  ought  to  be  returned  and 
kept  up  with  a truss.  When  the  part  is  ad- 
herent and  irreducible,  the  swelling  ought 
to  be  emptied  by  pressure,  and  supported 
with  a suspensory  bandage.  If  the  hernia 
could  in  this  manner  be  made  gradually  to 
return  into  the  abdominal  ring  again,  a truss 
would  afterward  be  requisite.  Proposals 
have  been  made  to  endeavour  to  excite  ad- 
hesive inflammation  in  the  cavity  of  the 
protruded  part  of  the  bladder  by  compres- 
sion, gradually  increased,  and  thus  oblite- 
rate the  pouch,  in  which  the  urine  lodges. 
Although  Desault  thought  the  attempt  cau- 
tiously made  justifiable,  be  deemed  the  re- 
sult very  uncertain. 

Were  the  retention  of  urine  accompanied 
with  a strangulated  state  of  the  protruded 
bladder,  and  the  contents  could  not  be 
pressed  into  the  other  part  of  this  organ,  a 
puncture  of  the  swelling  with  a trocar  has 
been  advised.  But  if  there  were  an  entero- 
cele  also  present,  as  often  happens,  this  ope- 
ration would  be  attended  with  risk  of  inju- 
ring the  intestine.  Hence,  Desault  prefer- 
red opening  the  tumour  by  a careful  irtci- 
sion  and  he  even  approved  of  cuttingaway 
the  protruded  cyst,  if  the  communication 
betwixt  it  and  the  rest  of  the  bladder  were 
obliterated.  For  additional  observations,  I 
refer  to  the  2d  vol.  of  the  First  Lines  of 
Surgery,  Ed.  4. 

6.  i Retention  of  Urine , caused  by  displace- 
ments of  the  Viscera  of  the  Pelvis. — The.  dis- 
placements, here  signified,  are.  a retrover- 
sion, prolapsus,  and  inversion  of  the  uterus, 
and  a prolapsus  of  the  vagina,  or  rectum. 
When  the  intimate  connexions  of  the  blad- 
der with  the  uterus  and  vagina  in  the  fe- 
male, and  with  the  rectum  in  the  male  sub- 
ject. are  considered,  it  is  obvious,  that  the 


latter  parts  cannot  be  displaced,  without 
drawing  along  with  them  the  bladder;  and 
that,  in  this  state,  whatever  may  be  its  con- 
tractile power,  it  cannot  contract  so  per- 
fectly as  to  expel  the  whole  of  the  urine. 
To  this  deficient  action  of  the  bladder  is 
necessarily  joined  an  increase  of  resistance 
on  the  part  of  the  urethra  ; for,  the  begin- 
ning of  this  canal  being  drawn  by  the  blad- 
der, changes  its  accustomed  direction,  and 
such  alteration  cannot  be  made  without  the 
sides  of  the  tube  being  pressed  together. 
Thus  the  retroverted  uterus  draws  the  os 
tinc.se  above  tiie  pubes,  and  the  posterior 
part  of  the  bladder  is  displaced,,  which,  in 
its  turn,  draws  along  with  it  the  commence- 
ment of  the  urethra,  pulls  it  upwards,  and 
increases  the  curvature,  which  this  canal  de- 
scribes under  the  symphysis  of  the  pubes, 
against  which  it  is  forcibly  applied. 

In  a prolapsus,  or  inversion  of  the  womb, 
vagina,  and  rectum,  the  back  part  of  the 
bladder,  instead  of  being  drawn  upward  and 
forward,  is  pulled  downward  and  backward, 
and  the  curvature  of  the  urethra  is  totally 
altered.  Below  the  pubes  the  bladder  form  ; 
a convexity,  and  not  a large  concavity,  as 
in  the  instance  of  a retroversion  of  the 
womb.  This  position  of  the  parts  should 
alwrays  be  recollected  in  passing  the  cathe 
ter,  as  it  shows  what  curvature  and  direc 
lion  should  be  given  to  the  instrument,  in 
order  to  facilitate  its  introduction. 

These  retentions  of  urine  are  not  often 
followed  by  any  very  bad  consequences. 
It  is  generally  sufficient  to  rectify  the  wrong 
position  of  the  bladder,  and  the  commence  - 
ment of  the  urethra,  by  the  reduction  of  the 
displaced  viscera,  and  a cure  is  then  a mat- 
ter of  course,  unless  the  excessive  disten- 
tion should  have  induced  considerable 
weakness  of  the  bladder,  in  which  event, 
recourse  must  be  had  to  the  means  previ- 
ously recommended  for  this  state  of  the 
organ.  The  reduction  of  the  viscera  gene- 
rally forms  the  first  indication,  and  the 
manner  of  accomplishing  it  is  described  un- 
der the  head  of  Uterus.  When  the  reduc- 
tion is  not  immediately  practicable,  or  when 
it  fails  to  remove  at  once  the  retention  of 
urine,  the  catheter  is  to  be  used.  Frequent- 
ly, when  the  urine  has  been  d'-awm  off,  the 
reduction  becomes  more  easy;  but,  some- 
times, the  altered  direction  of  the  urethra 
renders  the  introduction  of  the  catheter  dif- 
ficult; nor  will  the  instrument  pass,  unless 
it  be  accommodated  to  the  preternatural 
state  of  that  canal.  Thus,  in  the  retrover- 
sion of  the  uterus,  a catheter,  very  much 
curved,  answers  better  than  one  nearly 
straight,  like  that  commonly  used  for  fe 
males. 

A curved  catheter,  says  Desault,  also  an- 
swers in  cases  of  prolapsus  uteri,  he.  ; but 
with  this  difference,  that,  in  a retroversion, 
the  concavity  of  the  instrument  must  be 
turned  towards  the  pubes,  but,  in  the  pro- 
lapsus, towards  the  anus.  Sometimes  the 
catheter  will  not  pass  unless  it  be  rotated, 
as  it  were,  and  sometimes,  when  a silver 


URINE,  RETENTION  OF. 


754 

catheter  cannot  in  any  manner  be  intro- 
duced, an  elastic  one  will  readily  enter. 

Were  every  effort  to  reduce  the  viscera, 
and  pass  a catheter  unavailing,  and  the  ha- 
zard of  the  bladder  giving  way  urgent,  the 
surgeon  would  be  called  upon  to  let  out  the 
urine  with  a trocar.  (See  Bladder , Punc- 
ture of.) 

7.  Retention  of  Urine  from  Ike  pressure  of 
the  Uterus , or  Vagina,  on  the  Keck  of  the 
Bladder.  Besides  the  distention  of  the  ute- 
rus and  vagina  in  pregnancy  and  parturition 
(which  cases  I mean  to  pass  over  as  be- 
longing more  properly  to  midwifery,)  there 
are  other  conditions  of  these  organs  which 
may  give  rise  to  a retention  of  urine.  I bus 
It  sometimes  arises  from  the  presence  of 
various  kinds  of  tumours,  or  collections  of 
bu)od,  or  other  fluid  in  the  uterus,  or  ovary ; 
or  the  distention  of  the  vagina  with  the 
menses,  pessaries,  &c. 

In  such  cases,  the  retention  of  urine  being 
only  symptomatic,  the  prognosis  must  de- 
pend upon  the  nature  of  the  cause,  of  which 
the  interruption  of  the  urinary  evacuation 
is  only  an  effect.  The  latter  complaint  is 
here  not  very  dangerous,  because  its  incon- 
venience may  be  obviated  by  means  of  the 
catueter.  But  when  the  cause  of  the  reten- 
tion of  urine  is  easily  removed,  and  the 
tone  of  the  bladder  is  not  impaired,  even 
the  catheter  is  not  always  necessary,  as 
when  the  complaint  is  induced  by  a pessary, 
or  collection  of  blood  in  the  vagina.  In 
other  examples,  in  which  the  cause  of  the 
difficulty  of  making  water  cannot  be  imme- 
diately obviated,  as  in  cases  of  tumours,  the 
catheter  must  be  employed.  In  scirrhous 
and  cancerous  diseases  of  the  uterus,  also, 
this  instrument  is  the  only  means  of  re- 
lieving the  retention  of  urine,  as  nature  and 
art  can  do  little  for  the  removal  of  the  cause. 
It  ought  to  be  known,  however,  that  as 
these  last  diseases  increase,  an  incontinence 
often  succeeds  to  a retention  of  urine,  in 
consequence  of  ulceration  taking  place  be  - 
tween the  upper  surface  of  the  vagina  and 
the  lower  part  of  the  bl&dder. 

8.  Retention  of  Urine  from  pressure  of  the 
Rectum  upon  the  Keck  of  the  Bladder.  Ab- 
scesses in  the  vicinity  of  this  intestine,  he- 
morrhoidal tumours,  alvine  concretions, and 
the  scirrho-contracted  state  of  the  gut,  he. 
may  bring  on  a retention  of  the  urine  by 
pressure  on  the  neck  of  the  bladder.  I he 
irritation,  also,  existing  in  these  cases,  may 
tend  to  produce  the  complaint  by  exciting 
a spasmodic  contraction  of  the  adjacent  part 
of  the  urethra.  Here  the  relief  of  the  re- 
tention of  the  urine  is  to  be  effected  by  re- 
moving. or  curing  the  other  disorder,  which 
operates  as  its  cause,  if  this  cannot  be  im- 
mediately accomplished,  the  catheter  must 
be  used,  though,  in  several  instances,  it  will 
be  better  to, avoid  even  the  irritation  of  the 
catheter,  and  try  the  effects  of  bleeding, 
the  warm  bath,  and  opium,  which  will  fre- 
quently enable  the  patient  to  make  water. 
The  last  means,  however,  will  not  suffice, 
when  the  cause  of  the  retention  is  likely  to 
continue  a long  time 


9.  Retention  of  Urine  from  Foreign  bodies 
in  the  Bladder.  Without  stopping  to  con- 
sider the  uncommon  kinds  of  retention  pro- 
duced by  carcinoma,  fungous  diseases,  and 
hydatids  in  the  bladder,  let  us  pass  on  to 
the  case,  in  which  the  urine  is  obstructed  by 
a calculus  a t the  neck  of  the  bladder.  Here 
the  patient,  by  altering  his  position,  fre- 
quently changes  the  situation  of  the  stone, 
and  is  immediately  able  to  make  water 
again.  However,  this  expedient  will  only 
procure  relief  while  the  calculus  is  loose 
in  the  cavity  of  the  bladder;  for,  after  it 
has  become  fixed  in  the  commencement  of 
the  urethra,  it  must  either  be  pushed  back 
with  a catheter,  taken  hold  of  and  brought 
out  with  the  urethra-forceps  used  by  Sir  A 
Cooper,  or  extracted  by  a kind  of  operation 
resembling  the  apparatus  minor.  See  Li- 
thotomy. 

Many  instances  of  various  kinds  of  worms 
in  the  bladder  are  upon  record.  On  this 
subject,  an  interesting  paper  w7as  published 
a few'  years  ago,  by  my  friend  Mr.  Law- 
rence, who  met  with  an  example,  in  which 
an  undescribed  species  of  worms  was  abun- 
dantly voided  from  the  bladder.  “ The  ori- 
gin of  those  animals  (says  Mr.  Lawrence) 
w hich  inhabit  the  internal  parts  of  living 
bodies,  is  involved  in  much  obscurity.  Al- 
though the  intestinal  w orms  appear  manifest- 
ly, from  their  peculiar  form,  consistence,  and 
organs,  to  be  particularly  designed  for  those 
situations  in  w hich  they  are  found  ; although 
they  have  generative  organs,  and  no  similar 
animals  are  knowrn  to  exist  out  of  living 
bodies,  yet  it  has  been  generally  conceived, 
thatthe  germs,  from  which  they  spring,  enter 
from  the  mouth.  The  production  of  hyda- 
tids in  various  parts  of  the  body,  cannot 
however,  be  accounted  for  on  such  a suppo- 
sition ; neither  can  wfe  very  easily  conceive 
that  ova  should  enter  from  without  into  the 
urinary  organs.”  The  following  facts,  also 
stated  by  Goeze  (as  Mr  Lawrence  observes,) 
entirely  overturn  this  opinion.  Professor 
Brendel,  of  Gottingen,  found  ascarides  in 
the  rectum  of  an  immature  embryo.  Blit 
menbach  discovered  tmniae  in  the  intestinal 
canal  of  young  dogs  a few  hours  alter  birth, 
he.  ( Vermch  einer  Katurgeschichte  der  Ein - 
geiveidewurmer , p.  55.)  The  case,  w7hich 
Mr.  Lawrence  has  recorded,  exhibits  an  un- 
questionable instance  of  peculiar  and  unde 
scribed  worms,  voided  from  the  urinary 
passages.  This  gentleman  says,  that  he 
knows  cf  no  other  case,  in  which  a distinct 
species  of  wrorm  has  been  clearly  proved  to 
come  from  the  bladder.  Most  of  the  cases 
published  were  instances  of  common  intes- 
tinal round  worms,  which  sometimes  perfo- 
rate the  intestines  and  are  discharged  by 
abscesses,  or  get  into  the  bladder,  after  the 
formation  of  adhesions  betwixt  this  organ 
and  the  bowels.  In  other  instances,  coag 
ula  of  blood,  mucus,  or  portions  of  the  mu- 
cous coat  of  the  bladder,  have  been  mista- 
ken for  worms  ; and  as  Mr  Lawrence  fur- 
ther observes,  some  of  the  descriptions  can 
apply  only  to  larva*  of  insects.  Two  spe 
cjmens  of  this  last  sort,  he  has  seen  himself. 


URINE*  RETE 

which  were  sent  trorn  the  country  as  worms 
voided  from  the  bladder.  (See  Medico- 
Chir.  Trans,  vol.  2,  p.  382,  fyc.) 

In  whatever  way  these  animals  get  into 
the  bladder,  a retention  of  urine  may  be 
produced,  either  when  they  are  numerous, 
or  when  there  is  only  one  present,  but  large 
enough  to  obstruct  the  vesical  orifice  ot  the 
urethra.  In  the  very  curious  example  rela- 
ted by  Mr.  Lawrence,  the  passage  of  the 
urine  was  obstructed,  and  the  use  of  the  ca- 
theter continually  necessary.  'Jhe  oil  of 
turpentine  was  given  internally,  with  some 
appearance  of  benefit  at  first ; but,  it  after- 
ward brought  on  febrile  symptoms  and  ery- 
sipelas, and  its  exhibition  could  not  be  kept 
up.  It  was  then  injected  into  the  bladder, 
with  an  equal  part  of  water.  This  . rather 
accelerated  the  discharge  of  the  worms  ; but 
they  came  away  at  times,  whether  the 
injection  was  used  or  not,  and  as  this  means 
produced  the  erysipelatous  indisposition 
again,  it  was  left  off.  Olive  oil  was  after- 
ward injected ; the  irritation  after  it  was 
less,  and  the  fits  of  pain  about  the  bladder 
less  violent.  It  was  calculated  that  at  the 
time  when  Mr.  Lawrence  was  writing  the 
particulars  of  the  case,  from  800  to  1000 
worms  had  been  discharged.  For  a detail 
of  the  symptoms,  and  a particular  descrip- 
tion of  the  worms  themselves,  we  must  re- 
fer to  the  above-mentioned  publication. 

According  to  the  observations  of  Desault, 
a retention  of  urine  is  frequently  occasioned 
by  coagula  of  biood  in  the  bladder.  The 
blood  is  said  sometimes  to  come  from  the 
kidneys,  sometimes  from  the  bladder,  and 
sometimes  it  even  regurgitates  from  the  ure- 
thra. While  fluid,  it  may  be  expelled  with 
the  urine  ; but,  when  coagulated,  it  is  no 
longer  capable  of  being  discharged.  It  is 
the  blood,  w hich  passes  into  the  bladder,  af- 
ter wrounds,  or  the  operation  of  lithotomy, 
that  is  most  disposed  to  coagulate.  If  the 
clots  were  too  large  to  pass  through  a cathe- 
ter, the  best  plan  would  be  to  inject  into 
the  bladder  lukewarm  water,  for  the  purpose 
of  loosening  and  dissolving  them. 

A retention  of  urine,  has  sometimes  arisen 
from  the  entrance  of  a piece  of  bougie  into 
the  bladder.  Even  whole  bougies,  which 
had  not  been  properly  secured,  have  been 
knownto  glide  into  the  cavity  of  that  organ. 

As  Desault  observes,  the  urethra  appears  to 
possess  a kind  of  antiperistaltic  action,  by 
which  it  tends  to  draw  into  the  bladder 
whatever  substances  it  includes  ; for,  says 
he,  it  is  constantly  noticed,  that  when  these 
substances  are  once  within  the  urethra,  if 
they  be  not  expelled  by  the  urine,  they  al- 
ways advance  towards  the  bladder ; a cir- 
cumstance which  cannot  be  accounted  for 
by  their  weight. 

The  insinuation  of  these  foreign  bodies 
into  the  bladder  is  a serious  occurrence 
both  for  the  patient  and  surgeon.  The  for- 
mer cannot  avoid  the  consequence  which 
will  sooner  or  later  originate  from  the  ex- 
traneous substance,  except  bv  submitting  to 
a dangerous  and  painful  operation  : the  lat- 
ter will  be  accused  of  being  the  author  of 


NT  ION  OF.  S7 

all  the  evil,  and  will  find  ii  uitticull  to  excul 
pate  himself.  In  order  to  obviate  the  neces 
sity  of  cutting  into  the  bladder,  in  such  cases, 
Desault,. proposed  the  use  of  small  spring 
forceps,  passed  into  the  bladder  through  a 
cannula,  hut,  although  the  instrument  seem- 
ed to  answer  on  the  dead  subject,  no  instan 
ces  of  its  doing  so  on  living  patients  are 
on  record.  Were  any  instrument  likely  to 
succeed,  1 think  it  would  be  the  urethra- 
forceps,  shaped  like  a sound,  employed  by 
Sir  A.  Cooper  for  the  extraction  of  small 
calcuii  from  the  bladder.  (See  Lithotomy 
and  Urinary  Calculi. 

10.  Retention  of  urine  from  Inflammation 
of  the  Urethra.  In  order  to  comprehend 
the  mechanism  of  this  case,  it  is  neces 
sary  to  remember,  that  inflammation  never 
exists,  without  swelling,  and  that  every 
tumefaction  of  the  lining  of  the  urethra, 
must  necessarily  lessen  its  diameter.  In- 
flammation of  the  urethra  is  most  common- 
ly produced  by  the  external  application,  or 
internal  exhibition,  of  lyttae  ; by  gonorrhoea ; 
the  unskilful  use  of  the  catheter;  the  em- 
ployment stimulating  injections;  bougies; 
& c.  Together  with  the  lessening  of  the  ca- 
nal by  the  effect  of  swelling,  there  can  also 
be  no  doubt,  that,  in  many  of  these  instan 
ces,  a spasmodic  contraction  of  the  urethra 
and  neck  of  the  bladder  also  contributes  to 
the  retention  of  urine.  Although  Desault 
believed  that  inflamed  parts,  endued  with  a 
contractile  power,  were  not  disposed  to  con- 
tract in  that  state,  yet,  it  should  be  recollect- 
ed, that  even  admitting  this  to  be  true,  the 
whole  length  of  the  urethra  is  seldom  in- 
flamed, and  a part  of  it  may  therefore  be  af- 
fected with  a spasmodic, action,  without  the 
theory  espoused  by  Desault  being  at  all  im- 
plicated. The  effects  of  opium,  tobacco, 
and  other  antispasrnodics,  often  evinced  in 
immediately  relieving  these  kinds  of  reten- 
tion of  urine,  seem  indeed  to  leave  no  doubt 
respecting  the  existence  of  a sort  of  spasm 
in  the  passage.  Whatever  may  be  the  cause 
of  inflammation  of  the  urethra,  the  diagno- 
sis is  free  from  all  obscurity.  Besides  the 
general  symptoms  of  inflammation,  the  pa- 
tient complains  of  a scalding  sensation  in 
the  passage  : he  experiences  a great  deal  of 
smarting,  which  is  sometimes  insupportable, 
when  he  makes  water;  the  penis  becomes 
,in  some  degree  swollen,  and  more  tender; 
and  a very  little  pressure  on  the  urethra 
gives  acute  pain.  In  the  mean  time,  the 
stream  of  urine  becomes  lessened  ; and,  at 
length,  this  fluid  can  only  be  voided  in  a 
very  narrow  current,  or  only  by  drops,  and 
often  not  at  all. 

The  disorder  is  to  be  treated  on  antiphlo  - 
gistic principles.  Diluting,  cooling,  mucila- 
ginous, beverages  ; venesection  ; leeches  to 
the  perinauim ; the  warm  bath ; opium, 
particularly  in  the  torm  of  clysters,  and  fo- 
mentations, are  the  means  which  usually 
give  relief.  When  inflammation  exists  in 
the  urethra,  it  is  always  desirable  to  avoid, 
as  long  as  possible,  the  employment  of  ca- 
theters, which  create  irritation,  and  of  course 
increase  the  cause  of  the  retention,  It  is 


URINE,  RETENTION  Oi 


o7cl 

particularly,  in  cases  of  this  description, 
ati<}  in  the  retentions  of  urine,  arising  irom 
strictures,  that  Mr.  Earle  has  suggested  the 
use  of  tobacco  in  the  form  of  clysters ; a 
method,  deserving  adoption  when  the  means 
above  enumerated  are  unavailing,  and  it  is 
preferable  to  the  catheter,  because  it  does 
not  cause  any  increase  of  irritation  and  in* 
flammatioq  in  the  urethra.  (See  Med.  Chir. 
Trans,  vol.  G,p-  82,  fyc-) 

11.  Retention  of  Urine  from  Laceration  of 
the  Urethra,  The  urethra  is  sometime'  rup- 
tured bv  violent  contusions  on  the  perinaeum , 
and  the  rough  and  unskiuul  use  of  bougies  and 
catheters.  The  consequences  usually  are, 
an  extravasation  of  urine  in  the  cellul  r mem- 
brane of  the  scrotum  and  penis  ; a conside- 
rable dark-coloured  swelling  ot  these  parts, 
often  followed  by  sloughing;  and  retention 
of  urine.  The  treatment  consists  in  in  re- 
ducing an  elastic  gum  catheter  into  the  blad- 
der. with  as  little  delay  as  possible,  and 
keening  it  there  until  the  breach  in  the  canal 
j3  repaired.  At  the  «ame  time,  the  evils 
threatened  from  the  effusion  of  the  urine  are 
to  be  lessened  as  much  as  possible,  by  ma- 
king two  or  three  free  incisions  in  a depend- 
ing part  of  the  swelling,  and  the  employ- 
ment of  fomentations,  and  antiphlogistic  re- 
medies. 

12.  Retention  of  Urine  from  Tumours  silu- 
ated  in  the  Perinaeum,  Scrotum,  or  Penis.  A 
retention  of  urine  has  been  known  to  arise 
from  phlegmonous  swellings  and  abscesses  ; 
extravasations  of  blood;  and  urinary  tu- 
mours and  calculi  formed  in  the  perineum  and 
scrotum  ; also  from  the  pressure  of  a sarco- 
cele  ; hydrocele : a very  large  scrota!  her- 
nia : an  aneurism  of  the  corpus  cavernosum  ; 
a ligature  on  the  penis  ; &c. 

The  radical  cure  of  all  such  retentions  oi 
urine  can  only  be  accomplished  by  curing 
the  disease,  on  which  they  are  dependent. 
However,  until  the  cause  can  be  obviated, 
the  urine  must  be  drawn  off  with  a catheter. 
Elastic  gum-catheters  usually  enter  more 
easiiy  than  those  made  of  silver,  as  by  their 
flexibility  they  accommodate  themselves  bet- 
ter lo  any  deviation  of  the  urethra  from  its 
ordinary  direction.  Desault  particularly  re- 
commended a catheter  of  middling  size  to 
be  selected,  and  introduced,  armed  with  its 
stilet,  until  is  stops  in  the  canal ; when  he 
advised  withdrawing  the  stilet  for  about  an 
inch  in  order  to  leave  the  beak  of  the  instill- 
ment quite  free,  so  that  it  may  follow  the 
curve  of  the  urethra.  Then  the  tube  and  the 
stilet  are  to  be  pushed  further  into  the  canal, 
care  being  taken,  however,  to  keep  the  stilet 
drawn  back  some  distance  irom  the  extremi- 
ty of  the  instrument.  By  these  precautions, 
says  Desault,  the  catheter  may  always  be 
pot  into  the  bladder.  Should  the  introduc- 
tion prove  neither  painful  nor  difficult,  De- 
sault thought  it  belter  not  to  annoy  the  pa- 
tient by  making  him  continually  wear  the 

instrument 

13  Retention  of  Uyfne  from Disease  of  the 
Prostate  Gland.  As  a great  deal  lias  been 
mu}  concerning  this  case  in  aforegoing  arti- 


cle, (see  Prostate  Gland,)  1 shall  not  here  tie 
tain  the  reader  long  upon  the  subject. 

When  the  swelling  of  the  prostate  gland 
is  of  an  inflammatory  kind,  the  retention  of  f 
urine  makes  its  appearance  with  the  same 
kind  of  symptoms  as  attend  inflammation 
about  the  neck  of  the  bladder. 

Here  similar  treatment  to  that  commonly 
adopted  for  the  retention  of  urine  produced 
in  the  latter  ca-se,  is  indicated  ; particularly 
bleeding,  fomentations,  the  warm  bath  open- 
ing medicines,  anodyne  clysters,  the  tinctura 
ferri  muriati,  and  in  very  obstinate  urgent 
cases,  an  enema  of  lobacco.  If  these  means 
fail,  the  surgeon  may  gently  endeavour  to 
introduce  an  elastic  gum  catheter. 

The  symptoms  of  the  retention  of  urine, 
caused  by  chronic  enlargement  of  the  pros- 
tate gland,  and  the  reason  of  the  impediment 
to  the  discharge  of  that  fluid  in  such  a case, 
are  explained  in  another  part  of  this  work. 
(See  p.  378,  fyc.  Vol.  2.)  From  the  remarks 
there  introduced,  it  appears,  that  when  the 
regular  evacuation  of  the  urine  begins  to  be 
impeded,  the  catheter  becomes  indispen- 
sable, though  the  surgeon  will  often  be 
foiled  in  his  endeavour  to  draw  off  the  urine 
with  it  unless  he  be  duly  acquainted  with 
the  morbid  changes  produced  in  the  parts. 
And,  as  Sabatier  long  ago  very  correctly- 
observed,  the  urine  may  not  be  discharged 
though  the  instrument  enter  a considerable 
way,  either  because  its  beak  becomes  en- 
tangled in  the  prostate  gland,  or  between  a 
swollen  portion  of  ilvs  gland  and  the  neck  of 
the  bladder . and  does  not  reach  the  urine. 
Hence  Sabatier  recommended  the  employ- 
ment of  a catheter  with  a very  long  beak, 
which  should  also  be  bent  considerably  up- 
wards. When,  however,  all  efforts  to  pass 
a catheter  fail,  the  only  resources  are  to 
force  a passage  with  a conical  catheter,  as 
explained  in  Vol.  1,  or  to  puncture  the  blad- 
der above  the  pubes.  (See  Bladder , Punc- 
ture of.)  In  this  case,  the  operation  should 
never  be  done  through  the  perinamm  or 
rectum,  as  the  great  size  which  the  diseased 
prostate  gland 'sometimes  attains,  would  be 
an  obstacle  to  making  a puncture  in  either 
of  these  situations.  Puncturing  the  bladder, 
however,  is  only  a temporary  means  of  re- 
lief; and  until  a catheter  can  be  passed 
quite  into  the  bladder,  the  cannula  of  the 
trocar  should  not  be  withdrawn. 

The  objections  to  leaving  the  cannula  in 
the  wound  any  considerable  time,  are  the 
irritation  of  the  extraneous  body  ; the  fear 
of  calculous  incrustations  lorming  both  on 
the  outside  and  inside  of  the  cannula  ; and 
the  hazard  of  not  being  able  to  find  the 
track  into  the  bladder  again,  if  the  instru- 
ment were  taken  out  for  the  purpose  ol 
being  cleaned.  However,  Sabatier  approves 
of  the  practice  under  the  foregoing  circum- 
stances. And  Colot  adduces  two  instances 
in  which  it  proved  very  serviceable  Sa- 
batier also  refers  to  another  example  of  simi- 
lar success,  related  in  the  thesis  by  Murray. 
When  Dr.  Murray  saw  the  patient,  the  can- 
nula had  been  worn  more  than  a year,  lhc 
patient  was  sixty  years  of  age.  and  enjoyed 


URINE,  RETENTION  OF. 


677 


very  good  health.  He  was  in  the  habit  of 
taking  a stopper  out  of  the  cannula  every 
four  hours.  The  wound  had  healed  very 
well  all  round  the  tube,  and  was  quite  free 
from  redness.  ( Sabatier , Medecine  Opkra- 
toire,  T.  2,  p.  140.)  For  further  observa- 
tions, see  Catheter  and  Prostate  Gland. 

14.  Of  the  Retention  of  Urine  produced 
hy  Strictures  in  the  Urethra.  From  the  ac- 
count, which  is  given  of  strictures  in  ano- 
ther part  of  this  Dictionary,  (see  Urethra , 
Strictures  of,\  it  appears  that  almost  every 
stricture,  bad  as  it  may  be,  is  capable  of 
being  rendered  still  worse,  and  the  morbid 
part  of  the  urethra  more  impervious  by  a 
spasmodic  affection.  Going  out  of  a warm 
into  a cold  situation,  drinking,  and  other 
kinds  of  intemperance,  will  often  bring  on 
an  irritable  state  of  the  canal,  attended  with 
a spasmodic  action  of  the  strictured  part, 
an  increased  difficulty  of  voiding  the  urine, 
and  even  a total  retention  of  this  fluid. 
The  patient  makes  repeated  efforts  to  re- 
lieve himself ; but  hardly  a drop  of  urine  is 
discharged.  In  the  meanwhile  the  bladder 
becomes  filled,  and  ascends  above  the 
pubes  ; the  abdomen  grows  tense  and  pain- 
ful; fever  comes  on;  the  countenance 
looks  red  ; the  brain  becomes  affected  ; and 
circumstances  assume  an  extremely  urgent 
appearance. 

In  this  case,  antiphlogistic  means  should 
be  adopted  without  delay.  The  patient 
ought  to  be  bled,  if  nothing  in  his  constitu- 
tion and  age  prohibit  this  evacuation,  which 
it  may  even  be  proper  to  repeat.  He  should 
also  be  put  into  the  warm  bath,  and  fomen- 
tations should  be  continually  applied  to  the 
hypogastric  region.  Slightly  diuretic  beve- 
rages may  be  prescribed,  and  leeches  put 
on  the  perinaeum.  The  principal  means, 
however,  from  which  the  greatest  benefit 
may  be  expected,  is  a liberal  dose  of  the 
tinctura  opii,  together  with  an  anodyne 
glyster.  This  is  also  another  example,  for 
which  Mr.  Earle  has  particularly  recom- 
mended the  exhibition  of  tobacco  in  the 
form  of  a clyster ; and  he  has  related  a 
case  in  illustration  of  the  efficacy  of  the 
plan.  (See  Medico- Chir.  Trans.  Vol.  6,  p. 
88.)  The  tinctura  ferri  muriati,  which,  ac- 
cording to  Mr.  Cline,  has  a specific  effect  in 
overcoming  spasm  of  the  urethra,  seems 
also  worthy  of  trial.  Indeed  it  should  al- 
ways be  tried  before  tobacco,  which  being 
sometimes  violent  in  its  effects,  ought  per- 
haps to  be  the  last  resource  in  the  way  of 
medicines.  When  such  measures  fail  in 
enabling  the  patient  to  empty  his  bladder, 
and  this  viscus  is  becoming  more  and  more 
distended,  an  immediate  attempt  should  be 
made  to  introduce  a small  flexible  elastic 
gum-catheter  through  the  stricture  or  stric- 
tures into  the  bladder,  which  object  may 
be  frequently  accomplished,  when  due  care, 
perseverance,  and  geritleness,  are  not  ne- 
glected. 

Sometimes  when  a small  flexible  catheter 
cannot  be  introduced,  a fine  bougie  admits 
of  being  passed  into  the  bladder,  and  on 
Vol,  II  ' 73 


being  withdrawn,  the  urine  follows,  and  is 
discharged. 

VVhen  all  the  preceding  plans  prove  un- 
availing, and  the  danger  arising  from  the 
retention  of  urine  continues  to  increase, 
either  the  stricture  must  be  forced  with  the 
conical  sound,  an  incision  practised  behind 
the  obstruction,  or  the  bladder  punctured 
Ihe  cannula  of  the  trocar  should  then  be 
left  in  the  wound  till  the  strictures  are 
either  cured,  or  at  least  till  the  urine  re- 
sumes its  natural  course. 

15.  Retention  of  Urine  from  the  Lodgment 
of  Foreign  Bodies  in  the  Urethra.  That  such 
accident  must  obstruct  the  discharge  of 
urine  is  too  plain  to  heed  any  particular  ex- 
planation. Calculi  are  the  most  common 
substances  which  bring  on  this  kind  of  case  ; 
but  articles,  introduced  into  the  urethra 
from  without,  such  as  bougies,  large  pins, 
&c.  are  occasionally  lodged  in  the  passage  ; 
and  I opce  extracted  from  a man’s  urethra 
a long  black  pin,  with  which  he  had  been 
examining  the  passage.  The  head  of  it  was 
towards  the  perinajuin,  and  the  point  about 
two  inches  from  the  orifice  of  the  glans.  1 
passed  the  point  through  the  lower  surface 
of  the  urethra,  and  then  taking  hold  of  it, 
drew  it  further  out,  turned  the  head  towards 
Ihe  glans,  from  the  orifice  of  which  it  was 
then  easily  removed.  When  substances 
like  calculi  lodge,  oily  injections  are  some- 
times tried  with  the  view  of  rendering  the 
passage  more  slippery ; and  occasionally 
the  dilatation  of  the  canal  with  bougies  or 
catheters,  followed  by  a very  forcible  ex- 
pulsion of  the  urine,  has  answered.  The 
ancients  sometimes  tried  the  effect  of  suc- 
tion. When  the  foreign  body  is  closely 
embraced  by  the  urethra,  and  it  cannot  be 
pushed  forward  with  the  fingers,  Desault  re- 
commends endeavouring  to  extract  it  with 
the  forceps,  invented  for  the  purpose  by 
Mr.  Hunter,  and  wffiich  are  contained  in  a 
cannula  ; or  the  urethra  forceps,  spoken  of 
in  the  articles  Lithotomy  and  Urinary  Calculi 
might  be  employed.  When,  however,  the 
foreign  body  is  too  large  to  be  taken  out  its 
this  manner,  it  must  be  extracted  by  an  in- 
cision. If  an  elastic  catheter  be  now  kept 
in  the  urethra,  so  as  to  prevent  the  urine 
from  coming  into  contact  with  the  cut  part, 
the  wound  will  heal  very  well.  Some  time 
ago  there  was  published  a case  of  calculus 
in  the  urethra,  attended  with  dysury,  where 
almost  instantaneous  relief  was  obtained 
from  the  exhibition  of  a tobacco  clyster. 
The  patient  soon  felt  a strong  desire  to  void 
his  urine;  and  “ upon  making  the  attempt, 
a large  calculus  came  rolling  along  the 
urethra,  with  complete  relief  of  all  his  com- 
plaints.” (See  Edinb.  Med.  and  Surg.  Jour- 
nal. Vol.  12,  p.  373.) 

Fr.  M.  Colot,  Trait6  de  V Operation  de  la 
Taille  ; avec  dts  Obs.  sur  la  Formation  de  la 
Pierre , et  les  Suppressions  de  V Urine,  fyc. 
12 mo.  Paris,  1727-  Sabatier,  De  la  M6de- 
cine  OpAratoire,  T.  2.  C.  B.  Trye,  Remarks 
on  Morbid  Retentions  of  Urine,  2d  Ed.  <vo. 
Gloucester,  1784.  Hey’s  Practical  Observa- 
tions in  Surgery.  Schreger  Chirurgische  Ver* 


07S ! UTERUS,  INVERSION  01 


s uche,  p.  187,  tyc.  der  Ischuria  Calculosa , 
8vo.  JV  urnberg,  1811.  Desault's  Parisian 
Chirurgical  Journal.  S.  T.  Summering,  Ab- 
handlung  iiber  die  schnell  und  larigsam  todl- 
lichen  Kranhheiten  der  Harnblase  und  Ham - 
rohre  hey  Mamurn  in  hohen  Alter.  4td. 
Frank.  1809.  Richter , Anfangsrunde  der 
JVundarzneykunst , B.  6,  p.  210,  fyc.  (Envies 
Chir.  de  Desault  par  Bichat,  T.  3.  Desault 
et  Chop  art,  Trait6  des  Maladies  des  Voies 
Urinaires,  8 vo.  1796.  JVauche,  JVouvelles  lie- 
cherches  sur  les  Retentions  d'  Urine  par  Retre- 
cissement  de  VUretre,  el  par  Paralysie  de  la 
Vessie,  tyc.  8 vo.  Paris,  1806.  Home's  Prac- 
tical Observations  »n  the  Treatment  of  Stric- 
tures, tyc.  3 vols.  and  on  Diseases  of  the  Pros- 
tate Gland,  2 vols.  8ro.  Land.  1811 — 1818. 
H.  Earle,  in  Medico- Chir.  Trans.  Vol.  6,  p. 
82,  fyc. 

UTERUS,  INVERSION  OF.  This  case 
may  either  be  complete  or  incomplete. 
When  it  is  incomplete,  only  the  fundus  of 
the  uterus  passes  through  the  os  tincse. 
When  the  inversion  is  complete,  4he  uterus 
becomes  entirely  turned  inside  out,  passing 
through  the  opening  in  its  cervix,  dragging 
along  with  it  a part  of  the  vagina,  and  de- 
scending more  or  less  far  down,  sometimes 
even  between  the  patient’s  thighs. 

The  inversion  of  the  uterus  mostly  arises 
from  the  manner  in  which  the  placenta  is 
extracted  after  delivery.  Immediately  after 
parturition,  the  uterus  is  not  yet  contracted, 
and  its  cervix  is  in  a widened  state.  When 
things  are  thus  disposed,  the  uterus  may 
easily  follow  the  after-birth,  which  is  attach- 
ed to  it,  and  thus  become  inverted.  The 
event  is  particularly  liable  to  happen.  1st, 
When  a premature  attempt  is  made  to  ex- 
tract the  placenta.  2dly,  When  the  funis  is 
pulled  outward,  without  due  care  being  ta- 
ken to  support  the  uterus  with  the  fingers  of 
the  left  band.  3dly,  When  the  operator 
draws  out  the  after  birth  too  roughly  and 
violently.  Though  the  placenta  is  some- 
times so  adherent  that  its  extraction  is  diffi- 
cult, and  a risk  must  be  encountered  of 
dragging  down  the  uterus  with  it,  this  dis- 
agreeable accident  may  generally  be  avoided 
by  performing  the  necessary  separation  of 
the  parts  with  the  fingers  introduced  into 
the  cavity  of  the  uterus. 

The  inversion,  following  delivery,  does 
not  always  proceed  from  unskilfulness ; but 
sometimes  happens,  notwithstanding  every 
precaution,  either  because  the  patients 
themselves  make  too  violent  efforts,  or  be- 
cause the  uterus  is  enlarged  and  heavy  ; or 
else  in  consequence  of  some  predisposition, 
some  unusual  laxity  of  the  organ,  which  can 
neither  be  foreseen  nor  prevented.  Ruysch 
saw  an  inversion  of  the  uterus  take  place, 
after  the  expulsion  of  the  placenta,  although 
delivery  had  occurred  in  the  most  favour- 
able way. 

Mr.  Windsor  believes,  that  where  the 
Vii crus  and  vagina  are  in  a relaxed  state, 
and  the  female  has  been  subject  to  prolapsus 
uteri,  there  is  a greater  disposition  to  the 
occurrence  of  inversion,  at  the  lime  »*f  la- 


bour, than  when  such  condition  of  the  part? 
does  not  exist.  (Med.  Chir.  Trans.  Vol.  10, 

p.  360.) 

A tendency  to  the  accident  is  very  com 
mon  in  women  who  have  once  been  afflict- 
ed with  it.  Amaud  mentions  a woman, 
who  had  an  inversion  of  the  uterus  after  her 
first  delivery,  but  the  part  was  reduced. 
She  was  attended  by  Amand  again  in  her 
next  confinement ; and  another  inversion 
of  the  uterus,  quite  as  bad  as  the  first,  would 
have  happened,  had  not  he,  on  perceiving 
the  disposition  to  the  accident,*  introduced 
his  finger  into  the  cavity  of  the  uterus,  and 
separated  the  placenta  from  its  attachments, 
before  making  any  attempt  to  extract  it. 

Besides  causes,  connected  with  parturi- 
tion, there  are  others  of  a different  nature 
Ruysch,  Mauriceau  and  Lamotte,  supposed 
an  inversion  of  the  uterus  could  only  happen 
at  the  time  when  the  placenta  was  extract- 
ed, or  a little  while  afterward.  The  acci 
dent  seemed  to  them  impossible  at  any 
other  period,  both  on  account  of  the  thick- 
ness of  the  uterus,  and  the  smallness  of  the 
os  tincae.  However,  many  facts  prove  that 
the  case  may  also  depend  on  internal 
causes,  and  affect  women  who  have  never 
had  children,  as  well  as  others  who  have 
had  them.  Thus  polypi  of  the  uterus  may 
bring  on  inversion  of  the  part.  As  their 
pedicle  is  attached  to  the  fundus  of  the 
uterus,  they  may  easily  drag  it  downward 
when  its  texture  is  lax  and  soft,  particular- 
ly as  the  operation  of  their  weight  is  conti- 
nual. (See  Denman  s Plates  of  a Polypus 
with  an  Inversion  of  the  Uterus.  Fol.  1801.) 
Uterine  hemorrhages  may  also  be  conducive 
to  the  accident,  both  because  they  relax  the 
texture  of  the  uterus,  and  because  they  are 
usually  attend'd  with  acute  pain,  which 
makes  the  diaphragm  and  abdominal  mus- 
cles act  upon  the  uterus  with  all  then- 
power. 

Levret  speaks  of  a case  of  inversion  of 
the  uterus,  where  the  displacement  was  not 
noticed  until  five  years  after  delivery.  In 
this  example,  it  is  conjectured  that  the  very 
gradual  and  slow  formation  of  the  disease 
must  have  been  the  reason  of  its  not  having 
attracted  earlier  attention.  (Did.  des  Sci- 
ences Mid  T.  23,  p.  288.  Also  Baudelocqve, 
in  Brogniard,  Bulletin  des  Sciences,  2,  JV.  1.) 

When  an  inversion  of  the  uterus  takes 
place  after  delivery,  there  are  certain  symp- 
toms by  which  it  may  easily  be  known 
The  uterus,  in  its  natural  situation,  thicken- 
ed and  swelled  as  it  is  at  this  period,  pre- 
sents itself  in  the  hypogastric  region  in  the 
form  of  a round  circumscribed  tumour  ; but 
when  it  has  fallen  downward,  and  become 
inverted,  a vacancy  is  felt  in  the  situation 
which  it  ought  to'  occupy.  When  the  in- 
version is  incomplete,  an  examination  with 
the  fingers  detects  in  the  vagina  a tumour, 
shapen  like  the  segment  of  a sphere,  having 
a smooth  surface,  and  being  surrounded 
with  the  cervix  uteri,  as  with  a kind  of  col- 
lar, round  which  the  finger  may  easily  be 
passed,  either  between  it  and  the  utems,  or 
between  it  and  the  vagina  When  the  in- 


UTERUS,  INVERSION  OF 


version  is  complete,  which  case  is  more 
rare  than  the  preceding,  a tfcmour  may  be 
felt  in  the  vagina,  from  which  it  sometimes 
even  protrudes,  apt  to  bleed,  of  an  irregu- 
larly round  shape,  hanging  by  a neck,  the 
lower  part  of  which  is  surrounded  by  the 
above  circular,  thick,  fles.hy  substance,  con- 
sisting of  the  os  uteri  itself.  The  slightest 
touch  makes  the  swelling  bleed.  The  part 
has  a red  colour,  which,  however,  generally 
diminishes  in  proportion  to  the  duration  of 
the  displacement.  In  lime,  indeed,  its  sur- 
face becomes  less  sensible  to  external  im- 
pressions, and  only  bleeds  at  the  menstrual 
periods,  the  blood  oozing  from  every  point 
of  the  swelling,  and  not  issuing  from  a sin- 
gle aperture  at  the  lower  part  of  the  tumour, 
as  in  cases  of  prolapsus  uteri. 

In  the  incomplete  inversion,  patients  feel 
acute  pain  in  the  groins  and  kidneys,  an 
oppressive  sense  of  heaviness  in  the  hypo- 
gastric region,  and  a tenesmus,  which,  com- 
pelling them  to  make  violent  efforts,  forces 
the  uterus  further  down,  and'sometimes  pro 
duces  a total  inversion  of  it.  Besides  these 
symptoms,  more  or  less  copious  hemor- 
rhages also  occur.  When  the  inversion  is 
complete,  the  pain  is  more  acute,  the  loss 
of  blood  more  considerable,  and  the  patient 
often  affected  with  peculiar  weakness,  fol- 
lowed by  cold  sweats,  convulsions,  and  de- 
lirium. 

In  both  forms  of  the  disease,  if  the  reduc- 
tion be  not  almost  immediately  effected, 
fatal  consequences  frequently  ensue,  either 
very  soon  after  the  accident,  from  the  vio- 
lence of  the  hemorrhage,  or  at  a more  or  less 
remote  period,  partly  from  repeated  losses 
of  blood,  and  partly  from  the  constitutional 
irritation  and  disturbance  incessantly  kept 
up. 

Happily,  as  Mr.  Windsor  observes,  the 
accident  admits  of  remedy,  if  an  intelli- 
gent person  be  present  to  replace  the  uterus; 
for  if  this  be  done  immediately,  and  the 
hand  of  the  accoucheur  be  retained  in  the 
cavity  of  this  organ,  until  it  has  contracted, 
and  the  patient  afterward  confined  to  the 
recumbent  posture,  she  will  generally  do 
well.  An  unsettled  point  appears  to  be,' 
whether  the  placenta,  if  still  remaining, 
should  be  extracted  before,  or  after  the  re- 
duction. Mr.  Windsor,. w ho  appears  inclin- 
ed to  prefer  the  latter  method,  refers  to  two 
examples,  in  which  each  plan  was  followed 
by  a recovery.  (See  Med  Chir.  Trans.  Vol. 
10,  p.  360.) 

And,  in  all  cases,  as  the  same  author  re- 
marks, th^  accoucheur,  after  the  expulsion 
of  the  placenta,  should  assure  himself  by 
manual  examination,  that  the  os  internum  is 
free,  while  an  endeavour  is  made  to  feel  the 
uterus  with  the  hand  placed  upon  the  abdo- 
men. “In  consequence  of  the  neglect  of 
this  practice  (says  Mr.  Windsor)  it  is  to  be 
feared,  that  many  lives  have  been  lost ; the 
true  cause  of  the  succeeding  hemorrhage 
not  being  ascertained  till  too  late,  as  hap- 
pened in  the  fatal  case  that  occurred  to  a mid- 
wife here  (Manchester)  last  winter.”  Some 
women  perish  at  once,  or  within  a few 


hours,  and,  when  they  live  longer,  the  re- 
duction is  exceedingly  difficult,  because  the 
uterus  and  its  cervix  are  becoming  more 
and  more  contracted. 

In  the  reduction,  Sabatier  regards  the  in- 
terposition of  linen,  between  the  hands  and 
the  uterus,  as  unnecessary  and  even  disad- 
vantageous, because  it  prevents  the  practi- 
tioner from  having  the  assistance  of  a correct 
feel  of  the  part.  The  trial  should  be  conti- 
nued as  long  as  the  patient’s  strength  will 
allow.  However,  if  the  tumour  were  in  an 
inflamed  state,  it  would  be  prudent  to  put 
the  patient  in  the  warm  bath,  use  emollient 
applications,  and  exhibit  anodyne  and  laxa- 
tive medicines,  &ic. 

When  the  reduction  cannot  be  accom- 
plished, many  die,  while  others  survive, 
subject  to  an  oppressive  sensfe  of  weight, 
and  frequent  hemorrhages,  which  bring  on 
great  emaciation.  Sabatier  attended  two 
patients,  who  bad  an  inversion  of  the  ute- 
rus, six  months,  and  yet  they  were  able  to 
go  about  their  family  affairs.  The  same 
author  had  heard  of  other  women,  who 
had  been  afflicted  with  an  inversion  of  dhe 
uterus  several  years. 

If  the  reduction  cannot  be  performed, 
and  the  patient  survive  the  immediate  ef- 
fects of  the  injury,  “some  degree  of  in- 
flammatory symptoms,  accompanied  with 
fever,  ensues.  The  abdomen  becomes  full, 
tender  to  the  touch,  and,  at  its  lower  part, 
sometimes  rather  hard  There  is  costiveness 
of  the  bowels,  and  sometimes  retention  of 
urine,  requiring  for  . a time  the  use  of  the 
catheter.  By  the  use  of  fomentations, 'ene- 
mata,  laxatives,  and  an  antiphlogistic  regi- 
men. the  symptoms  abate,  the  power  of 
expelling  the  urine,  especially  if  the  uterus 
is  first  raised  a little  in  the  vagina,  is  regain- 
ed, and  the  patient  gradually  recovers  the 
full  power  of  this  function.  Afterward  she 
becomes  able  to  walk  about,  suckles  her 
infant,  and  perhaps  enjoys  apparently  even 
a tolerable  state  of  health ; yet,  the  sangui- 
neous discharges  generally  after  a time,” 
return  profusely,  and  her  pale  countenance, 
and  emaciated  appearance  indicate  the 
greatest  debility. 

“ About  the  time,  when  she  relinquishes 
the  office  of  suckling,  the  menses  return 
more  regularly,  the  discharges  of  blood  are 
very  considerable  in  quantity,  or  of  long 
duration  ; the  mucous  discharges  are  gene- 
rally copious  at  other  times  ; and  the  con- 
stitution begins  to  sink  under  the  reiterated 
losses  it  sustains.  The  pulse  becomes  fre- 
quent, the  appetite  is  impaired,  a cough, 
with  hectic  symptoms  sometimes  occurs, 
and  the  patient  is  quite  unable  to  pursue  her 
usual  domestic  duties.  In  this  state  pallia- 
tive means,  as  the  use  of  astringent  add 
other  remedies,  become  inadequate  to  check 
the  exhausted  progress  of  the  complaint, 
and  the  unfortunate  sufferer  must  soon 
perish,  unless  some  decisive  means  be  devi- 
sed for  her  relief.  In  this  painful  extremity, 
the  extirpation  of  the  uterus  itself  has  been 
proposed  - as  thcjjjatost  efficient  means  of  re- 
lief. a«nil^^||^nle  as  the  operation  at  first 


UTERUS,  INVERSION  OF. 


, ' 


view  seems,  it  is  known  to  have  been  al- 
ready performed  with  success.”  Windsor , 
in  Med.  Chir.  Trans.  VoL  10,  p.  36  i — 63.) 

One  of  the  most  afflicting  consequences 
of  an  inversion  of  the  uterus,  is  so  consi- 
derable an  inflammation  of  the  part,  as  to 
induce  a danger  of  its  mortifying.  In  this 
circumstance,  the  extirpation  of  the  uterus 
lias  been  also  suggested,  and  even  practised  ; 
an  operation  that  has  had  but  little  success, 
the  majority  of  patients  on  whom  it  has 
been  practised  under  such  circumstances 
having  died. 

The  practice,  of  extirpating  the  inverted 
uterus,  through  apprehension  of  the  part 
mortifying,  cannot  be  too  strongly  repro- 
bated ; for  unless  mortification  das  really 
happened,  the  uterus  may  possibly  be 
brought  into  a state  again,  in  which  the 
inconveniences  arising  from  its  inversion 
would  be  very  supportable,  and  the  opera- 
tion altogether  avoided.  Even  supposing 
mortification  were  to  take  place,  the  indica- 
tion would  be  to  appease  the  bad  symptoms, 
and  promote  the  separation  of  the  sloughs 
by  suitable  applications,  without  doing  any 
injury  to  the  living  parts.  One  example,  in 
which  the  latter  practice  was  successfully 
adopted,  is  recorded  by  Rousset.  That  the 
extirpation  of  the  uterus,  when  this  organ  is 
completely  or  incompletely  inverted, totally 
irreducible,  and  attended  with  the  suffer- 
ings and  reduced  health,  so  well  described 
by  Mr.  Windsor,  may  sometimes  be  advisea- 
ble,  cannot  now  be  doubted.  The  unequi- 
vocal examples  on  record  of  the  removal  of 
the  cancerous  uterus  by  Osiander,Dupuy4reii, 
Langenbeck,  and  others,  and  the  cases, 
published  by  Mr.  Newnham  and  Mr.  Wind- 
sor, wdiere  the  inverted  and  irreducible 
uterus  urns  successfully  extirpated,  furnish 
sufficient  evidence  in  favour  of  the  practice 
without  referring  to  numerous  other  cases 
reported  on  older  authorities,  the  correct- 
ness of  some  of  which  may  be  question- 
able. 

In  fact,  polypi,  growing  from  the  uterus, 
frequently  attain  so  considerable  a size,  that 
they  protrude  out  of  the  vagina,  and  are  oc- 
casionally mistaken  for  the  uterus  itself. 
The  surgeon  extirpates  the  tumour  with  a li- 
gature ; the  operation  does  not  undeceive 
him  about  the  nature  of  the  part ; his  patient 
has  a favourable  recovery  ; and  the  case  is 
published  as  an  instance  of  the  successful 
extirpation  of  the  uterus  itself. 

Although  it  is  easy  to  distinguish  the  in- 
version of  the  uterus,  which  happens  soon 
after  delivery,  it  is  not  so  to  make  out  the 
nature  of  such  cases,  as  happen  in  other 
circumstances,  notwithstandingthe  presence 
of  the  same  kind  of  symptoms.  As  cases  of 
the  latter  kind  are  uncommon,  apd,  conse- 
quently, not  expected,  mistakes  are  the 
more  liable  to  be  made.  A polypus  has 
often  been  mistaken  for  an  inversion  of  the 
uterus,  but,  it  should  be  recollected,  that 
the  upper  part  of  a polypus  is  always  nar- 
row ; and  the  tumour,  which  is  not  very 
sensible,  is  irreducible  ; wEereas^the  uterus, 
in  a state  of  irtcomplet^j^Wl^,  forms 


a semi-spherical  swelling,  sometimes  a little 
oblong,  but  always  broader  above  than  be 
low.  It  is  very  sensible,  and  may  generally 
be  reduced.  And,  when  the  itiversion  is 
complete,  the  tumour  has  a greater  resem- 
blance to  a polypus,  inasmuch  as  it  seems 
to  have  a pedicle,  but  the  impossibility  of  in- 
troducing a probe  far  at  the  circumference 
of  such  pedicle,  as  can  be  done  in  cases  of 
polypi,  will  generally  serve  at  once  as  a 
criterion  of  the  nature  ot  the  disease. 

The  greatest  obscurity  in  the  diagnosis  is 
said  to  prevail  when  the  inversion  is  partial 
and  chronic,  because  the  os  uteri  tl^en  encir- 
cles the  summit  of  the  tumour,  justasit  does 
a polypus,  and,  in  both  cases,  the  finger  will 
pass  all  round  between  the  parts.  (See 
Newnham' s Essay  on  Inversio  Uteri,  with  a 
History  of  the  successful  Extirpation  of  that 
Organ , p.  82,  8 vo.  Load.  1818.)  However, 
as  I do  not  believe  with  this  gentleman,  that 
the  neck  of  the  polypus  is  frequently  as  large, 
and  sometimes  larger,  than  its  inferior  por- 
tion, 1 should  yet  expect,  that  the  difference 
in  the  form  of  the  two  swellings,  perceptible 
on  manual  examination,  would  here  be  an 
important  criterion.  In  general,  also,  the 
fact,  that  inversion  of  the  uterus  first  hap- 
pens, at  or  soon  after  delivery,  is  a conside- 
ration, that  would  tend  to  a right  discrimi- 
nation of  the  cases,  inasmuch  as  the  first 
protrusion  of  a polypus  directly  after  delive- 
ry, is  rare,  and,  when  it  does  happen,  under 
these  circumstances,  is  probably  always  com- 
plete, and  not  partial. 

Reduction  is  the  only  plan,  whether  the 
case  has  arisen  from  the  w eight  of  a polypus 
or  trorn  uterine  hemorrhage.  However,  this 
proceeding  is  generally  useless,  when  the 
disease  originates  from  obesity.  In  the 
latter  case,  as  the  cause  still  continues  in 
full  force,  the  uterus  is  soon  displaced  again, 
and  a pessary  is  the  only  means  to  which 
the  patient  can  resort. 

Having  delivered  many  additional  obser- 
vations on  the  subject  of  inversion  of  the 
womb,  in  the  2d  vol.  of  the  First  Lines  of 
Surgery,  Ed.  4,  I shall  here  conclude  with 
referring  to  some  works,  in  which  the 
reader  will  find  valuable  instruction  on  the 
subject.  F.  B.  Wachter , de  Prolapsu  et 
Inversione  Uteri,  Tlalae,  1745.  Act.  JVaturw 
Cur.  Vol.  6,  Obs.  107,‘  uterus  feliciter  extir - 
patus.  Nauche , des  Maladies  de  i Uterus,  8vo. 
Paris,  1816.  Osiander,  Ncuc  Denkwitrdig- 
keiten,  1 B.  p.  307.  Sabatier.  Midecine 
Op6raloire,  T.  2.  Diet,  des  Sciences  Med. 
T.  23,  p.  287.  W.  Newnham , on  the  Symp- 
toms, Causes,  and  Treatment  of  Inversio 
Uteri , with  a History  of  the  successful  Extir- 
pation of  that  Organ , during  the  Chronic 
Stage  of  the  Disease,  8 vo  Land.  1818.  J. 
Windsor,  Obs.  on  Inversion  of  the  Uterus,  with 
a Case  of  successful  Extirpation  of  that  Organ, 
Med.  Chir.  Trans.  Vol  10,  p.  358.  §c.  Den- 
man's Plates  of  a Polypus,  with  an  Inversion 
of  the  Uterus',  1801.  Dr.  Bail  lie's  Series  of 
Engravings,  tyc.  Fuse.  9,  Tab.  5.  C leghorn 
in  J\1cd.  Communications , Vol.  2 ; a,  chronif 


UTERUS,  PROLAPSUS  OF 


581 

case.  E.  B.  Herzog  de  Inversionc  Uteri,  4 to.  When,  in  the  course  of  time,  a prolapsus 

Wirceb.  1817.  uteri  changes  from  the  incomplete  to  the 

UTERUS,  POLYPI  OF.  (Sc e Polypus.)  complete  state,  all  the  inconveniences  de 
UTERUS,  PROLAPSUS  OF.  The  pending  upon  the  pressure  of  the  part  upon 
womb,  situated  in  the  upper  and  middle  the  rectum  and  bladder  subside : that  is  to 
part  of  the  pelvis,  is  but  imperfectly  se-  say,  the  feces  and  urine  are  now  freely  void 
cured  in  its  natural  place  by  means  of  its  ed.  But,  on  the  other  hand,  the  symptoms 
broad  and  round  ligaments.  Hence  it  some-  arising  from  the  stretching  of  the  peritonae 
times  descends  into  the  lesser  cavity  of  the  um  become  considerably  worse.  The  ute- 
pelvis,  so  as  to  pass  more  or  less  down  the  rus  dra^s  down  with  it  the  vagina,  which 
vagina,  or  even  protrude  beyond  the  labia,  becomes  doubled  on  itself,  and  a part  of  the 
The  first  case  is  the  incomplete  ; the  second,  bladder,  connected  with  the  upper  part  of 
the  complete  prolapsus  uteri.  the  latter  tube,  is  also  drawn  down.  Some 

In  the  first  form  of  the  disease,  where  the  of  the  abdominal  viscera  may  even  fall  into 


uterus  has  not  passed  down  so  low  as  to 
protrude  externally,  some  of  the  complaints 
which  the  patient  experiences  depend  upon 
the  pressure  of  the  d isplaced  viscusupon  the 
parts  unaccustomed  to  it,  particularly  the 
bladder  and  rectum  ; while  other  inconve- 
niences arise  from  the  tension  of  the  liga- 
ments, destined  to  retain  the  organ  in  its 
natural  position.  These  last  grievances  are 
chiefly  a sense  of  heaviness  in  the  pelvis, 
and  a dragging  pain  in  the  loins  ; symptoms 
which  are  aggravated  when  the  patient  sits 
up,  or  walks  about ; but  diminish  when  she 
remains  in  bed,  though  as  the  disease,  when 
neglected,  scarcely  ever  fails  to  grow  worse, 
they  rarely  subside  altogether.  However, 
such  amendment  actually  sometimes  hap- 
pens in  consequence  of  the  parts  becoming 
gradually  habituated  to  their  change  of  si- 
tuation. When  the  disease  comes  on  with 
great  suddenness,  the  symptoms  are  re- 
marked to  be  much  more  severe  than  when 
it  takes  place  slowly.  In  the  first  case,  long- 
continued  syncope,  pain  over  the  whole 
abdomen,  tenesmus,  uterine  hemorrhage,  in- 
flammation of  the  peritonseum,  and  severe 
febrile  symptoms  may  be  excited. 

With  regard  to  the  effects,  caused  by  the 
pressure  of  the  tumour  on  the  bladder  and 
rectum,  they  consist  of  more  or  less  diffi- 
culty in  voiding  the  urine  and  feces.  The 
dysury  and  constipation  increase  in  propor- 
tion as  the  patient  continues  in  an  upright 
posture,  and  the  uterus  descends  nearer  to 
the  inferior  orifice  of  the  vagina.  Some- 
times the  irritation  brings  on  a consi- 
derable mucous  discharge,  which,  when  the 
patient  suffers  little  other  inconvenience 
from  the  prolapsus,  is  apt  to  be  mistaken 
for  fluor  albus,  or  gonorrhoea 

A woman  may  become  pregnant,  not- 
withstanding an  incomplete  prolapsus  of  the 
womb.  The  displacement  may  even  take 
place  at  a more  or  less  advanced  period  of 
gestation,  {Portal  des  Accouchemens)  while, 
in  other  still  more  uncommon  instances,  the 
prolapsus  has  been  remarked  to  disappear 
when  the  period  of  labour  drew  near.  Cases 
exemplifying  both  these  facts,  are  related 
by  Loder,  ( Journ . fiir  die  Chir.  B.  2,  p.  13,) 
by  Saviard,  Portal,  (Mem.  de  VAcad.  de 
Chir.  T.  3,)  in  the  Journ.  de  Medecine  T. 
45  , and  by  Chopart.  (Traite  des  Maladies 
des  Voies  Urinaires.)  A prolapsus  uteri  may 
also  happen  during  parturition.  {Garin, 
Journ.  de  Med.  continue,  T.  4,  p.  265 ; Du- 
creux,  Mem.  de  l’ Acad,  de  Chir.  T.  8,  p.  393.) 


the  cul-de-sac,  formed  by  the  vagina,  and 
considerably  increase  the  size  of  the  tu- 
mour. The  swelling,  protruding  between 
the  thighs,  is  of  an  oblong,  nearly  cylindri- 
cal form,  and  terminates  below  in  a narrow 
extremity,  in  which  a transverse  opening, 
the  os  tinea?,  may  be  discerned,  from  which 
the  menses  are  discharged  at  the  periods 
prescribed  by  nature.  However,  the  cylin- 
drical shape  of  the  tumour  may  lead  to  mis- 
takes, for  the  vagina,  being  doubled  on 
itself,  and  exposed  to  the  effects  of  the  air, 
sometimes  looks  like  skin.  Hence  women, 
thus  afflicted,  have  occasionally  been  sup- 
posed to  be  hermaphrodites,  the  tumour  be- 
ing mistaken  for  a penis.  ’ Such  a case  is 
recorded  by  Saviard. 

The  patient  is  generally  troubled  with 
tenesmus,  and  sometimes  feels  acute  pain 
in  the  tumour  itself,  which  is  subject  to  in- 
flame and  ulcerate,  in  consequence  of  its 
depending  posture,  the  friction  to  which  it 
is  exposed,  and  the  irritation  of  the  urine. 

The  direction  both  of  the  bladder  and 
the  urethra  becomes  horizontal,  so  tbat  the 
urine  is  thrown  forwards,  or  even  upwards, 
in  which  latter  case  it  wets  the  abdomen 
Frequently  the  bladder  cannot  be  emptied 
without  the  assistance  of  the  catheter  ; and 
sometimes  the  displaced  uterus  becomes 
affected  with  inflammation  and  swelling.  In 
many  cases  there  are  profuse  hemorrhages. 
However,  some  women  become  so  habitua- 
ted to  the  disease  that  they  hardly  seem  to 
experience  any  annoyance  from  it : when 
ever  they  are  in  the  erect  posture,  and  walk 
about,  the  womb  falls  down,  bringing  with 
it  the  vagina  ; and,  as  soon  as  they  lie  dovvn 
on  their  backs,  the  parts  as  readily  return 
into  their  natural  position  again. 

The  incomplete  prolapsus  is  alone  sub- 
ject to  any  obscurity,  which,  however,  may 
be  dispelled  by  manual  examination.  In 
this,  however,  some  precautions  are  neces- 
sary. For  instance,  as  the  womb  generally 
returns  into  Its  natural  situation  when  the 
patient  lies  down,  the  examination  should 
always  be  made  as  she  is  standing  up.  For 
the  same  reason,  if  she  is  in  the  habit  of 
lying  long  in  bed,  the  morning  is  not  the 
best  period  of  the  day  for  the  examination. 
The  practitioner  may  also  be  deceived  if  fie 
examine  the  parts  when  the  rectum  and 
bladder  are  distended  with  their  contents, 
in  which  state  the  uterus  may  be  hindered 
from  descending  as  low  as  at  other  periods. 
If  attention  be  paid  to  these  circurastan 


UTERUS,  PROLAPSUS  OF 


fibii 


ces,  an  incomplete  prolapsus  may  always 
be  distinguished  without  risk  of  error. 
However,  the  records  of  surgery  prove  that 
the  case  has  sometimes  been  mistaken  by 
the  inexperienced,  or  ignorant,  for  a poly- 
pus, and  the  part  extirpated  under  this  sup- 
position. So  serious  a blunder  will  be 
avoided,  if  care  be  taken  to  remember  that 
polypi  are  generally  softer  and  less  sensible 
than  the  uterus  ; that,  in  a case  of  prolapsus, 
the  os  tincae  is  situated  at  the  lower  part  of 
the  swelling  ; and,  that  if  by  chance  any 
resembling  aperture  should  be  met  with 
upon  the  corresponding  portion  of  a poly- 
pus, the  prolapsus  may  still  be  known  by 
the  greater  depth  to  which  a prohe  will  en- 
ter such  opening.  A polypus  of  the  uterus, 
I believe,  is  always  broadest  at  that  extre- 
mity, which  is  nearest  the  vulva  ; but  the 
womb,  in  a state  of  incomplete  prolapsus, 
forms  a tumour  which  is  narrower  below 
than  above.  With  very  few  exceptions,  the 
womb  is  likewise  reducible,  and  the  patient 
directly  afterward  feels  great  relief;  whereas 
a polypus  cannot  be  pushed  ba'qk,  and  the 
attempt,  instead  of  giving  relief,  only  in- 
creases the,  patient’s  sufferings. 

In  a complete  prolapsus,  no  doubt  can 
ever  prevail  about  the  real  nature  of  the 
case,  for  whatever  uncertainty  the  feel  of 
the  parts  may  create,  none  can  ever  remain 
when  the  swelling  is  distinctly  visible. 

Although  Mauriceau,  Saviard,  and  Monro 
have  recorded  instances  of  prolapsus  uteri 
in  maidens,  such  cases  are  exceedingly  rare. 
The  disease  is  hardly  ever  met  with,  except 
in  women  who  have  had  children,  and  ge- 
nerally in  those  who  have  borne  a great 
many.  This  particularity  is  ascribed  by 
writers  to  the  elongation  of  the  ligaments  of 
the  uterus  it)  women,  in  whom  this  organ 
has  been  repeatedly  gravid.  The  same  con- 
sideration may  also  account  for  the  fre- 
quency of  prolapsus  uteri  during  the  first 
months  subsequent  to  parturition,  especially 
as  the  womb  remains  for  some  time  after 
labour  more  enlarged  and  heavy  than  natu- 
ral. The  disease  is  more  common  in  thin 
than  fat  women,  and  is  said  often  to  take 
place  in  females  when  they  suddenly  change 
from  a fat  to  a very  emaciated  state.  The 
displacement  is  facilitated  by  jo.  capacious 
vagina,  by  a great  width  of  the  lesser  ca- 
vity of  the  pelvis,  and  the  effects  of  tedious 
and  profuse  attacks  of  fiuor  albus.  Prolap- 
sus uteri  has  also  been  brought  on  by  vio- 
lent concussions  of  the  body  ; the  protract  ed 
efforts  of  vomiting,  coughing,  or  crying, 
hard  labour,  and  lifting,  or  carrying  heavy 
burdens.  In  what  has  been  stated,  one  may 
discern  the  reason  why  the  affliction  is  so 
frequent  among  the  lower  classes  of  society, 
and  why  women,  for  a certain  time  after 
parturition,  should  avoid  an  erect  posture, 
and  every  kind  of  exertion.  In  the  treat- 
ment of  prolapsus  uteri,  there  are  two  indi- 
cations ; the  first  is  to  reduce  the  part ; and 
the  second  is  to  keep  it  from  falling  down 
again. 

In  the  incomplete  prolapsus,  the  first  in- 
dication is  very  easy  of  accomplishment  ; 


and,  indeed,  when  the  patient  is  placed  on 
her  back,  with  her  pelvis  raised  somewhat 
higher  than  her  chest,  the  utprus  often  re 
turns  of  itself  into  its  natural  situation  again. 
At  all  events,  the  reduction  may  be  imme- 
diately effected  by  pushing  the  uterus  up 
into  the  pelvis  with  the  fingers. 

More  difficulty  generally  attends  the  re- 
duction of  a complete  prolapsus  Here  the 
same  posture  is  to  be  chosen  as  in  the  for- 
mer case  ; but  the  legs  and  thighs  should  be 
bent.  The  rectum  should  also  be  first  emp- 
tied with  clysters.  Sometimes,  indeed, 
every  attempt  at  reduction  fails,  notwith- 
standing the  adoption  of  the  most  vigorous 
measures,  the  use  of  the  warm  bath,  purga- 
tives, venesection,  low  diet,  fomentations, 
&lc.  Occasionally,  the  part  is  returnecLafter 
a great  deal  of  trouble;  but,  owing  to  the 
long  altered  state  of  parts,  the  reduction 
brings  on  worse  symptoms  than  resulted 
from  the  continuance  of  the  prolapsus. 
S?jch  a case  is  recorded  by  Richter.  (Bibl. 
der.  Chir.  B.  3,  p,  141.)  The  patient’s  suf- 
ferings were  so  much  increased  by  the  re- 
duction, and  so- obstinate  a constipation 
came  on,  that  it  became  absolutely  neces- 
sary to  let  the  uterus  descend  again  In  any 
irreducible  case,  all  that  can  be  done  is  to 
support  the  swelling,  and  prevent  its  in- 
crease with  asu«pensory  bandage,  and  draw 
off  the  urine  with  a catheter  whenever  re- 
quisite. In  these  cases,  the  altered  course 
of  the  meatus  urinarius  is  to  be  remember- 
ed, and  the  catheter  directed  horizontally 
towards  the  rectum 

When  the  displaced  uterus  is  inflamed, 
and  considerably  swelled,  the  attempt  at 
reduction  should  be  preceded  by  antiphlo- 
gistic remedies,  the  patient  should  be  kept 
in  bed,  be  put  on  a low  regimen,  be  bled., 
take  purgative  medicines,  use  the  warm 
bath,  and  drink  diluent  beverages,  while 
emollient  applications  are  made  to  the  part 
itself.  This  plan  of  treatment  has  often 
been  attended  with  complete  success,  in 
cases  of  prolapsus  uteri,  of  long  standing  and 
considerable  size.  Ruysch  disapproved  of 
making  any  attempt  to  reduce  the  uterus 
while  it  was  inflamed  and  swelled.  He  also 
thought  that  the  operation  should  be  post- 
poned when  the  uterus  was  in  an  ulcerated 
state.  However,  Sabatier  rightLy  observes, 
that,  as  this  complication  is  only  accidental, 
and  merely  arises  from  the  friction  to  which 
the  tumour  is  exposed,  and  the  irritation  of 
the  urine,  the  plan  of  immediately  replacing 
the  part  cannot  be  attended  with  any  dan- 
ger. Off  the  contrary,  since  the  cause 
which  produces  and  keeps  up  the  ulceration 
will  cease,  as  soon  as- the  reduction  is  ac- 
complished, the  sores  will  heal  after  the 
uterus  is  put  into  its  natural  situation  again. 

When  a prolapsus  uteri  occurs  in  the 
early  stage  of  pregnancy,  this  state  should 
not  let  the  practitioner  neglecl  to  reduce  the 
part.  Several  instances  are  recorded,  in 
which  the  reduction  was  successfully  ac- 
complished in  pregnant  women ; and  one 
case  of  this  kind  is  reported  by  Giraud. 
( Journ . de  Mrdecine.  T 45.)  When  preg- 


UTERUS,  RETROVERSION  OF 


583 


nancy  is  tar  advanced,  or  the  disease  is  of 
long  standing,  the  reduction  is  difficult. 
Perhaps,  says  Sabatier,  it  may  be  more  pru 
dent,  in  these  circumstances,  to  let  the  ute- 
rus continue  protruded,  than  to  disturb  the 
mother  and  foetus  with  reiterated  attempts 
to  reduce  the  part.  The  uterus,  however, 
should  not  be  left  to  itself,  but  be  well  sup- 
ported with  a suitable  bandage,  and  the  pa- 
tient kept  in  bed.  When  the  prolapsus 
uteri  occurs  at  the  period  of  delivery,  every 
attempt  at  reduction  is  both  useless  and 
dangerous.  In  this  case,  the  delivery  of 
the  foetus-should  be  expedited  by  gradually 
dilating  the  os  tinea?,  which,  at  the  same 
time,  should  be  carefully  supported.  The 
extraction  of  the  placenta  also  requires  a 
great  deal  of  caution,  and  it  should  be  ac- 
complished by  introducing  one  hand  into 
the  uterus,  with  the  palm  turned  away  from 
the  cavity  of  this  viscus,  towards  the  out- 
side of  the  placenta,  which  is  to  be  gradu- 
ally separated  from  its  edges  towards  its 
centre. 

In  cases  of  complete  prolapsus  uteri, 
Ruysch  was  an  advocate  for  leaving  the 
expulsion  of'the  foetus,  if  alive,  to  be  effect- 
ed by  nature  ; and  the  same  writer  advises 
us  to  be  content  with  supporting  the  os 
tinea?.  But  when  the  child  is  dead,  he 
recommends  extracting  it  with  one  hand, 
while  the  uterus  is  supported  with  theother. 
Sabatier,  however,  entertains  different  sen- 
timents. The  expulsion  of  the  child,  he 
says,  is  not  less  the  effect  of  the  contraction 
of  the  diaphragm  and  abdominal  muscles, 
than  of  the  womb  itself.  Hence,  when 
eitberof  these  agents  fails  to  co-operate,  the 
delivery  becomes  either  very  difficult,  or 
impossible.  This  is  exactly  what  happens 
in  the  present  case  ; for  the  uterus  having 
fallen  down,  cannot  be  compressed. by  the 
diaphragm  and  abdominal  muscles.  Nor 
can  Sabatier  discern  the  reason  why  Ruysch 
should  recommend  the  line  of  conduct  to 
differ,  according  to  the  different  state  of  the 
child.  This  is  quite  passive  in  parturition, 
and  contributes  not  in  the  least  to  its  own 
expulsion. 

The  second  indication,  or  that  of  keeping 
the  uterus  reduced,  demands  the  employ 
merit  of  astringent  injections  and  pessaries. 

The  uterus,  in  a state  of  prolapsus,  is 
sometimes  also  affected  with  -cirrhus  and 
cancer.  A case  of  this  description  was  met 
with  by  Ruysch  ; and,  very  recently,  a wo- 
man wdiose  uterus  was  cancerous,  and  in  a 
state  of  complete  prolapsus,  without  any 
inversion,  was  attended  by  Lai.genbeck, 
who  succeeded  in  removing  the  diseased  , 
organ  with' a knife,  and  the  patient  recover- 
ed According  to  this  author’s  description, 
after  the  vagina  had  been  separated  from 
the  uterus,  the  latter  organ  was  detached 
from  the  peritoneum,  without  the  latter 
membrane  being  opened,  a small  portion  of 
the  fundus  uteri  being  left,  however,  as  it 
appeared  quite  sijund.  The  bleeding  was 
very  profuse,  and  required  the  use  of  the 
needle  and  ligatures.  The  ovaries  and  di- 
vided ligamenta  rotunda  were  found  con- 


nected with  the  removed  portion  of  the 
uterus.  (Bibl.  filr  die  Chir.  B.  1,  p.  551, 
12mo.  Hannover,  1818.  Saviard , Obserr 

Chir.  12 mo.  Paris,  1702.  J.  G.  Preund,  De 
Novo  arlificio  curandi  procidentiam  Uteri, 
Franco f ad  Viadn.  1710.  Levret , in  Journ , 
de  MM.  T.  40,  et  Obs.  snr  la  Cure  Radicate 
des  plusiturs  Polypes,  fyc.  Morgagni,  de 
Sedibus  et  Causis  Morbotum , Episl.  45, 
Kulmus,  de  Ulen  Delapsv. , Suppressions  Uri- 
nre,  et  subsequent  is  Mortis * Causa,  Gedani, 
1782.  White,  in  Med.  Obs.  and  Inq.  Vol.  2. 
Shaw,  in  Mem.  of  the  Medical  Society  of 
London , Vol.  1.  Portal,  (.'ours  d' Anatomic 
Med.  T.  5,  p.  538,  et  M6m.  de  VAcad.  de 
Chir.  T.  3.  Sabatier , in  Mem.  de  VAcad.  de 
Chir.  T.  3,  p.  361,  and  Medecine  Operatoire , 
T.  2.  Ducreux,  in  M6m.  de  l' Acad,  de  Chir.  T. 
S,  p.  493  Osiandtr,  Annalen,  B.  1,  p.  175. 
Diet,  des  Scietices  M6d.  T.  23,  art.  liysler op- 
to sc. 

UTERUS,  RETROVERSION  OF.  Re- 
troversion of  the  uterus  is  said  to  happen, 
when  its  fundus  is  forced  downward  and 
backwards  betw  een  the  sacrum  and  the  pos- 
terior part  of  the  vagina,  while  its  cervix 
inclines  towards  the  symphysis  pubis.  The 
ancients  are  thought  to  have  had  some  im- 
perfect notipns  of  this  case,  and,  in  proof  of 
this  opinion,  certain  passages  are  referred  to 
in  (Elius,  (Telrab.  4,  Serm.  4,  C.  77.)  Mercu- 
rial is,  Mercatus,  and  others,  (See  Diet,  des 
Sciences  M6d.  T.  28,  p.  273.)  Be  this  as  it, 
may,  it  is  generally  confessed,  that  the  sub- 
ject had  fallen  into* oblivion,  when  Dr.  Win. 
Hunter  called  the  attention  of  his  pupils  to 
the  subject,  in  1754,  and  afterward  drew  up 
an  interesting  paper  concerning  it.  (Med 
Obs.  and.  Inquiries,  Vol.  4.  8 to.  I.ond.  1771.) 
Subsequently,  the  knowledge  of  the  sub- 
ject was  extended  by  the  observations  of 
Wlzezeck,  (De  Ulero  retrojlexo.  Prag.  1777,) 
the  remarks  of  Richter,  (Chir.  Bibl.  B.  5 ,p. 
521,  fy  B.  9,;/.  182.)  and  those  of  Wall,  (Hiss, 
de  Uteri  retroversions,  Hal.  1782,)  and  by  the 
memoir  of  Desgranges,  t9  which  the  prize  of 
the  Royql  Academy  of  Surgeryat  Paris  was 
adjudged,  in  the  year  1785.  According  to 
Sabatier,  retroversion  of  the  womb  was  a 
case  mentioned  by  Gregoift?  in  his  private 
lectures  on  midwifery  at  Paris.’ 

Walter  Wall,  an  English  surgeon,  who  had 
attended  Gregoire,  suspected  Jbat  *he  had 
met  with  a retroversio  uteri  in  a woman, 
some  months  advanced  in  pregnancy,  and  he 
called  in  Dr.  Hunter,  in  order  to  have  the 
advantage  of  his  advice.  The  woman  was 
attacked  with  an  obstinate  constipation,  and 
retention  of  urine,  and  died  in  about  a week. 
A large  tumo  r w'hs  found  occupying  the 
whole  of  the  pelvis,  and  pushirTg  the  vagina 
against  the  os  pubis.  It  had  been  found  im- 
practicable to  push  the  swelling  back  into  the 
abdiunep,  although  the  patient  had  been  put 
on  her  knees  and  elbows,  while  one  hand 
had  been  introduced  into' the  vagina,  and 
two  fingers  of  .the  other  hand  into  the  rectum. 
Great  curiosity  existed  about  what  informa- 
tion would  be  afforded  by  dissection.  On 
opening  the  body,  the  bladder,  which  was 
exceedingfy  full  of  urine,  filled  almost  the 


UTERUS,  RETROVERSION  OF. 


484 


whole  anterior  part  of  the  abdomen,  in  the 
panic  manner  as  the  uterus  does  in  the  last 
month  of  pregnancy.  When  it  had  been 
emptied,  that  part  of  it,  in  which  the 
ureters  terminate,  and  which  is  connected 
with  the  vagina  and  cervix  uteri,  was  found 
raised  up,  as  high  as  the  upper  aperture  of 
the  pelvis,  by  a large  tumour,  which  filled 
the  r.  hole  cavity  of  the  pelvis,  and  was 
found  to  be  the  uterus.  A catheter,  when 
passed  into  the  vagina,  couid  ;.e  made  to  lift 
up  the  latter  viscusand  the  upper  part  of  the 
tumour.  This  portion  of  the  swelling,  on 
which  the  bladder  lay,  consisted  of  the  cer- 
vix uteri,  while  the  fundus  of  this  organ  was 
situated  downwards  .toward  the  os  coccygis 
and  anus.  The  uterus  was  so  large  that  it 
could  not  be  taken  out  of  Ihe  pelvis,  before 
the  'symphysis  pubis  was  divided,  and  the 
two  ossa  innominata  were  pulled  asunder  It 
was  found  impossible  to  assign  any  cause  for 
ihe  displacement  of  the  uterus,  as  the  pa- 
tient had  been  making  no  exertion,  and  had 
met  with  no  tall,  though  she  is  said  to  have 
been  frightened  at  something  just  before  the 
complaint  commenced. 

Dr.  Hunter,  struck  with  the  singular  na- 
ture of  the  case,  i nought  it  deserving  of  the 
attention  of  medical  men,  and  he  made  it 
the  subject  of  a lecture  which  he  delivered 
in  1754.  Fie  was  afterward  consulted  by 
,-evera!  persons,  who  were  afflicted  with  the 
Tetroversio  uteri ; but,  not  in  so  acute  a way, 
as  in  the  above  instance  All  the  patients 
were  in  the  third  month  of  pregnancy  and 
first  suffered  a difficulty  of  making  water, 
succeeded  by  retention  of  urine,  and  after- 
ward by  constipation.  Dr.  Hunter  always 
emptied  the  bladder  by  means  of  a cathe- 
ter and  glysters,  which  measures  sometimes 
effected  a cure,  the  uterus  spontaneously  re- 
suming its  natural  position.  In  every  in- 
stance, the  accident  disappeared,  when  preg- 
nancy was  more  advanced,  aifd  the  uterus 
had  acquired  larger  dimensions,  in  some 
cases, in  which  Dr  Hunter  was  consulted  too 
late,  the  trials  to  replace  the  uterus  proved 
fruitless,  and  the  women  died.  Dr.  Hunter 
was  so  firmly  convinced  of  the  impossibility 
of  saving  patietfcs  circumscribed  in  the 
above  manner,  unless  extraordinary  means 
were  resorted  to,  that  he  thought  one  should 
endeavouc  to  diminish  the  size  of  the  uterus, 
by  introducing  a trocar  into  the  body  of  this 
yiscus,  through  the  posterior  parietes  of  the 
vagina,  so  as  to  let  out  the  water  of  the 
amnios,  the  relative  quantity  of  which  is 
known  to  be  greater  in  the  early,  than  in  the 
advanced  stage  of  pregnancy.  (See  Jourel 
in  Bulletin  de  la  Faculti  de  Mid.  p.  173,  an. 
(1812.) 

Such  a puncture  might  certainly  be  the 
means  of  the  uterus  resuming  its  natural 
position  ; but  there  would  be  considerable 
danger  of  its  exciting  the  conlraction'ol  the 
uterus,  and  causing  abortion.  No  risk  of 
this  kind  would  be  encountered  by  punctur- 
ing the  bladder  above  the  pubes.  In  this 
manner,  a free  passage  would  be  afforded  for 
the  escape  of  the  urine,  and  the  reduction  of 
the  uterus  might  be  effected 


Mr.  Lynn,  a surgeon  in  Suffolk,  knew  an 
instance  of  the  bladder  bursting,  and  the 
urine  becoming  exlravasated  in  the  abdo- 
men, in  a case  of  retroversion  of  the  uterus, 
in  consequence  of  the  patient’s  refusal  to 
submit  to  the  preceding  operation.  The 
woman  was  forty  years  of  age,  of  a relaxed 
habit,  mother  of  several  children,  and  had 
been  pregnant  four  months.  She  had  also 
been  for  sometime  afflicted  with  a prolapsus 
of  the  vagina.  The  swelling  had  been  a few 
days  reduced,  when  in  consequence  of  trip- 
ping, she  felt  something  become  displaced  in 
her  abdomen,  and  fall  toward  the  lower  part 
of  her  back.  She  was  immediately  attacked 
with  constipation,  retention  of  urine,  nausea, 
and  pain  in  her  belly.  The  means  which 
were  employed,  not  proving  effectual,  Mr. 
Lynn  suspected  a retroversio  uteri,  and  in- 
troduced his  fingers  into  the  vagina,  in  order 
to  ascertain  the  fact.  Flis  fingers  were  stop- 
ped by  a tumour,  as  large  as  a child’s  head. 
The  swelling  occupied  the  back  part  of  this 
passage,  and  descended  as  low  as  the  peri- 
naeum.  Being  certain,  that  the  uterus  was 
displaced,  he  attempted  to  reduce  it.  The 
patient  was  put  into  various  positions,  and 
the  fingers  of  one  hand  were  introduced  into 
the  vagina,  while  those  of  the  other  were 
passed  into  the  rectum.  The  use  of  the 
catheter  was  not  forgotten  ; but  it  could  not 
be  introduced  far  enough  to  reach  the  urine 
Glysters  were  stopped  at  the  very  beginning 
of  the  rectum.  The  abdomen  was  exceed- 
ingly tense,  especially  in  the  hypogastric  re- 
gion. A proposal  was  made  to  puncture  the 
bladder  ; but  the  patient  refused  to  submit, 
and  preferred  being  left  to  her  fate.  On  the 
seventh  day  of  her  illness,  she  was  very 
much  reduced  ; and  became  affected  with 
nausea,  and  hiccough,  the  forerunners  of 
mortification.  At  length,  she  felt  something 
give  way  in  her  abdomen,  and  the  ease, 
which  succeeded,  revived  her  hopes.  These, 
however,  were’ not  of  long  duration,  for, 
after  being  delivered,  she  sunk,  and  died  the 
next  morning.  On  opening  the  body,  the 
bladder  was  found  to  have  sloughed,  and 
burst  at  several  points,  and  two  parts  ot 
urine  were  consequently  extravasated  in  the 
abdomen. 

Retroversio  uteri  is  a dangerous  affection  , 
but  it  is  not  invariably  fatal,  particularly 
when  the  patient  receives  succour,  before 
the  disorder  has  made  much  progress 
Though  Callisen  met  with  a case  after  deli- 
very, and  Desault  knew  an  instance  in 
which  the  displacement  was  produced  by  a 
polypus,  retroversio  uteri  scarcely  ever 
occurs,  except  in  the  early  months  of  preg- 
* nancy,  and  in  women  whose  pelvis  is  very 
wide,  while  its  brim, is  very  contracted.  U 
the  uterus,  in  a pelvis  of  this  conformation, 
be  pushed  back  by  a distended  bladder,  and 
pressed  against  (lie  sacrum,  while  the  soft 
parts  yield,  the  womb  becomes,,  as  "it  were, 
wedged,  and  is  incapable  of  changing  its 
position.  In  this  immoveable  state,  it  presses 
upon  the  surrounding  parts,  and  the^e  upon 
it,  so  that  a very  serious  train  of  bad  symp- 
toms are  the  consequence. 


VAGINA  IMPERFORATE 


63G 


The  lirst  care  oi  a practitioner,  consult-: 
«d  in  a case  of  retroversio  uteri,  should  be 
to  empty  the  bladder  and  large  intestines, 
and  to  relax  the  parts  by  every  possible 
means.  Then  lie  should  immediately  pro- 
ceed to  replace  the  uterus,  by  placing  the  pa- 
tient in  a suitable  posture,  and  making  me- 
thodical pressure  in  the  rectum  and  vagina. 
Should  he  be  so  fortunate  as  to  succeed, 
the  patient  is  to  be  confined  in  bed,  her 
bowels  are  to  be  kept  open,  and  she  is  to  be 
advised  always  to  obey  the  calls  of  nature 
the  first  moment  she  feels  any  inclination  to 
make  water.  She  is  also  to  be  enjoined  to 
avoid  all  kinds  of  exertion,  and  wait  till  the 
gradual  enlargement  of  the  uterus  removes 
the  possibility  of  this  viscus  descending  into 
the  pelvis.  ( Sabatier , Mddecine  Opiraioirc, 
T.  2.) 

Some  practitioners,  of  considerable  emi- 
nence, rather  discourage  the  manual  interfe- 
rence to  reduce  the  uterus,  believing  that 
drawing  off  the  urine  will  generally  render 
such  interference  unnecessary.  ( Croft , in 
Lond.  Med.  Journ.  Vol.  9,  p.  53.  Denman’s  In- 
troduction to  Midwif  'ery , 4 to.  Lond.  1801.  S. 
Merriman , on  Retroversion  of  the  Womb,  8 vo. 
Lond.  1810.) 

(See  Lynn , IV.  Hunter,  Garthshore , Bird, 
and  Hooper,  in  Med.  Obs.  and  fnq.  Vo  Is.  4,  5, 
and  6,  Ckeston  and  C leghorn,  in  Med.  Com- 
munications, Vol.  2.  John  Clarke,  Practical 
Essays  on  the  Management  of  Pregnancy  and 
Labour , Lond.  1793.  Murray,  in  Uteri  Retro- 
versionem  Animadversiones,  Upsal.  1797. 
Denman’s  Introduction  to  Midwifery,  Load. 
1810.  S'.  Merriman,  on  Retroversion  of  the 

Womb,  fyc.  8 vo.  Lond.  1810.  Joltr.,  De  Utero 
Retroverso,Jen.  1 87.  Desgranges,  in  Journ. 
de  Med.  T.  66,  p.  85.  Klein,  Chir.  Bemerkun- 
gen,  p.  235.  Baudelocque  sur  le  Renverse- 
ment  de  la  Matrice , fyc.  Paris , 1803.  Cockell , 
Essay  on  Retroversion  of  the  Uterus.  Lond. 
1785.  Richter,  Chir.  Bibl.  B.  4.  p.  61, — 70 
—235—555:  B.  5,  p.  132—548;  B.  7,  p. 

292;  B.  8,p.  715;  B.  9,  p.  182;  B.  11,  p. 
310 — 328  ; B.  12,  p.  45 — 50.) 

UVA  URSl,  which  was  first  brought  into 
notice  by  De  Haen,  was  once  considered  a 
powerful  remedy  in  calculus ; but  though  its 
virtue  in  lessening  the  irritation  of  the  blad- 
der, is  still  acknowledged,  its  claim  to  utility 
on  any  other  principle,  is  quite  ' rejected. 
Dr.  Austin  recommended  it  for  lessening  the 
irritability  of  the  bladder,  and  diminishing 
The  secretion  of  diseased  mucus,  which,  he 
supposed,  greatly  contributed  to  the  aug- 
mentation of  the  stone. 


Mr.  15.  Bell  also  strongly  recommended  it 
in  gonorrhoea,  where  the  irritability  of  the 
bladder  was  excited  in  a high  degree,  and 
where  the  urine  was  loaded  with  viscid 
matter,  fn  these  cases,  he  directed  a scru- 
ple, or  half  a dram  of  the  powder,  three 
times  a day. 

Dr.  Saunders  orders  three  drams  of  uva 
ursi  to  be  macerated  in  a pint  of  hot  water, 
and  two  or  three  ounces  of  the  strained 
liquor  to  be  given  three  times  a day.  (Charm. 
Chirurg.) 

UVULA,  AMPUTATION  OF.  The  uvula 
is  subject  to  several  kinds  of  enlargement, 
in  which  it  becomes  both  longer  and  more 
bulky  than  natural,  or  is  simply  lengthened. 
In  consequence  of  such  changes,  it  becomes 
troublesome  in  deglutition  and  speaking,  and 
causes  a disagreeable  tickling  at  the  root  of 
the  tongue,  frequent  retchings,  and  an  an- 
noying cough. 

When  things"have  attained  this  state,  me- 
dicines are  often  ineffectual,  and  the  only 
plan  of  relief  consists  in  amputating  a por 
tion  of  the  uvula. 

The  ancients  used  to  take  hold  of  the 
uvula  with  a pair  of  forceps,  and  cut  off  a 
piece  of  it  below  the  blades  of  the  instru 
ment.  Fabriciusab  Aquapendente  objected 
to  this  method,  because  it  employed  both 
hands,  and  a third  was  needed  for  holding 
the  tongue  and  lower  jaw.  He  preferred 
scissors,  and  having  the  left  hand  at  libertv. 

When  the  size  of  the  uvula  was  considera- 
ble, and  bleeding  apprehended,  Pare  recon, 
mended  the  application  of  a ligature  to  the 
part,  by  means  of  an  instrument,  composed 
of  a ring,  mounted  on  a slender  handle,  and 
formed  with  a groove  upou  its  convexity.  A 
ligature  is  put  round  the  ring  with  a slip- 
knot, which  is  to  be  tightened  by  means  of 
another  ring,  of  much  smaller  size,  mounted 
like  the  preceding  one,  upon  a long  slender 
handle.  The  ligature  is  tcy  be  left  in  the 
mouth,  and  when  it  does  not  make  suffi- 
cient constriction,  it  is  to  be  tightened. 

Fabricius  Hildanus  subsequently  descri- 
bed an  instrument  constructed  on  the  same 
principles.  Sabatier  takes  hold  of  the  uvula 
with  a pair  of  forceps,  made  with  holes  in 
the  blades,  like  those  used  for  the  extraction 
of  polypi.  He  then  divides  the  uvula  with  a 
pair  of  scissors,  made  with  concave  cutting 
edges. 

Sabatier  never  saw  any  bleeding  of  con 
sequence  follow  this  trivial  operation.  (See 
Midec.ine  Opiratoire,  T.  3.) 


y. 


V"  AGIN  A IMPERFORATE.  Female  in- 
fants are  often  born  with  different  im- 
perforations  of  the  vagina.  Sometimes  this 
passage  is  not  completely  shut  up,  so  that 
the  usual  evacuations  happen  in  an  uninter- 
rupted manner,  and  it  i«  a considerable  time 
Vot.1L.  74 


before  the  malformation  is  discovered. 
Some  females  are  even  stated  to  .have  be- 
come pregnant,  notwithstanding  such  ob- 
struction ; and  in  these  cases,  the  membrane 
which  shut  up  a part  of  the  mouth  of  the 
vagina,  either  was  torn  by  the  effects  of 


586 


VAGINA,  PROLAPSUS  OF. 


labour,  or  divided  as  much  as  was  necessa- 
ry for  delivery. 

Two  membranes,  one  placed  beyond  the 
other,  and  obstructing  the  vagina,  have  also 
been  found.  That  which  is  commonly  met 
with  is  only  the  hymen,  thicker  and  strong- 
er than  natural.  Ruysch  describes  the  case 
of  a woman  who  bad  been  in  labour  three 
days,  and  could  not  be  delivered  The  head 
presented  itself,  but  was  prevented  from 
coming  out  by  the  hymen,  which  shut  up 
the  vagina,  and  was  very  tense.  Ruysch 
made  an  incision  into  the  membrane  ; but 
to  no  purpose,  since  there  was  another  mem- 
brane, of  a thicker  texture,  situated  more 
deeply  in  the  passage.  As  soon  as  this  se- 
cond membrane  was  divided,  the  child  was 
expelled,  and  the  case  ended  well. 

When  the  vagina  is  completely  imperfo- 
rate, and  the  time  of  the  menses  commence, 
many  complaints  occur,  which  afflict  the 
patient  with  more  severity,  in  proportion  as 
the  blood  accumulates  in  the  passage,  and 
they  may  even  lead  to  a fatal  termination 
when  the  cause  is  not  understood,  or  riot 
detected  till  it  is  too  late.  These  complaints 
are  very  similar  to  those  of  pregnancy  ; for 
instance,  rumbling  noises  in  the  bowels,  loss 
of  appetite,  nausea,  vomiting,  enlargement 
of  the  mararaffi,  spasms,  convulsions,  swell- 
ing of  the  abdomen,  &,c.  Hence,  girls  in 
this  situation  have  often  been  supposed  to 
be  pregnant,  although  they  were  not  in  a 
state  even  to  become  so  ; and  some  young 
women  have  been  known  to  die,  after  dread- 
ful sufferings. 

When  the  malformation  consists  altoge- 
ther in  the  orifice  of  the  vagina  being  shut 
up  by  a membrane,  the  patient  may  be  ea- 
sily relieved  by  a crucial  incision,  or  a sin- 
gle cut,  the  edges  of  which  are  kept  apart 
by  a tent  of  suitable  shape  and  size.  In- 
stances of  the  success  of  such  an  operation 
are  to  be  found  in  numerous  writers.  Fa- 
bricius  ab  Aquapendente  informs  us,  that  a 
female  child  was  born  with  a membrane 
which  completely  shut  up  the  vagina.  The 
girl  experienced  no  inconvenience  from  it 
till  she  was  about  thirteen,  when  the  period 
of  her  menses  began.  As  the  blood  was  re- 
tained, she  became  afflicted  with  severe 
pains  in  the  loins,  the  lower  part  of  the  ab- 
domen, and  about  the  upper  part  of  the 
thighs.  She  was  supposed  to  be  attacked 
with  sciatica,  and  treated  accordingly.  Me- 
dicines were  prescribed  which  did  no  good  ; 
and  at  length  she  became  hectic,  and  redu- 
ced to  a complete  state  of  marasmus,  in 
which  she  passed  restless  nights,  lost  her  ap- 
petite, and  was  delirious.  A painful,  very 
elastic  tumour  afterward  presented  itself 
in  that  part  of  the  abdomen  which  corres- 
ponds to  the  uterus.  The  pains  were  aggra- 
vated every  month,  at  the  period  when  the 
patient  ought  to  have  menstruated.  She  was 
in  a dying  condition  when  Fabricius  ab 
Aquapendente  was  consulted,  who,  after  as- 
certainin'; the  real  nature  of  the  case,  per- 
formed the  requisite  operation.  A prodi- 
gious quantity  of  black  putrid  blood  was 
discharged  from  the  vagina  ; the  bad  symp- 


toms gradually  subsided,  and  the  patient  re- 
covered. (See  also  J.  C.  Loder , Obs.  Imper  j 
J'orationis  Vagina.  Jcone  illusirota,  4to.  Jena , 
1800  ; and  numerous  ol her  cases  on  record. ) 

When  the  malformation  is  produced  by 
an  extensive  accretion  of  the  sides  of  this 
passage  to  each  other,  the  cure  is  Sometimes 
difficult.  The  result  of  the  operation  is 
doubtful,  because  it  is  impossible  to  reach 
the  situation  of  the  blood  without  cutting 
through  a considerable  thickness  of  parts, 
in  doing  which  there  is  some  danger  of 
wounding  the  rectum,  or  bladder.  A lady, 
twenty-four  years  of  age,  after  having  tried, 
for  eight  years,  such  remedies  as  seemed 
best  calculated  for  exciting  the  menstrual 
discharge,  became  affected  with  a large  hard 
swelling  of  the  abdomen,  and  a kind  of  her- 
petic affection  round  the  body  near  the  na- 
vel. At  length  it  was  discovered,  that  the 
impefforation  of  the  vagina  was  the  sole 
cause  of  all  the  bad  symptoms  which  the 
patient  had  long  endured.  An  incision  was 
made,  which  enabled  the  operator  to  intro- 
duce his  finger  into  a large  cavity,  and  which 
gave  vent  to  a considerable  quantity  of 
blood.  It  was  thought  that  an  opening  had 
been  made  into  the  vagina  ; but  the  patient 
having  died  three  days  afterward,  it  was 
seen  that  a mistake  had  been  made,  as  the 
cavity,  in  which  the  finger  had  been  intro- 
duced, was  that  of  the  bladder.  The  vagina 
was  closed  below  by  a substance  of  an  inch 
in  diameter,  and  half  an  inch  thick.  The  up- 
per part  of  this  passage,  the  uterus,  and  the 
Fallopian  tubes,  were  exceedingly  enlarged, 
and  filled  with  a dark  brown,  sanious  fluid. 
A similar  fluid  was  extravasated  in  the  ab- 
domen, and  it  was  discovered  to  have  pass- 
ed there  through  a rupture  which  had  taken 
place  in  the  Fallopian  tube.  The  ovaries 
were  in  a natural  state.  De  Haen,  who  has 
related  this  case  in  the  sixth  part  of  his 
work,  entitled  Ratio  Medendi , was  of  opi- 
nion, that  in  Order  to  avoid  opening  the 
rectum,  or  bladder,  only  one  oblique  cut 
should  be  made  in  the  membrane  which 
stops  up  the  vagina,  just  as  was  advised  by 
Meeckren.  (Sabatier  de  la  Midecine  Optra- 
toire,  T.  1.) 

VAGINA,  PROLAPSUS,  OR  INVER- 
SION OF.  According  to  Sabatier  and  Lev- 
ret,  the  displaced  part  does  not  consist  of 
all  the  coals  of  the  vagina,  in  the  same 
manner  as  the  inverted  uterus  is  formed  of 
the  whole  substance  of  this  viscus.  These 
writers  contend  that  the  lining  of  the  vagina 
is  alone  displaced,  in  consequence  of  the 
swelling  and  thickening  with  which  it  is  af- 
fected. Upon  this  point,  however,  Richter 
does  not  accede  to  the  opinion  of  Sabatier 
and  Levret,  but  describes  the  vagina  as  be- 
ing liable  to  two  kinds  of  prolapsus.  In  one 
case,  all  its  tunics  are  stated  to  be  included 
in  the  protrusion,  the  part  becoming  invert- 
ed at  the  same  time  that  it  falls  down,  lti 
the  other  example,  it  is  only  the  relaxed 
lining  of  the  vagina  which  descends,  and 
makes  the  protrusion. 

The  possibility  of  a prolapsus  of  the  whole 
of  the  vagina,  together  with  all  its  coats. 


V ACilNA,  PROLAPSUS  Ol 


537 


says  Richter,  has  been  doubted  by  Sabatier 
and  Levret;  but  without  any  real  founda- 
tion. If  it  be  possible  for  the  inner  coat  of 
the  vagina  to  separate  from  the  external, 
with  which  it  is  intimately  connected,  (an 
event  which  every  body  admits  as  happen- 
ing in  the  second  kind  of  prolapsus  of  the 
vagina,)  why,  asks  Richter,  should  it  be  im- 
possible for  the  whole  of  this  tube,  together 
with  all  its  coats,  to  be  separated  from  the 
surrounding  parts,  to  which  it  is  Ies3  closely 
adherent  ? Sometimes  the  rectum,  inclu- 
sive of  all  its  coats,  forms  what  is  termed  a 
prolapsus  ani,  and  why  may  not  the  vagina 
be  displaced  in  a similar  manner,  since  it 
must  be  much  more  liable  than  the  rectum 
to  be  propelled  downwards  in  the  violent 
straining  at  the  time  of  delivery  ? Richter 
asks,  whether  every  prolapsus  uteri  is  not 
accompanied  with  such  a displacement  of 
the  vagina  ? Cases  are  upon  record,  where 
the  prolapsus  of  the  vagina  happened  all  on 
a sudden,  in  consequence  of  falls,  the  start- 
ing of  a horse,  &c.  ( Hoin , Levret,  Journ.  de 
T.  40.)  Here  it  cannot  be  supposed, 
that  the  case  w as  merely  a protrusion  of  the 
inner  coat,  which  can  only  be  gradually  re- 
laxed and  elongated.  Lastly,  some  instances, 
in  which  the  prolapsus  of  the  vagina  was 
several  inches  in  length,  have  been  gradual- 
ly reduced  by  means  of  external  pressure. 
(Hoin.)  How  can  it  be  imagined,  says  Rich- 
ter, that  such  cases  could  proceed  from  any 
degree  of  relaxation  to  which  the  membra- 
nous lining  of  the  vagina  is  liable  ? 

Richter  acknowledges,  however,  that  a 
prolapsus  of  all  the  coats  of  the  vagina  is 
much  less  common  than  that  arising  from 
relaxation  of  the  membranous  lining  of  this 
passage  ; he  states,  that  when  it  occurs,  it  is 
generally  a consequence  of  a prolapsus  of 
the  uterus  ; and  that  it  cannot  easily  hap- 
pen at  all,  except  about  the  period  of  deli- 
very. (See  Jlnfangsgr.  der  Wundarzn.  B.  7, 
Kapitel  4.) 

According  to  Sabatier,  the  prolapsus,  or 
inversion  of  the  vagina,  appears  like  a thick, 
circular  substance,  irregularly  plaited  in  the 
middle,  and  at  the  bottom  of  which  the 
cervix  uteri  is  situated,  having  descended 
further  down  than  natural.  The  displaced 
portion  of  the  vagina  increases,  or  dimi- 
nishes, according  as  the  patient  sits  up,  or 
keeps  in  bed  a certain  time.  The  complaint 
is  accompanied  with  a sense  of  heaviness 
in  the  hypogastric  region  ; tenesmus ; and 
a difficulty  of  making  water,  in  consequence 
of  the  alteration  produced  in  the  direction 
of  the  meatus  urinarius. 

Such  is  the  prolapsus  of  the  vagina  in  an 
early  state  ; but  when  it  has  been  of  long 
standing,  and  the  patients  have  remained 
for  a long  while  without  any  assistance,  the 
membranous  lining  of  the  passage  becomes 
more  and  more  thickened;  and  the  tumour, 
which  it  forms,  becomes  more  considera- 
ble, elongated,  and  hardened.  In  this  state 
there  still  continues,  at  the  lower  part  of  the 
swelling,  an  opening,  out  of  which  the  usual 
evacuations  are  made.  The  grievances  suf- 
fered are  similar  to  those  arising  from  a pro- 


lapsus uteri,  to  which,  indeed,  the  present 
case  bears  a great  resemblance.  The  pro- 
lapsus vaginas,  however,  differs,  inasmuch 
as  the  tumour  formed  by  a descent  of  the 
uterus  is  very  firm,  and  terminates  in  a nar- 
row end,  where  may  be  observed  the  oblong 
transverse  opening,  named  the  os  tineas; 
while  the  tumour,  arising  from  a prolapsus 
of  the  vagina,  is  soft,  thicker  below  than 
elsewhere,  and  ends  in  an  irregular  aper- 
ture. 

Occasionally,  a prolapsus  of  a very  limit- 
ed portion  of  the  vagina  is  observed.  This 
case  is  generally  the  consequence  of  an  un- 
common sort  of  rupture,  termed  the  vaginal 
hernia  (see  Hernia ;)  but  it  should  also  be 
known,  that  in  some  cases  of  dropsy,  a cir- 
cumscribed protrusion  of  the  vagina,  in  the 
form  of  a cyst,  or  pouch,  filled  with  fluid, 
is  sometimes  noticed.  ( Richter , Op.  et  loco 
citato.) 

When  the  prolapsus  vaginae  is  recent,  the 
partway  be  easily  reduced,  and  kept  up 
with  a pessary.  The  use  of  astringent  lo- 
tions will  also  tend  to  prevent  a relapse- 
But  when  the  case  has  been  of  long  stand- 
ing, it  is  neither  easy  to  effect  the  reduction, 
nor  to  prevent  a recurrence  of  the  disor£,j\ 
Softening,  relaxing  remedies,  in  this  cir- 
cumstance, are  recommended,  and  the  pa- 
tient should,  in  particular,  confine  herself 
to  her  bed,  and  wear  a T bandage,  which 
should  be  made  to  press  upon,  and  support 
a piece  of  sponge  in  the  orifice  of  the  va- 
gina. 

It  is  reasonable  to  expect,  that  after  a 
prolapsus  vaginae  has  continued  a long  while, 
the  reduction  must  be  difficult ; because  the 
vagina  in  this  stale  becomes  affected  with 
swelling  and  induration.  According  to  the 
reports  of  Hoin  and  Levret,  a large  protru- 
sion of  this  kind,  ten  inches  in  length,  was 
so  diminished  by  keeping  the  patient  inva 
riably  confined  in  bed  upon  her  back,  that 
in  the  course  of  a month,  the  rest  of  the  tu- 
mour admitted  of  being  reduced.  Indeed, 
as  Richter  observes,  there  can  be  little 
doubt,  that  the  treatment  which  has  been 
advised  by  some  authors,  for  the  diminution 
of  very  old,  enormous,  omental  ruptures, 
would  here  be  equally  applicable  ; viz.  long 
confinement  in  bed  upon  the  back,  with  the 
buttocks  somewhat  elevated  ; unremitting, 
well  directed  external  pressure  ; a very  low 
diet  ; and  repeated  mercurial  purges. 

During  pregnancy,  a prolapsus  of  the 
whole  substance  of  the  vagina  may  cause, 
much  embarrassment  and  even  danger.  Irv 
one  case  of  this  description,  where  the  pro- 
trusion was  five  inches  in  length,  it  became 
necessary  to  turn  the  child,  and  the  displaced 
vagina  was  lacerated.  The  woman,  howe 
ver,  recovered.  ( Pietsch , Journal  de  Med. 
T.  34.)  In  another  instance,  where  the  pro- 
lapsus became,  at  each  return  of  the  labour- 
pains,  as  large  as  a man’s  head,  the  practi- 
tioner succeeded  in  holding  the  parts  back, 
while  delivery  wras  effected  with  the  aid  ot 
the  forceps.  (See  Loder’s  Journ.  1 B.  p. 
490.)  When  this  is  impracticable,  it  is  ne- 
cessary, according  to  Richter,  to  make  an 


VAR 


VAR 


588 

iqcision  through  both  sides  of  the  prolapsus  ; 
a measure,  says  he,  to  which  the  practitioner 
may  the  more  readily  make  up  his  mind, 
inasmuch  as  the  parts  have,  in  some  cases, 
been  lacerated,  without  any  ill  consequen- 
ces. 

A prolapsus  of  the  inner  membrane  of  the 
vagina,  while  small  and  recent,  might  per- 
haps be  removed  by  astringent  applications. 
When,  however,  it  is  of  long  standing,  indu- 
rated, and  of  large  size,  much  expectation 
ol  success  .from  this  treatment  cannot  be  en- 
tertained. Richter  sees  no  reason  why,  in  such 
a case,  the  superfluous  relaxed  part  should 
not  be  cut  away,  especially  if  the  disease  be 
accompanied  with  ulceration,  and  other  se- 
rious complaints.  As  he  observes,  there  can 
be  no  doubt,  that  a prolapsus  of  the  inner 
membrane  of  the  vagina,  when  limited  to 
one  part  ol  this  canal,  may  always  be  safely 
extirpated,  either  with  a knife,  or  a ligature. 
(Anfangsgr.  der  Wundarsn . B.  7,  Chap.  4.) 

As  the  swelling  of  the  membranous  lining 
of  this  passage  is  folded  back  on  itself,  it 
sometimes  increases  in  such  a degree,  that 
the  tumour  falls  into  a state  of  mortification. 
In  this  event,  some  writers  have  advised  the 
ej^Arpation  of  the  swelling,  justifying  the 
practice  on  the  authority  of  some  distinguish- 
ed practitioners,  and  the  little  danger  atten- 
dant on  the  operation. 

Even  Sabatier  only  objects  to  this  pro- 
ceeding, on  the  ground  of  the  danger  of  mis- 
taking a prolapsus  of  the  uterus,  for  one  of 
the  vagina.  However,  no  modern  surgeons 
in  this  country  would  hesitate  about  reject- 
ing such  an  operation,  and  leaving  the  sloughs 
to  separate  of  themselves. 

The  prolapsus,  arising  from  a hernia  in 
the  vagina,  can  only  be  ascertained  by  at- 
tending to  the  symptoms  which  characterize 
this  sort  of  rupture.  See  Hernia. 

Consult  particularly  Sabatier,  Medecine 
Op6ratoire,  T.  2,  p.  486,  fyc.  Edit.  2.  Rich- 
ter, Ansfangsgrtinde  der  Wundarzneykunst , B. 
7,  Kap.  4. 

VARICOCELE.  (from  varix,  a distended 
vein,  and  kuav,  .a  tumour.)  Many  writers 
mean  by  the  term  varicocele,  a varicose  en- 
largement of  the  spermatic  veins,  which  lat- 
ter affection  I have,  with  Celsus  and  Pott, 
treated  of  under  the  name  of  Cirsocele. 

Pott  remarks,  that  the  varicocele  (which 
is  an  enlargement  and  distention  of  the 
blood-vessels  of  the  scrotum)  is  very  seldom 
an  original  disease,  independent  of  any  other, 
and  when  it  is,  is  hardly  an  object  of  surge- 
ry. The  blood-vessels  of  the  scrotum  are 
of  different  size  in  different  people  ; and  like 
the  vessels  in  other  parts  of  the  body,  are 
liable  to  become  varicose;  but  they  are 
seldom  so  much  enlarged  as  to  be  irouble- 
-sorae,  unless  such  enlargement  is  the  conse- 
quence of  a disease,  either  of  the  testicle, 
or  spermatic  chord.  When  this  is  the  case, 
the  original  disease  is  what  engages  our  at- 
tention, and  not  this  simple  effect  of  it ; and, 
therefore,  considered  abstractedly,  the  vari- 
cocele is  a disease  of  no  importance,  ( Poll's 
Chirurgical  Works , Vol , 2.) 


VARICOSE  ULCER.  See  Ulcer,  and1 
Varicose  Veins.  . 

^VARICOSE  VEINS.  The  term  varix , 
is  applied  by  surgeons  to  the  permanently' 
dilated  state  of  a vein,  attended  with  an  ac- 
cumulation of  dark-coloured  blood,  the  cir- 
culation of  which  is  materially  retarded  in 
the  affected  vessel.  When  veins  are  vari- 
cose, they  are  not  only  dilated,  they  are  also 
evidently  elongated  ; for  besides  being  irre- 
gular, and  in  several  places  studded  with 
knots,  they  make  a variety  of  windings,  and 
coiling  themselves,  form  actual  tumours  from 
the  assemblage  of  their  convolutions  in  one 
particular  place.  When  the  branches  of  a 
vein,  thus  dilated  and  elongated,  are  nume- 
rous, and  confined  to  a certain  part  of  the 
body,  they  constitute  a very  distinct  swell- 
ing. Indeed,  when  the  diseased  vessels  are 
situated  near  the  integuments,  the  surgeon 
can  feel,  and  even  see  their  tortuous  course 
These  things,  for  instance,  are  remarkably 
obvious  in  the  vena  saphena  interna,  in 
which  the  affection  is  particularly  common. 
This  vessel  may  be  observed  to  form  in  its 
course  several  ol  these  swellings,  in  the  inter- 
spacesof  which  it  runs  in  a very  serpentine 
manner. 

Varices  are  most  commonly  observed  in 
tl/Q  lower  extremities,  reaching  sometimes 
even  as  far  up  as  the  abdomen.  They  have, 
hovVever,  been  noticed  in  the  upper  extremi- 
ties, and  it  is  probable  that  the  whole  venous 
system  is  susceptible  of  the  affection..  As  a 
well-informed  writer  observes  ; “ The  great 
venous  trunks  sometimes  become  varicose. 
When  the  disease  is  situated  near  the  heart, 
it.  is  attended  with  pulsation,  which  renders 
it  liable  to  be  mistaken  tor  aneurism.  Mor- 
gagni observed,  that  the  jugular  veins  were 
occasionally  very  much  dilated,  and  pos- 
sessed a pulsation.  (Letter  8,  art.  9, 10,  U.) 
He  also  relates  a case  in  which  the  vena 
azygos,  for  the  length  of  a span,  was  so 
much  dilated,  that  it  might  be  compared  with 
the  vena  cava.  The  patient  died  suddenly  in 
consequence  of  the  rupture  of  this  varix  into 
the  right  side. of  the  chest.  (Letter  26,  art. 29.) 
A similar  case  is  related  by  Portal,  w ho  also 
mentions  an  instance  in  which  the  right  sub- 
clavian vein  was  excessively  dilated,  and 
burst  iuto  she  cbest-  (C 'ours  d' Anatomic 
Medicate,  tom.  3,  p.  354,  373.)  Mr.  Clme 
described  in  his  lectures  the  case  of  a wo- 
man who  had  a large  pulsating  tumour  in  her 
neck,  which  burst  and  proved  fatal  by  be- 
morrhage.  A sac  proceeded  from  the  inter- 
nal jugular  vein ; the  carotid  artery  was 
lodged  in  a groove  at  the  posterior  part  of 
this  sac.  The  veins  of  the  upper  extremity 
very  rarely  become  varicose.  Excepting 
cases  of  aneurismal  varix,  the  only  instance 
of  this  disease  w ith  which  I am  acquainted, 
is  mentioned  by  Petit.  ( Trait 6 des  Maladies 
Chir.  Tom.  2,  p 49.)  In  this  case,  a varix 
was  situated  at  the  bend  of  the  arm  : the  pa- 
tient was  so  fat  that  no  other  vein  could  be 
found  for  the  purpose  of  venesection,  which 
operation  Petit  repeatedly  performed  by 
puncturing  this  varix.  The  superficial  epi- 
gastric veins  sometimes  become  varicose. 


VARICOSE  VEINS. 


589 


out  the  most  frequent  seats  of  this  disease 
are  the  venae  saphenae,  the  spermatic,  and 
hemorrhoidal  veins.”  (See  Hodgson's  Trea- 
tise on  the  Diseases  of  Arteries  and  Veins,  p. 
538,  539.)  The  deep-seated  veins  of  the 
extremities  seldom  become  varicose.  The 
disease  rarely  occurs  before  the  adult  period 
of  life,  and  its  progress  is  extremely  slow. 
It  is  very  frequently  remarked  in  pregnant 
women,  who  have  passed  a certain  age; 
but  it  is  particularly  unusual  for  it  to  happen 
in  young  women,  even  during  a series  of 
repeated  pregnancies.  Surgeons  have  not 
hitherto  made  out  any  very  precise  infor- 
mation, respecting  the  kinds  of  constitution 
which  promote  the  occurrence  of  a varicose 
enlargement  of  the  veins.  Nor  has  it  been 
well  proved,  that  the  disease  often  proceeds 
from  swellings  of  the  abdominal  viscera,  or 
any  other  species  of  tumour  capable  of  me- 
chanically obstructing  the  venous  circula- 
tion. One  or  more  veins  of  the  same  limb 
are  at  first  most  commonly  affected  with  a 
slight  degree  of  dilatation,  without  pain  or 
any  sensation  of  uneasiness.  This  beginning 
change  ordinarily  advances  with  great  slow- 
ness, except  in  cases  Where  it  accompanies 
pregnancy,  in  which  circumstance,  one,  or 
both  the  lower  extremities,  as  early  as  the 
first  months,  are  frequently  seen  covered  with 
largely  dilated  veins,  or  even  with  tumours 
formed  by  an  assemblage  of  varices.  The 
veins  gradually  become  more  ami  more  dis- 
tended, lengthened,  coiled  up,  and  tortuous. 
The  patient  then  begins  to  complain  of  a 
sense  of  heaviness,  numbness,  and  sometimes 
of  very  acute  wandering  pain,  through  the 
whole  of  the  affected  limb.  In  a more  ad- 
vanced stage,  in  proportion  as  the  varices 
increase,  and  especially  when  the  dilated 
veins  actually  form  tumours,  the  limb  swells 
and  becomes  more  or  less  cedematous,  ac- 
cording to  the  extent  of  the  disease,  and  the 
time  which  it  has  existed.  Delpech  thinks, 
however,  that  the  cederna  in  this  ca3e,  is  not 
such  as  to  justify  the  conclusion,  that  the  in- 
creased size  of  the  veins,  and  the  way  in 
which  they  distend  the  integuments,  produce 
a mechanical  interruption  of  the  function 
of  the  absorbent  systopi.  For,  says  he, 
enormous  varices  are  sometimes,  though  not 
often' met  with,  which  are  not  attended  with 
any  swelling  of  the  cellular  substance ; and 
cases  are  slid  more  frequently  seen,  in  which 
there  is  a considerable  degree  of  cederna, 
while  the  varices  are  scarcely  remarkable. 
When  the  latter  have  prevailed  a long  while, 
and  made  much  progress,  the  coats  of  the 
affected  veins  are  not  unfrequently  thicken- 
ed, swelled,  and  indurated,  forming  a sort  of 
half-canal,  or  solid  tube.  As  Mr.  Hodgson 
remarks,  *•  the  blood  occasionally  deposits 
strings  of  coagulum  in  varicose  veins : when 
this  is  the  case,  the  vessel  is  incapable  of 
being  emptied  by  pressure,  and  is  firm  to 
the  Joueh.  The  deposition  does  not  in  ge- 
neral fill  the  vessel,  but  by  diminishing  its 
calibre,  it  retards  the  flow  of  blood,  and 
causes  the  dilatation  to  increase  in  the  inferior 
portion  of  fhe  vein,  and  in  the  branches 
which  open  into  it.”  (On,  the  Diseases  of 


Arteries  and  Veins,  p.  541.)  'Ibis  gentleman 
has  seen  four  cases,  in  which  the  coagulum 
accumulated  to  such  an  extent,  that  the  ca- 
nals of  the  dilated  vessels  were  obliterated., 
and  a spontaneous  cure  was  the  consequence 
The  excessive  distention  of  the  coats  of  n 
superficial  vein  produces  an  inflammatory 
irritation,  at  first  in  the  adjoining  cellular 
membrane,  and  afterward  in  the  integu- 
ments. These  organs  become  at  first  con- 
nected together  by  the  adhesive  inflamma- 
tion ; and  if  the  distention  continues  to  ope- 
rate, they  may  at  length  ulcerate  and  burst, 
and  hemorrhage  be  the  consequence.  In 
such  cases,  the  effusion  of  blood  is  some- 
times considerable  ; but,  says  Delpech,  we 
have  no  example  of  its  having  proved  dan- 
gerous. The  syncope  following  it;  or  a 
moderate  compression,  suffices  for  its  stop- 
page. A more  common  occurrence  than 
bleeding,  is  the  coagulation  of  the  blood  in 
the  cavity  of  a varicose  vein.  The  vessel 
then  becomes  hard  and  incompressible,  and 
it  loses  tiiat  elastic  yielding  softness,  which 
renders  it  capable  of  being  diminished  by 
gentle  pressure.  If  the  parts  be  already  in- 
flamed, Delpech  conceives,  that  the  clot  in 
the  diseased  vein  may  act  as  an  extraneous 
body,  and  bring  on  ulceration,  by  the  effects 
of  which  it  is  at  last  brought  into  view.  It^ 
this  sort  of  case,  it  is  extremely  uncommon 
for  hemorrhage  to  occur  ; for  in  general,  the 
vessel  is  already  obliterated  by  the  preceding 
inflammation.  But  the  ulcer  itself  is  very 
difficult  to  heal,  and  may  be  kept  up  a long 
while  by  the  cedpmatous  swelling  of  the 
limb.  Varices,  or  rather  the  oedema,  which 
is  the  consequence  of  them,  has  the  same 
effect  upon  every  other  species  of  ulcer, 
and  even  upon  the  most  simple  solution  of 
continuity.  While  the  swelling  of  the  limb 
cannot  be  dispersed  ; while  the  edges  of  a 
solution  of  continuity  are  kept  asunder  by 
the  tense  state  of  the  skin;  and  while  the 
divided  parts  are  irritated  by  this  painful 
tension  ; every  thing  is  unfavourable  to  cica- 
trization. Thus  we  see  the  most  simple 
wounds,  which  have  been  allowed  to  suppu- 
rate, and  ulcers  which  should  have  healed 
rapidly,  continue  uncured  a great  many 
years,  merely  because  the  limbs  on  which 
they  are  situated,  are  affected  with  an  oede- 
matous  swelling,  the  consequence  of  vari- 
ces. Such  is  the  condition  of  things  in  the 
case  which  has  been  improperly  named  the 
varicose  ulcer.  ( Delpech , Pricis  des  Mala- 
dies Chir.  Tom.  3,  sect.  8,  art.  3.) 

In  the  investigation  of  the  causes  of  vari- 
ces, it  is  usual  to  dwell  very  much  upon  the 
mechanical  obstructions  which  may  affect 
the  circulation  of  the  blood  in  the  veins. 
Surgeons  have  thought  themselves  justified 
iu  regarding  this  as  the  only  cause,  because 
a circular,  moderate  compression,  incontes- 
tably retards  the  course  of  the  blood  iu 
these  vessels,  and  produces  a temporary  dila- 
tation of  them,  i'he  opinion  seems  also  to 
derive  confirmation  from  the  knotty  appear 
ance  of  varicose  veins,  a circumstance  which 
has  been  accounted  for  by  supposing  that 
the  distention  is  greatest  in  the  situation  of 


V ARICOSE  VEINS 


<>90 


the  valves.  Lastly,  the  idea  is  further  sup- 
ported by  the  well-known  fact  of  the  fre- 
quent occurrence  of  varices  during  the  state 
of  pregnancy.  But  it  has  not  been  remem- 
bered, that  the  use  of  garters,  for  example, 
is  extremely  common  ; yet  varices  of  the 
legs  are  infinitely  less  frequent ; that  very 
large  varices  are  met  with  in  persons,  who 
have  never  employed  anjr  kind  of  ligatures, 
to  which  the  origin  of  the  complaint  can 
be  imputed  ; that  when  the  dilatation  of  the 
veins  extends  to  the  thighs  and  parietes  of 
the  abdomen,  no  causes  of  this  description 
even  admit  of  suspicion;  that  varicose  veins 
are  observable  round  several  kinds  of  tu- 
mours, especially  scirrhi,  when  there  is  no 
possibility  of  pointing  out  any  mechanical 
obstruction  to  the  circulation  of  the  blood  ; 
that  varices  sometimes  make  their  appear- 
ance at  the  commencement  of  pregnancy, 
and  long  before  the  enlargement  ot  the 
womb  can  impede  the  free  return  of  the 
blood  through  the  veins  in  the  pelvis  ; that 
nothing  is  more  unusual,  than  a varicose  di- 
latation of  the  veins  of  the  lower  extremi- 
ties in  consequence  of  swellings  of  the  ab- 
dominal viscera  ; and  lastly,  it  has  been  for- 
gotten, that  the  knots  of  the  dilated  veins 
are  far  too  numerous  to  admit  of  being  as- 
cribed to  the  resistance  of  the  valves.  It 
cannot  be  denied,  that  pressure  applied  in 
the  track  of  the  vessels  tends  to  promote 
their  dilatation  : but  it  can  neither  be  con- 
sidered as  tiie  only  cause,  nor  as  the  princi- 
pal one.  The  foregoing  observations,  made 
by  Delpech,  render  it  probable,  that  some 
unknown  general  cause  is  concerned  in  pro- 
ducing varices,  the  formation  of  which  may 
also  be  facilitated  by  the  impediments  to  the 
free  return  cf  the  blood,  occasioned  by 
certain  attitudes,  and  particular  articles  of 
clothing. 

Mr.  Hodgson  conceives  it  probable,  that, 
in  some  instances,  the  valves  are  ruptured  in 
consequence  of  muscular  exertions  or  ex- 
ternal violence,  in  which  cases  the  pressure 
of  the  column  of  blood  is  the  first  cause  of 
the  dilatation  of  the  veins.  Sometimes  also 
the  disease  appears  to  arise  from  preternatu- 
ral weakness  in  the  coats  of  the  veins,  as, 
in  those  instances,  in  which,  without  any 
evident  cause,  it  exists  in  various  parts  of  the 
same  person.  ( Treatise  on  the  Diseases  of 
Arteries  and  Veins , p.  537.) 

Experience  proves,  says  Delpech,  that 
there  is  no  ceriain  mode  of  curing  varices , 
strictly  so  called,  which  he  thinks  cannot  be 
wondered  at,  since  the  nature  and  causes  of 
the  disease  are  completely  unknown.  The 
same  source  of  knowledge,  however,  also 
proves,  that  the  increase  in  the  dilatation  of 
varicose  veins  may  be  retarded,  and  that  the 
oedematous  swelling,  attendant  on  the  com- 
plaint, may  be  beneficially  opposed  by  me- 
thodical and  permanent  compression.  When 
the  whole  of  a limb,  affected  with  varices,  is 
subjected  to  this  last  mode  of  treatment,  the 
dilated  veins  subside,  the  circulation  is  more 
regularly  performed, and  the  ccdema  and  pain 
'.ease  There  is  not  (says  Delpech)  any  bet- 
ter method  cf  healing  the  solutions  of  con- 


tinuity in  the  soft  parts,  produced  or  kept  up 
by  the  varicose  state  of  the  limb,  and  its 
consequences.  But  sometimes,  as  soon  as 
the  compression  is  discontinued,  the  varices 
make  their  appearance  again,  the  pain  recurs, 
the  oedema  returns,  and  the  ulcers  which 
were  healed  break  out  afresh. 

Inflammation  of  the  integuments  covering 
a varix,  or  varicose  tumour,  cannot  invaria- 
bly be  prevented  by  compression  ; nor  will 
this  treatment  always  succeed  even  in  remo- 
ving the  intolerable  pain  which  sometimes 
attends  numerous  clusters  of  varicose  veins. 
In  the  first  case,  rest  and  relaxing  applica 
tions  will  often  succeed  ; and  in  the  second, 
the  topical  use  of  sedatives  frequently  gives 
relief.  It  has  been  proposed  to  puncture  and 
empty  varicose  veins;  but  if  a temporary 
emptiness  and  relaxation  of  these  vessels 
were  to  remove  the  pain  for  a time,  things 
would  fall  into  the  old  state  again  in  the 
course  of  a few  days.  If  the  plan  were 
adopted,  it  would  be  necessary  to  make  a 
free  opening  in  the  dilated  vein,  and  extract 
the  coagulum.  The  vessel  would  then  need 
no  ligature  above  and  below  the  opening, 
for  the  slightest  compression  would  afterward 
stop  the  bleeding,  and  the  vessel  be  oblitera 
ted  by  the  subsequent  inflammation. 

We  learn  from  Celsus,  that  the  ancients 
were  accustomed  to  remove  varices  by  exci- 
sion, or  destroy  them  with  the  oautery.  ( De 
Re  Medicd,  lib.  7,  cap . 3.)  When  the  vein 
was  much  convoluted,  extirpation  with  the 
knife  was  preferred  ; but  in  other  cases,  the 
dilated  vessel  was  exposed  by  an  incision, 
and  then  cauterized.  Petit,  Boyer,  and  many 
British  surgeons,  have  also  sometimes  cut  out 
clusters  of  varicose  veins. 

Delpech  remarks,  that  the  extirpation  of 
tumours  composed  of  numerous  varices  has 
been  practised,  either  for  the  purpose  of  re 
moving  the  pain  in  the  situation  of  the  dis- 
ease, or  other  inconveniences.  This  opera- 
tion has  been  successfully  performed  ; but  it 
appears  not  to  have  constantly  had  the  effect 
of  preventing  the  formation  of  new  varices, 
and  it  has  sometimes  proved  tedious,  diffi- 
cult, and  severely  painful  in  its  execution. 
In  fact,  an  erroneous  judgment  must  neces- 
sarily be  formed  of  the  extent  of  these  swell- 
ings, when  they  are  judged  of  only  from  the 
appearance  which  they  present  under  the 
skin.  Varices  are  not  always  confined  to  the 
superficial  veins,  and  when  they  extend 
deeply,  the  operation  must  be  ineffectual. 
The  opinion  of  Delpech  is,  that  it  should 
never  be  undertaken,  unless  the  disease  be 
accompanied  with  perilous  symptoms,  or  the 
patient  nearly  deprived  of  the  use  of  his 
limb. 

It  has  been  thought,  that  one  of  the  esta- 
blished principles  in  the  treatment  of  aneu- 
risms might  be  advantageously  extended  to 
the  cure  of  varicose  veins.  By  tying  the 
principal  venous  trunk  above  the  point  to 
which  the  varicose  affection  reaches,  it  is 
said,  that  the  course  of  the  blood  in  the  mor- 
bid vessels  may  be  totally  stopped  ; the  co- 
lumn of  this  fluid  made  to  coagulate  ; and 


VARICOSE  VEINS. 


'1j  i 


.he  consequent  obliteration  of  the  vessels 
themselves  accomplished. 

The  practice  of  tying  veins  for  the  cure 
of  varices,  appears  to  have  been  employed 
in  the  . days  of  Pare  and  Dionis,  (Cours  d' Ope- 
rations de  Chirurgic,  p.  610,)  who  have  ac- 
curately described  the  operation  of  tying  and 
dividing  the  vein  between  the  two  ligatures. 
Sir  Everard  Home  has  related  many  cases 
of  varicose,  veins  in  the  lee,  some  of  them 
accompanied  with  tedious  ulcers,  which,  af- 
ter the  vena  saphena  major  had  been  tied,  as 
it  passes  over  the  inside  of  the  knee,  were 
readily  healed,  and  the  dilatation  of  the  veins 
of  the  leg  relieved. 

This  practice  has  sometimes  answered ; 
but  it  bas  also  had  its  failures. 

Among  other  evils,  an  inflammation  of  the 
lied  vein  has  been  observed  extending  very 
far  in  (he  vessel,  and  succeeded  by  great  con- 
stitutional disorder,  symptoms  very  anala- 
gous  to  those  of  typhus  fever,  and  death.  In 
some  of  these  cases,  previously  to  their  ter- 
mination, abscesses  form  in  the  direction  of 
the  vessel  below  or  above  the  ligature ; in 
others,  such  collections  of  matter  are  not 
observed.  (See  Travers  on  Wounds  and 
Ligatures  of  Veins.  Surgical  Essays,  Part 
1,p.  216,  ard  Oldknoiv,  in  Edinb.  .Med.  and 
Surg.  Journ.  Vol.  5.  R.  Carmichael , in  Trans, 
of  the  King's  and  Queen's  College  of  Physi- 
cians, Vol.  2,  p.  345,  $-c.)  Indeed,  the  dan- 
gers arising  from  an  inflammation  of  the  in- 
ternal coat  of  the  veins  are  now  generally 
acknowledged,  and  every  endeavour  should 
be  made  to  avoid  them.  A case  which  hap- 
pened in  Guy’s  Hospital,  in  1S16,  fully  proves 
them : the  femoral  vein  happened  to  be 
pricked  in  an  operation  for  aneurism,  and  a 
ligature  was  applied  round  the  aperture.  In- 
flammation of  its  internal  coat  took  place, 
extending  up  into  the  vena  cava,  and  the  pa- 
tient is  supposed  to  have  died  of  the  indis- 
position resulting  from  it.  (See  Travers's 
Surgical  Essays,  Part  1,  p.  222.) 

Hence  arises  one  of  the  most  weighty  ob- 
jections to  the  practice  of  tying  the  trunks 
of  varicose  veins,  with  the  view  of  curing 
their  morbid  dilatation,  and  its  effects  upon 
the  limb. 

As  Mr.  Brodie  observes,  it  seems  to  be 
now  established  by  the  experience  of  mo- 
dern surgeons,  that  a mechanical  injury,  in- 
flicted on  the  trunk  of  one  of  (lie  larger 
veins,  is  liable  to  be  followed  by  inflamma- 
tion of  its  internal  membrane,  and  a fever 
of  a very  serious  nature  ; and  (he  occasional 
occurrence  of  these  symptoms,  after  the  liga- 
ture, or  even  the  simple  division  of  the  vena 
saphaena,  has  made  surgeons  less  confident 
than  formerly  of  the  propriety  of  attempt- 
ing such  operations  for  the  relief  of  a vari- 
cose state  of  the  branches  of  that  vessel  in 
the  leg.  Certain  reflections,  however,  indu- 
ced Mr.  Brodie  to  think,  that  the  same  ill 
effects  would  not  follow  a similar  operation 
performed  on  the  branches  themselves. 

Where  the  whole  of  the  veins  of  the  leg 
are  in  a state  of  morbid  dilatation,  and  the 
distress  produced  by  the  disease  is  not  refer- 
red to  any  particular  part,  there  seem  to  he 


no  reasonable  expectations  of  benelit,  except 
from  the  uniform  pressure  of  a well-applied 
bandage.  But  not  unfrequehtly  we  find  an 
ulcer  which  is  irritable,  and  difficult  to  heal 
on  account  of  its  connexion  with  some  Vari- 
cose vessels  ; or  without  being  accompanied 
by  an  ulcer,  there  is  a varix  in  one  part  of 
the  leg,  painful,  and  perhaps  liable  to  bleed, 
while  the  veins  in  other  parts  are  nearly  in  a 
natural  stale,  or,  at  any  rate,  are  not  the 
source  of  particular  uneasiness.  In  some  of 
these  cases,  I formerly  applied  the  caustic 
potash,  so  as  to  make  a slough  of  the  skin 
and  veins  beneath  it ; but  I found  the  relief 
which  the  patient  experienced  from  the  cure 
of  the  varix,  to  afford  but  an  inadequate  com 
pensation  for  the  pain  to  which  he  was  sub- 
jected by  the  use  of  the  caustic,  and  the  in 
convenience  arising  from  the  tedious  healing 
of  the  ulcer,  which  remained  after  the  sc 
paration  of  the  slough. 

“ In  other  cases,  1 made  an  incision  with 
a scalpel  through  the  varix  and  skin  over  it. 
This  destroyed  the  varix  as  completely  as  it 
was  destroyed  by  the  caustic,  and  I found  it 
to  be  preferable  to  the  use  of  the  caustic,  as 
the  operation  occasioned  less  pain,  and  as, 
in  consequence  of  there  being  no  loss  of  sub- 
stance, the  wound  was  cicatrized  in  a much 
shorter  space  of  time.  1 employed  the  ope- 
ration, Such  as  I have  described  it,  with  ad- 
vantage in  several  instances ; but  some 
months  ago  I made  an  improvement  in  the 
method  of  performing  it,  by  which  it  is  much 
simplified;  rendered  less  formidable,  not 
only  in  appearance,  but  also  in  reality ; and 
followed  by  an  equally  certain,  but  more 
speedy  cure. 

“ It  is  evident,  (says  Mr.  Brodie,)  that  the 
extensive  division  of  the  skin  over  a varix  can 
be  attended  with  no  advantage.  On  the  con- 
trary, there  must  be  a disadvantage  in  it,  as  a 
certain  time  will  necessarily  be  required  for 
the  cicatrization  of  the  external  wound.  The 
improvement  to  which  1 allude,  consists  in 
this  : the  varicose  vessels  are  completely  di- 
vided, while  the  skin  over  them  is  preserved 
entire,  with  the  exception  of  a moderate  punc- 
ture, which  is  necessary  for  the  introduction 
of  the  instrument  with  which  the  incision  of 
the  veins  is  effected.  Thus  the  wound  of 
the  internal  parts  is  placed  under  the  most 
favourable  circumstances  for  being  healed, 
and  the  patient  avoids  the  more  tedious  pro- 
cess which  is  necessary  for  the  cicatrization 
of  a wound  in  the  skin  above. 

“ For  this  operation,  I have  generally  em- 
ployed a narrow,  sharp-pointed  bistoury, 
slightly  curved,  with  its  cutting  edge  on  the 
convex  side.  Having  ascertained  the  pre- 
cise situation  of  the  vein,  cr  cluster  of 
veins,  from  which  the  distress  of  the  patient 
appears  principally  to  arise,  I introduce  the 
point  of  the  bistoury  through  the  skin  on 
one  side  of  the  varix,  and  pas;  it  on  between 
the  skin  and  the  vein,  with  one  of  the  flat  surfa- 
ces turned  forwards,  and  the  other  backwards, 
until  it  reaches  the  opposite  side.  I then 
turn  the  cutting  edge  of  the  bistoury  back- 
wards, and  in  withdrawing  the  instrument, 
the  division  of  the  varix  19  effected.  The 


VEINS,  DISEASES  01 


592 


patient  experiences  pain,  which  is  occasion- 
ally severe,  but  subsides  in  the  course  of  a 
short  time.  There  is  always  hemorrhage, 
which  would  be  often  profuse  if  neglected, 
but  which  is  readily  stopped  by  a moderate 
pressure,  made  by  means  of  a compress  and 
bandage  carefully  applied.” 

Mr.  Brodie  particularly  enjoins  the  ne- 
cessity of  keeping  the  patient  quietly  in  bed 
for  four  or  five  days  after  the  ope  ation,  and 
removing  the  bandage  and  first  dressings 
with  the  utmost  care  and  gentleness.  He 
also  cautions  surgeons  not  to  make  the  in- 
cision more  deep  than  absolutely  necessary. 
Inflammation  of  the  coats  of  the  veins  has 
not  occurred  in  any  of  the  cases,  in  which 
Mr.  Brodie  has  adopted  this  method  of  treat- 
ment. This  gentleman  wishes  it  to  be  un- 
derstood, however,  that  he  does  not  recom- 
mend the  practice  indiscriminately,  but  with 
a due  attention  to  the  circumstances  of  each 
individual  case.  “ The  cases  for  which  it  is 
fitted, "are  not  those  in  which  the  veins  of 
the  leg  generally  are  varicose,  or  in  which 
the  patient  has  little  or  no  inconvenience 
from  the  complaint;  but  those  in  which 
there  is  considerable  pain  referred  to  a par- 
ticular varix ; or  in  which  hemorrhage  is 
liable  to  take  place  from  the  giving  way  of 
the  dilated  vessels ; or  in  which  they  occa- 
sion an  irritable  and  obstinate  varicose  ul- 
cer.” (See  Mdd.  Chir.  Trans.  Vol.  7,  p. 
195,  et  seq  ) 

On  the  subject  of  cutting  through  veins 
affected  with  varix,  it  is  proper  to  observe, 
that  even  this  plan  has  been  known  to  bring 
on  severe  and  fatal  symptoms.  Cases,  con- 
firming this  fact,  are  recorded  in  a valuable 
modern  work,  which  should  be  in  the  hands 
of  every  practical  surgeon.  (See  Hodgson's 
Treatise  on  the  Diseases  of  Arteries  and  Veins, 
p.  555,  et  seq.)  It  is  but  justice  to  state, 
.however,  that,  in  these  examples,  Mr.  Bro- 
die’s  manner  of  doing  the  operation  was  not 
adopted.  On  the  contrary,  his  method,  as 
far  as  l have  yet  heard,  receives  very  gene- 
ral approbation.  Some  cases  and  observa- 
tions highly  in  favour  of  it,  are  detailed  by 
Mr.  Carmichael.  (See  Tram,  of  the  King’s 
mid  Queen’s  College  of  Physicians,  Vol.  2, 
p.  369,  fyc.) 

Cases  of  spontaneous  varix  in  the  veins  of 
the  arm  are  rarely  observed.  When  these 
vessels  become  varicose,  it  is  almost  always 
in  consequence  of  a communication  being 
formed,  in  the  operation  of  venesection, 
between  the  brachial  artery  and  one  of  the 
veins  at  the  bend  of  the  arm.  The  super- 
ficial veins  in  this  situation  then  become 
more  or  less  dilated,  by  the  impulse  of  the 
.stream  of  arterial  blood  which  is  thrown 
into  them.  There  is,  however,  a good  deal 
of  difference  between  these  accidental  va- 
rices, actually  induced  by  a mechanical 
cause,  and  those  which  originate  sponta- 
neously, or  from  causes  not  very  clearly 
understood.  The  former  never  acquire  the 
size  which  the  latter  often  attain ; they 
never  exceed  a certain  magnitude,  whether 
pressure  be  employed  or  not  ; they  never 
form  tumours  composed  of  an  assemblage 


of  varicose  veins  ; they  are  never  filled  wuh 
tough  coagula  of  blood  ; their  coats  are 
never  thickened,  nor  constitute  the  solid 
half-canal  remarked  in  the  other  species  of 
varices;  the  skin,  which  covers  them,  is 
not  disposed  to  inflame  and  ulcerate  ; they 
are  not  subject  to  occasional  hemorrhage  ; 
and  the  limb  is  not  affected  with  any  cede- 
matous  swelling.  ( Delpech , Traiti  des  Ma- 
ladies Chir.  T.  3,  p.  261.)  These  circum- 
stances render  it  evident,  that  here  all  sur- 
gical interference  would  be  unnecessary. 

See  Aneurism,  where  the  aneurismal  va- 
rix is  described  ; Cirsocele,  where  the  varix 
of  the  spermatic  chord  is  treated  of;  He- 
morrhoids, where  the  diseased  and  enlarged 
veins  of  the  rectum  are  considered  ; Vari- 
cocele, where  those  of  the  scrotum  are  no- 
ticed. 

VA'RIX.  (from  varius,  unequal.)  The 
term  varices  is  applied  to  a kind  of  knotty, 
unequal, dark-coloured  swelling. arising  from 
a morbid  dilatation  of  veins.  (See  Varicose 
Veins.) 

VEINS,  DISEASES  OF.  To  the  obser- 
vations and  references  made  in  the  prece- 
ding article  ( Varicose  Veins,)  I here  annex  a 
few  remarks  on  the  principal  diseases  of  the 
venous  system,  in  order  to  render  what  has- 
been  already  stated,  in  other  parts  of  the 
work,  more  complete. 

It  is  justly  observed  by  Mr  Hodgson,  that 
11  the  veins  are  liable  to  all  those  morbid 
changes  which  are  common  to  soft  parts  in 
general ; but  the  membranous  lining  of  these 
vessels  is  peculiarly  susceptible  of  inflam- 
mation. When  a vein  is  wounded,  the  in- 
flammation, which  is  the  effect  of  the  injury, 
sometimes  extends  along  the  lining  of  the 
vessel  into  the  principal  venous  trunks,  and 
in  some  instances,  even  to  the  membrane 
which  lines  the  cavities  of  the  heart.  This 
inflammation  sometimes  produces  an  effu- 
sion of  coagulating  lymph,  by  which  the 
opposite  sides  of  the  vein  are  united,  so  as 
to  obliterate  the  tube ; in  this  manner  a 
great  extent  of  the  vessel  is  occasionally 
converted  into  a solid  cord.  In  some  in- 
stances, the  secretion  of  pus  into  the  cavity 
of  the  vessel  is  the  consequence  of  inflam- 
mation of  the  membranous  lining  of  veins : 
under  these  circumstances,  the  matter  is 
either  mixed  with  the  circulating  blood,  or, 
the  inflammation  having  produced  rfdhcsion 
of  the  sides  of  the  vessel  at  certain  intervals, 
boundaries  are  formed  to  the  collection  ot 
pus,  which  in  this  manner  form  a chain  ot 
abscesses  in  the  course  of  the  vessel. 

“ When  the  inflammation  of  veins  is  not 
very  extensive,  its  symptoms  are  the  same 
as  those  of  local  inflammation  in  general : 
but  when  the  inflammation  extends  into  the 
principal  venous  trunks,  and  pus  is  secreted 
into  the  vessel,  it  is  accompanied  with  a 
high  degree  of  constitutional  irritation,  and 
with  symptoms  which  bear  a striking  re- 
semblance to  those  of  typhus  fever.  (See 
Hodgson’s  Treatise  on  the  Diseases  of  Arteries 
and  Veins,  p.  611,  512.) 

Besides  the  example  of  inflammation  ot 
femoral  and  other  large  veins,  brought  on 


VENEREAL  DISEASE. 


o9J 


by  u ligature  round  a small  aperture,  acci- 
dentally made  in  the  femoral  vein,  in  the 
operation  for  popliteal  aneurism,  as  men- 
tioned in  a foregoing  article,  (Varicose  Veins.) 
Mr.  Travers  reports  another  case,  in  which 
a fatal  inflammation  of  the  femoral  and  ex- 
ternal iliac  veins,  with  marks  of  diffused  in- 
flammation up  to  the  right  auricle,  was  ap- 
parently caused  by  the  application  of  a liga- 
ture to  the  mouth  of  the  femoral  vein,  after 
an  amputation.  (P.  227.)  And  the  same 
catastrophe  would  appear  to  be  occasionally 
the  result  of  venous  inflammation  after  am- 
putation, even  where  the  femoral  vein  is 
not  tied.  (See  Carmichael,  in  Trans,  of 
King's  and  Queen's  College  of  Physicians, 
Val.  2,  p.  365.)  In  short,  Mr.  Travers’s  ob- 
servations, as  well  as  those  of  Mr.  Hodgson 
and  Mr.  Carmichael,  tend  to  prove,  “ that 
the  inflammation  of  the  interior  tunic  of  a 
vein  sometimes  follows  a puncture,  some- 
times a division,  a ligature  encircling  the 
tube,  or  including  only  a part  of  it,  or  arises 
spontaneously  from  an  inflamed  surface,  of 
which  the  vein  forms  a part.”  (P.  238.) 
Mr.  Carmichael  relates  an  instance,  in  which 
the  appearances  after  death  seem  to  evince 
that  the  patient  died  subsequently  to  an  op- 
eration .for  femoral  aneurism,  of  inflamma- 
tion and  suppuration  within  the  femoral 
vein,  and  extending  both  down  the  saphena, 
and  upwards  through  the  common  iliac  vein. 
The  femoral  vein  had  been  pricked  in  the 
operation,  but  not  tied.  (Trans,  of  the 
King's  and  Queen's  College  of  Physicians, 
Ireland,  Vol.  2.  p.  350,  fyc.)  In  order  to 
avoid  the  danger  of  wounding  the  femoral 
vein,  above  the  edge  of  the  sartorius,  Mr. 
Carmichael  recommends  “ introducing  the 
needle  on  the  pubal  side  of  the  artery 
(P.  357)  a direction  which  should  have  been 
considered  in  the  article  .Aneurism. 

Inflammation  frequently  produces  a thick- 
ening of  the  coats  of  the  veins,  as  well  as 
adhesion  of  their  sides,  and  obliteration  of 
their  cavities.  Indeed,  in  some  instances, 
these  vessels  have  been  found  to  resemble 
arteries  in  the  thickness  of  their  coats,  and 
in  retaining  a circular  form  when  cut  across. 
( Hodgson , up.  cit.  p.  513.) 

Ulceration  sometimes  extends  to  the  coats 
of  veins,  and,  by  exposing  their  cavities, 
gives  rise  to  hemorrhage.  In  certain  exam- 
ples, it  commences  in  the  membranous  li- 
ning, and  destroys  the  other  coats.  In  ge- 
neral, however,  the  adhesive  inflammation 
precedes  the  ulcerative,  and  by  obliterating 
the  cavities  of  these  vessels,  prevents  the  oc- 
currence of  hemorrhage.  When  sphacela- 
tion takes  place  in  the  vicinity  of  veins, 
their  cavities,  like,  those  of  arteries  under 
similar  circumstances,  are  filled  with  exten- 
sive plugs  of  coaguium,  which  prevent  he- 
morrhage upon  the  separation  of  the  mor- 
tified part. 

Veins  are  sometimes  Ruptured,  without 
any  previous  morbid  alteration  in  their 
structure,  and  the  accident  may  be  induced 
by  muscular  exertions,  external  violence, 
the  sudden  effects  of  the  cold  bath,  &,c. 

Although  a deposition  of  calcareous  mat- 
R Vot,.  If,  75 


ter  almost  invariably  takes  place  in  the  ar- 
teries of  persons  advanced  in  life,  it  is  an 
extremely  rare  occurrence  -in  the  coats  of 
veins 

Loose  calculi  have  been  found  in  the  ca- 
vities of  veins ; and  tumours  sometimes 
grow  from  their  lining.  In  a case  of  scir- 
rhous pylorus,  Mr.  Hodgson  found  a turnout*) 
larger  than  a hazel  nut,  growing  from  the 
lining  of  the  splenic  vein,’ and  resembling  in 
its  appearance  and  consistence  the  disease 
which  existed  at  the  pylorus.  (P.  524.) 

The  venous,  like  the  arterial  system,  ap- 
pears to  be  capable  of  carrying  on  a colla- 
teral circulation,  when  any  part  of  it  is  im- 
pervious. Even  after  the  obliteration  of 
the  vena  cava  inferior,  the  blood  lias  been 
known  to  be  conveyed  with  facility  loibe 
heart  through  the  lumbar  veins  and  vena 
azygos.  In  the  case  recorded  by  Dr.  Baillie, 
( Trans,  for  the  Improvement  of  Medical  and 
Chir.  Knowledge,  Vol.  1,  p.  127.)  it  is.  re- 
markable, that  the  vena  cava  inferior  was 
obliterated  at  the  point  where  the  venae 
cavee  hepaticee  opened  Into  it,  so  that  not 
only  the  blood  from  the  lower  extremities, 
but  also  that  from  the  liver,  must  have  pass- 
ed through  collateral  channels  to  the  heart. 

Want  oi:  room  having  prevented  me  from 
introducing  further  observations  on  the  dis- 
eases of  veins,  I must  refer  to  the  following 
works  for  additional , information.  J.  Hun- 
ter, in  Trans,  for  the  Improvement  of  Med. 
and  Chir.  Knowledge,  Vol.  J.  Abernethy's 
Works.  J.  Hodgson  on  the  Diseases  of  Arte- 
ries and  Veins.  Longuet , Dis.  sur  1' Inflam- 
mation des  Veins,  Paris,  1815.  B.  Tracers, 
in  Surgical  Essays,  Part  1,  8ro.  Lond.  1818. 
F.  A.  B.  Puch el t , Das  Venensystem  in  Seinen 
Krankhaflen  Verhaltnissen.  Sro.  Leipz  1818. 
R.  Carmichael,  in  Trans,  of  the  Association  of 
Fellows,  fyc.  of  the  King's  and  Queen's  Col- 
lege of  Physicians  in  Ireland,  Vol.  2,  Svo. 
Dublin,  ISIS. 

VENEREAL  DISEASE.  (Lues  Venerea 
Morbus  Gallicus.  Syphilis.)  About  the  year 
1494,  or  1495,  the  venereal  disease  is  said 
to  have  made  its  first  appearance  in  Europe. 
Some  writers  believe, that  it  originally  broke 
out  at  the  siege  of  Naples  ; but  most  of  them 
suppose  that,  as  Columbus  returned  from 
his  first  expedition  to  the  West  Indies  about 
the  above  period,  his  followers  brought  the 
disorder  with  them  from  the  new  to  the  old 
world.  Other  authors,  however,  among 
whom  is  Mr.  B.  Bell,  maintain  the  opinion, 
that  the  venereal  disease  was  well  known 
upon  the  old  continent,  arid  that  it  pre- 
vailed among  the  Jews,  Greeks,  and  Ro- 
mans, and  their  descendants,  long  before 
the  discovery  of  America. 

Although  many  considerations  lead  me 
to  reject  the  common  history  of  syphilis  as 
fabulous,  I mean  that  account  which  refers 
its  origin  to  America,  or  the  French  array 
in  Italy,  it  does  not  appear  to  me.  that  any 
utility  would  be  likely  to  result  from  agita- 
ting this  question  in  modern  tunes,  because, 
if  it  be  true,  as  the  most  candiAwid  intelli- 
gent surgeons  of  the  present  rally 

acknowledge,  that  they  cannot  precisely 


A 


V IbNEltEAL  DISEASE 


b94 


define  what  the  venereal  disease  is,  nor  al- 
ways point  out  the  exact  circumstances,  in 
which  it  differs  from  some  other  anomalous 
complaints,  even  when  the  cases  are  before 
their  eyes,  how  can  such  discrimination  be 
attempted  from  a mere  review  of  old  de- 
scriptions, unaccompanied  with  the  advan- 
tage of  letting  the  reader  judge  from  the 
living  patients  themselves  P But,  as  far  as 
the  nature  of  the  venereal  disease  has  been 
unravelled,  and  it  is  allowable  to  judge  from 
such  comparisons,  I may  be  permitted  to 
remark,  that,  in  degree  of  severity,  the 
acuteness  of  symptoms,  rapidity  of  propa- 
gation, and  extent  and  quickness  of  fatality, 
no  forms  of  disease,  now  ever  conjectured 
to  be  venereal,  bear  the  least  resemblance 
to  the  destructive  malady,  with  which  the 
army  before  Naples,  at  the  close  of  the  fif- 
teenth century,  was  afflicted  : nor  will  any 
ignorance  of  the  uses  of  mercury,  as  will  be 
presently  noticed,  explain  differences  so 
strongly  marked. 

The  venereal  disease  is  supposed  to  arise 
from  a specific  morbid  poison,  w hich,  when 
applied  to  the  human  body,  has  the  power 
of  propagating  or  multiplying  itself,  and  is 
capable  of  acting  both  locally  and  constitu- 
tionally. 

Mr.  Hunter  was  of  opinion,  that  the  ef- 
fects produced  by  the  foison  arise  from  its 
peculiar  or  specific  irritation,  joined  with 
the  aptness  of  the  living  principle  to  be  irri- 
tated by  such  a cause,  and  the  parts  so  irri- 
tated acting  accordingly.  Hence,  he  con- 
sidered. that  the  venereal  virus  irritated  the 
living  parts  in  a manner  peculiar  to  itself, 
and  produced  an  inflammation,  peculiar  to 
that  irritation,  froiri  which  a matter  is  pro- 
duced, peculiar  to  the  inflammation. 

The  venereal  poison  is  capable  of  aflat: t- 
ing  the  human  body  in  two  different  ways  : 
locally,  that  is,  in  those  parts  only  to  which 
it  is  first  applied  ; and  constitutionally,  that 
is,  in  consequence  oi  its  absorption. 

In  whatever  manner  the  venereal  disease 
was  first  produced,  it  began,  says  Mr.  Hun- 
ter, in  the  human  race,  as  no  other  animal 
seems  capable  of  being  affected  by  it.  He 
conceives  also,  that  the  parts  of  generation 
were  those  first  affected  ; for,  if  the  disease 
had  taken  place  on  any  other  part,  it  would 
not  have  gone  further  than  tne  person  in 
whom  it  first  arose.  On  the  contrary,  if 
the  disease,  in  the  first  instance  ot  its  for- 
mation, be  presumed  to  have  attacked  the 
parts  of  generation,  where  the  only  natural 
connexion  takes  place,  between  one  human 
being  and  another,  except  that  between  the 
mother  arid  child,  it  was  in  the  most  favour- 
able situation  for  being  propagated  ; and 
Mr.  Hunter  infers,  also,  that  the  first  effects 
of  the 'disease  must  have  been  local,  in  con- 
sequence ol  ijie  fact,  now  well  established, 
that  none  of  the  constitutional  effects  are 
communicable  to  other  persons,  ihat  is  to 
say,  infectious^ 

Thus,  the  Atfinberless  cases  of  the  vene- 
real diseasaJpicting  generation  after  gene- 
ration, ijyjdjBbservable  in  all  the  known 
parts  effme  world,  are.  supposed  to  be 


originally  derived  from  the  amours  oi  some' 
unfortunate  individual,  in  whom  the  poison 
was  first  formpd,  from  causes  beyond  the 
reach  of  human  investigation.  But,  that  any 
statement  of  this  kind  is  more  valuable  than 
unsupported  conjecture,  is  a proposition  to 
which  my  mind  is  not  prepared  to  assent, 
particularly  when  it  is  considered,  that  sores 
on  the  genitals,  giving  rise  to  such  constitu- 
tional symptoms  as  puzzle  the  most  discern- 
ing practitioners  of  the  present  enlightened 
days  of  medical  science,  are  often  of  a very 
diversified  character,  so  as  hardly  to  admit, 
of  reference  to  one  common  origin.  And, 
as  l have  already  hinted,  every  modern  spe  - 
culation, about  the  first  origin  of  the  distem- 
per, promises  but  little  instruction  orsuccess, 
because  the  question  relates  to  a disease, 
the  diagnosis  of  which  is  still  very  unsettled, 
and  the  complete  definition  of  which  has 
hitherto  baffled  men  of  the  greatest  genius 
and  experience. 

According  to  Mr.  Hunter,  the  venereal 
poison  is  commonly  in  the  form  of  pus,  or 
some  other  secretion.  In  most  cases,  it  ex 
cites  an  inflammation,  which  (to  use  the 
same  author's  language,)  is  attended  with  a 
specific  mode  of  action,  different  from  an 
other  actions  attending  inflammation,  and 
accounting  for  the  specific  quality  in  the 
matter. 

The  formation  of  matter,  though  a general;, 
is  not  a constant  attendant  on  this  disease  , 
for  inflammation,  produced  by  the  venereal 
poison,  sometimes  does  not  terminate  in 
suppuration.  But,  if  Mr.  Hunter’s  senti- 
ments are  correct,  it  is  the  matter  produced, 
whether  with  or  without  inflammation, 
which  alone  contains  the  poison.  Hence  a 
person,  having  the  venereal  irritation  in  any 
form,  not  attended  with  a discharge,  cannot 
communicate  the  disease  to  another.  In 
proof  of  this  doctrine,  he  states,  that  though 
married  men  often  contract  the  disease,  and 
continue  to  cohabit  with  their  wives,  even 
for  weeks,  yet,  in  the  whole  of  his  practice, 
he  never  once  found,  that  the  complaint  w as 
communicated  under  such  circumstances, 
except  when  connexion  had  been  continu- 
ed after  the  appearance  of  the  discharge. 

The  late  Mr.  Hey,  of  Leeds,  however, 
gave  it  as  his  opinion,  that  a man  might  com 
municate  lues  venerea,  after  all  the  symp- 
toms of  the  disease  had  been  removed,  and 
he  was  apparently  in  perfect  health.  (Sec 
I, fed.  Chir.  Trans.  Vol.  7,  p.  547.)  This  senti- 
ment is  not  only  repugnant  to  the  authority 
of  Mr.  Hunter,  but  to  common  observation 
and  all  sound  reasoning.  The  very  case, 
which  Mr.  Hey  adduced,  in  proof  of  the 
occurrence,  is  decidedly  inadequate  to  the 
intended  purpose,  in  consequence  oi  the  im- 
possibility of  trusting  to  the  accounts  which 
patients,  under  circumstances  involving 
their  honour,  are  apt  to  give  ot  themselves.  In 
the  case,  recited  by  Mr  Hey,  the  gentleman 
might  have  had  some  venereal  affection, at 
the  period  of,  or  subsequently  to,  his  mar- 
riage; and  yet  his  feelings,  and  a sense  of 
the  disgrace  of  infecting  a virtuous  woman, 
might  compel  him  to  conceal  the  real  truth 


VENEREAL  DISEASE. 


> wm  his  surgeon.  Again,  it  is  to  be  remem- 
bered, that  the  lady  herself  might  have  de- 
viated from  the  path  of  chastity,  and  ex- 
posed herself  to  infection  ; and,  if  she  had 
done  so,  she  would  neither  have  informed 
her  husband,  nor  Mr.  Hey.  I confess,  that 
it  is  at  all  times  painful  to  suspect  the  vera- 
city of  individuals,  whose  situations  in  life 
are  respectable  ; but,  whenever  an  occur- 
rence takes  place,  decidedly  contrary  to  the 
evidence  of  general  experience,  every  pos- 
sibility is  to  be  recollected,  in  order  to  avoid 
the  necessity  of  admitting  doctrines  not 
founded  upon  truth. 

Mr.  Hey,  with  much  more  reason,  joins  in 
the  belief  of  the  possibility  of  the  venereal 
disease  being  communicated  to  the  fetus  in 
utero,  though  in  wbat  manner  the  infection 
is  transmitted  is  a question  not  yet  elucida- 
ted. An  universal  desquamation  of  the 
cuticle  ; a hoarse  squeaking  voice  ; copper- 
coioured  blotches  ; a scaly  eruption  upon 
the  chin  ; and  an  unnatural  redness  of  the 
anus  ; are  the  common  symptoms  which  Mr. 
Hey  sets  down  as  proofs  of  syphilis  in  very 
young  infants.  As  these  complaints  yield  to 
snjalllffoses  of  the  submuriate  of  mercury, 
or  the  hVdrargyrus  cum  creta,  arid  either  the 
nurse  or  parent  has  had  some  venereal  or 
syphiloid  disease  at  no  very  distant  period, 
the  cases  are  often  regarded  as  decided  spe- 
cimens of  one  of  these  disorders. 

The  venereal  poison  would  appear  to  be 
very  irregular  in  its  effects,  different  persons 
being  variously  affected  by  it  and  hence, 
probably,  one  cause  of  a great  deal  of  the 
uncertainly,  yet  prevailing  about  its  distin- 
guishing characters.  Thus,  as  Mr.  Hunter 
mentions,  two  men  sometimes  have  connex- 
ion with  the  same  woman  ; both  catch  the 
disease  ; but  one  may  have  very  severe,  the 
other  exceedingly  mild,  symptoms.  He 
knew  of  an  instance,  in  which  one  man 
gave  the  disease  to  different  women,  some 
of  whom  had  it  with  great  severity,  while 
the  others  suffered  but  slightly.  On  the 
same  point,  1 find  an  interesting  statement, 
made  by  Dr.  Hennen,  in  his  Report  of  Ob- 
servations on  Syphilis  in  the  Military  Hospi- 
tals in  Scotland  : — “ We  have  had  (says  he) 
frequent  opportunities  of  remarking  two  or 
more  sores,  of  different  kinds,  existing  at  the 
same  time  : an  irregularly-shaped  diffused 
sore  ; an  elevated  sore,  covered  with  a light 
coloured  slough,  as  if  a bit  of  shamoy  leather 
had  been  stuck  on  by  some  tenacious  sub- 
stance ; a groove,  or  streak  along  the  glans, 
as  if  made  by  a scraping  instrument,  filled 
with  purulent  matter;  and  the  true  and  per- 
fect chancre,  according  to  Mr.  Hunter’s  difi- 
nition  ; or  the  true  syphilitic  ulcer,  according 
to  Mr.  Carmichael.  This  last  has,  in  some 
cases,  occupied  the  glans ; in  some,  the 
prepuce ; while  the  sores  of  another  des- 
cription have  been  on  the  same  part  close 
beside  it,  or  on  another  part  at  a distance. 
Three  of  these  cases  I particularly  selected 
for  examination  and  public  demonstration, 
at  the  Castle  Hospital ; in  one,  the  Hunte- 
rian chancre  vva-s  on  the  glans,  and  a sore, 
without  any  hardness  on  the  prepuce  ; in  an- 
other, it  was  on  the  prepace,  and  a simple 


ulcer  on  the  glans  in  the  third,  a most  per 
iectspecimen  of  Hunterian  chancre  occupied 
the  internal  prepuce,  close  to  the  corona 
glandis  ; and,  at  about  half  an  inch  from  it, 
nearer  the  frftnum,  but  farther  from  the 
glans,  was  an  elevated  ulcer.  In  all  these 
cases,  the  Hunterian  chancre  healed  (without 
mercury)  several  days  before  the  others. 

“ Soldiers  (says  Dr.  Hennen)  arc  gregari- 
ous in  their  amours,  arid  we  have  frequently 
several  men  at  the  same  time  in  hospital,  in- 
fected by  the  same  woman,  with  whom  they 
have  had  connexion  in  very  rapid  succession  : 
some  of  them  have  had  one  kind  of  sore,  some 
another,  and  some  both.  (Principles of  Mili- 
tary Surgery,  Ed.  2,  p.  52o.)  But,  if  there 
facts,  which  agree  with  my  own  observa- 
tions, lie  rather  adverse  to  the  theory  of  a 
plurality  of  venereal  poisons  (See  Carmi- 
chaels Essays  on  the  Venereal  Disease,  fyc.,) 
they  still  leave  difficulties,  which  cannot  be 
entirely  solved  by  reference  to  peculiarities 
of  constitution,  and  different  states  of  the 
health,  because  no  explanation,  on  this  prin- 
ciple, would  account  for  a man  having,  at 
the  same  time,  upon  the  penis,  two  or  til rte 
different  kinds  of  ulcers,  apparently  excitod 
by  one  cause.  Neither*  will  any  difference 
of  texture  afford  the  needed  explanation, 
though  the  utmost  latitude  be  given  to  the 
doctrine,  that  the  appearance  and  progress  of 
sores  are  considerably  modified  by  the  na- 
ture of  the  parts.  It  is  only  necessary  to 
consider  the  above  passage  from  Dr.  Hen- 
nen’s  work,  to  perceive  that  the  particular 
texture,  whether  prepuce,  skin,  glans,  or 
corona  glandis,  does  not  always  communi- 
cate to  sores  one  invariable  character,  even 
when  they  arise,  as  the  evidence  would  dis- 
pose one  to  suppose,  as  nearly  as  possible 
under  the  same  circumstances,  and  from  the 
same  source  of  infection. 

But,  though  in  such  examples,  no  data, 
with  which  1 am  acquainted,  lead  to  any  safe 
inference,  respecting  the  exact  cause  of  the 
diversity,  of  effect,  produced  in  different 
persons,  and  even  on  different  parts  of  the 
same  individual,  by  one  kind  of  virus,  not  a 
doubt  can  be  entertained,  that  generally 
climate  and  constitution  have  vast  influence 
over  the  venereal  disease.  In  all  warm 
countries,  the  disorder,  as  far  as  regards  the 
natives,  and  those  who  have  been  long  set- 
tled there,  is  not  ofily  much  milder  in  its 
symptoms,  but  much  more  easy  of  cure.  In 
the  West  Indies,  the  Brazils,  &c.  it  has  fora 
long  period  of  time  been  very  commonly 
cured  by  means  of  sarsaparilla,  guaiacum, 
mezereon,  &c.  without  a grain  of  mercury 
It  is  alleged,  however,  that  this  mildness  of 
syphilitic  complaints,  and  their  facility  of 
cure,  in  warm  climates,  do  not  extend  to 
strangers,  recently  arrived  there,  who  are 
said  even  to  suffer  more  from  the  virulence 
of  the  disease,  than  in  their  native  climate. 
In  Portugal,  during  the  fate  war,  the  dread- 
ful ravages  of  the  venereal  disease  among 
the  British  soldiers,  and  its  comparatively 
milder  phenomena  among  the  inhabitants  of 
the  country,  were  particularly  noticed.  “In 
the  British  army,  (says  Mr.  Fergusson)  it  is 
probable,  that  more  men  have  sustained  the 


VENEREAL  DISEASE 


mos*  piduneholy  of  all  mutilations,  during 
tfie  four  years  that  it  lias  been  in  Portugal, 
through  this  disease,  than  the  registers  of  all 
1 lie  hospitals  in  England  could  produce  for 
the  lust  century  ; while  venereal  ulceration 
has  not  only  been  more  intractable  to  the 
operation  of  mercury,  than  under  similar 
circumstances  at  home;  hut  the  constitution, 
while  strongly  under  the  influence  of  the 
lemedy,  has  become  affected  with  the  se- 
condary symptoms  in  a proportion  that 
could  not  have  been  expected.'  With  the 
natives,  on  the  contrary,  the  disease  is  very 
mild  ; curable,  for  the  most  part,  by  topical 
Treatment  alone,  or  wearing  itself  out  when 
received  into  the  constitution,  after  running 
a certain  course, not  always  a very  destruc- 
tive one,  without  the  use  of  any  adequate 
mercurial  remedy,  &ic.  The  bulk  of  the 
people,  and  of  all  the  military  at  the  hospitals, 
even  though  a general  order  has  been  given 
out,  enjoining  the  use  of  mercury,  cure 
themselves,  or  get  cured,  by  other  means.  I 
have  now  been  upwards  of  two  years  at  the 
head  of  their  hospital  department,  and  I 
can  declare,  that  it  never  occurred  to  me, 
among  all  the  venereal  patients,  whom  in 
that  time  I have  seen  pass  through  the  hos- 
pitals, to  meet  a single  one  under  the  in- 
fluence of  mercury,  excepting  those  cases, 
wherein  I myself  have  personally  superin- 
tended its  administration.  They  go  out 
cured  by  topical  remedies  gdone  : and  I have 
lived  long  enough  among  them  to  ascertain, 
that  their  return  to  hospital  under  such  cir- 
cumstances for  secondary  symptoms,  is  far 
from  being  an  universal,  or  even  a frequent 
occurrence.  ( Fergusson , in  Med.  and  Chir. 
Trans.  VoL  4,p.  1,2.) 

The  inference,  at  which  Mr.  Fergusson 
arrives,  is,  that  in  Portngal,  the  disease  is 
exhausted,  and  has  lost  much  of  its  virulence, 
in  the  some  manner  as  the  natural  small  pox, 
unresisted  by  inoculation  appears  to  have 
changed,  in  the  same  country,  into  a very 
mild  disease,  which  does  well  under  any 
mode  of  treatment. 

u Yet  (says  Mr.  Fergusson)  1 have  no 
doubt,  that  were  this  mild  disease,  or  the 
mildest  that  was  ever  produced  from  the 
improved  inoculation  of  England,  communi- 
cated to  a tribe  of  Indians,  or  to  a plantation 
of  negroes,  or  any  other  class  of  people, 
who  had  never  before  known  the  small  pox, 
it  would  desolate,  with  all  the  fury  of  pesti- 
lence, destroying  wherever  it?  could  find 
victims,  and  never  ceasing  until  it  had  des- 
troyed the  whole.”  And,  on  the  same  prin- 
< spies,  Mr.  Fergusson  attempts  to  explain 
the  severe  effects  of  the  inoculation  of  the 
e xhausted  syphilitic  virus  of  Portugal  into  the 
constitution  of  the  British,  or  other  stanger, 
;snd  the  impossibility  of  curing  the  disease 
by  the  same  treatment,  which  answers  for 
the  natives  themselves.  (Med.  Chir.  Trans. 
Vol.  4,  p.  7,  10.)  On  the  other  hand,  Mr. 
Guthrie  does  not  admit,  that  the  disease 
which  the*-troops  contracted  in  Portugal  was 
more  violent,  than  the  same  complaint  in 
England  ; <>r  rather  he  admits  the  fact,  but 
gives  a different  explanation  of  it  from  that 
erf  Mr.  Fergusson  : and  refers  the  severe 


effect  of  the  disease  upon  the  soldiers  in 
Portugal  to  the  operation  of  the  climate 
upon  their  northern  constitutions,  and  to 
their  irregularity  and  intemperance,  vices, 
to  which  the  natives  are  not  addicted.  (See 
Med.  Chir.  Trans.  Vol.  8,  p.  563.) 

It  has  been  a contested  question,  whether 
the  venereal  disease  and  gonorrhoea  arise 
from  the  same  poison  ? Mr.  Hunter  ac- 
knowledges,. that  the  opinion,  of  their  ori- 
ginating from  two  distinct  poisons,  seems  to 
have  some  foundation,  when  the  difference 
in  the  symptoms,  and  method  of  cure,  is 
considered.  But  he  asserts,  that  if  this 
question  be  taken  up  upon  other  grounds, 
and  experiments  be  made,  the  result  of 
which  can  be  safely  depended  upon,  this  no- 
tion will  be  found  to  be  erroneous.  As  the 
arguments  of  Mr.  Hunter,  in  support  of  the 
doctrine  that  both  diseases  are  produced  by 
the  same  virus,  are  noticed  in  the  article 
Gonorrhoea , I shall  not  here  repeat  them. 

On  the  other  hand,  Mr.  Bell  relates  some 
experiments,  from  which  the  conclusion  is 
made,  that  the  poisops  of  the  venereal  dis- 
ease, and  gonorrhoea,  are  entirely  different 
and  distinct. 

Matter  was  taken  upon  the  point  of  a 
probe,  from  a chancre  on  (he  glans  penis, 
before  any  application  was  made  to  it,  and 
completely  introduced  into  the  urethra. 
For  the  first  eight  days,  the  gentleman  who 
made  this  experiment,  felt  no  kind  of  unea- 
siness ; but  about  this  period,  he  was  attack  - 
ed with  pain  in  making  Water.  On  dilating 
the  urethra,  as  much  as  possible,  nearly  the 
whole  of  a large  chancre  was  discovered, 
and  in  a few  days  a bubo  formed  in  each 
groin.  No  discharge  took  place  from  the 
urethra,  during  the  whole  course  of  the 
disease  ; but  another  chancre  was  soon  per- 
ceived in  the  opposite  side  of  the  urethra, 
and  red  precipitate  was  applied  to  it,  as  well 
as  to  the  other,  by  means  of  a probe  pre- 
viously moistened  for  the  purpose.  Mercu- 
rial ointment  was  at  the  same  time  rubbed 
ou  the  outside  of  each  thigh,  by  which  a 
profuse  salivation  was  excited.  The  buboes, 
which  till  then,  had  continued  to  increase, 
became  stationary,  and  at  last,  disappeared 
entirely  ; the  chancres  became  clean,  and 
by  a due  continuance  of  mercury,  a com- 
plete cure  was  at  last  obtained.  If  this 
case,  and  another  to  which  1 shall  present- 
ly advert,  could  be  entirely  depended  upon,, 
they  would  tend  to  disprove  the  part  of  Mr. 
Hunter’s  theory,  accounting  for  the  different 
effect's  of  the  same  poison  by  its  application 
in  the  case  of  chancre  to  a non-secreting 
surface,  covered  with  cuticle,  and  in  that  of 
gonorrhoea  to.  a secreting  mucous  membrane. 
However  this  may  be,  l have  never  seen  a 
chancre  within  the  urethra. 

The  next  experiment  was  made  with  the 
matter  of  gonorrhoea,  a portion  of  which 
was  introduced  between  the  prepuce  and 
glans,  and  allowed  to  remain  there  without 
being  disturbed.  In  the  course  of  the 
second  day,  a slight  degree  of  inflammation 
was  produced,  succeeded  by  a discharge  of 
matter,  which  in  the  course  of  two  or  three 
days,  disappeared. 


VENEREAL  DISEASE. 


The  same  experiment  was  repeated  ; but 
no  chancre  ever  ensued  from  it. 

Two  medical  students  were  anxious  to 
ascertain  the  point  in  question  ; and  with 
this  view,  they  made  the  following  experi- 
ments, at  a time,  when  neither  of  them  had 
ever  laboured  under  either  gonorrhoea,  or 
syphilis,  aud  both  in  these  and  in  the  pre- 
ceding experiments,  the  matter  of  infection 
was  taken  from  patients  who  had  never 
made  use  of  mercury. 

A small  dossil  of  lint,  soaked  in  the  mat- 
ter of  gonorrhoea,  was  by  each  of  them  in- 
serted between  the  prepuce  and  the  glans, 
and  allowed  to  remain  on  the  same  spot  for 
the  space  of  twenty-four  hours.  From  this 
it  was  expected,  that  chancres  would  be  pro 
duced ; but  in  one,  a very  severe  degree  of 
inflammation  ensued  over  the  whole  glans 
and  pra>putium,  giving  all  the  appearance 
of  what  is  usually  termed,  gonorrhoea,  spuria. 
A considerable  quantity  of  fetid  matter  was 
discharged  from  the  surface  of  the  inflamed 
parts,  and  for  several  days,  there  was  rea- 
son to  fear,  that  an  operation  would  be  ne- 
cessary for  the  removal  of  a paraphymosis. 
By  the  use  of  saturnine  poultices,  laxatives., 
and  low  diet,  however,  the  inflammation 
abated,  the  discharge  ceased,  no  chancre 
took  place,  and  the  case  got  entirely  well. 
In  the  other  gentleman,  says  Mr.  B Bell, 
the  external  inflammation  was  slight,  but  in 
consequence  of  the  matter  finding  access  to 
the  urethra,  he  was  attacked  on  the  second 
day  with  a severe  gonorrhoea,  with  which 
lie  was  troubled  for  more  than  a year. 

The  next  experiment  was  made  by  the 
friend  of  the  latter  student ; he  inserted  the 
matter  of  gonorrhcea,  with  a lancet,  beneath 
the  skin  of  the  prasputium,  and  likewise, 
into  the  substance  of  the  glans  ; but  although 
this  was  repeated  three  different  times,  no 
chancres  ensued.  A slight  degree  of  inflam- 
mation was  excited  : but  it  soon  disappear- 
ed, without  any  thing  being  done  for  it. 
His  last  experiment  was  attended  with  more 
serious  consequences.  The  matter  of  a 
chancre  was  inserted  on  the  point  of  a probe 
to  the  depth  of  a quarter  of  an  inch,  or 
more  in  the  urethra.  No  syifiptorns  of  go- 
norrhoea ensued  ; but  in  the  course  of  five, 
or  six  days,  a painful  inflammatory  chancre 
was  perceived  on  the  spot,  to  which  the 
matter  was  applied.  To  this  succeeded  a 
bubo,  which  ended  in  suppuration,  notwith- 
standing the  immediate  application  of  mer- 
cury; and  the  sore,  that  was  produced, 
proved  both  painful  and  tedious.  Ulcers 
were  at  last  perceived  in  the  throat,  nor  was 
a cure  obtained,  till  a very  large  quantity  of 
mercury  bad  been  given,  and  the  patient 
kept  in  close  confinement  for  thirteen  weeks. 
(On  Gonorrhoea  Virulenta  and  Lues  Venerea, 
Vol.  1,  Edit.  2 ,p.  43S,  fyc.)  Mr.  Evans,  it 
appears,  has  also  several  times  inoculated 
with  the  matter  of  gonorrhoea,  but  in  every 
case,  it  failed  to  produce  any  effect.  (On 
Ulceration  of  the  Genital  Organs,  p.  81,  8to. 
Lond.  1819.) 

Some  other  facts  6n  record  however, 
♦end  rather  to  support.  Mr.  Hunter’s  infer- 


enco,  if  any  conclusion  can  bo  ventured 
upon  without  the  aid  of  the  most  minute 
details.  Thus,  Vigarous  mentions  an  in- 
stance, in  which  six  young  Frenchmen  had 
connexion  with  the  same  woman,  one  after 
the  other.  The  first  and  fourth  in  the  order 
of  connexion,  had  chancres  and  buboes,  the 
second  and  third  gonorrbma,  the  fifth  chan- 
cre, and  the  sixth  bubo.  (CEuvres  de  Chir. 
Practique  Montp.  1812,  p.  8.)  And  Dr. 
Hennen,  who  refers  to  this  case,  mentions  a 
similar  one,  in  which  the  first  person  esca- 
ped, the  second  had  true  chancres  and  eleva- 
ted sores,  and  the  third  gonorrhoea.  The 
connexion  took  place  within  an  hour.  (Mi- 
litary Surgery,  Edit.  7.  p 52G.)  These  facts 
would  indeed  be  much  more  interesting,  if 
the  disease,  with  which  the  women  were 
affected,  had  been  ascertained,  and  one 
could  securely  calculate  upon  the  men  not 
having  exposed  themselves,  within  a given 
time,  to  any  other  sources  of  infection.  In 
short,  without  a perfect  history  and  descrip 
tion  of  cases  of  this  kind,  from  their  begin 
Ring  to  their  end,  no  light  is  thrown  by 
them  on  the  question  about  the  venereal 
and  gonorrhoeal  poisons.  Nor  does  Dr. 
Hennen  quote  them  with  this  view  ; but  for 
the  purpose  of  exemplifying  the  variety  of 
effects,  produced  on  different  individuals 
apparently , by  the  same  infection,  though 
the  same  consideration,  which  prevents  any 
certain  inference  from  such  observations,  in 
regard  to  the  identity  of  the  venereal  and 
gonorrhoeal  poisons,  seems  also  to  interfere 
with  the  other  conclusion.  In  the  experi- 
ments, detailed  both  by  Hunter  and  B Bell, 
there  is  also  one  point  assumed  by  both 
parties,  though  it  is  far  from  being  deter- 
mined ; viz.  that  the  matter  discharged  from 
the  urethra  is  always  of  one  kind,  in  respect 
to  its  infectious  principle  whatever  this  may 
be,  and  that  the  secretion  from  every  chan- 
cre contains  one,  and  only  one  species  of 
infectious  matter.  From  the  candid  and 
very  practiqal  work  of  Mr  Evans,  it  would 
appear,  that  some  ulcerations  on  the  penis, 
such  as  would  usually  be  called  chancres, 
though  they  have  of  late  years  been  some- 
times named  elevated  ulcers,  arise  from  an 
altered  secretion,  without  any  breach  of  sur- 
face, or  discernible  disease  in  the  female  or- 
gans. The  same  gentleman  was  also  fre- 
quently present  at  the  examinations  of  the 
public  women  in  Valenciennes,  and  always 
surprised  at  the  small  portion  of  disease  to 
be  found  among  them  : “ At  one  which  1 
attended,  (says  he,)  no  less  than  200  women 
of  the  lowest  description,  and  of  course, 
the  most  frequented  by  soldiers,  were  exa- 
mined, and  not  one  case  of  disease  was 
found  among  them  ; nevertheless  the  mili- 
tary hospitals  had,  and  continued  to  have, 
their  usual  number  of  venereal  cases  (ulcer- 
ations.) 

le  At  an  inspection  I have  since  attended, 
where  100  women  -were  examined,  only  two 
were  found  with  ulcerations : 1 noticed 
several  with  increased  secretions,  and  one 
with  purulent  discharge,  but  these  were 
taken  no  notice  of  by  the  attending 


VENEREAL  DISEASE. 


.m 


geons,  as  they  uiu  not  come  sufEicietitly  under 
the  head  of  virulent  gonorrhoea. 

“ That  the  two  women,  above  mentioned 
as  having  ulcers,  infected  the  whole  of  the 
men  diseased  in  garrison,  during  the  prece- 
ding fifteen  days,  no  one  can  for  a moment 
admit  even  as  likely  ; but  if  it  be  allowed, 
that  an  altered  secretion  be  sufficient  for  the 
production  of  this  disease,  (the  ulcus  eleva- 
tum) we  shall  at  once  have  an  explanation 
of  how  it  happened,  that  the  military  hos- 
pitals continued  to  have  their  usual  number 
of  venereal  cases,  he.”  ( Evans  on  Ulcera- 
tions of  the  Genital  Organs,  p.  72,  73,  fyc.) 
From  the  investigations  of  the  same  author, 
the  ulcus  elevatum  is  the  most  frequent  of 
nil  the  sores  met  with  on  the  genitals,  and 
besides  being  excited  by  diseased  secretions, 
and  gonorrhoeal  matter,  is  capable  of  being 
transferred  bp  inoculation,  and  even  of  ori- 
ginating spontaneously.  (P.  67 — SI,  fyc.) 

Lagneau  admits,  that  gonorrhoea  may  not 
always  proceed  from  the  same  poison  as 
the  venereal  disease  ; but  he  believes,  that 
in  the  greater  number  of  instances,  the 
virus  is  of  the  same  quality.  He  is  led  to 
this  opinion  by  the  consideration  of  several 
women  having  been  infected  by  the  same 
man  with  both  complaints,  and  of  the  two 
diseases  having  been  communicated  to 
several  men  who  had  cohabited  with  one- 
woman,  and  as  is  presumed  with  her  alone, 
at  least,  inasmuch  as  may  relate  to  the  pos- 
sibility of  any  other  infection  weakening 
the  conclusion  attempted  to  be  drawn  from 
the  case;  a point,  which  has  only  been  as- 
sumed, and  by  no  means  ascertained.  How- 
ever, be  this  and  other  similar  narrations 
true,  or  not,  in  every  particular,  I agree  with 
Mr.  Guthrie  in  believing,  that  the  evidence, 
adduced  on  the  point  under  consideration, 
justifies  the  opinion,  “ that  ulcers  will  arise 
on  the  penis  from  the  matter  of  gonorrhoea  ; 
that  gonorrhoea  will,  in  itsturn,  be  caused  by 
the  matter  of  these  same  ulcers,  and  that  both 
occur  in  consequence  of  promiscuous,  or 
uncleanly  intercourse.  That  many  of  the 
ulcers , produced  in  this  manner,  will  occasion- 
ally assume  every  character  of  chancre,  and 
cannot  be  distinguished  from  it,  I am  perfect- 
ly satisfied  of  from  repeated  observation  ; 
but  I am  equally  certain,  that  a gonorrhoea 
in  men,  with  the  worst  appearances  and 
symptoms,  can,  and  often  does,  arise  from 
irritating  causes  common  to  parts  free  from 
any  specific  disease,  or  poison,  is  not  distin- 
guishable from  one  that  has  arisen  from 
promiscuous  intercourse,  and  that  both 
complaints  are  curable  in  the  same  way, 
and  without  mercury.”  On  the  question, 
whether  gonorrhoea,  or  the  ulcers  resulting 
from  the  matter  of  gonorrhoea,  can  produce 
constitutional  symptoms,  Mr.  Guthrie  be- 
lieves, that  they  generally  do  not,  although 
he  does  not  affirm,  that  they  cannot  under 
particular  circumstances  of  constitution  ; 
and  he  is  further  of  opinion,  that  if  such 
symptoms  ever  really  arise,  they  become 
serious  only  in  consequence  of  the  exhibi- 
tion of  mercury.  fSee  Med.  C-iiir.  Trans. 
Vol.  8,  p.  564 


From  what  has  been  already  observed,  it 
must  be  evident,  that  one  of  the  greatest 
obstacles  to  our  arrival  at  a satisfactory 
knowledge  of  the  nature  of  lues  venerea,  is 
the  fact,  that  under  this  denomination,  many 
various  diseases  are  comprised  and  con- 
founded, and  the  particular  distinctions  of 
each  of  which  are  not  yet  sufficiently  made 
out,  to  enable  surgeons  to  form  a well- 
founded,  and  practical  classification  of  them, 
satisfactory  to  every  impartial  observer, 
and  agreeing  with  general  experience. 
But  though  such  progress  has  not  yet  been 
made,  the  attention  of  modern  practitioners, 
and  especially  that  of  Mr.'Carmichael,  has 
been  directed  to  the  subject.  In  fact,  not- 
withstanding some  mysterious  circumstan 
ces  in  particular  syphilitic  cases  may  not 
admit  of  complete  and  satisfactory  explana 
lion  by  the  doctrine  of  a plurality  of  poisons, 
no  intelligent  surgeons,  I believe,  now  sup- 
pose that  the  diseases,  frequently  Communi- 
cated by  sexual  intercourse,  always  proceed  1 
from  one  peculiar  poison.  As  Mr.  Rose  has 
observed,  long  before  syphilis  is  supposed  to 
have  commenced  its  career  in  the  world, 
some  of  these  diseases  were  frequently  met 
with,  and  Mr.  Pearson  thinks,  that,  in  addi- 
tion to  those  formerly  known,  new  forms  of 
disease  have  occasionally  arisen,  “ which 
are  succeeded  by  a regular  series  of  symp- 
toms nearly  resembling  the  progress  of  lues 
venerea.”  ( Obs . on  the  Effects  of  various 
articles  of  the  Materia  Medica  in  the  Cure  of 
Lues  Venerea,  2 d Ed.  Introd.  p,  53;  and 
Rose  in  Med.  Chir.  Trans.  Vol.  8,  p.  418b 
Mr.  Hunter  also,  in  the  seventh  chapter  of 
his  Treatise  on  the  Venereal  Disease,  speaks 
of  many  examples  of  new-formed  diseases, 
arising  from  peculiar  poisons,  quite  different 
he  supposes,  from  every  other  virus  pre- 
viously known,  or  judged  of  b)'  its  effects. 
But,  though  Mr.  Rose  appears  to  join  in  the 
belief  of  a plurality  of  poisons,  he  is  very 
far  from  considering  it  settled,  how  far  the 
variety  in  the  symptoms  of  venereal  cases 
is  to  be  attributed  to  different  poisons,  or 
how  far  the  symptoms  of  the  same  poison 
may  be  modified,  and  altered  by  constitu- 
tion, climate,  4and  habits'  of  life.  He  re- 
marks, that  we  seldom  have  an  opportunity 
of  tracing  different  cases  to  the  same  source 
of  infection,  and  of  comparing  their  pro- 
gress with  each  other.  (Vol.  cit.p.  419.) 
And,  1 may  add,  that  as  far  as  observations 
of  this  nature  have  been  made,  and  can  be 
trusted,  they  rathertend  to  prove,  as  al read} 
noticed  in  the  foregoing  columns,  that  dif 
rerent  individuals,  when  infected  nearly  at 
the  same  time,  and  by  the  same  woman,  arc 
very  far  from  having  any  uniformity  in  their 
complaints  ; some  having  one  kind  of  sore  : 
some  another;  and  others  claps,  he.  And 
the  tenor  of  the  remarks,  made  likewise  by 
Mr.  Evans,  as  far  as  he  has  yet  entered  into 
the  subject,  lead  equally  to  ihe  conclusion, 
that  one  primary  complaint,  when  it  pro- 
duces another,  does  not  always  occasion 
one  resembling  itself.  Thus,  the  ulcus 
elevatum  on  the  penis,  though  capable  of 
being  communicated  by  inoculation,  appear- 


V ENEivEAL  DISEASE 


od  sometimes  10  be  the  effect  of  one  kind 
of  infection,  sometimes  of  another,  and 
sometimes  even  to  have  a spontaneous  ori- 
gin. Who  shall  unravel  all  these  intricacies, 
1 know  not,  whether  he  bring  to  his  assist- 
ance plurality  of  poisons,  or  states  of  the 
parts  and  constitution,  climate,  neglect, 
wrong  treatment,  or  any  other  circumstance, 
which  can  possibly  be  conceived  to  have 
influence  over  the  appearances,  progress, 
and  consequences  of  the  disease?  Nay,  it 
would  appear  from  some  of  the  curious  and 
perplexing  histories  mentioned  in  the  pre- 
ceding pages,  that  one  kind  of  primary  com- 
plaint in  an  individual  may  impart  to  other 
persons  primary  complaints  of  a different 
nature,  so  that  even  the  hope  of  elucidating 
parts  of  this  abstruse  subject,  by  adverting 
to  a plurality  of  infections,  and  a vigilant 
observation  of  their  characteristic  effects, 
meets  with  discouragement  almost  at  its 
very  birth  ; and  though  the  doctrine  of  se- 
veral kinds  of  poisons  being  concerned  in 
the  production  of  syphilis  and  syphiloid 
diseases  still  maintains  its  ground,  an  abso- 
lute proof  of  its  correctness  can  hardly  be 
said  to  have  been  yet  afforded  ; nor,  indeed,- 
could  it  be  obtained,  unless  the  inoculation 
of  healthy  individuals  with  the  matter  of 
the  different  forms  of  disease  were  justifia- 
ble for  the  elucidation  of  the  question. 
And,  as  this  is  not  the  case,  I think,  with 
Mr.  Carmichael,  that  it  might  be  a benefit 
to  society,  if  criminals  were  sometimes  per- 
mitted to  commute  a heavier  punishment 
by  submitting  to  such  experiments,  without 
which  the  inquiry  into  the  reality,  number, 
nature,  and  etfects  of  the  morbid  poisons 
under  consideration,  can  perhaps  never  be 
brought  4o  a satisfactory  termination.  “ I 
am  perfectly  aware  (says  Mr.  Carmichael,) 
how  much  the  state  of  the  human  constitu 
tion  will  modify  local  diseases,  and  am 
willing  to  attribute  to  a certain  extent,  the 
great  variety  of  appearances,  we  witness 
daily  in  venereal  complaints,  to  this  cause 
alone.  But,  we  observe  that  many  of  those 
primary  ulcers  evince,  from  their  very  com- 
mencement, such  peculiar  and  distinct  cha- 
racters, that  it  would  be  quite  an  absurdity  to 
believe,  that  the  virus  is  always  the  same, 
and  the  variety  of  characters  dependant 
alone  upon  constitution.  Thus  nothing  can 
be  more  opposite,  from  the  commencement, 
than  the  common  chancre,  with  its  hardened 
base,  like  a piece  of  cartilage  under  the  skin, 
and  the  sloughing  ulcer.  The  first  is  slow 
and  chronic  ; the  latter  begins  with  a morti-, 
lied  spot,  extends  by  alternate  sloughing  and 
phagedenic  ulceration,  and  makes  more  pro- 
gress in  tnree  days,  than  the-  former  in  as 
many  Weeks. 

“ The  phagedenic  ulcer  is  equally  distinct 
from  chancre,  as  it  does  not  evince,  at  any 
period,  a hardened  base,  but  gradually  creeps 
from  one  part  to  another  of  the  penis,  leav- 
ing those  parts  to  heal,  which,  in  thp  first  in- 
stance, it  attacked  ; so  that,  when  the  disease 
has  existed  for  some  months,  the  gltuis  is 
seen  to  exhibit  its  entire  Surface  furrowed 
over  with  ulcerations  and  cicatrices. 


byb 

“ There  is  a raised  ulcer,  also,  with  elcva 
ted  edges,  approaching  the  nature  ot  the 
phagedenic  ulcer,  yet,  whose  characters  are 
sufficiently  distinct  to  be  considered  as  a 
separate  species.  But,  the  most  common 
venereal  primary  ulceration  presents  such 
various  appearances  in  different  individuals, 
that,  until  a more  exact  knowledge  is  ob- 
tained;  it  is  better  described  by  its  negative, 
than  its  positive  qualities,  and  it  may  be  de- 
signated an  ulcer  without  induration,  raised 
edges,  or  phagedenic  surface. 

“ If  (continues  Mr.  Carmichael)  the  plura- 
lity of  venereal  poisons  is  supported  by  the 
variety  of  primary  ulcers,  it  is  equally  so  by 
the  multiplicity  of  constitutional  eruptions. 
A primary  ulcer,  which  was  not  phagedenic, 
or  sloughing,  at  first,  may  afterward,  like 
any  other  ulcer,  become  so  by  irritation, 
neglect,  or  inflammation.  But  1 do  not 
conceive,  that  we  have  grounds  for  suppo- 
sing, that  the  state  of  the  constitution  can  so 
modify  morbid  poisons,  as  to  cause  the  same 
virus  to  produce  in  one  person  the  chronic 
scaly  lepra,  and  psoriasis,  and  to  assume  in 
another  a decided  pustular  form,  each  pus- 
tule spreading  rapidly  into  a deep  ulcer. 
(On  the  Symptoms  and  Specific  Distinctions  of 
Vtncrtal  Diseases,  p.6,  fyc.  8 vo.  Lund.  1818.) 

The  same  gentleman,  in  his  Essays  on  this 
subject,  published  some  years  previously  to 
the  above  date,  gives  his  reasons  for  believ- 
ing that  certain  primary  appearances  are  fol- 
lowed by  a corresponding  train  of  constitu- 
tional symptoms.  1st.  That  the  syphilitic 
chancre  gives  rise  to  scaly  eruptions,  lepra, 
and  psoriasis,  an  excavated  ulcer  of  the  ton- 
sils, and  pains  and  nodes  of  the  bones.  2dly. 
That  the  ulcer,  without  induration,  raised 
edges,  or  phagedenic  surface,  gonorrhoea 
virulenta,  and  excoriation  of  the  glans  and 
prepuce,  are  followed  by  a papular  eruption, 
which  ends  in  desquamation,  pains  in  the 
joints  resembling  those  of  rheumatism,  sore- 
ness of  the  fauces,  and  frequently  swelling 
of  the  lymphatic  glands  of  the  neck  ; but 
without  any  nodes  of  tue  bones  3dly. 
That  the  ulcer,  with  elevated  edges,  in  the 
few  instances  in  which  it  was  traced  by  Mr 
Carmichael  to  its  constitutional  symptoms, 
was  followed  by  a pustular  eruption,  which 
terminated  in  mild  ulcers,  pains  in  the  joints, 
and  ulcers  in  the  throat,  but  no  appearance 
of  nodes.  4;hly.  That  the  phagedenic  and 
sloughing  ulcers  are  generally  attended  with 
constitutional  symptoms  of  peculiar  obsti 
nacy  and  malignancy  : \oz.  pustular  spots 
and  tubercles,  which  form  ulcers,  generally 
spreading  with  a phagedenic  edge,  and  heai- 
ine  from  the  centre  Extensive  ulceration 
of  the  fauces,  particularly  of  the  back  of  the 
pharynx,  obstinate  pains  of  the  knees,  and 
other  joints,  w hile  nodes  are  frequently  pre- 
sent, and  the  bones  of  the  nose  are  occasion  - 
ally  affected.  (See.  Carmichael's  Essays  and 
his  0$s.  on  the  Symptoms,  i \-c,  of  Ven.  Dis- 
eases, p.  9.) 

The  observations  of  other  modern  writers 
seem  generally  to  coincide  with  those  of 
Mr.  Carmichael,  respecting  the  great  variety 
of  character  in  primary  venereal  sores,  and 


VENEREAL  DISEASE. 


GGU 

partly  also  with  regard  to  iiie  hypothesis  of 
(here  being  various  kinds  of  poisons,  or  in- 
fectious matter,  But,  on  some  other  great 
questions,  immediately  connected  with 
these  points,  little  similarity  of  opinion  pre- 
vails between  him  and  other  gentlemen, 
who  have  laudably  arid  impartially  entered 
into  the  disquisition.  And,  in  the  first  place, 
without  adverting  again  to  certain  state- 
ments, already  premised,  which  render  it 
probable,  that  differences  of  the  virus,  or,  at 
all  events,  differences  in  the  forms  of  the 
primary  complaints  in  the  contaminating 
individuals,  would  nbt  always  explain  the 
reason  of  the  diversified  appearances  and 
nature  ot  the  primary  forms  of  disease  in  the 
contaminated,  I shall  Iav.’before  the  reader 
other  evidence,  having  an  immediate  rela- 
tion to  Mr.  Carmichael’s  sentiment,  that 
each  kind  of  primary  veneral  sore  is  follow- 
ed by  a peculiar  and  corresponding  train  of 
constitutional  symptoms.  In  the  cases  re- 
cited by  Mr.  Rose,  “ most  of  the  papular 
eruptions  followed  ulcers,  which  were  not 
very  deep,  and  which  healed  without  much 
difficulty.  Several  of  them  had  a thickened, 
but  not  a particular  indurated  margin.  This 
corresponds  with  the  observations  cf  Mr. 
Carmichael, — I could  not , howtvcr,  discover 
any  decidedly  uniform  character  in  such  sores  ; 
and  the  16th  case  I should  have  considered 
as  a well-marked  instance  of  chancre.” 
(Med.  Chir.  Trans.  Vol.  8,  p.  399.)  In 
another  place,  it  is  staled,  that  the  appear- 
ances of  sores  can  seldom  be  relied  on  in 
parts  of  such  vascular  structure,  and  in 
the  midst  of  sebaceous  glands.  (P.  419.) 
With  respect  to  the  phagedenic  ulcer,  Mr. 
Rose  expresses  his  belief,  that  it  is  rarely 
followed  by  secondary  symptoms,  though  he 
inclines  to  the  opinion,  that  it  arises  from 
the  application  of  some  morbific  matter,  ac- 
knowledging, however,  (he  great  difficulty 
of  deciding,  “ whether  the  great  degree  of 
erethismus,  excited  by  the  local  affection, 
should  be  attributed  to  any  peculiarity  in 
that  matter,  or  is  owing  to  the  peculiar  state 
of  the  constitution.”  (Med.  Chir.  Trans. 
Vol.  8,  p.  372.)  And  he  then  refers  to  the 
ease,  reported  by  Mr.  Fergusson,  where 
• the  infection  was  communicated  by  an 
opera  dancer  at  Lisbon,  apparently  in  per- 
fect health,  who  continued  on  the  stage  for 
several  months  afterward,  occasionally  in 
fecting  others,  without  any  thing  extraordi- 
nary, as  far  as  he  could  learn,  in  the  nature 
of  the  symptoms.”  (Op.  cit.  Vol.4,p.  IE) 
And,  on  the  same  subject,  Mr.  Guthrie  does 
not  think,  ‘‘  that  Mr.  Carmichael’s  opinion, 
as  to  the  secondary  symptoms,  peculiar  to 
the  phagedenic  and  sloughing  ulcer,  re- 
ceives any  support  from  what  occurred  to 
the  troops  in  Portugal  ; because  it  did  not 
appear,  that  either  of  (hem,  following  sexual 
intercourse,  were  dependent  on  the  cause 
which  produced  the  ulcer.  Where  many 
men  have  had  intercourse  with  the  same 
woman  (and  with  no  others  ?)  they  have  not 
all  had  the  same  complaint,  although  one  of 
th  ? ulcers,  so  originating,  has  become  pha- 
gedenic. or  sloughed  ; neither  has  the  same 


woman  herself  suffered  from  this  distemper 
indeed,  the  nature  of  an  ulcer  of  either  kind 
must,  after  a short  time,  effectually  prevent 
any  intercourse,  and  we  often  find,  that  their 
peculiar  characters  only  appear  after  the 
ulcer  has  existed  for  several  days.  I firmly 
believe  also,  that  in  the  greater  number  of 
cases  of  sloughing  ulcer,  where  mercury  is 
not  given,  no  secondary  symptoms  would  ap- 
pear : and,  in  thost  cases  in  which  they  did 
appear,  I apprehend,  they  would  be  equally 
dependent  on  the  state  of  the  constitution, 
as  to  the  mode  of  cure,  arid  their  destructive 
characters.  In  other  words,  my  observations 
lead  me  to  conclude,  that  these  ulcers  do  not 
depend  upon  a specific  poison,  but  on  the  stale 
of  the  constitution , under  particular  excite- 
ment, and  that,  when,  secondary  symptoms 
occur , they  are  not  dependent  on  the  stale  of 
the  ulcer ; although  1 am  ready  to  admit,  that 
in  a constitution  where  an  ulcer  will  readily 
become  phagedenic,  the  secondary  symp- 
toms, when  they  occur,  may  be  different  to 
a certain  extent  from  those  that  follow  more 
simple  ulcers,  in  a healthier  habit  of  body.” 
(Guthrie  in  Med.  Chir.  Trans.  Vol.  8 ,p.  664.) 
My  observations  lead  me  to  believe,  with 
Mr.  Guthrie,  that  primary  sloughing  ulcers 
do  not  depend  upon  any  peculiar  poison, 
and  I am  also  disposed  to  join  him  in  the 
opinion,  that  when  hurtful  local  treatment 
is  out  of  the  question,  they  are  chiefly  owing 
to  the  stale  of  the  constitution.  According 
to  my  experience,  all  kinds  of  ulcers  on  the 
genitals  may,  from  particularity  of  constitu- 
tion, impairment  of  health,  and  sometimes 
from  the  pernicious  effects  of  the  immode- 
rate and  indiscriminate  einploymentof  mer- 
cury, assume  in  their  progress  a sloughing 
disposition,  and  even  have  it  from  their 
very  commencement.  Mr.  Rose  mentions 
a case  in  which  a healthy  young  man  was 
affected  with  a sloughing  sore  on  the  penis, 
in  consequence  of  a suspicious  connexion. 
It  was  not  attended  with  any  constitutional 
disturbance,  and  yielded  readily  to  mercury. 
The  same  patient,  twice  afterward,  at  a very 
considerable  interval,  had  a fresh  infection, 
and  the  sores  each  time  had  precisely  the 
same  character  as  the  first.  This,  says  Mr 
Rose,  is  no  uncommon  occurrence,  and  it  is 
not  probable  that  the  sloughing  and  appear- 
ance of  the  sores  arose  from  the  peculiarity 
of  the  poison.  (Med.  Chir.  Trans.  Vol.  S, 
p.  420.)  And  another  intelligent  and  expe- 
rienced surgeon,  who  has  particularly  at- 
tended to  this  investigation,  declares  his 
conviction,  that  many  varieties  of  sore, 
independently  of  the  sloughy  chancre,  men  - 
tioned  by  Mr.  Carmichael,  lead  to  constitu- 
tional symptoms,  differing  in  no  respect  from 
those  he  has  described,  and  admitting' of  the 
same  mode  of  cure.”  Nor  does  he  believe, 
with  Mr.  Carmichael,  that  only  one  particu 
lar  species  of  sore  is  capable  of  producing 
the  true  secondary  symptoms  of  lues.  ( J 
Baud,  on  Syphilis,  p.  51  ) 

From  these  observations,  I think  we  may 
safely  infer,  that  with  respect  to  the  slough- 
ing ulcer,  it  neither  arises  from  the  applica- 
tion of  any  one  specific  poison  to  the  part. 


venereal  disease 


col 


nor  is  it  connected  with  any  regular  train 
secondary  symptoms. 

Dr.  Hennen  assures  us,  that  he  has  fre- 
quently had  occasion  to  observe,  that  erup- 
tions of  the  same  nature  and  character  have 
succeeded  to  the  foul,  indurated,  excavated 
ulcer,  and  to  the  simple  excoriation.  “ In 
fifteen  cases  of  eruptions,  unaccompanied 
by  any  other  symptoms,  which  succeeded 
the  Hunterian  sore,  six  were  tubercular, 
five  exanthematous,  two  pustular,  one  tu- 
bercular and  scaly,  and  one  tubercular  and 
vesicular. 

“In  four  cases  following  the  same  sore, 
but  in  which  the  eruptions  were  complica- 
ted with  sore  throat,  two  were  tubercular, 
one  was  tubercular  and  scaly,  and  one  was 
tubercular  and  axanthematous. 

“ In  twelve  cases  following  the  non  Hunte- 
rian sore,  and  in  which  eruptions  were  the 
only  symptoms,  six  were  pustular,  three 
were  exanthematous,  and  one  was  tubercu- 
lar and  scaly. 

11  In  seven  cases  where  the  eruption  was 
accompanied  with  sore  throat,  three  were 
exanthematous,  two  were  tubercular,  one 
was  papular,  scaly,  and  tubercular,”  and 
one  was  pustular  and  tubercular.  Dr.  Hen- 
nen also  recites  an  instance  in  which  a 
Hunterian  chancre  was,  at  the  distance  of 
ten  weeks,  succeeded  by  a papular  eruption , 
which,  in  the  course  of  a month,  was  remo- 
ved by  low  diet,  purgatives,  and  the  decoc- 
tion of  sarsaparilla.  In  two  months  after- 
ward, an  eruption  of  a similar  nature  ap- 
peared without  any  fresh  infection.  This 
Was  treated  with  mercury,  which  was  admi- 
nistered five  weeks,  so  as  to  excite  a mode- 
rate salivation.  Under  this  treatment  the 
eruption  faded,  having,  during  its  progress, 
assumed  the  appearance  of  vesicles  and  pus- 
tules, and  at  length  falling  off  in  amber- 
coloured  scales , with  livid  bases.  Notwith- 
standing this  mercurial  course,  the  patient 
was  h third  time  admitted,  ten  weeks  after- 
ward, (without  any  intervening  primary 
affection)  with  a pustular  eruption,  which 
was  finally  cured  without  mercury,  and  the 
pustules  falling  off  in  squamulae.  In  ano- 
ther month,  without  any  fresh  infection,  he 
Was  a fourth  time  taken  into  hospital, 
with  a very  thickly  dispersed  pustular  erup- 
tion, somewhat  different  from  the  former, 
the  pustules  being  more  nunaerous,  smaller, 
and  acuminated.  They  yielded  to  non- 
mercurial treatment.  During  all  these 
attacks,  there  was  apththous  sore  throat, 
and  occasional  flying  pains  in  the  joints. 
The  inference  drawn  from  this  case  is,  that 
even  a full  and  judiciously  conducted  mer- 
curial course  does  not  prevent  the  reappear- 
ance of  venereal  eruptions,  and  that  they 
assume  at  different  times  different  charac- 
ters, notwithstanding  the  interruption  they 
receive  in  their  natural  progress  by  the  use 
of  that  remedy.  (On  Military  Surgery,  Ed. 
2,  p.  528—530.)  After  these  accounts,  I 
can  have  no  hesitation  in  coming  to  another 
conclusion,  which  is,  that,  with  the  excep- 
tion of  the  partial  confirmation  of  Mr.  Car- 
michael’s doctrine  by  Mr.  Rose,  as  far  as 
Vol.  IE.  “ 75 


of  relates  to  the  frequency  of  papular  erup 
tions  after  superficial  primary  ulcers,  the 
regular  connexion  of  particular  forms  of 
secondary  symptoms  with  any  given  de- 
scriptions of  primary  sores,  is  so  far  from 
being  supported  by  the  testimony  of  other 
observers,  that  one  kind  of  primary  ulcer 
may  lead,  in  the  same  patient,  to  eruptions 
of  several  different  sorts,  either  existing  to- 
gether on  various  parts  of  the  body,  or 
breaking  out  in  succession  ; and  no  regular 
connexion  can  be  traced  between  any  one 
species  of  primary  sore,  and  any  determi- 
nate class  of  secondary  symptoms.  These 
truths,  1 believe,  must  be  admitted,  disad- 
vantageous as  they  are  to  the  prospect  of 
bringing  the  diagnosis  of  syphilis  to  a final 
settlement,  so  as  to  enable  the  writer  to  de- 
scribe the  disease  with  accuracy,  and  the 
practitioner  to  recognize  and  treat  it  with 
certainty.  The  first  essential  step  to  the 
elucidation  of  this  subject,  however,  is  un- 
doubtedly the  subversion  of  every  doctrine 
relative  to  it,  which  is  repugnant  to  gene- 
ral experience.  The  same  facts,  which  may 
render  it  necessary  for  Mr.  Carmichael  to 
retract  some  of  his  inferences,  and  which 
have  now  been  established  beyond  all 
doubt  or  possibility  of  successful  contradic- 
tion, by  the  very  impartial,  disinterested, 
and  extensive  investigations,  made  in  the 
army  hospitals,  would  have  obliged  even 
Hunter  himself,  had  he  been  alive,  to  con- 
fess the  mistaken  views  which  he  some- 
times took  of  the  nature  of  the  venereal  dis- 
ease. 

Among  other  doctrines,  Mr.  Hunter  incul- 
cates, that  “ the  venereal  matter,  when 
taken  into  the  constitution,  produces  an 
irritation  which  is  capable  of  being  continu- 
ed, independent  of  a continuance  of  ab- 
sorption, and  the  constitution  has  no  poiver 
of  relief ; therefore,  a lues  venerea  continues 
to  increase."  The  same  criterion  was  pro- 
posed by  Mr.  Abernethy,  who  states,  that 
the  “ constitutional  symptoms  of  the  vene- 
real disease  are  generally  progressive,  and 
never  disappear  unless  medicine  be  employ- 
ed.” ( Surgical  Observations , p.  137.)  And* 
notwithstanding  some  dissent  may  be  tra- 
ced in  both  old  and  modern  writers  from 
the  belief  that  mercury  was  absolutely  es 
sential  to  the  cure  of  the  venereal  disease,, 
and  an  opposite  conclusion  might  easily 
have  been  drawn  from  the  whole  history  of 
this  subject,  including  the  practice  of  for- 
mer and  present  times,  the  contrary  hypo- 
thesis was  that  always  taughtin  all  the  great 
medical  schools  of  this  country,  even  down 
to  so  late  a period  as  eight  or  ten  years  ago. 
But  the  error  no  longer  prevails,  and  no 
facts  are  more  completely  established  than 
that  mercury,  however  useful  it  may  fre- 
quently be  in  the  treatment  of  the  venereal 
disease,  is  not  absolutely  necessary  for  the 
cure  either  of  the  primary  or  secondary 
symptoms,  and  that  the  disease,  so  far  from 
always  growing  worse,  unless  mercury  be 
administered,  alternately  gets  well,  without 
the  aid  of  this,  or  any  other  medicine.  If 
any  man  yet  doubt  the  general  truth  of  this 


VENEREAL  DISEASE 


602 


statement,  let  him  impartially  consider  the 
many  facts  and  arguments  brought  forward 
in  proof  of  it  in  the  writings  of  Mr.  Fergus- 
son,  Mr.  Rose,  Dr.  Hennen,  Dr.  Thomson, 
Mr.  Guthrie,  Mr.  Bacot,  and  other  modern 
practitioners.  In  short,  if  there  be  such  a 
sceptic  now  living  in  this  country,  let  him 
peruse  the  returns  made  by  the  surgeons  of 
the  whole  British  army,  documents  which 
will  be  noticed  in  the  sequel  of  this  article  ; 
let  him  consider  the  evidence  of  the  sur- 
geons of  other  countries,  especially  that  of 
Cullerier,  who  annually  demonstrates  to  his 
class  of  pupils  the  cure  of  venereal  ulcers 
without  mercury  ; and  the  testimony  and 
practice  of  the  German  surgeons,  who  were 
attached  during  the  war  to  regiments  of 
their  countrymen  in  the  British  service. 
The  fact  is  therefore  indisputable,  that  the 
venereal  disease,  in  all  its  ordinary  and  di- 
versified forms,  is  capable  of  a spontaneous 
cure,  and  consequently,  that  the  question, 
whether  the  disease  is  syphilitic  or  not,  can 
never  be  determined  by  the  circumstance 
of  the  complaint  yielding,  and  being  perma- 
nently cured,  without  the  aid  of  mercury. 
Yet,  as  Mr.  Rose  has  observed,  the  supposi- 
tion, that  syphilis  did  not  admit  of  a natural 
cure,  and  that  mercury  was  the  only  reme- 
dy that  had  the  power  of  destroying  its 
virus,  was  of  late  so  much  relied  upon,  that 
where  a disease  had  been  cured  without  the 
use  of  that  medicine,  and  did  not  afterward 
return,  such  fact  alone,  whatever  might  have 
been  the  symptoms,  was  regarded  as  suffi- 
cient proof  that  it  was  not  a case  of  syphi- 
lis. And,  as  the  same  writer  very  judi- 
ciously remarks,  the  refutation  of  these  no- 
tions is  of  considerable  importance,  “ not 
so  much  in  reference  to  the  treatment  of 
syphilis  under  common  circumstances,  for 
the  strikingly  good  effects  of  mercury  will 
probably  not  render  it  adviseable  in  general 
to  give  up  the  use  of  that  remedy,  but  from 
the  change  it  will  produce  in  our  views  of  the 
diagnosis  of  the  disease.  The  distinction 
which  has  engaged  such  a share  of  attention 
of  late  years,  and  which  is  evidently  so  im- 
portant between  syphilis  and  syphiloid  dis- 
eases, has  been  made  to  depend  so  much  on 
the  former  admitting  of  no  cure,  except  by 
mercury,  that  if  this  principle  should  be 
found  to  be  erroneous,  the  difficulties  which 
have  attended  it  will  in  a great  measure  be 
explained.”  (Med.  Chir.  Trans.  Vol.  8,  p. 
350,  351.)  That  it  is  erroneous  will  appear 
more  clearly  when  the  treatment  of  syphi- 
lis falls  under  consideration. 

Excluding  from  present  attention  works 
of  ancient  date,  it  is  curious  to  find  how 
very  near  several  writers,  within  the  last 
twenty  or  thirty  years,  arrived  at  the  same 
point  to  which  recent  investigations  have 
led.  Thus,  Mr.  B.  Bell  observes,  a chancre 
might  frequently  be  cured  with  external 
applications  alone,  and  as  we  know  from 
experience  that  the  virus  is  not  always  ab- 
sorbed, the  cure  would  in  a few  instances 
prove  permanent ; but  as  we  can  never  with 
certainty  know  whether  this  would  happen 
or  not,  while,  in  a great  proportion,  of  cases. 


there  would  be  reason  to  think  that  absorp- 
tion would  take  place,  we  ought  not  in  any 
case  to  trust  to  it.”  (On  Gonorrhoea  Virulen - 
ta,  tyc.  Vol.  2,  Ed.  2,  p.  325,  8 vo.  Edinb. 
1797.)  And,  in  some  reflections  upon  a 
case  of  doubtful  nature,  Dr.  Clutterbuck 
long  ago  remarked  : “ Supposing  even  that 
the  diseased  appearances  had  after  a time 
got  well  ot  themselves,  I should  deem  even 
this  no  absolute  proof  of  their  not  being  of  a 
venereal  nature.  I have  seen  cases  which 
induce  me  to  believe,  that  the  venereal  dis- 
ease, in  some  of  its  stages,  and  in  certain 
circumstances,  may  get  well  without  mereury 
or  any  other  remedy.  But  this  is  contrary  to 
the  doctrine  of  Mr.  Hunter,  who  supposed 
that  venereal  actions  go  on  increasing,  with- 
out any  tendency  to  wear  themselves  oat 
That  lues  venerea  is  much  modified  by  cli- 
mate, and  other  circumstances,  is  generally 
allowed  ; that  it  has  been  cured  by  other 
means  than  mercury,  we  have  also  very 
sufficient  evidence  in  the  older  writers  on. 
the  subject  : not  to  mention  the  late  suc- 
cessful trials  with  acids  and  other  substan- 
ces. Many  of  the  appearances  on  the  skin  go 
off  spontaneously.  ‘ When  purple  spots  ap- 
pear on  the  skin,”  (Mr.  Hunter  observes,  p, 
319,)  “ giving  it  a mottled  appearance  in 
this  disease,  many  of  the  spots  disappear, 
whilst  others  continue  and  increase.”  (U. 
Clutterbuck , Remarks  on  some  of  the  Opinions 
of  the  late  Mr.  John  Hunter,  p.  27,  Sto. 
Lond.  1799.)  If  Dr.  Clutterbuck  had  ad* 
vanced  one  step  further,  and  declared  that 
the  venereal  disease  might  be  eured  without 
mercury,  or  any  other  remedy,  in  all,  or 
nearly  all  its  forms,  and  not  merely  in  some 
of  them,  he  would  actually  have  anticipa- 
ted the  most  important  fact,  recently  esta- 
blished chiefly  by  the  meritorious  labours 
of  the  army  surgeons,  whose  opportunities 
of  making  the  investigation  were  better  on 
several  accounts  than  those  of  private  prac- 
titioners, who  generally  soon  lose  sight  of 
their  patients,  and  never  have  them  suffi- 
ciently under  their  control  and  observation 
to  render  a full  perseverance  in  any  method 
a matter  of  certainty.  At  all  events,  Dr. 
Clutterbuck  may  justly  claim  the  merit  of 
having  distinctly  marked  the  fact,  that  the 
circumstance  of  a disease  giving  way,  and 
being  cured  without  mercury,  is  no  proof  that 
the  case  is  not  venereal. 

One  of  the  most  ingenious  theories  ever 
devised  for  explaining  all  the  perplexities 
and  irregularities  of  syphilis,  is  unquestion- 
ably that  of  the  late  Mr.  Hunter  . for,  it 
accommodated  itself  almost  to  every  thing, 
and  every  believer  in  it  fancied  he  could 
account  satisfactorily  for  many  puzzling 
occurrences  which  admitted  of  no  good  ex- 
planation on  other  principles.  Mr.  Hunter 
inculcated,  that  the  parts  contaminated  by 
the  absorption  of  the  venereal  poison,  do 
not  immediately  begin  to  be  palpably  dis- 
eased, but  only  acquire  a disposition  to  take 
on  the  venereal  action.  He  further  believed, 
that  when  this  disposition  was  once  formed 
in  a part,  it  necessarily  changed  into  action, 
or  manifest  disease,  at  some  future  period. 


VENEREAL  DISEASE 


603 


.That  mercury  can  cure  the  disease,  when 
positively  formed,  but  uot  the  disposition  to 
it.  That  although  mercury  cannot  destroy 
the  disposition  already  contracted,  yet  that 
it  can  prevent  it  from  being  formed  at  all. 
That  the  disposition  never  becomes  the  real 
disease,  or,  in  Mr.  Hunter’s  language,  goes 
into  action  during  the  use  of  mercury.  That 
the  action  having  oncetaken  place,  always 
increases,  never  wearing  itself  out.  That 
parts,  once  cured,  never  become  again  con- 
taminated from  the  same  stock  of  infection. 
And,  that  the  matter  of  secondary  ulcers, 
or  those  which  break  out  in  consequence 
of  absorption,  is  not  infectious.  What  Mr. 
Hunter  meant  by  the  term  disposition , I 
think  is  better  explained  than  the  grounds 
for  the  adoption  of  the  theories  connected 
with  it,  viz.  the  presumption  of  its  being 
formed  in  all  the  parts  capable  of  contami- 
nation ; the  certainty  of  its  future  change 
into  actual  disease ; the  impossibility  of 
curing  it  by  mercury  previously  to  such  a 
a change ; but  the  possibility  of  preventing 
its  formation  at  all  by  the  timely  use  of  that 
remedy. 

Dr.  Clutterbuck  has  well  observed,  that 
the  only  foundation  for  all  these  hypothe- 
ses, connected  with  the  phrase  disposition, 
is  the  fact,  that  secondary  symptoms  some- 
times arise,  notwithstanding  a fall  use  of 
mercury.  If,  says  this  gentleman,  we  were 
to  suppose,  with  Mr.  Hunter,  that  all  the 
parts  which  are  susceptible  become  at  once 
contaminated,  and  mercury  has  no  influence 
over  them  in  this  state,  the  constitution 
should  become  affected  in  almost  all  cases, 
for  absorption  probably  always  precedes 
the  application  of  remedies.  Either,  there- 
fore, mercury  does  prevent  the  future  action, 
or  a more  frequent  absence  of  susceptibility 
to  the  disease  must  be  supposed,  than  there 
are  grounds  for  imagining.  ( Remarks  on 
the  Opinions  of  Mr.  Hunter , p.  9 — 12.)  But, 
surgeons  of  the  present  day,  enlightened  by 
many  new  facts  unequivocally  determined 
since  Mr.  Hunter’s  time,  know  very  well 
that  a disposition  to  the  disease  is  in  many 
instances  not  produced  at  all,  even  though 
the  matter  of  a chancre  be  supposed  to  be 
absorbed,  since  in  a large  proportion  of 
cases  of  chancres,  which  had  all  the  charac- 
teristic appearances  of  such  ulcers,  accord- 
ing to  Mr.  Hunter’s  own  description,  no 
secondary  symptoms  followed,  though  the 
patients  were  treated  and  cured  without  any 
mercury.  Yet,  if  Mr.  Hunter’s  theory  were 
true,  the  disposition  must  have  been  pro- 
duced, the  action  or  disease  itself  in  the 
form  of  secondary  symptoms  must  have 
ensued,  sooner  or  later,  and  no  cure  could 
have  been  ultimately  effected  without  mer- 
cury. Fortunately  fur  mankind,  unsound 
as  some  of  the  theories  seem,  which  are 
attached  by  Mr.  Hunter  to  the  supposed 
disposition  to  the  venereal  disease,  or  its  latent 
form,  there  wras  one  piece  of  advice  given 
by  him,  which  may  be  said  to  have  had  a 
beneficial  effect  in  practice,  though  founded 
upon  these  very  doctrines  ; and  it  was  this, 
that  we  should  push  our  medicine  no 


farther  than  the  cure  of  the  visible  effects  of 
the  poison,  and  allow  whatever  parts  may 
be  contaminated  to  come  into  action  after- 
ward.” (On  the  Venereal  Disease,  p 334.) 
This  maxim,  I know,  has  been  regarded  by 
some  admirers  of  long  salivations  as  the 
cause  of  many  relapses  and  imperfect  cures ; 
but  when  1 advert  to  the  dreadful  mischief, 
which  formerly  attended  protracted  courses 
of  mercury  for  latent  and  imaginary  com- 
plaints, my  mind  regrets  that  Mr.  Hunter 
himself  should  not  have  adhered  strictly  in 
practice  to  his  own  principle,  Irom  which 
he  undoubtedly  deviated  with  his  patients, 
and  even  in  certain  other  parts  of  his  wri- 
tings. However,  the  effect  has  been  to 
discourage  long  courses  of  mercury  j and, 
perhaps,  in  this  way,  the  world  has  been 
benefited  by  the  counsel,  though  not  rigor- 
ously adopted  by  him  who  gave  it.  Con- 
fessing my  own  inability  to  reconcile  the 
various  theories,  about  the  nature  and 
effects  of  the  venereal  poison,  to  many 
facts,  which  are  disclosed  in  practice,  I 
shall  now  proceed  to  offer  a few  remarks 
on  each  of  the  primary  and  secondary 
symptoms. 

Chancres.  The  penis,  as  Mr.  Hunter  has 
observed,  which  in  men  is  the  common  seat 
of  a chancre,  is,  like  every  other  part  of  the 
body,  liable  to  diseases  of  the  ulcerative 
kind,  and,  on  some  accounts,  is  rather  more 
so  than  other  parts.  When  attention  is  not 
paid  to  cleanliness,  excoriations  or  superfi- 
cial ulcers  often  originate.  The  genitals, 
also,  like  almost  every  other  part  that  has 
been  injured,  when  once  they  have  suffered 
from  the  venereal  disease,  are  very  liable  to 
ulcerate  again.  Since  therefore  the  penis 
is  not  exempted  from  common  diseases, 
every  judgment  of  the  nature  of  ulcers  upon 
it,  as  Mr.  Hunter  truly  remarks,  should  be 
formed  with  great  attention,  particularly  as 
all  diseases  upon  this  part  are  suspected  to 
be  venereal.  But  for  a particular  descrip- 
tion of  the  many  ordinary  complaints,  which 
are  apt  to  occur  on  the  genitals,  either  pre- 
ceded or  unpreceded  by  sexual  intercourse, 
I refer  to  Mr.  Evans’s  treatise.  (See  Patho- 
logical and  Practical  Remarks  on  Ulcerations 
of  the  Genital  Organs,  8 vo.  Lond.  1819.) 
From  facts  already  mentioned  in  this  ar- 
ticle, however,  it  would  appear  that  primary 
syphilitic  ulcers  or  chancres,  by  which  I 
imply  sores  capable  of  giving  rise  to  the 
secondary  symptoms  of  the  venereal  dis- 
ease, have  no  determinate  external  charac- 
ter, are  extremely  diversified  in  their 
appearance,  and  absolutely  cannot  be 
distinguished  by  their  mere  look  from  sores 
which  are  of  a common,  or  at  least  a verv 
different  nature.  This  is  another  important 
fact,  for  which  every  man  in  the  profession 
who  seeks  only  truth,  and  the  expulsion  of 
errors  from  the  doctrines  of  surgery,  must 
feel  obliged  to  the  army  surgeons.  Nor  is 
their  merit  lessened  by  the  consideration, 
t ,a<  the  detection  of  mistake  on  this  point, 
like  the  discovery  of  the  error,  concerning 
the  invariable  progress  of  the  venereal 
disease  from  bad  to  worse,  unless  medicU>e 


VENEREAL  DISEASE. 


be  given,  Las  taken  place  in  opposition  to 
the  tenets  of  Mr.  Hunter.  “ Venereal  ulcers 
(says  he,)  commonly  have  one  character , 
which,  however,  is  not  entirely  peculiar  to 
them  ; for  many  sores  that  have  no  dispo- 
sition to  heal  ( which  is  the  case  with  a 
chancre ,)  have  so  far  the  same  character. 
Jl  chancre  has  commonly  a thickened  base ; 
and,  although  in  some,  the  common  inflam- 
mation spreads  much  further,  yet  the  specific 
is  confined  to  this  base."  (P.  215.)  And 
elsewhere,  he  observes,  a chancre  first  be- 
gins with  an  itching  in  the  part.  When  the 
inflammation  is  on  the  glans  penis,  a small 
pimple,  full  of  matter,  generally  arises, 
without  much  hardness  or  seeming  inflam- 
mation, and  with  very  little  tumefaction  ; 
lor  the  glans  penis  is  not  so  apt  to  swell 
in  consequence  of  inflammation  as  many 
other  parts  are,  especially  the  prepuce. 
Mr.  Hunter  also  explains,  that  chancres, 
situated  on  the  glans,  are  not  attended  with 
so  much  pain  and  inconvenience  as  sores  of 
this  nature  on  the  prepuce.  When  chancres 
occur  on  the  fraenum,  or  particularly  on  the 
prepuce,  a much  more  considerable  degree 
of  inflammation  soon  follows,  attended 
with  effects  more  extensive  and  visible. 
These  latter  parts,  being  composed  of  very 
loose  cellular  membrane,  afford  a ready 
passage  for  the  extravasated  fluids.  The 
itching  is  gradually  converted  into  pain  : in 
some  cases  the  sdrface  of  the  prepuce  is 
excoriated,  and  afterward  ulcerates;  while, 
in  other  examples,  a small  pimple  or  ab- 
scess appears  on  the  glans,  and  then  turns 
into  an  ulcer.  The  parts  become  affected 
with  a thickening , which  at  first,  while  of  the 
true  venereal  kind , is  very  circumscribed  ; not 
diffusing  itself,  as  Mr.  Hunter  observes,  gra 
dually  and  imperceptibly  into  the  surround- 
ing parts  ; but  terminating  rather  abruptly. 
Its  base  is  hard , and  the  e.dges  a little  promi- 
nent. When  it  begins  on  the  fraenum,  or 
near  it.,  that  part  is  very  commonly  wholly 
destroyed,  or  a hole  is  often  made  through 
it  by  ulceration.  Mr.  Hunter  thought  it 
better,  in  general,  under  the  latter  circum- 
stance, to  divide  the  part  at  once. 

When  the  venereal  matter  is  applied  to 
the  body  of  the  penis,  or  front  of  the  scro- 
tum, where  the  cuticle  is  thicker  than  that 
of  the  glans  penis  and  prepuce,  the  chancre 
generally  makes  its  appearance  in  the  form 
of  a pimple,  w hich  commonly  forms  a scab, 
in  consequence  of  evaporation.  The  first 
scab  is  generally  rubbed  oil';,  after  which  a 
second,  still  larger  one,  is  produced. 

When  the  disease  is  more  advanced,  it  is 
often  attended  with  inflammation  peculiar 
to  the  habit,  becoming  in  many  instances 
more  diffused,  and  often  producing  phymo- 
sis  and  paraphvmosis.  However,  says  Mr 
Hunter,  there  is  yet  a hardness  around  the 
sores,  which  is  peculiar  to  such  as  are  caused 
by  the  venereal  virus,  particularly  those  on 
the  prepuce. 

Mr.  Carmichael,  also,  in  his  arrangement 
of  primary  ulcers  on  the  penis,  considers 
the  true  chancre  as  being  particularly  dis- 
tinguished by  its  hardened  base,  which  he 


compares  to  a piece  of  cartilage  under  the 
skin.  It  is  to  be  observed,  however,  that 
Mr.  Carmichael,  by  the  true  chancre,  or 
primary  syphilitic  ulcer,  does  not  signify 
that  it  is  the  only  sore  from  which  second- 
ary symptoms  may  arise  ; but  his  observa- 
tions lead  him  to  regard  it  as  the  cause  of 
such  constitutional  effects  as  belong  to  w hat 
he  deems  the  true  form  of  syphilis,  or  that 
in  which  the  use  of  mercury  is  the  most  de- 
cidedly indicated.  It  would  give  me  sincere 
pleasure  to  find  any  agreement  on  this  part 
of  the  subject  among  other  observers. 
The  reader,  indeed,  must  already  knowr, 
that  the  hardened  base,  which  both  Hunter 
and  Carmichael  have  regarded  as  a distin- 
guishing character  of  a true  chancre,  is  not 
found  to  be  so  by  other  gentlemen,  who 
have  most  impartially  investigated  this 
point.  Thus,  Dr.  Hennen  observes,  “ we 
are  not  in  possession  of  the  knowledge  of 
any  invariable  characteristic  symptoms,  by 
w^hich  to  discriminate  the  real  nature  of  the 
primary  sore,  and  w e are  equally  at  a loss 
in  many  of  the  secondary  symptoms.  I am 
well  aware  that  some  practitioners  have 
assumed  to  themselves  the  possession  of  a 
“ tactus  eruditus,”  by  which  they  can  at 
once  distinguish  a chancre,  or  a venereal 
ulcer,  or  eruption,  in  w hich  mercury  is  in- 
dispensable, from  one  of  a different  nature  ; 
but  I have  seen  too  many  instances  of  self- 
deception  to  give  them  all  the  credit  that 
they  lay  claim  to.  It  would  be  by  no 
means  difficult  to  show  that  the  high  round 
edge,  the  scooped  or  excavated  sore,  the 
preceding  pimple,  the  loss  of  substance,  the 
hardened  base  and  edge , whether  circumscri- 
bed or  diffused,  and  the  tenaciously  adhesive 
discharge  of  a very  fetid  odour,  are  all  ob- 
servable in  certain  states  and  varieties  of 
sores,  unconnected  with  a venereal  origin. 
The  hardened  edge  apd  base,  particularly, 
can  be  produced  artificially  by  the  applica- 
tion of  escharotics  to  the  glans  or  penis  of 
a sound  person  ; and  if  any  ulceration,  or 
warty  excrescence,  previously  exists  on 
these  parts,  this  effect  is  still  more  easily 
produced.”  (On  Military  Surgery,  Ed.  2,  p. 
517.)  Now,  if  it  be  asked,  whether  the 
chancre  with  a hardened  base,  and  promi- 
nent edge,  is  distinguished  by  its  not  admit- 
ting of  cure  without  mercury  ? and  by  any 
regularity  or  peculiarity  in  the  nature  of 
secondary  symptoms,  when  they  originate 
from  such  an  ulcer?  modern  experience 
denies  the  validity  of  both  these  criteria. 
If  Mr.  Rose’s  excellent  paper  be  consulted, 
the  reader  will  see  that  this  gentleman  has 
certainly  cured,  without  the  aid  of  mercury, 
ulcers,  which  had  a decidedly  marked  indu- 
ration of  the  margins  and  bases,  by  which 
the  syphilitic  chancre,  according  to  Mr. 
Carmichael,  is  easily  distinguished.  (Med. 
Chir.  Trans.  Vol.  8 ,p.  42 R fyc.  ; also  Guth- 
rie, Vol.  cit.  p.  576.)  And,  us  for  the  other 
points,  sufficient  evidence  has  already  been 
detailed  in  the  foregoing  columns  to  satisfy 
any  impartial  mind,  that,  as  far  ns  the  eye 
can  teach  us,  no  kind  of  primary  sore  has 
yet  been  satisfactorily  proved  to  be  the 


VENEREAL  DISEASE 


cause  of  only  one  set  of  peculiar  constitu- 
tional symptoms  ; but,  on  the  contrary,  that 
a great  variety  of  appearances  in  the  skin, 
throat,  &.c.  may  follow  sores,  which,  as  far 
as  external  characters  are  concerned,  seem 
exactly  alike.  The  only  partial  exception 
to  this  remark  is  the  great  frequency  of  pa- 
pular eruptions  alter  superficial  sores ; a 
point  on  which  both  Mr.  Carmichael  and 
JMr.  Rose  agree,  though  the  latter  gentleman 
does  not  represent  even  this  connexion  as 
constant.  Mr.  Hunter  computed,  that  claps 
occur  more  frequently  than  chancres,  in  the 
proportion  of  four  or  five  to  one.  1 am  not 
prepared  to  offer  any  opinion  on  this  calcu- 
lation, in  reference  either  to  chancres,  as 
defined  by  that  interesting  writer,  or  under 
the  more  comprehensive  view  of  them,  to 
which  the  results  of  modern  investigations 
would  lead.  One  intelligent  writer,  how- 
ever, has  observed,  that  presftnt  experience 
does  not  justify  Mr.  Hunter’s  conclusion  re- 
specting the  infrequency  of  chancre  com- 
pared with  gonorrhoea.  (J.  Bacot,  Obs.  on 
Syphilis,  p.  54.)  Yet,  in  Dublin,  if  Mr.  Car- 
michael’s statement  be  correct,  the  fre- 
quency of  gonorrhoea,  as  compared  with 
that  of  what  is  sometimes  termed  the  true 
venereal  chancre,  must  be  so  great  as  to 
defy  all  computation  ; for  he  informs  us, 
that  since  the  descriptions  of  the  success  of 
the  non-mercurial  practice  fell  into  his 
hands,  he  has  been  anxious  to  ascertain,  by 
personal  observation,  whether  true  syphili- 
tic chancres  did  really  admit  of  being  cured 
without  mercury  ; but,  says  he,  “ this  dis- 
ease, as  described  by  Hunter,  has  diminish- 
ed in  so  extraordinary  a degree  in  this 
country,  that,  strange  to  say,  I have  from 
that  period  met  with  only  one  case  of  true 
chancre.”  ( Observations  on  the  Symptoms, 
fyc.  of  Venereal  Diseases,  p.  14.)  As  this 
chancre  remained  stationary  a month,  it 
was  thought  proper  to  employ  mercurial 
frictions,  and  it  then  soon  healed,  leaving  a 
callosity  which  continued  two  months 
longer.  However,  after  the  above  passage 
wus  written,  Mr.  Carmichael  met  with  two 
cases  of  “ well  marked  chancre,”  each  of 
which  wras  attended  with  psoriasis  syphili- 
tica, scaly  from  its  commencement.  No 
mercury  was  given.  For  five  weeks,  the 
disease  gained  ground  ; but,  in  the  end,  both 
cases  were  cured,  merely  sarsaparilla  hav- 
ing been  administered.  The  following 
observations,  contained  in  the  appendix  to 
Mr.  Carmichael’s  work,  do  him  infinite  cre- 
dit. “ Although,  (says  he,)  these  two  cases 
cannot  fail  to  make  a due  impression,  yet, 
if  they  stood  alone,  their  evidence  could 
not  be  deemed  sufficient  to  establish  a be- 
lief, that  true  syphilis,  like  the  papular 
disease,  is  capable  of  yielding  to  the  powers 
of  the  constitution,  or  to  remedies  in  which 
mercury  does  not  form  an  ingredient.  But 
this  deficiency  seems  to  be,  in  a great  mea- 
sure, supplied  by  the  testimony,  of  Mr.  Rose, 
Mr.  Hennen,  and  other  equally  intelligent 
surgeons,  who  had  the  advantage  of  serving 
with  our  army  on  the  continent ; and,  if  in 
the  preceding  pages  I appear  to  he  sceptical 


dOui 

with  respect  to  the  accuracy  of  their  observa 
tions,and  doubted  that  it  wastrue  chancre,  and 
true  syphilitic  eruption,  which  yielded  to  their 
prescriptions,  unaided  by  mercury,  these  two 
cases  have  satisfied  me  that  every  attention 
is  due  to  the  exactness  and  discernment  of 
these  respectable  individuals  ; and  if  1 hesi- 
tated until  1 saw  with  my  own  eyes,  and 
judged  with  m>  own  understanding,  I claim 
for  my  own  observations  no  larger  a mea- 
sure of  faith  from  others.”  And  he  after- 
ward adds,  “ In  thus  relinquishing  my  opi- 
nion, that  true  syphilis  differs  from  oiher 
venereal  complaints,  by  always  requiring 
mercury  for  its  cure,  it  is  necessary  to 
reduce  the  doctrine  I hold  to  this  propo- 
sition : that  with  respect  to  the  use  of  that 
medicine,  it  differs  from  them  only  in  not 
being  injured,  but  decidedly  benefited  by 
it  in  all  its  symptoms  and  stages.”  (P.  216, 
219.) 

According  to  Mr.  Hunter,  there  are  three 
ways  in  which  chancres  may  be  produced  ; 
first,  by  the  poison  being  inserted  into  a 
wound  ; secondly,  by  being  applied  to  a 
non-secreting  surface;  and,  thirdly,  by  be- 
ing applied  to  a common  sore.  A wound,  it 
seems,  is  much  more  readily  infected  than 
a sore.  To  whichever  of  these  three  differ- 
ent surfaces  the  pus  is  applied,  it  produces 
its  specific  inflammation  and  ulceration,  at- 
tended with  a secretion  of  pus.  The  mat- 
ter produced  in  consequence  of  these  dffer- 
ent  modes  of  application,  he  says,  partakes 
of  the  same  nature  as  the  matter  which  was 
applied,  because,  be  observes,  the  irritations 
are  alike.  How  the  alleged  examples  of 
very  different  primary  sores  being  sometimes 
communicated  by  the  application  of  the 
maiter  of  chancre,  are  to  be  reconciled 
with  the  Hunterian  doctrines,  it  is  difficult 
to  suggest,  unless  Mr.  Carmichael’s  obser 
vation  about  the  present  excessive  rarity  of 
the  true  syphilitic  chancre,  can  furnish  the 
explanation.  However,  as  far  as  I can  be- 
lieve my  own  eyes  and  judgment,  I now  see 
in  London  the  same  forms  of  chancre, 
which  used  to  prevail  during  my  apprentice- 
ship at  St.  Bartholomew’s  Hospital  more 
than  twenty  years  ago.  And  if  any  differ- 
ence can  be  particularized,  it  is  only  that 
which  depends  upon  their  being  less  rarely 
converted  into  worse  diseases  than  mere 
syphilitic  ulceration,  by  the  dreadful  effects 
of  immoderate  courses  of  mercury. 

With  respect  to  the  three  modes,  in  which 
Mr.  Hunter  speaks  of  the  venereal  poison 
being  applied  and  taking  effect,  I know  not 
why  he  should  have  altogether  excluded  se- 
creting surfaces;  for  of  this  nature  (as  a late 
writer  remarks)  are  the  glans  penis  and  co- 
rona glandis,  ( Bacot  on  Syphilis,  p.  55,)  and 
of  a similar  kind,  are  the  insides  of  the  labia, 
the  surfaces  of  the  nymphae,  &ic.  where  sores 
are  common  enough.  Whatever  may  be 
the  truth  of  the  impossibility  of  the  forma- 
tion of  chancres  within  the  urethra,  the 
latter  considerations  certainly  tend  to  prove 
that  the  secreting  nature  of  its  membrane, 
is  not  the  only  reason  for  the  alleged  fact. 

I shall  not  here  detain  the  reader  with 


VENEREAL  DISEASE. 


<K)0 


descriptions  ot  the  primary  ulcer  with  eleva- 
ted edges,  the  phagedenic,  and  the  sloughing 
chancre.  Such  descriptions  I have  embo- 
died in  the  last  edition  of  the  First  Lines  of 
Surgery,  with  the  sentiments  of  Mr.  Carmi- 
chael, respecting  the  train  of  constitutional 
symptoms,  appertaining,  as  he  believes,  to 
each  form  of  ulcer.  It  is  an  interesting  dis- 
quisition, but  as  far  as  my  observations  and 
inquiries  go,  it  has  not  yet  reached  any  de- 
gree of  certainty  or  precision  ; and  as  I have 
already  explained,  the  reports  published  by 
other  gentlemen  engaged  in  this  investiga- 
tion, do  not  by  any  means  confirm  the  much 
desired  intelligence,  that  such  progress  has 
been  made  in  the  knowledge  of  all  the  diver- 
sified symptoms  of  the  venereal  disease,  that 
its  varieties  can  now  be  classed  both  in  re- 
gard to  the  primary  ulcers,  and  the  secondary 
symptoms  connected  with  each  description 
of  chancre. 

I firmly  believe,  that  with  respect  to  all 
the  appearances  of  this  disease,  both  in  its 
primary  and  secondary  forms,  a vast  deal 
depends  upon  constitution,  independent- 
ly of  the  nature  ot  the  virus.  And  I adopt 
this  opinion,  at  the  same  lime  that  many  re- 
flections, already  hinted  at  in  this  article, 
lead  me  to  join  in  the  belief,  that  syphilitic 
diseases  may  depend  upon  a variety  of  poi- 
sons, whereby  some  of  the  perplexity  of  these 
cases  may  be  explained. 

The  local,  or  immediate  effects  of  the  ve- 
nereal disease,  are  seldom  wholly  specific; 
but  are  usually  attended  both  with  the 
specific  and  constitutional  inflammation. 
Hence,  Mr.  Hunter  advises  particular  atten- 
tion to  be  paid  to  the  manner  in  which  a 
chancre  first  appears,  and  to  its  progress. 
If  the  inflammation  spreads  in  a quick  and 
considerable  way,  the  constitution  must  be 
more  disposed  to  inflammation,  than  natural. 
When  the  pain  issevere,  Mr.  Hunter  remarks, 
there  is  a strong  disposition  to  irritation. 
Chancres,  also,  sometimes  soon  begin  to 
slough,  there  being  a strong  tendency  to 
mortification. 

It  is  also  observed  by  Mr.  Hunter,  that 
when  there  is  a considerable  loss  of  sub- 
stance, either  from  sloughing  or  ulceration, 
a profuse  bleeding  is  no  uncommon  circum- 
stance, more  especially,  when  the  ulcer  is  on 
the  glans.  The  adhesive  inflammation  does 
not  appear  to  take  place  sufficiently  to  unite 
the  veins  of  this  part  of  the  penis,  so  as  to 
prevent  their  cavity  from  being  exposed, 
and  the  blood  escapes  from  the  corpus  spon- 
giosum urethrae.  The  ulcers,  or  sloughs,  often 
extend  as  deeply  as  the  corpus  cavernosum 
penis,  and  similar  bleedings  are  the  conse- 
quence. 

With  respect  to  chancres  in  women,  the 
labia  and  nymphae,  like  the  glans  penis  in 
ruen,  are  subject  to  ulceration,  and  the  ulce- 
rations are  generally  more  numerous  in  fe- 
males than  males,  in  consequence  of  the 
surface  on  which  the  sores  are  liable  to 
form  being  much  larger.  As  Mr.  Hunter 
observes,  chancres  are  occasionally  situated 
ou  the  edge  of  the  labia ; sometimes  on  the 
outside  of  these  parts ; and  even  on  the  pe- 


rinaeum.  When  the  sores  are  formed  or;  the 
inside  of  the  labia  or  nymphae,  they  can 
never  dry  or  scab ; but  when  they  are  ex- 
ternally situated,  the  matter  may  dry  on 
them,  and  produce  a scab,  just  as  hap- 
pens with  respect  to  chancres  situated  on 
the  scrotum,  or  body  of  the  penis. 

Mr.  Hunter  remarks,  that  the  venereal 
matter  from  these  sores  is  apt  to  run  down 
the  perinagum  to  the  anus,  and  excoriate  the 
parts,  especially  about  the  anus,  where  the 
skin  is  thin,  and  where  chancres  may  be 
thus  occasioned. 

Chancres  have  been  noticed  in  the  vagi- 
na ; but  Mr.  Hunter  suspected  that  they 
were  not  original  ones;  but  that  they  had 
spread  to  this  situation  from  the  inside  of  the 
labia. 

Before  any  of  the  virus  has  been  taken  up 
by  the  absorbents,  and  conveyed  into  the 
circulation,  a chancre  is  entirely  a local  af- 
fection. From  the  Hunterian  doctrines, 
however,  it  would  appear  that  absorption 
must  generally  soon  follow  the  occurrence 
of  the  sore  ; and  all  the  modern  opinions 
concerning  the  nature  of  ulceration  itself, 
would  lead  to  the  same  inference.  When 
no  secondary  symptoms  take  place  after  the 
cure  of  chancre  without  mercury,  I believe 
few  surgeons  of  the  present  day  would  at- 
tempt to  account  for  the  fact  by  the  hypo- 
thesis of  the  matter  not  having  been  absorb- 
ed ; and  this  observation  is  made  with  every 
disposition  on  my  part  to  express  my  assent 
to  the  truth  of  another  circumstance,  viz* 
that  some  persons  appear  much  more  sus- 
ceptible of  the  effects  of  the  venereal  disease 
than  other  individuals.  It  is  remarked  by 
Mr.  Hunter,  that  the  interval  between  the 
application  of  the  poison,  and  its  effects 
upon  the  parts  is  uncertain  ; but  that  on  the 
whole,  a chancre  is  longer  in  appearing, 
than  a gonorrhoea.  However,  the  nature  of 
the  parts  affected  makes  some  difference. 
When  a chancre  occurs  on  the  fraenum,  or 
at  the  termination  of  the  prepuce  in  the 
glans,  the  disease  in  general  comes  on  earlier; 
these  parts  being  more  easily  affected  than 
either  the  glans  penis,  common  skin  of  this 
organ,  or  the  scrotum.  He  adds,  that  in 
some  cases,  in  which  both  the  glans  and 
prepuce  were  contaminated  from  the  same 
application  of  the  poison,  the  chancre  made 
its  appearance  earlier  on  the  latter  part. 
Mr.  Hunter  knew  of  some  instances  in  which 
chancres  appeared  twenty-four  hours  after 
the  application  of  the  matter;  and  others,  in 
which  an  interval  of  seven  weeks,  and  even 
two  months  elapsed  between  the  time  of 
contamination,  and  that  when  the  chancre 
commenced.  However,  here,  os  in  almost 
all  other  statements  about  this  perplexing 
subject,  we  never  know  with  certainty  that 
the  writer  has  sufficient  grounds  for  the  as- 
sumed fact,  that  it  is  only  one  kind  of  poison 
which  is  spoken  of. 

TREATMENT  OF  CHANCRES. 

It  was  one  of  Mr.  Hunter’s  opinions,  that 
the  ulceration  arising  from  venereal  inllam- 


venereal  disease. 


m 


yaation,  generally,  if  not  always,  continues 
till  cured  by  art,  and  his  theoretical  reason 
for  this  circumstance  was,  that  as  the  in- 
flammation in  the  chancre  spreads,  it  is  al- 
ways attacking  new  ground,  so  as  to  produce 
a succession  of  irritations,  and  hinder  the 
disease  from  curing  itself. 

It  was  no  doubt  the  foregoing  opinion  of 
Mr.  Hunter,  which  formed  the  authority  for 
the  position  which  was  always  forcibly  in- 
sisted upon  in  the  surgical  lectures  which  I 
attended  some  years  ago  in  London,  viz. 
that  all  venereal  complaints,  when  not  coun- 
teracted by  remedies,  invariably  grow  pro- 
gressively worse  and  worse.  But  modern 
experience  apprizes  us,  that  this  doctrine  is 
far  from  being  correct.  As  I have  noticed 
in  the  foregoing  pages,  Mr.  Fergusson  assures 
us,  that  in  Portugal,  the  disease  in  its  prima- 
ry state  among  the  natives  is  curable  without 
mercury,  and  by  simple  topical  treatment  j 
that  the  antisyphilitic  woods,  combined  with 
sudorifics,  are  an  adequate  remedy  for  con- 
stitutional symptoms ; and  that  the  viruieuce 
of  the  disease  has  there  been  so  much  miti- 
gated, that  after  running  a certain  course 
(commonly  a mild  one)  through  the  respec- 
tive orders  of  parts,  according  to  the  known 
laws  of  its  progress,  itexhauslsilself  and  ceases 
spontaneously.  (See  Med.  and  Chir.  Trans. 
Vol.  4,  p.  2 — 6.)  • Iri  the  third  edition  of  the 
First  Lines  of  the  Practice  of  Surgery,  it  was 
sufficiently  proved,  from  several  conclusions 
drawn  from  the  writings  of  Mr.  Pearson, 
( Obs . on  the  Effects  of  Various  Articles  in  the 
Cure  of  Lues  Venerea,)  that  venerea!  sores 
might  be  benefited,  and  even  healed  under 
the  useof  several  inert  insignificant  medicines 
And  as  I have  previously  explained,  the 
possibility  of  curing  chancres  and  other  ve- 
nereal complaints,  without  mercury,  was 
Jong  since  remarked  by  Dr.  Clutterbuck, 
who  thence  very  justly  inferred,  that  the 
healing  of  a sore  without  this  remedy  was 
no  test  that  it  was  not  venereal.  (See  Re- 
marks on  the  Opinions  of  the  late  John  Hun- 
ter, 1799.) 

But  although  the  whole  history  of  the 
venereal  disease,  and  of  the  various  articles 
of  the  materia  medica,  if  carefully  reflected 
upon,  must  have  led  to  the  same  conclusion, 
the  truth  was  never  placed  in  such  a view  as 
to  command  the  general  belief  of  all  the 
most  experienced  surgeons  in  this  and  other 
countries  of  Europe.  I do  not  mean  to  say, 
thnt  the  truth  was  not  seen  arid  remarked  by 
several  of  the  older  writers  ; for  that  it  was 
so  any  man  may  convince  himself  by  refer- 
ring to  several  works,  quoted  in  the  course 
of  this  article.  But  it  is  to  be  understood, 
all  indecision  could  never  be  renounced,  as 
long  as  prejudices  interfered  with  the  only 
rational  plan  which  could  be  adopted,  with 
the  view  of  bringing  the  question  to  a final 
settlement ; I mean  experiments  on  a large 
and  impartial  scale,  open  to  the  observation 
of  numerous  judges,  yet  under  such  control 
as  insured  the  rigorous  trial  of  the  practice. 
Nor  could  such  investigation  be  so  well 
made  by  any  class  of  practitioners  as  the 
army  surgeon?,  whose  patients  are  nume- 


rons,  obliged  to  follow  strictly  the  treatment 
prescribed,  w itbout  any  power  of  going  from 
hospital  to  hospital,  or  from  one  surgeon  to 
another,  as  caprice  may  dictate,  or  of  eluding 
the  observation  of  the  medical  attendants 
after  a seeming  recovery.  And  here  I must 
take  the  opportunity  of  stating,  that  as  far 
as  my  judgment  extends,  the  most  important 
and  cautions  document  yet  extant  on  the  two 
questions  of  the  possibility  and  expediency  of 
curing  the  venereal  disease  without  mercury, 
is  the  paper  of  Mr.  Rose.  For  let  it  not  be 
presumed,  that  because  the  army  surgeons 
find  the  venereal  disease  curable  without 
mercury,  they  mean  to  recommend  the  total 
abandonment  of  that  remedy  for  the  distem- 
per, any  more  than  they  would  argue  that 
possibility  and  expediency  are  synonymous 
terms.  At  the  time  when  Mr.  Rose  publish- 
ed his  observations,  he  had  tried  the  non- 
mercurial treatment  in  the  Coldstream 
Regiment  of  Guards,  during  a year  and 
three  quarters,  and  had  thus  succeeded  in 
curing  all  the  ulcers  on  the  parts  of  genera 
tion  which  he  met  with  in  that  period , to - 
gether  with  the  constitutional  symptoms  to 
which  they  gave  rise.  “ I may  not  be  war- 
ranted in  asserting,  (says  this  gentleman,) 
that  many  of  these  were  venereal,  but  un- 
doubtedly a considerable  number  of  them 
had  all  the  appearances  of  primary  sores, 
produced  by  the  venereal  virus,  and  arose 
under  circumstances,  where  there  had  been 
at  least  a possibility  of  that  virus  having  been 
applied.  Admitting  that  there  is  nothing  so 
characteristic  in  a chancre,  as  to  furnish  in - 
controvertible  proof  of  its  nature,  it  will  yet 
be  allowed,  that  there  are  many  symptoms 
common  to  such  sores,  although  not  en- 
tirely peculiar  to  them,  and  whenever  these 
are  met  with,  there  are  strong  grounds 
to  suspect,  that  they  are  the  effects  of 
the  syphilitic  virus.  In  a sore,  for  in- 
stance, appearing  shortly  after  suspicious 
connexion,  where  there  is  loss  of  substance, 
a want  of  disposition  to  granulate,  and  an 
indurated  margin  and  base,  there  is  certain- 
ly a probability  of  that  poison  being  present. 
Among  a number  of  cases  of  such  a descrip- 
tion, taken  indiscriminately,  the  probability 
of  some  being  venereal  is  materially  increas- 
ed, and  must  at  last  approach  nearly  to  a 
certainty.  On  this  principle  some  of  the 
sores  here  referred  to,  must  have  been 
venereal.  They  were  also  seen  by  different 
surgeons,  on  whose  judgment  I would  rely, 
who  agreed  in  considering  many  of  them 
as  well  marked  cases  of  true  chancre.” 
( Rose  in  Med.  Chir.  Trans.  Vol.  8 ,p.  357,  fyc.) 
The  men  thus  treated,  were  examined  almost 
every  week,  for  a considerable  time  after 
their  apparent  cure,  “both  that  the  first  ap- 
proach of  constitutional  symptoms  might  be 
observed,  and  that  any  deception  from  an 
underhand  use  of  mercury  might  be  guarded 
against.”  (P.  359.)  Sixty  cases  of  ulcers  on 
the  penis  were  also  cured  by, Mr.  Dense,  in 
the  York  Hospital,  by  means  of  simple  dress- 
ings, the  only  general  remedy  being  occasion 
al  purgatives.  The  practice  was  likewise  ex 
tepsivelv  tried  by  Mr.  Why  tr  per  and  .**■ 


VENEREAL  DISEASE. 


608 


Good,  surgeons  of  the  Guards,  with  the  same 
kind  of  success.  In  Mr.  Rose’s  practice,  all 
idea  of  specific  remedies  were  entirely  laid 
aside.  The  patients  were  usually  confined  to 
their  beds,  and  such  local  applications  were 
employed,  as  the  appearances  of  the  sores 
seemed  to  indicate.  Aperient  medicines, 
antimony,  hark,  vitriolic  acid,  and  occasion 
ally  sarsaparilla,  were  administered.  (P. 
363.)  Upon  an  average  (says  Mr.  Rose) 
one  out  of  every  three  of  the  sores  thus  treat- 
ed , was  followed,  by  some  form  or  other 
of  constitutional  affection:  this  was  in  most 
instances  mild,  and  sometimes  so  slight,  that 
it  would  have  escaped  notice,  if  it  had  not 
been  carefully  sought  for.  The  constitu- 
tional symptoms  were  evidently  not  3uch  as 
could  be  regarded  as  venereal,  if  we  give 
credit  to  the  commonly  received  ideas  on 
the  subject.  Caries  of  the  bones , and  some  of 
the  least  unequivocal  symptoms,  did  not  oc- 
cur. In  no  instance  was  there  that  uniform 
progress,  with  unrelenting  fury,  from  one 
order  of  symptoms  and  parts  affected  to  an- 
other, which  is  considered  as  an  essential 
characteristic  of  true  syphilis.”  (Med.  Chir. 
Trans.  Vol.  8,  p.  422.)  The  constitutional 
symptoms  also  yielded,  without  the  aid  of 
mercury,  and  frequently  primary  sores,  cor- 
responding to  what  had  been  called  the 
true  chancre,  with  indurated  base,  were 
cured  in  this  manner,  yet  were  followed  by 
no  secondary  symptoms.  We  are  also  in- 
formed, that  “ several  cases  occurred  of  a 
cluster  of  ill-conditioned  sores  over  the 
whole  inner  surface  of  the  prepuce,  and 
behind  the  corona  glandis;  and  also  of  a 
circle  of  small  irritable  sores,  situated  on 
the  thickened  and  contracted  ring  at  the  ex- 
treme margin  of  the  prepuce.  These  occa- 
sionally produced  buboes.”  None  of  the  sores 
of  this  description  met  with  by  Mr.  Rose , were 
followed  by  any  constitutional  affection.  ( Vol. 
cit.  p.  370.)  He  bears  testimony  to  the  ill 
effects  of  mercury  and  stimulants  in  cases 
of  phagedenic  ulcers,  and  confirms  a not 
uncommon  opinion,  that  they  are  seldom 
followed  by  secondary  symptoms,  which 
opinion  should  be  qualified  with  the  condi- 
tion mentioned  by  Mr.  Guthrie,  (Med.  Chir. 
Trans.  Vol.  8,  p.  565.)  that  no  mercury  be 
given.  Lastly,  as  I have  already  stated, 
Mr.  Rose  observed,  that  most  of  the  cases  of 
papular  eruptions  followed  ulcers,  which 
were  not  very  deep,  and  healed  without 
much  difficulty.  (P.  399.) 

Although  the  fact  of  the  possibility  of 
curing  every  kind  of  ulcer  on  the  genitals, 
without  mercuiy,  is  now  so  fully  confirmed 
by  the  statements  of  Mr.  Guthrie,  (Med. 
Chir.  Trans.  Vol.  8,  p.  558,  and  676.)  ; Dr. 
I.  Thomson,  (Edinb.  Med.  and  Surg.  Journ. 
for  January , 1818;)  Dr.  Hennen,  (Op.  cit. 
Nos.  54  and  55,  and  Principles  of  Military 
Surgery , Ed.  2.)  ; Mr.  Bacot,  (On  Syphilis, 
p.  26,  fyc.)  ; and  many  other  careful  obser- 
vers, and  it  is  of  great  importance  in  rela- 
tion to  the  removal  of  an  erroneous  doc- 
trine concerning  the  diagnosis,  the  expedien- 
cy of  the  practice  must  evidently  be  deter- 
mined by  other  considerations,  the  princi- 


pal of  which  are  the  comparative  quickness 
of  the  cures  effected  with,  and  without  mer- 
cury ; the  comparative  severity  and  frequen- 
cyof  secondary  symptoms  ; and  the  generally 
acknowledged  fact,  that  a syphilitic  primary 
sore  is  not  indicated  with  any  degree  of  cer- 
tainty by  its  mere  external  character,  or  in- 
deed any  other  criterion,  that  I know  of. 

Respecting  the  comparative  quickness  of 
the  cures  of  chancres,  or  reputed  chancres, 
without  the  aid  of  mercury,  much  disagree- 
ment prevails  in  the  different  reports,  even 
those  collected  by  the  same  individuals, 
whose  statements  must  therefore  be  deem- 
ed perfectly  impartial,  though  inconclusive. 
(See  Hennen's  Military  Surgery , Ed.  2,  p. 
536,  fyc.)  Some  of  Mr.  Rose’s  best  marked 
cases  of  chancre,  that  is  to  say,  such  as  were 
distinguished  by  the  indurated  base  and  cir- 
cumference, healed  in  a very  short  time. 
But  even  respecting  these,  or  any  other 
kinds  of  chancre,  no  regularity  on  this  point 
can  be  found.  Mr.  Guthrie  observes,  if  the 
“ ulcers  were  not  without  any  marked  ap- 
pearance, and  did  not  amend  in  the  first  fort- 
night,or  three  weeks,  they  generallyremain- 
ed  for  five, or  seven  weeks  longer  ; and  the 
only  difference  in  this  respect  between  them 
and  the  raised  ulcer  of  the  prepuce  was, 
that  this  often  remained  fora  longer  period, 
and  that  ulcers,  possessing^the  true  charac- 
ters of  chancre,  required  in  general  a still 
longer  period  for  their  cure,  that  is,  from 
six,  eight,  to  ten,  twenty,  and  even  in  one 
case,  twenty-six  weeks,  healing  up  and  ul- 
cerating again  on  a hardened  base.  Those 
that  required  the  greatest  length  of  time  had 
nothing  particular  in  their  appearance,  that 
would  lead  us  to  distinguish  them  from 
others  of  the  same  kind,  that  were  healed 
in  a shorter  time.”  (Med.  Chir.  Trans.  Vol. 
8,  p.  558.)  The  same  writer  afterward  ex- 
presses his  belief,  that  almost  all  the  pro- 
tracted cases  would  have  been  cured  in  one 
half,  or  even  one-third  of  the  time,  if  a 
moderate  course  of  mercury  had  been  re- 
sorted to. 

In  relation  to  the  question  before  us,  one 
of  the  most  important  documents  which  I 
met  with,  is  an  official  circular,  signed  by 
Sir  James  M‘Grigor  and  Dr.  Franklin,  from 
which  it  appears,  that  in  1940  cases  of  pri- 
mary venereal  ulcerations  on  the  penis, 
cured  without  mercury . between  December, 
1816,  and  December,  1818,  (including  not 
only  the  more  simple  sores,  but  also  a re- 
gular proportion  of  those  with  the  most 
marked  character  of  syphilitic  chancre)  the 
average  period  taken  up  by  the  treatment, 
when  bubo  did  not  exist,  was  21  days, ; with 
bubo,  45  days.  (See  H ennen's  Military  Sur- 
gery, Ed.  2,  p.  545.)  And  it  further  appears, 
that  during  the  period  above  specified,  2827 
chancres,  a more  considerable  proportion 
of  which  were  probably  Hunterian  chan- 
cres, were  treated  with  mercury,  and  that 
the  average  period  required  for  the  cure, 
when  there  was  no  bubo,  was  33  days  ; 
with  bubo,  50.  As  far  therefore  as  a judg- 
ment can  be  formed  from  this  official  esti- 
mate, and  no  calculation  is  ever  likely  to  be 


VENEREAL  DISEASE. 


<509 


furnished  on  a larger,  or  more  impartial 
scale,  the  evidence  tends  to  prove,  that  pri- 
mary sores  may  generally  be  cured  rather 
sooner  without,  than  with,  the  administra- 
tion of  mercury.  But,  as  practitioners  are 
not  obliged  to  restrict  themselves  either  to 
the  mercurial,  or  non-mercurial  practice, 
I am  of  opinion,  that  the  total  rejection  of 
mercury  is  by  no  means  justified  by  any 
facts,  yet  before  the  public,  concerning  the 
time  requisite  for  the  cure  on  either  plan, 
because,  as  it  is  universally  admitted,  that 
some  cases  are  very  tedious,  unless  mercury 
be  given,  neither  reason  nor  experience  will 
sanction  the  exclusive  adoption  of  only  one 
mode  of  practice,  whether  the  backward- 
ness to  heal  exist,  or  not.  On  the  contrary, 
as  far  as  the  consideration  of  time  has 
weight,  prudence  and  common  sense  teach 
us  to  diversify  the  treatment  according  to 
circumstances  But  it  may  be  inquired, 
since  the  backward  disposition  of  a sore  to 
heal  cannot  be  known  at  first  by  its  mere 
appearance,  should  the  treatment  begin  with 
mercury,  or  not?  Now,  although  late  writers 
dwell  very  much  on  the  impossibility  of 
judging  of  the  nature  of  a sore  by  its  look 
alone,  one  fact  is  certain, thatsome  ulcers  on 
the  penis  have  a clean  appearance  from  their 
very  commencement;  some  cases  are  simple 
excoriations  ; and  others,  though  ill-condi- 
tioned, are  so  small,  that  a fair  chance 
offers  itself  of  destroying  every  part  of  the 
disease  with  caustic.  In  all  such  cases,  I 
should  never  commence  with  mercury. 
With  respect  to  phagedenic  and  sloughing 
chancres,  repeated  experience  has  con- 
vinced me  that  they  are  cases,  in  the  first 
stage  of  which,  at  all  events,  mercury  should 
always  be  avoided  ; and  I believe  with  Mr. 
Guthrie,  that  when  this  is  strictly  done, 
secondary  symptoms  are  rare.  One  sore  of 
this  kind  was  long  ago  pointed  out  by  Mr. 
Pearson  as  not  requiring  mercury  ; and  the 
attention  of  surgeons  has  been  of  late  par- 
ticularly directed  to  it  by  Mr.  Bacot.  “ It 
is  characterized  by  a great  derangement  of 
the  general  health,  by  a high  state  of  in- 
flammation of  the  part,  by  great  local  pain, 
and  proceeds  rapidly  to  the  destruction  of 
the  parts.  The  situation  of  this  sore  is  most 
commonly  in  the  angle  between  the  pre- 
puce and  glans  penis  ; and  those  of  a full 
habit  of  body,  the  young  and  the  vigorous, 
are  most  liable  to  its  attack.  The  most 
prompt  and  vigorous  antiphlogistic  means 
are  necessary  to  arrest  the  progress  of  this 
sore  ; and  the  blood,  taken  away  in  these 
cases,  presents  the  usual  inflammatory  ap- 
pearances, frequently  in  a very  high  degree. 
The  exhibition  of  mercury  in  this  species  of 
sore  is  highly  mischievous,  and  productive 
of  the  worst  consequences ; nor  does  it 
often  happen  that  secondary  symptoms 
succeed,  &,c.  (On  Syphilis,  p.  57.)  Here, 
according  to  Mr.  Pearson’s  observations, 
made  many  years  ago,  mercury  is  not  per- 
haps necessary  for  the  security  of  the  con- 
stitution ; but,  I conceive,  it  might  be  more 
correct  to  say,  that  the  safety  of  the  consti- 
tution actually  requires  that  mercury  should 
vot,  n,  5 77 


be  strictly  avoided,  because  there  Is  some 
ground  for  believing,  that  in  these  in- 
stances, it  is  not  only  injurious  to  the  local 
disease,  but  conducive  to  secondary  symp- 
toms. However,  if  the  latter  symptoms 
should  arise,  notwithstanding  mercury  has 
not  been  administered  during  the  cure  of 
the  ulcer,  alterative  doses  of  that  medicine 
may  still  be  useful,  as  Mr.  Carmichael  ob- 
serves, when  the  disease  is  in  the  wane, 
but  not  until  then  ; previously  to  which  pe 
riod,  the  best  internal  remedies  are  antimo- 
nials,  sarsaparilla,  guaiacum,  compound 
powder  of  ipecacuanha,  arseniate  of  kali, 
the  nitrous  acid,  and  nitro-muriatic  bath. 
(See  Obs.  on  the  Symptoms , fyc.  of  the  Vene- 
real Disease,  p.  209.) 

With  respect  to  chancres,  with  a hardened 
base  and  margin,  it  certainly  appears  that 
many  of  them  have  healed  tolerably  fast 
without  mercury;  but  a large  proportion  of 
them  seem  to  be  tedious  when  that  medi- 
cine is  not  employed.  (See  three  cases 
recorded  in  the  work  last  quoted.)  It  may 
be  thought,  however,  that  the  official  docu- 
ment, circulated  by  Sir  James  M'Grigor  and 
Dr.  Franklin,  tends  to  prove,  that,  at  all 
events,  these  sores  heal  sooner  without  than 
with  mercury.  But  this  deduction  seems 
hardly  allowable  ; because,  as  these  faithful 
and  impartial  reporters  have  sensibly  re- 
marked, the  2827  sores,  treated  with  mer- 
cury, may  be  fairly  presumed  to  have 
partaken  of  the  character  of  Hunter’s  chan- 
cre, in  a greater  proportion  than  the  1940 
primary  sores  treated  without  mercury.  (See 
Hennen's  Military  Surgery , p.  545.)  Con- 
sequently, though  the  sores  treated  with 
mercury  seem,  on  the  average,  to  have  heal- 
ed more  slowly  than  others  treated  with  it ; 
yet  it  is  to  be  taken  into  the  account,  that  a 
larger  number  of  the  first  cases  were  ulcers 
with  a hardened  base  and  margin,  and  that 
if  they  had  not  had  the  mercurial  treatment 
extended  to  them,  it  is  possible  their  com- 
plete cure  might  generally  have  been  still 
more  tedious.  As  the  evidence  now  stands, 
therefore,  1 conceive  it  right  to  employ  mer- 
cury with  moderation  for  all  sores  on  the 
penis,  having  the  characters  of  the  Hunterian 
chancre,  and  appearing  after  a suspicious 
connexion. 

A consideration,  however,  which  ought  to 
have  greater  influence  than  the  slowness  or 
quickness  of  the  treatment  of  primary  sores, 
with  and  without  mercury,  is  the  question, 
whether,  upon  the  average,  secondary  symp- 
toms are  more  frequent  after  the  non-mercu- 
rial practice,  than  the  other  ? On  this  most 
interesting  point,  the  reports  vary,  as  indeed 
they  do  on  almost  every  matter  in  the  inves- 
tigation, excepting  the  facts  of  the  possibility 
of  curing  all  forms  of  the  venereal  disease 
without  mercury,  the  great  rarity  of  any  af- 
fection of  the  bones,  and  the  general  mild- 
ness of  the  secondary  symptoms,  when  that 
medicine  is  not  employed.  On  all  these 
points,  the  testimonies  are  strong  and  con- 
vincing. But  while  Mr.  Rose  found  secon- 
dary symptoms  take  place  in  one-third  of  his 
cases  treated  without  mercury,  (Med.  Ckir. 


610 


VENEREAL  DISEASE. 


Trans.  Vol.  8,  p.  222,)  the  proportion  in  the 
York,  and  some  other  hospitals,  was  only 
about  one-tenth.  (Vol.  cit.  p.  559.)  In  the 
1940  cases  of  primary  sores  on  the  penis, 
treated  without  mercury  in  the  army  hospi- 
tals, between  D-*c.  1816,  and  Dec.  1818, 
there  were  only  96  instances  of  secondary 
symptoms  of  different  sorts,  or  not  more  ihan 
one-twentieth.  But  the  proportion  of  cases 
of  secondary  symptoms  in  the  case  of  pri- 
mary ulcers,  treated  with  mercury,  was  still 
smaller,  and  this  in  an  important  degree,  be- 
ing only  51  out  of  2827  cases,  or  about  orie- 
fifty- fifth.  Were  it  not  necessary  here  to 
make  a considerable  allowance  for  the  pro- 
bable circumstance  of  the  Hunterian  chancre 
prevailing  most  in  the  cases  treated  with 
mercury,  a point  admitted  by  Sir  James 
M‘Grigor  and  Dr.  Franklin,  we  should  here 
have  a powerful  and  decisive  evidence  in 
favour  of  the  general  superiority  of  mercury 
for  the  prevention  of  secondary  symptoms. 
Nor  am  1 certain  that  the  conclusion  can  be 
much  weakened  by  the  probability  of  the 
difference  here  alluded  to,  because,  from  the 
evidence  of  late  brought  to  light  respecting 
the  nature  of  the  class  of  diseases  which  go 
under  the  name  of  syphilis,  we  have  no  right 
to  infer,  that  what  has  been  called  the  frue, 
or  Hunterian  chancre,  is  more  disposed  than 
some  other  primary  sores  to  occasion  se- 
condary symptoms.  Indeed,  Mr.  Guthrie 
declares,  in  the  cases  referred  to  in  his  paper, 
that  where  mercury  was  not  used,  these 
symptoms  more  frequently  followed  the 
raised  ulcer  of  the  prepuce,  than  the  true 
characteristic  chancre  of  syphilis  affecting 
the  glans  penis.  (Med.  Chir.  Trans.  Vol.  8, 
p.  577.)  On  the  whole,  as  the  reports  now 
stand,  and  as  far  as  I can  judge  from  cases 
which  I have  seen  myself,  the  secondary 
symptoms  are  more  frequent  when  primary 
ulcers  are  promiscuously  treated  without 
mercury.  But  it  by  no  means  follows  from 
this  fact,  that  the  wray  to  have  the  smallest 
possible  number  of  cases  of  secondary  symp- 
toms, is  to  employ  mercury  in  all  instances 
of  sores  on  the  genitals.  This  both  reason 
and  experience  contradict,  inasmuch  as  mer- 
cury, given  in  cases  which  do  not  require  it 
for  the  security  of  the  constitution,  is  fre- 
quently itself  a source  of  cutaneous  diseases, 
sore  throats,  and  nodes,  which,  without  its 
baneful  influence,  would  never  have  occur- 
red. The  prudent  course  seems  here  to  be, 
to  exercise  our  judgment  and  discretion,  and 
to  be  guided  in  some  measure  by  the  ap- 
pearance and  progress  of  the  sore,  according 
to  principles  already  suggested;  for  though 
the  look  of  a sore  may  not,  in  the  present 
state  ot  our  knowledge,  always  enable  us  to 
form  a certain  inference  respecting  the  risk 
of  secondary  symptoms,  if  mercury  be  omit- 
ted, it  cannot  be  said,  that  the  danger  would 
be  positively  obviated  by  having  recourse  at 
once  to  mercury  in  every  kind  of  primary 
sore,  and  notwithstanding  every  thing  which 
has  been  lately  published,  I still  flatter  my- 
self, that  surgeons,  accustomed  to  see  much 
of  venereal  cases,  can  yet  distinguish  exco- 
riations, boils,  simple  healthy  sores,  and 


some  other  similar  ailments,  («ep  Evans  on 
Ulcerations  of  the  Genital  Organs,  8 vo.  Lond. 
1819,)  from  ulcers,  by  which  the  constitution! 
is  liable  to  be  affected.  Until  further  data 
exist,  I cannot  venture  to  lay  do  vn  other 
directions  about  (he  treatment  of  primary 
sores.  It  is  with  pleasure,  however,  that  [ 
subjoin  the  advice  of  other  gentlemen,  whose 
sentiments  and  talenf«  deserve  respect, 
though  their  opinions  may  not  exactly  agree 
with  my  own.  “ In  every  primary  ulcer, 
(says  Dr.  Hennen,)  I would  give  up  the  idea 
of  using  mercury  at  first,  treating  it  as  if  it 
were  a simple  ulceration,  by  cleanliness, 
rest,  and  abstinence,  and  applying  to  it  the 
most  simple,  and  mildest  dressings.  If  the 
sore  did  not  put  on  a healing  appearance  in 
a reasonable  time,  the  extent  of  which  must 
depend  upon  the  circumstances  of  the  pa- 
tient, I should  make  use  of  more  active 
dressings.  But  if,  beyond  all  calculation,  it 
remained  open,  1 should  certainly  not  sacri- 
fice every  consideration  to  a dislike  of  mer- 
cury, knowing  how  many  persons  have  been 
seriously  benefited  by  a judicious  and  mild 
administration  of  that  remedy.”  (On  Mili- 
tary Surgery,  Ed.  2,  p.  518.)  When  primary 
ulcers  resist  common  means  » certain  lime, 
Mr.  Barot  would  also  have  recourse  to  mer- 
cury. (On  Syphilis,  p.  69  ) Like  me,  how- 
ever, the  latter  author  does  not  approve  of 
invariably  postponing  that  remedy,  until  the 
latter  criterion,  viz.  the  backwardness  of  the 
sore  to  be  healed  by  other  methods,  is  af- 
forded. 

Whenever  the  employment  of  mercury  in 
this  work  is  recommended,  I am  very  far 
from  wishing  to  be  thought  an  advocate  for 
pushing  that  medicine,  as  the  phrase  is.  On 
the  contrary,  experience  has  fully  convinced 
me,  that  in  no  forms  of  chan'  re,  nor  in  any 
other  stages  of  the  venereal  disease,  is  it 
proper  to  exhibit  mercury  in  the  unmerciful 
quantity,  and  for  the  prodigious  length  of 
time,  which  custom,  ignorance,  and  preju- 
dice, used  t»*  sanction  in  former  days.  Vio- 
lent salivations,  at  all  events,  ought  to  be  for 
ever  exploded. 

When  I was  an  apprentice  at  St.  Bartho- 
lomew’s Hospital,  mo^t  of  the  venereal  pa- 
tients in  that  establishment  were  seen  with 
their  ulcerated  tongues  hanging  out  of  their 
mouths;  their  faces  prodigiously  swelled; 
and  their  saliva  flowing  out  in  streams.  The 
wards  were  not  sufficiently  ventilated,  and 
the  stench  was  so  great,  that  the  places  well 
deserved  the  appellation  of  foul.  Yet,  not- 
withstanding mercury  was  thus  pushed,  (as 
the  favourite  expression  was,)  it  was  then 
common  to  see  many  patients  suffer  the  most 
dreadful  of  mutilations,  in  consequence  of 
sloughing  ulcers  of  the  penis;  other  patients 
whose  noses  and  palates  were  lost  ; others 
who  were  covered  with  nodes  and  dreadful 
phagedenic  sores. 

Happily,  at  the  present  day,  this  attach- 
ment to  violent  salivations  no  longer  pre- 
vails; simple  excoriations  and  common  ul- 
cers are  more  attentively  discriminated  ; and 
even  in  what  are  reputed  to  be  true  syphili- 
tic chancres,  mercury  is  seldom  given,  except 


VENEREAL  DISEASE 


611 


m very  moderate  doses,  or  such  quantities 
as  only  gently  affect  the  gums  and  salivary 
glands.  The  surgeon,  now  no  longer  blind- 
ed with  the  conti  ual  tear  of  the  rapid  and 
furious  progress  of  syphilis  when  not  duly 
unresisted  by  mereury,  avoids  the  very  mode 
ot  practice  which  was  itself  the  cause  of  all 
the  aggravated  forms  of  the  disease.  The 
consequence  is,  that  very  bad  instances  of 
the  ravages  of  lues  vener*  a are  now  hardly 
ever  observed  in  the  above  hospital,  and  the 
few  aggravated  cases  which  are  met  w ith, 
are  geneially  in  lhat  state  previously  to  their 
admission.  Another  benefit,  also  resulting 
from  modern  investigations,  which  proves 
that  chancres,  and  all  other  varieties  ol  the 
venereal  disease,  do  not  absolutely  require 
mercury  for  their  cure,  is  the  safety  with 
which  it  is  now  knowm  thai  the  u-e  of  such 
medicine  may  be  postponed,  where  the  pa- 
tient’s present  state  of  health  would  not  well 
bear  its  exhibition.  And  ! know,  tha«  an  ig- 
norance of  this  fact  has  formerly  caused  the 
death  of  many  a poor  sutferer. 

The  greater  present  mildness  of  syphilitic 
diseases  in  England,  I ascribe  chiefly  to  the 
more  judicious  treatment  now’  adopted,  and 
not  to  any  change  or  modification  in  the  na- 
ture of  the  disorder.  There  are  others,  how- 
ever, who  mrtj  think  as  Mr.  Fergusson  does 
with  regard  to  syphilis  in  Portugal,  that  the 
disease  has  exhausted  a great  deal  of  its  vi  > 
rulence  from  long  continuance  among  us. 
But  before  we  are  altogether  justified  in 
drawing  such  a conclusion,  we  must  forget 
all  the*  bad  practice  wnich  prevailed  in  for- 
mer days,  and  hich,  in  my  opinion,  is  suffi- 
cient to  account  tor  the  more  severe  forms 
in  which  syphilis  then  presented  itself. 

According  to  Mr.  Hunter’s  ideas,  the  most 
simple  method  of  treating  a chancre  is  to 
extirpate  it  with  caustic,  or  the  knife,  where- 
by it  is  reduced  to  the  state  of  a common 
sore,  or  w’ound,  and  heal$  up  as  such.  How- 
ever, he  sanctions  this  practice  only  on  the 
first  appearance  of  the  chancre,  when  the 
surrounding  parts  are  not  yet  contaminated  ; 
for,  he  says,  it  is  absolutely  ecessary  to  re- 
move the  w’hole  of  the  diseased  part,  and  this 
object  is  exceedingly  difficult  of  accomplish- 
ment, when  the  disease  has  spread  considera- 
bly. When  the  chancre  is  situated  on  the  glans 
penis,  he  thought  touching  the  sore  with  the 
lunar  caustic  preferable  to  cuttim:  it  aw'ay, 
because  the  hemorrhage  from  the  cells  of 
the  glans  u7ould  be  considerable  after  the  use 
of  the  knife 

The  caustic  should  be  pointed  at  the  end 
like  a pencil,  in  order  that  it  may  only  touch 
9uch  parts  as  are  really  disease  ; and  its  ap- 
plication should  be  repeated  till  the  surface 
of  the  sore,  after  the  separation  of  the  last 
sloughs,  assumes  a red  ancLhealthy  appear- 
ance, wrhen  it  will  heal,  litce  any  other  sore 
made  with  caustic. 

When  tiie  sore  is  on  the  prepuce,  or  the 
common  skin  of  the  penis,  and  in  art  incipient 
state,  the  same  practice  may  be  adopted  w ith 
success  When  the  chancre  is  large,  how- 
ever, it  cannot  be  destroyed  with  the  argen- 
tum nitratura,  which  does  cot  extirpate  the 


increasing  sore  deeply  enough.  In  sucli 
cases,  Mr.  Hunter  thought  that  the  potassa 
cum  calce  might  answer  belter.  When  the 
caustic  could  not  lie  conveniently  employed, 
this  author  sometimes  recommended  the  ex- 
cision of  chancres,  a plan  which  he  had 
adopted  himself,  and  the  part  afterward 
healed  with  common  dressings.  However, 
says  he.  as  our  knowledge  of  the  extent 
of  the  disease  is  not  always  certain  ; a :d  as 
this  uncer  amty  increase;  with  the  size  of 
the  chancre,  the  cure  must  he  in  some  mea- 
sure promoted  by  proper  dressings,  and  it 
will  t»e  prudent  to  dress  the  sore  w ith  mercu- 
rial ointment.  When  a chancre  is  destroyed 
almost  immediately  on  its  first  appearance, 
Mr.  Hunter  believes  lhat  there  is  I i t tie  dan- 
ger of  the  constitution  being  infected,  as  it 
is  reasonable  to  conclude  lhat  there  has  not 
been  time  for  absorption  to  take  place. 
However,  on  account  of  the  impossibility 
of  being  certain  on  this  point,  he  recom- 
mends mercury  to  be  given  from  motives 
of  prudence,  the  quantity  of  which  medicine, 
be  says,  should  he  proportioned  to  the  dura- 
tion a, id  progress  of  the  sore.  When  the 
chancre  is  large,  Mr.  Hunter  deems  mercury 
absolutely  necessary,  and  he  conceives  that 
very  little  good  is  to  be  done  by  the  extirpa- 
tion. 

With  respect  to  dressings  for  chancres,  Mr. 
Hunter  seems  to  have  placed  a good  deal  of 
confidence  in  those  which  contain  mercury  ; 
but  I do  not  believe  that  the  same  attach- 
ment to  them  prevails  non  which  existed 
twenty  years  ago.  And  the  established  fact 
of  mercury  not  being  absolutely  necessary  i i 
any  way  for  the.  cure  of  different  venereal 
sores,  must  have  the  effect  of  removing  some 
prejudices  on  this  [mrt  of  the  subject.  As 
common  mercurial  ointment  is  always  more 
or  less  rancid,  I have  found  it  in  many  cases 
a bad  kind  of  dres  ing  ; and  now  never  ap- 
ply it  to  ulcerated  surfaces.  In  ordinary 
cases,  I believe  astringent  lotions  made  w ith 
the  sulphate  of  copper,  acetate  of  lead,  alum, 
&,c.  answer  the  best.  Some  chancres  are  in- 
dolent, and  require  stimulants,  like  the  hy- 
drargyri  nitrico  oxydurn  blended  with  oint- 
ment, the  unguentura  hydrargyri  nitrati  more 
or  less  weakened,  ora  solution  of  the  nitrate 
of  silver.  Mr.  Hunter,  always  partial,  even 
in  cases  of  indolent  chancres,  to  mercurial 
dressings  expresses  his  preference  to  a salve 
containing  calomel,  as  being  more  active 
than  common  mercurial  ointment.  In  phage- 
denic and  sloughing  chancres,  the  carrot  and 
fermenting  poultices,  solutions  of  the  extracts 
of  hemlock  and  opium ; hut  particularly 
bread  and  water  poultices  with  opium,  and 
lotions  of  the  arsemate  of  kali,  nitrous  acid, 
and  nitrate  of  sliver,  merit  tiial. 

In  general,  Mr.  Hunter  was  an  advocate 
for  changingthe  dressings  very  often,  because 
the  matter  separates  them  from  the  sore, 
so  as  to  diminish  their  effects.  He  states, 
that  changing  the  appli*  at  ions  thrice  a day, 
will  not  be  found  too  often,  particularly 
when  they  are  in  the  form  of  an  ointment. 

When  the  venereal  nature  of  a chancre  is 
removed,  the  sore  frequently  becomes  eta- 


VENEREAL  DISEASE 


612 

tionary,  in  which  case  Mr.  Hunter  observes, 
that  new  dispositions  have  been  acquired, 
and  the  quantity  of  disease  in  the  part  ha£ 
been  increased  When  chancres  are  only 
stationary,  Mr.  Hunter  says,  they  may  often 
be  cured  by  touching  them  slightly  with 
the  lunar  caustic.  In  these  cases,  no  cica 
trization  seems  possible,  till  the  contamina- 
ted surface,  or  the  new  tiesh  which  grows 
on  that  surface,  has  either  been  destroyed 
or  altered.  When  sores  are  situated  under 
the  prepuce,  where  they  are  concealed  by 
a phymosis,  some  emollient,  or  gently  as- 
tringent lotion, should  frequently  be  injected 
under  the  fore-skin,  so  as  to  wash  out  any 
matter  which  might  otherwise  lodge  there, 
and  cause  additional  irritation. 

Contrary  to  the  doctrines,  which  the  facts 
of  modern  experience  have  now  fully  esta- 
blished, Mr.  Hunter  believed,  that  mercury 
should  be  given  in  every  case  of  chancre , hovv- 
ever  slight,  and  even  when  it  has  been  de- 
stroyed by  caustic,  or  other  means,  on  its 
very  first  appearance.  The  remedy,  he  says, 
should  be  continued  for  some  time  after  the 
chancre  has  healed , in  order  to  hinder  the  ve- 
nereal disposition  from  forming.  Here  we 
find  even  Hunter  himself  falling  into  some 
inconsistencies  ; for,  in  other  parts  of  his 
work,  he  seems  to  approve  of  the  principle 
of  giving  mercury  only  when  actual  and 
visible  disease  exists,  becau-e  it  cannot  cure 
the  disposition  to  it,  even  if  it  exists.  Now, 
though  the  chancre  is  cured,  no  further  ab- 
sorption of  the  virus  from  it  is  possible,  and 
whatever  disposition  to  the  disease  can  arise 
from  absorption,  must  have  already  been 
formed,  and  therefore  cannot  be  prevented, 
and,  according  to  Mr.  Hunter’s  own  theory, 
the  virus  has  been  long  ago  expelled  from 
the  system,  together  with  some  of  the  ex- 
cretions, mercury  is  recommended  with  the 
view  of  protecting  the  constitution.  How- 
ever, if  Mr.  Hunter’s  explanations  are  not 
altogether  satisfactory  on  this  part  of  the 
subject,  I believe  the  fault  is  in  his  theory, 
because,  in  cases  where  mercury  is  deemed 
adviseable,  general  experience  appears  to 
sanction  the  practice  of  continuing  its  use 
for  some  time  after  the  chancre  is  perfectly 
healed.  Yet  many  exceptions  to  this  rule 
present  themselves ; for,  if  a chancre  is 
large,  and  very  long  in  healing,  its  syphilitic 
character  is  generally  extinct  a good  while 
before  cicatrization  is  completed,  and  per- 
severance in  mercury  under  these  circum- 
stances would  be  both  an  absurd,  and  a 
dangerous  practice. 

Hence,  in  a great  measure,  the  cause  of 
the  numerous  instances  of  the  mercurial  dis- 
ease, as  Mr.  Mathias  has  named  it,  and 
which,  in  former  days,  did  far  more  mis- 
chief than  syphilis  itself.  (See  An  Inquiry 
into  the  History  and  Nature  of  the  Disease, 
produced  in  the  Human  Constitution  by  the 
Use  of  Mercury,  3d  Ed  8 vo.  Land.  1816.) 
This  part  of  (lie  subject  is  noticed  by  Mr. 
Hunter,  who  states,  that  in  very  large  chan- 
cres, it  may  not  always  be  necessary  to 
continue  cither  the  external  or  internal  ad- 
ministration of  mercury  till  the  sore  is 


healed  ; for  the  venereal  action  is  just  as 
soon  destroyed  in  a large  chancre,  as  it  is  in 
a small  one,  since  every  part  of  the  sore  is 
equally  affected  by  the  medicine,  and,  of 
course,  cured  with  equal  expedition.  But, 
in  regard  to  cicatrization,  circumstances  are 
different,  because  a large  sore  is  longer  than 
a small  one  in  becoming  covered  with  skin. 
Hence,  according  to  Mr.  Hunter,  a large 
chancre  may  be  deprived  of  its  venereal 
action,  long  before  it  has  healed  ; while,  on 
the  other  hand,  a small  one  may  heal  before 
the  syphilitic  affection  has  been  destroyed. 
In  the  latter  case,  he  represents  it  as  most 
prudent,  both  on  account  of  the  chancre 
and  constitution,  to  continue  the  employment 
of  mercury  a little  vjhile  after  the  sore  is 
healed;  advice  which,  as  1 have  already 
stated,  is  at  variance  with  certain  parts  of 
his  own  theory,  however  well  justified  it 
may  be  by  experience. 

As  Mr.  Hunter  has  explained,  chancres 
both  in  men  and  women  often  acquire,  du- 
ring the  treatment,  new  dispositions,  w hich 
are  of  various  kinds,  some  retarding  the 
cure,  and  leaving  the  parts  in  an  indolent 
thickened  state,  after  the  cure  is  accom- 
plished. In  other  instances,  a new  disposi- 
tion arises,  which  utterly  prevents  the  parts 
from  healing,  and  often  produces  a much 
worse  disease  than  that  from- much  it  ori- 
ginated. Such  new  dispositions  may  lead 
to  the  growth  of  tumours.  They  are  more 
frequent  in. men  than  women,  and  generally 
occur  only  when  the  inllammation  has  been 
violent  from  some  peculiarity  of  the  parts, 
or  constitution.  They  have  sometimes  been 
considered  as  cancerous. 

Among  the  diseases  in  question,  Mr.  Hun- 
ter notices  those  continued,  and  often  in- 
creased inflammations,  suppurations,  and 
ulcerations,  which  become  diffused  through 
the  whole  prepuce,  and  also,  along  tile 
common  skin  of  the  penis,  which  becomes 
of  a purple  hue,  attended  with  such  a gene- 
ral thickening  of  the  cellular  membrane,  as 
makes  the  w'hole  organ  appear  considerably 
enlarged.  The  same  writer  observes,  that 
the  ulceration  on  the  inside  of  the  prepuce 
will  sometimes  increase,  and  run  between 
the  skin  and  the  body  of  the  penis,  and  eat 
holes  through  different  places,  till  the  whole 
is  reduced  to  a number  of  ragged  sores. 
The  glans  often  shares  the  same  fate,  till 
more  or  less  of  it  is  gone.  Frequently,  the 
urethra  in  this  situation  is  wholly  destroyed 
by  ulceration,  and  the  urine  is  discharged 
some  way  farther  back.  The  ulceration,  if 
unchecked,  at  length  destroys  all  the  parts. 
In  this  acute  case,  prompt  relief  is  demand- 
ed ; but  often  the  proper  mode  of  treatment 
cannot  be  at  once  determined,  owing  to  our 
ignorance  in  r^pect  to  the  exact  nature  of 
the  peculiar  cause  of  the  disease.  Mr 
Hunter  states,  that  the  decoction  of  sarsa- 
parilla is  often  of  service,  when  given  in 
large  quantities ; and  that  the  extract  of 
hemlock,  and  sea  bathing,  are  sometimes 
capable  of  effecting  a cure.  According  to 
my  own  experience,  the  omission  of  mer 
cury  is  here  the  most  essential  thing. 


VENEREAL  DISEASE 


Glo 


Sometimes  alter  a chancre  has  healed, 
the  cicatrix  breaks  out  again,  and  puts  on 
the  appearances  of  the  preceding  sore. 
Occasionally,  similar  diseases  break  out  in 
different  places  from  that  of  the  cicatrix. 
Mr.  Hunter  believes,  that  they  differ  from  a 
chancre  in  generally  not  spreading  so  fast, 
nor  so  far;  in  not  being  so  painful,  nor  so 
much  inflamed  ; in  not  having  such  hard 
bases  as  venereal  sores  have  ; and  in  not 
producing  buboes.  This  writer  is  of  opi- 
nion, that- they  are  not  venereal,  and  he 
states,  that  they'  are  very  apt  to  recur. 

Mr.  Hunter  does  not  specify  any  particular 
mode  of  cure  for  all  these  cases  ; but  he 
mentions  one  instance,  which  seemed  to  be 
cured  by  giving  forty  drops  of  the  liquor 
potassae,  every  evening  and  morning,  in  a 
basin  of, broth  ; and  he  adverts  to  another 
case,  which  was  permanently  cured  by  sea- 
bathing. 

In  some  instances,  after  a chancre  has 
healed,  the  parts,  as  Mr.  Hunter  remarks, 
do  not  ulcerate ; but  appear  to  become 
thickened  and  indurated.  Both  the  glans 
and  prepuce  seem  to  swell,  so  as  to  form  on 
the  end  of  the  penis  a tumour,  or  excres- 
cence, shaped  very  much  like  a cauliflower, 
and  when  cut  into,  showing  radii,  running 
from  its  base,  or  origin,  towards  the  exter- 
nal surface.  It  is  extremely  indolent,  and 
not  always  a consequence  of  the  venereal 
disease;  for  Mr.  Hunter  has  seen  it  arise 
spontaneously'. 

No  medicine  seems  to  be  at  all  likely  to 
cure  the  disease  ; the  only  successful  means 
is  to  amputate  a considerable  part  of  the 
penis,  and  then  to  keep  a proper  catheter 
introduced  in  the  urethra. 

Another  disposition,  induced  by  the  pre- 
vious occurrence  of  chancres,  is  that  to  ex- 
crescences, or  cutaneous  tumours,  called 
warts.  These  are  frequently  considered  not 
simply  as  a consequence  of  the  venereal 
poison,  but  as  possessed  of  its  specific  dis- 
position, and  therefore,  says  Mr.  Hunter, 
surgeons  have  recourse  to  mercury  for  the 
cure  of  them  ; and  it  is  said,  that  such  treat- 
ment often  removes  them.  This  eminent 
practitioner  never  saw  mercury  produce 
this  effect,  although  the  medicine  was  given 
in  sufficient  quantity  to  cure  recent  chan- 
cres, and  a lues  venerea,  in  the  same  person. 
(See  Wart.) 

Mr.  Hunter  takes  notice  of  sloughs,  which 
occur  in  the  tonsils,  from  the  effect  of  mer- 
cury on  the  throat,  and  are  apt  to  be  mis- 
taken for  venereal  complaints.  He  also 
mentions  that,  sometimes,  when  the  original 
chancre  has  been  doing  well,  and  been 
nearly  healed,  he  has  seen  new  sores  break 
out  on  the  prepuce,  near  the  first,  and  as- 
sume all  the  appearance  of  chancres. 

When,  in  the  treatment  of  chancres,  a 
bubo  arises,  while  the  constitution  is  under 
the  influence  of  a sufficient  quantity  of 
mercury  to  cure  such  sores,  which  medicine 
has  also  been  rubbed  into  the  lower  extre- 
mity, on  the  same  side  as  the  bubo,  Mr. 
Hunter  suspects,  that  the  swelling  in  the 
groin  is  not  venereal,  butis  produced  by'  the 


mercury.  In  these  cases,  he  always  pre- 
ferred conveying  mercury  into  the  system 
in  some  other  manner. 

With  respect  to  the  treatment  of  chancres 
in  women,  since  it  is  difficult  to  keep  dress- 
ings on  the  parts,  Mr  Hunter  advises  the 
sores  to  be  frequently  washed  with  some 
mercurial  soluti  n,  and  speaks  of  one  made 
with  oxymuriate  of  mercury,  as  perhaps 
being  the  best,  since  it  will  act  as  a specific, 
and  stimulant  also,  when  this  is  requisite. 
When  the  chancres,  however,  are  irritable, 
they  are  to  be  treated  in  the  same  manner 
as  similar  complaints  in  men.  When  the 
sores  extend  into  the  vagina,  this  passage 
must  be  kept  from  becoming  constricted,  or 
closed  by  the  introduction  of  lint. 

Sometimes,  after  a chancre  and  all  vene- 
real disease  are  cured, the  prepuce  continues 
thickened  and  elongated,  so  that  the  glans 
cannot  be  uncovered.  Perhaps,  the  case  is 
often  without  remedy.  Mr.  Hunter,  how- 
ever, very  properly  recommends  trying 
every  possible  means,  and  he  informs  us, 
that  the  steam  of  warm  water,  hemlock 
fomentations,  and  cinnabar  fumigations,  are 
frequently  of  singular  service. 

When  the  thickeniug  and  enlargement  of 
the  prepuce  cannot  be  removed  by  appli- 
cations, all  the  portion,  anterior*  to  the 
glans  penis,  may  be  cut  away.  (See  Phy- 
mosis .) 

Bubo.  The  immediate  consequence  of  a 
chancre,  which  is  called  a bubo,  and  also 
the  remote  effects,  implied  by  the  constitu- 
tional,, or  secondary  symptoms , arise  from  the 
absorption  of  recent  venereal  matter  from 
some  surface,  where  it  has  either  been  ap- 
plied or  formed. 

We  are  already  aware,  that  Mr.  Hunter 
believed  the  matter  of  gonorrhoea  to  be  ca- 
pable of  communicating  the  venereal  dis- 
ease. Hence,  he  explains  in  the  following 
terms,  the  three  ways  in  which  he  thought  a 
bubo  might  arise  in  consequence  of  absorp- 
tion. He  observes,  that  the  first  and  most 
simple  manner,  is  when  the  matter,  either 
of  a gonorrhoea,  or  chancre,  has  only  been 
applied  to  some  sound  surface,  without 
having  produced  any  local  effect  on  the 
part;  but  has  been  absorbed,  immediately 
after  its  application.  Mr.  Hunter  affirms, 
that  he  has  seen  instances  of  this  kina, 
though  he  confesses  that  they'  are  very  rare, 
and  that,  in  most  cases  apparently  of  this 
nature,  a small  chancre  may  be  found  to 
have  existed. 

The  second  mode  of  absorption,  or  that 
taking  place  in  a gonorrhoea,  Mr.  Hunter 
represents  as  more  frequent.  That  second 
ary  symptoms  do  occasionally  follow  go- 
norrhoea is  yet  commonly  admitted,  though 
whether  they  differ  essentially  from  those 
which  follow  true  chancres,  is  a point  not 
yet  completely  settled.  However,  as  far 
as  Mr  Carmichael’s  experience  goes,  there 
is  a difference,  a part  of  which  consists  in 
the  eruption  being  of  the  papular  kind,  as  it 
is  also  after  many  instances  of  simple  pri- 
mary ulcers.  (See  Obs.  on  the  Symptoms, 
be.  of  Venereal  Diseases , 8vo.  Land.  1818.' 


014 


VENEREAL  DISEASE 


The  thira  mode  is  (he  absorption  of  mat- 
ter from  an  ulcer,  which  may  either  be  a 
chancre,  or  a bubo.  This  mode  is  by  far 
the  most  common,  and  it  proves,  with  many 
other  circumstances,  that  a sore,  or  ulcer, 
Is  the  most  favourable  for  absorption.  Mr. 
Hunter  believed,  that  absorption  was  more 
apt  to  take  place  from  sores  on  the  prepuce, 
than  those  on  the  glans. 

A fourth  mode  of  absorption  from  a 
wound  is  also  an  occasional  occurrence. 

Mr.  Hunter  notices,  that  what  is  now 
commonly  understood  by  a bubo,  is  a swell- 
ing, taking  place  in  the  absorbing  system, 
especially  in  the  glands,  and  arising  from 
the  absorption  of  some  poison,  or  other 
irritating  matter.  When  such  swellings 
take  place  in  the  groin,  they  are  calle^l  bu- 
boes, whether  they  proceed  from  absorption 
or  not. 

Mr.  Hunter  regards  every  abscess  in  the 
absorbing  system  as  a bubo,  whether  in  the 
vessels,  or  the  glands,  when  it  originates 
from  the  absorption  of  venereal  matter. 

The  matter  is  taken  up  by  the  absorbent 
vessels,  and  is  conveyed  by  them  into  the 
circulation.  In  its  passage  through  these 
vessels,  it  often  affects  them  with  the  spe- 
cific inflammation.  The  consequence  is 
the  formation  of  buboes,  which  are  vene- 
real abscesses.  These  are  exactly  similar 
to  a chancre  in  their  nature  and  effects,  the 
only  difference  being  in  resard  to  size.  As 
the  lymphatic  vessels  and  glands  are  irrita- 
ted by  the  specific  matter,  before  it  has  un- 
dergone any  change  in  its  passage,  the 
Inflammation  produced,  and  the  matter  se- 
creted, partake  of  the  specific  quality. 

Inflammation  of  the  absorbent  vessels 
themselves  is  not  nearly  so  frequent,  as  that 
of  the  glands.  In  men,  such  inflammations, 
in  consequence  of  chancres  upon  the  glans, 
or  prepuce,  generally  appear  like  a cord, 
leading  along  the  back  of  the  penis  from  the 
sores.  Sometimes,  the  absorbents  inflame, 
in  consequence  of  the  thickening  and  exco- 
riation of  the  prepuce  in  gonorrhoea.  The 
indurated  lymphatics  often  terminate  insen- 
sibly near  the  root  of  the  penis,  or  near  the 
pubes;  while,  in  other  instances,  they  ex- 
tend further  to  a lymphatic  gland  in  the 
groin.  Mr.  Hunter  believed,  that  this  affec- 
tion of  the  absorbent  vessels  is  truly  venereal. 
The  formation  of  a hard  cord,  he  conceived, 
arose  from  a thickening  of  the  coats  of  the 
absorbents,  and  from  an  extravasation  of  coa- 
gulable  lymph  on  their  inner  surface. 

A cord,  of  the  above  kind,  often  suppu- 
rates, sometimes  in  more  places  than  one, 
so  as  to  form  one,  two,  or  three  buboes,  or 
small  abscesses  in  the  body  of  the  penis. 

Inflammation  much  more  frequently  aftects 
the  absorbent  glands,  than  the  vessels.  The 
structure  of  the  former  parts  appear  to  con- 
sist of  the  ramifications  and  reunion  of  the 
absorbent  vessels.  From  this  structure,  ob- 
serves Mr.  Hunter,  we  may  reasonably  sup- 
pose, that  the  fluid  absorbed  is  in  some  mea- 
sure detained  in  the  glands,  and  thus  has  a 
greater  opportunity  of  communicating  the 
/ disease  to  them-  than  to  the  distinct  vessel?. 


* Swellings  of  the  absorbent  glands  may 
originate  from  other  diseases,  and  should  be 
carefully  discriminated  from  those  which 
arise  from  the  venereal  poison.  With  this 
view,  Mr.  Hunter  advises  us  first  to  inquire 
into  the  cause,  in  order  to  ascertain  whether 
there  is  any  venereal  complaint  at  some 
greater  distance  from  the  heart,  such  as 
chancres  on  the  penis,  or  any  preceding^dis- 
ease  in  this  situation.  He  recommends  us  to 
inquire,  whether  any  mercurial  ointment 
has  been  at  all  applied  10  the  leg  and  tnigh 
on  the  diseased  side ; for  mercury  applied  to 
those  parts  for  the  cure  of  a chancre,  will 
sometimes  cause  glandular  enlargements, 
which  are  occasionally  mistaken  for  vene- 
real buboes.  This  irritation  of  the  inguinal 
glands  by  the  mechanical  action  of  mer- 
curial ointment,  has  also  been  particularly 
noticed  by  Professor  Assalini,  who  states, 
that  he  has  had  frequent  opportunities 
of  convincing  himself  of  the  fact.  (See 
Manuale  di  Chirurgia,  p.  67.)  Mr.  Hunter 
reminds  us  to  observe,  whether  there  has 
been  any  preceding  disease  in  the  constitu- 
tion, such  as  a cold,  fever,  &ic.  The  quick 
or  slow  progress  of  the  swelling  is  likewise  to 
be  marked,  and  the  tumour  must  be  distin- 
guished from  femoral  hernia,  lumbar  ab- 
scesses, and  aneurisms  of  the  crural  artery. 
In  particular  cases,  it  would  appear,  that 
some  time  elapses  ; before  (he  venereal  mat- 
ter produces  its  effec  ts  on  the  absorbent 
glands  after  its  absorption.  Mr.  Hunter  no- 
tices, that,  sometimes,  at  least,  six  days 
transpire  first ; a circumstance,  which  can 
only  be  known  by  the  chancres  having 
healed  six  days  before  the  bubo  began  to 
appear.  However,  as  the  last  matter  of  a 
chancre  is  probably  not  venereal,  he  infers, 
that  in  cases  of  this  kind,  absorption  must 
have  taken  place  earl  ier  than  other  considera- 
tions would  lead  one  to  suppose.  Accord- 
ing to  Mr.  Hunter,  in  general,  only  the 
glands  nearest  to  the  seat  of  absorption  are 
attacked.  Thus,  when  the  matter  is  taken 
up  from  the  penis  in  men,  the  inguinal 
glands  are  affected  ; and  when  from  the 
vulva  in  women,  those  glands  swell  which 
are  situated  between  the  labium  and  thigh, 
and  the  round  ligaments. 

It  was  one  of  Mr.  Hunter’s  opinions,  that 
only  one  gland  at  a time  is  commonly  affect- 
ed by  the  absorption  of  venereal  matter.  If 
this  sentiment  be  correct,  the  circumstance 
may  be  considered  as  a kind  of  criterion  be- 
tween venereal  and  other  buboes.  The 
second  order  of  lymphatic  vessels  and  glands 
are  never  affected ; as,  for  instance,  those 
along  the  iliac  vessels,  or  back.  Mr.  Hunter 
informs  us,  that  he  also  observed,  that 
when  the  disease  was  contracted  by  a sore, 
or  cut  upon  the  finger,  the  bubo  occurred  a 
little  above  the  bend  of  the  arm,  by  the 
side  of  the  biceps  muscle,  and  no  swelling 
of  this  sort  formed  in  the  arm-pit.  How- 
ever, he  had  heard  of  a fevv  rare  cases, 
in  which  a swelling  in  the  axilla  was  also 
produced. 

When  buboes  arise  from  a venereal  dis- 
ease on  the  penis?  they  are  situated  in  the 


VENEREAL  DISEASE 


GIG 


glands  of  the  groin.  When  a bubo  arises 
from  a gonorrhoea,  either  groin  may  be 
attacked.  But  when  the  disease  originates 
from  a chancre,  the  bubo  most  frequently 
takes  place  in  the  nearest  groin. 

The  situation  of  the  absorbent  glands,  how- 
ever, is  not  always  exactly  the  same,  and 
the  course  of  the  lymphatics  therefore  is  sub- 
ject to  some  variety.  Hence,  Mr.  Hunter 
has  seen  a venereal  bubo,  produced  by  a 
chancre  on  the  penis,  situated  a considerable 
way  down  the  thigh  ; he  has  also  often  seen 
buboes  as  high  as  the  lower  part  of  the  belly, 
before  Poupart’s  ligament . and  sometimes 
near  the  pubes.  At  the  present  day,  swell- 
ings of  the  femoral  glands  are  never  consi- 
dered venereal. 

The  seat  of  absorption  is  more  extensive 
in  the  female  sex,  and  the  course  of  some 
of  the  absorbents  is  also  different.  Hence, 
buboes  in  women  may  occur  in  three  situa- 
tions, two  of  which  are  totally  different  from 
those  in  men 

When  chancres  are  situated  forwards, 
near  the  meatus  urinarius,  nympha?,  clitoris, 
labia,  or  mons  veneris,  the  absorbed  matter 
is  generally  conveyed  along  one,  or  both  of 
the  round  ligaments,  and  the  buboes  are 
formed  in  those  ligaments,  just  before  they 
enter  the  abdomen.  Mr.  Hunter  suspected 
such  buboes  not  to  be  glandular  ones,  but 
only  inflamed  absorbents. 

When  chancres  are  situated  far  back,  near 
or  on  the  perinaeum,  the  absorbed  matter  is 
carried  forward  along  the  angle,  between  the 
labium  and  the  thigh,  to  the  glands  in  the 
groin,  and  often,  in  this  course,  small  buboes 
are  formed  in  the  absorbents  similar  to  those 
abscesses  which  occur  on  the  penis  in  men. 

When  the  effects  of  the  poison  do  not  rest 
iiere,  a bubo  in  the  groin  may  be  occasioned 
in  the  same  manner  as  in  men 
( Owing  to  the  difficulty  of  being  sure,  that 
women  are  quite  free  from  infection,  it  is 
often  more  difficult  to  decide  in  them,  than 
in  men,  whether  a bubo  is  venereal,  or  not. 
In  men,  who  have  had  no  local  complaint, 
the  bubo  can  only  be  venereal,  when  direct 
absorption  from  the  surface  of  the  skin  has 
taken  place. 

A bubo,  says  Mr.  Hunter,  commonly  be- 
gins with  a sense  of  pain,  which  leads  the 
patient  to  examine  the  part,  where  a small 
hard  tumour  is  to  be  felt.  This  increases, 
like  every  other  inflammation,  that  has  a 
tendency  to  suppuration,  and  unless  check- 
ed, pus  forms,  and  ulceration  follows,  the 
matter  making  its  way  to  the  skin  very  fast. 

The  above  celebrated  writer  remarks, 
however,  that  there  are  some  cases,  which 
are  slow  in  their  progress.  This  circum- 
stance he  imputes  either  to  the  inflammatory 
process  being  kept  back  by  mercury,  or 
other  means,  or  to  its  being  retarded  by  a 
scrofulous  tendency. 

The  inflammation,  he  says,  is  at  first  con- 
fined to  the  gland,  which  may  be  moved 
about  in  the  cellular  membrane  ; but  when 
the  part  has  become  enlarged,  or  when  the 
inflammation,  and  suppuration,  are  more 
advanced,  the  surrounding  parts  become 


more  inflamed,  and  the  tumour  is  more  dif- 
fused. Some  buboes  become  complicated 
with  an  erysipelatous  and  cedematous  affec- 
tion, by  which  they  are  rendered  more  dif- 
fused, and  less  disposed  to  suppurate. 

Mr.  Hunter  allows,  that  to  distinguish, 
with  certainty,  the  true  venereal  bubo  from 
other  swellings  of  the  glands  in  the  groin, 
may  be  very  difficult.  He  represents  the 
true  venereal  bubo,  in  consequence  of  a 
chancre,  as  being  most  commonly  confined 
to  one  gland.  It  preserves  Us  specific  dis- 
tance till  suppuration  has  taken  place,  and 
then  becomes  mure  diffused.  It  is  rapid  in 
its  progress  from  inflammation  to  suppura- 
tion and  ulceration.  The  suppuration  is 
commonly  large,  considering  the  size  of  the 
gland,  and  there  is  <»nly  one  abscess.  The 
pain  is  very  acute,  and  the  inflamed  part  of 
the  skin  is  of  a florid  red  colour. 

Mr.  Hunter  describes  such  buboes  as 
arise  without  any  visible  cause,  as  being 
of  two  kinds.  One  sort  inflame  and  suppu- 
rate briskly.  These  he  always  suspected 
to  be  venereal,  although  he  allows  there 
was  no  proof  of  it,  and  only  a presump- 
tion deduced  from  the  quick  progress  of  the 
disease. 

The  second  kind  are  generally  preceded, 
and  attended  with  slight  fever,  or  the  com- 
mon symptoms  of  a cold,  and  they  are 
generally  indolent  and  slow  in  their  progress. 
If  they  are  quicker  than  ordinary,  they 
become  more  diffused  than  venereal  buboes, 
and  they  are  often  not  confined  to  one 
gland.  When  very  slow,  they  give  but 
little  sensation  ; but,  when  quicker,  the  sen- 
sation is  more,  acute,  though  not  so  much  so 
as  in  venereal  cases.  They  usually  do  not  sup- 
purate. and  often  become  stationary.  When 
they  do  suppurate,  it  is  in  a slow  manner,  and 
frequently  in  more  glands  than  one,  while 
the  inflammation  is  more  diffused,  and  not 
considerable,  in  relation  to  the  swelling. 
The  matter  makes  its  way  to  the  skin  slowly, 
and  the  part  affected  is  of  a more  purple 
colour.  Sometimes,  the  abscesses  are  very 
large,  yet  not  painful. 

In  considering  whether  the  swellings  of 
the  inguinal  elands  are,  or  are  not  venereal, 
the  first  thing  to  be  attended  to  is,  whether, 
or  not,  there  are  any  venereal  complaints. 
If  there  are  none,  Mr.  Hunter  observes,  that 
there  is  a strong  presumptive  proof,  that  the 
swellings  are  not  venereal.  When  the 
swelling  is  only  in  one  gland,  very  slow  in 
its  progress,  and  gives  but  little,  or  no  pain, 
it  is  probably  merely  scrofulous.  However, 
when  the  swelling  is  considerable,  diffused, 
and  attended  with  some  inflammation  and 
pain,  the  constitution  is  most  probably  af- 
fected with  slight  fever,  the  symptoms  of 
which  are  lassitude,  loss  of  appetite,  want  of 
sleep,  small  quick  pulse,  and  an  appearance 
of  approaching  hectic.  Such  swellings  are 
long  in  getting  well,  and  do  not  seem  to  be 
affected  by  mercury,  even  when  very  early 
applied. 

Mr.  Hunter  mentions  his  having  seen  the 
above  affection  of  the  groin,  together  with 
the  constitutional  indisposition,  take  place 


VENEREAL  DISEASE. 


*ilO 


where  there  were  chancres ; and  he  was 
puzzled  to  determine,  whether  the  disease 
in  the  groin  was  sympathetic,  from  derange- 
ment of  the  constitution,  or  whether  it  arose 
from  the  absorption  of  matter.  He  had 
long  suspected,  that  there  was  a mixed 
case,  and  was  at  last  certain,  that  such  a 
case  might  prevail.  He  had  seen  instances, 
in  which  the  venereal  matter,  like  a cold,  or 
fever,  only  irritated  the  glands  to  disease, 
producing  in  them  scrofula,  to  which  they 
were  disposed. 

In  such  cases,  says  Mr.  Hunter,  the  swell- 
ings commonly  arise  slowly,  give  but  little 
pain,  and  if  mercury  be  given  to  destroy  the 
venereal  disposition,  their  progress  is  acce- 
lerated. Some  suppurate  while  under  this 
resolving  course  ; and  others,  which  proba- 
bly had  a venereal  taint  at  first,  become  so 
indolent,  that  mercury  has  no  effect  upon 
them,  and  in  the  end,  they  either  get  well 
of  themselves,  or  by  other  means. 

According  to  Mr.  Hunter,  buboes  are 
local  complaints. 

TREATMENT  OF  BUBOES. 

When  a bubo  is  judged  to  be  venereal, 
and  only  in  an  inflamed  state,  an  attempt  is 
to  be  made  to  resolve  the  swelling.  The 
propriety  of  the  attempt,  however,  depends 
on  the  progress  which  the  disease  has  made. 
If  the  bubo  be  very  large,  and  suppuration 
appears  to  be  near  at  hand,  resolution  is  not 
likely  to  be  effected.  When  suppuration 
has  already  taken  place,  Mr.  Hunter  much 
doubted  the  probability  of  any  success  at- 
tendingthe  endeavour,  which  now  may  only 
retard  the  suppuration,  and  protract  the 
cure. 

The  resolution  of  these  inflammations, says 
Blr.  Hunter,  depends  principally  on  mercury , 
and  almost  absolutely  on  the  quantity , which 
can  be  made  to  pass  through  them.  When 
suppuration  has  taken  place , the  cure  also  de- 
pends on  the  same  circumstances.  Hence,  he 
recommended  the  mercury  to  be  applied  to 
such  surfaces  as  allow  the  remedy,  when 
absorbed,  to  pass  through  the  diseased  gland. 
In  this  manner,  he  conceived,  that  the  dis- 
ease in  the  groin  might  be  subdued,  and  that 
the  constitution  would  be  less  likely  to  be 
contaminated.  At  the  same  time,  he  admit- 
ted, that  the  situation  of  many  buboes  is 
such,  as  not  to  have  much  surface  for  ab- 
sorption beyond  them  ; for  instance,  the  bu- 
boes on  the  body  of  the  penis,  arising  from 
chancres  on  the  glans,  or  prepuce. 

As  venereal  buboes  are  an  effect,  or  conse- 
quence of  chancres,  or  venereal  sores,  and 
glandular  swellings  in  the  groin  may  take 
place  from  other  kinds  of  sores,  or  local  ir- 
ritations, and  even  from  various  constitution- 
al causes,  while  modern  surgeons  profess 
their  incapacity  always  to  pronounce  the 
character  either  of  a primary  sore,  or  a 
bubo,  by  its  first  appearance,  and  progress, 
it  is  evident,  that  the  same  difficulties  pre- 
sent themselves  here,  as  in  cases  of  primary 
sores,  respecting  the  principles,  by  which 
rhe  treatment  should  be  guided.  It  is  like- 


wise to  be  remembered,  that  buboes,  when 
supposed  to  be  decidedly  syphilitic,  are  not , 
as  Mr.  Hunter  imagined,  absolutely  incurable 
without  mercury.  The  firm  confidence  also, 
which  Mr.  Hunter  had  in  the  doctrine  of  the 
benefit  derived  from  the  practice  of  rubbing 
mercury  into  surfaces,  from  which  it  would 
be  conveyed  directly  to  the  diseased  glands, 
so  as  both  to  resolve  the  swelling  and  pre- 
serve the  constitution,  is  not  now  regarded 
as  an  unquestionable  subject.  As  Mr.  Bacot 
has  judiciously  remarked,  there  is  some  in- 
consistence in  Mr.  Hunter’s  own  statements 
upon  this  point  •,  for,  in  one  place  he  affirms, 
that  mercury,  applied  to  the  legs  and  thighs 
for  the  cure  of  a chancre,  will  sometimes 
cause,  instead  of  disperse,  a bubo.  (P.404.) 
And  Mr.  Bacot  believes  himself,  that  mer- 
cury as  frequently  promotes  the  suppuration 
of  buboes,  as  their  dispersion.  (On  Syphilis , 
p 74.)  And,  respecting  the  practice  of  try- 
ing to  make  the  mercury  pass  through  the 
diseased  glands,  Mr.  Hunter  rather  contra- 
dicts himself  in  another  page,  where  he  con- 
fesses his  own  doubts  of  its  utility  in  suppu» 
rated  buboes.  However,  Mr.  Hunter  ad- 
mits, that  mercury  alone  is  not  always  capa- 
ble of  effecting  the  cure  of  such  buboes  as 
are  deemed  venereal ; and  when  the  inflam- 
mation rises  very  high,  he  approves  of  bleed- 
ing, purging,  and  fomentations.  When  the 
inflammation  is  erysipelatous,  he  has  a high 
opinion  of  bark;  and,  when  it  is  scrofulous, 
he  praises  hemlock,  and  poultices  made  with 
sea-water.  He  was  also  aware  of  the  fact 
of  emetics  sometimes  occasioning  the  ab- 
sorption of  the  matter  of  buboes,  after  it  is 
distinctly  formed. 

If  there  is  generally  great  difficulty  in 
pronouncing  at  first  the  nature  of  a primary 
sore,  as  to  the  question  of  its  being  syphilitic 
or  not,  the  same  difficulty  must  occur  with 
respect  to  judging  of  the  glandularswellings, 
excited  by  it.  And,  on  this  account,  and 
from  the  encouraging  circumstances,  that 
all  buboes  may  be  cured  without  mercury, 
and  that  the  course  of  the  venereal  disease, 
unresisted  by  that  mineral,  is  not  so  terrible 
and  incurable,  as  used  to  be  supposed,  some 
surgeons,  instead  of  having  immediate  re- 
course to  mercury,  prefer  a little  delay,  in 
order  to  see,  whether  the  swelling  will  sub- 
side, or  not,  under  the  use  of  common  an- 
tiphlogistic means.  Thus,  Dr.  Hennen  dis- 
approves of  using  mercury  immediately  a 
bubo  presents  itself ; and  he  states,  that  the 
same  principles,  which  guide  him  in  the  pri- 
mary ulcers,  would  have  the  same,  if  not 
greater  force,  in  the  case  of  buboes.  “ In 
their  irritable  state  (says  he)  I consider  mer- 
cury altogether  inadmissible.”  (On  Military 
Surgery,  Ed.  2 ,p.  518.) 

Although  the  correctness  of  some  of  the 
principles,  by  which  Mr.  Hunter  regulated 
his  practice  in  buboes,  must  now  be  ques- 
tionable, inasmuch  as  he  calculates  too  much 
on  the  absolute  necessity  for  mercury,  and 
on  the  usefulness  of  making  it  pass  through 
the  diseased  glands,  I conceive,  that  some 
of  his  directions  are  yet  too  important  to 
excluded  from  this  work.  He  sayr  : 


VENEREAL  DISEASE. 


017 


'quantity  of  mercury,  necessary  for  the  reso- 
lution of  a bubo,  must  be  proportioned  to 
the  obstinacy  of  the  complaint ; but  that  care 
must  be  taken  not  to  extend  the  employment  of 
the  medicine  so  far  as  to  produce  certain  effects 
on  the  constitution.  When  the  bubo  is  in  a 
situation,  which  admits  of  a large  quantity 
of  mercury  being  rubbed  in,  so  as  to  pass 
through  the  swelling,  and  when  the  com- 
plaint readily  yields  to  the  use  of  half  a 
drachm  of  mercurial  ointment,  every  night, 
the  mouth  not  becoming  sore,  or  at  most, 
only  tender,  Mr.  Hunter  thinks  it  sufficient 
to  pursue  this  course,  till  the  gland  is  redu- 
ced to  its  natural  size.  In  this  manner,  the 
constitution  will  probably  be  safe,  provided 
thfe  chancre,  which  may  have  caused  the 
bubo,  heals  at  the  same  time.  When  . the 
mouth  is  not  affected  in  six,  or  eight  days, 
and  the  gland  does  not  readily  resolve,  then 
two  scruples,  or  a drachm,  may  be  applied 
every  night ; and,  continues  Mr.  Hunter,  if 
there  should  still  be  no  amendment,  even 
more  must  be  rubbed  in.  In  short  (says  he) 
if  the  reduction  is  obstinate,  the  mercury 
must  be  pushed  as  far  as  can  be  done  with- 
out a salivation. 

When  there  is  a bubo  on  ea^li  side,  so 
much  mercury  cannot  be  made  to  pass  through 
each,  as  the  constitution  in  general  will  not 
bear  this  method.  However,  Mr.  Hunter 
sanctions  the  plan  of  minding  the  soreness 
of  the  mouth  less  in  this  kind  of  case ; 
though,  he  adds,  that  it  is  belter  to  let  the  bu- 
boes proceed  to  suppuration , than  to  load  the 
system  with  too  much  merewry. 

When  the  situation  of  buboes  will  not  al- 
low an  adequate  quantity  of  absorbed  mer- 
cury to  pass  through  them,  the  frictions 
must  be  continued  in  order  to  affect  the  con- 
stitution ; but,  according  to  Mr  Hunter  in 
this  case,  more  mercury  will  be  requisite, 
than  when  the  remedy  can  be  made  to  pass 
directly  through  the  diseased  gland  ; an  as- 
sertion, which  may  now  be  doubted. 

Many  buboes  remain,  without  either  co- 
ming to  resolution,  or  suppuration  ; and, 
notwithstanding  every  attempt  to  promote 
these  changes,  the  glands  become  hard  and 
scirrhous.  Mr.  Hunter  conceived,  that  these 
cases  are  either  scrofulous  at  first,  or  be- 
come so  as  soon  as  the  venereal  disposition 
is  removed.  He  advises  the  use  of  hemlock, 
sea-water,  poultices,  and  sea-bathing. 

According  to  a modern  surgeon,  of  judg- 
ment and  considerable  experience,  when 
buboes  are  in  a chronic  stationary  state,  the 
application  of  blisters  to  the  swelling  is  at- 
tended with  the  most  beneficial  effects.  And, 
lie  rightly  observes,  that  when  such  tumours 
are  extremely  hard  and  indolent,  it  is  more 
advantageous  to  let  the  patient  have  the  be- 
nefit of  the  open  air,  exercise,  and  his  ac- 
customed mode  of  living,  than  to  confine 
him  in  an  hospital.  ( Jlssalini , in  Manuals  di 
Chirurgia , p.  64  ; Milano,  1812.)  Stimula- 
ting the  skin  with  the  antimonial  ointment, 
is  also  sometimes  a good  practice. 

The  suppuration  of  buboes  frequently  can- 
not be  prevented  by  any  known  means. 
They  are  then  to  be  treated,  in  some  re- 
Vot,  II  ' 7* 


spects, like  any  other  abscess.  Before  open- 
ing buboes,  Mr.  Hunter  conceived  it  advan- 
tageous to  let  the  skin  become  as  thin  as 
possible,  because  a large  opening  would 
then  be  unnecessary,  and  no  measures  re- 
quisite for  keeping  the  skin  from  closing, 
before  the  bottom  of  the  sore  had  healed. 

Mr.  Hunter  was  doubtful , whether  the  ap- 
plication of  mercury  should  be  continued 
through  the  whole  suppuration.  He  was  in- 
clined to  continue  it ; but,  in  a smaller  quan- 
tity. 

There  has  been  much  dispute,  whether  a 
bubo  should  be  opened,  or  allowed  to  burst 
of  itself,  and  whether  the  opening  should  be 
made  with  a cutting  instrument,  or  caustic. 
On  this  subject,  Mr.  Hunter  remarks,  that 
there  is  no  peculiarity  in  a venereal  abscess 
to  make  one  practice  more  eligible  than 
another.  The  surgeon,  he  says,  should  be 
guided  in  some  degree,  by  the  patient.  Some 
patients  are  afraid  of  caustics  ; others,  of 
cutting  instruments.  But,  when  the  surgeon 
has  the  choice,  Mr.  Hunter  expresses  a pre- 
ference to  opening  the  bubo  with  a lancet, 
in  which  method,  no  skin  is  lost.  But  he 
observes,  that  wrhen  a bubo  is  very  large, 
and  there  will  be  a great  deal  of  loose  skin, 
after  the  discharge  of  the  matter,  he  thinks, 
that  caustic  may,'  perhaps,  be  better,  as  it 
will  destroy  some  of  the  redundant  skin,  and 
occasion  less  inflammation,  than  what  is 
caused  by  an  incision.  The  potassa  cum 
calce  is  the  caustic  commonly  employed. 

After  the  bubo  has  been  opened,  surgeons 
usually  poultice  it,  as  long  as  the  discharge 
and  inflammation  are  considerable,  and  then 
they  employ  dressings,  which  must  be  of  a 
quality,  adapted  to  circumstances.  In  the 
mean  while,  mercury  is  continued,  both  to 
make  the  bubo  heal,  and  prevent  the  bad 
effects,  which  might  otherwise  arise  from 
the  matter  being  continually  absorbed. 

The  mercurial  course  is  to  be  pursued,  till 
the  sore  is  no  longer  venereal.  But,  in  ge- 
neral, since  this  point  is  difficult  to  ascer- 
tain, Mr.  Hunter  advises  the  continuance  of 
mercury  till  the  part  has  healed,  and  even 
somewhat  longer,  if  the  bubo  has  healed 
very  quickly  ; for,  the  constitution  is  apt  to 
become  contaminated.  However,  he  did 
not  approve  of  this  long  use  of  mercury  in 
all  cases;  because  buboes  often  assume,  be- 
sides the  venereal,  other  dispositions,  which 
mercury  cannot  cure,  and  will  even  exas- 
perate. 

Sometimes  thesores,  whentheyarelosing, 
or  entirely  deprived  of  the  venereal  disposi- 
tion, become  changed  into  ulcers  of  another 
kind,  and,  most  probably  of  various  kinds. 
How  far  it  is  a disease  arising  from  a vene- 
real taint,  and  the  effects  of  a mercurial 
course  jointly,  says  Mr.  Hunter,  is  not  cer- 
tain. He  suspected,  however,  that  the  na- 
ture of  the  part,  or  constitution,  had  a prin- 
cipal share  in  the  case,  and,  I believe,  few 
surgeons  of  the  present  time  entertain  any 
doubt  of  the  abuse  of  mercury  being  a very 
frequent  cause,  independently  of  any  other 
circumstance.  (See  Mathias  on  the  Mercuri- 
al Disease.  Ed.  3.) 


VENEREAL  DISEASE. 


CIS 

Mi'.v  Hunter  observes,  Ilia!  sue])  diseases 
make  the  cure  of  the  venereal  affection  much 
more  uncertain,  because,  when  the  sore  be- 
comes stationary,  or  the  mercury  begins  to 
disagree,  we  are  ready  to  suspect  that  the 
virus  is  gone  ; but,  this  (he  supposes)  is  not 
always  the  case.  He  had  seen  some  buboes 
exceedingly  painful  and  tender  to  almost 
every  thing  that  touched  them,  and  the 
more  mild  the  dressings  were,  the  more  pain- 
ful the  parts  became. 

In  some  instances,  the  skin  alone  becomes 
diseased.  The  ulceration  spreads  to  the 
surrounding  integuments,  while  a new  skin 
forms  in  the  centre,  and  keeps  pace  with 
the  ulceration,  so  that  an  irregular  sore, 
which  Mr.  Hunter  compares  with  a worm- 
eaten  groove,  is  formed  all  round.  It  ap- 
pears only  to  have  the  powerof  contamina- 
ting the  parts,  which  have  not  yet  been  af- 
fected ; and  those  which  have,  readily  heal. 
According  to  the  same  author,  when  buboes 
become  stationary,  and  are  little  inclined  to 
spread,  attended  with  a sinus,  or  two,  hem- 
lock, joined  with  bark,  is  the  medicine  most 
frequently  serviceable.  It  is  to  be  used  both 
externally  and  internally.  Mr.  Hunter  also 
speaks  favourably  of  sarsaparilla,  sea-bath- 
ing, and  sea-water  poultices.  He  states, 
that  at  the  Lock  Hospital,  gold  refiners’  wa- 
ter has  been  found  an  useful  application  ; 
and  that  in  some  cases,  benefit  has  arisen 
from  drinking  large  quantities  of  orange- 
juice,  and  from  the  use  of  mezereon. 

Lues  venerea.  Surgeons  imply,  that  a 
lues  venerea  has  taken  place,  when  the  vene- 
rea! virus  has  been  absorbed  into  the  circu- 
lation. Mr.  Hunter  does  not  think  the  epi- 
thet constitutional  strictly  proper  in  its  ap- 
plication to  this  form  of  the  venereal  disease. 
By  constitutional  disease,  he  observes,  he 
should  understand  that,  in  which  every  part 
of  the  body  is  acting  in  one  way,  as  in  fevers 
of  all  kinds  ; but,  the  venereal  poison  seems 
to  be  only  diffused  through  the  circulating 
fluids,  and,  as  it  were,  to  force  certain  parts 
of  the  body  to  assume  the  venereal  action, 
which  action  is  perfectly  local.  To  use  Mr. 
Hunter’s  phrase,  it  takes  place  in  different 
parts  in  a regular  succession  of  susceptibili- 
ties. Only  a few  parts  are  acting  at  the 
same  time  ; and  a person  may  be  constitu- 
tionally affected  in  this  way,  and  yet  almost 
every  function  may  be  perfect. 

The  venereal  poison  is  generally  conveyed 
into  the  system  from  a chancre.  It  may, 
also,  according  to  Mr.  Hunter’s  doctrine,  be 
absorbed  from  a gonorrhoea.  There  is  like- 
wise a possibility  of  its  getting  into  the  cir- 
culation from  the  surface  of  the  body,  with- 
out any  previous  ulceration.  According  to 
his  doctrine,  it  may  bo  absorbed  from  com- 
mon ulcers,  without  necessarily  rendering 
them  venereal ; and  it  may  be  taken  up  from 
wounds,  in  which  cases,  it  generally  first 
causes  ulceration. 

Venereal  ulcers.  In  consequence  of  the 
blood  being  contaminated  with  real  venereal 
pus,  it  might  be  expected  that  the  local 
effects  thi  s produced,  would  be  similar  in 
their  nature  to  those  producing  them.  Mr. 


Hunter  believed,  that  this  is  not  the  case, 
lie  notices,  that  the  local  effects  from  a 
constitutional  contamination,  are  all  of  one 
kind,  viz.  ulcers,  let  the  effects  make  their 
appearance  on  any  surface  whatever,  either 
the  throat  or  common  skin.  But  Mr.  Hun- 
ter conceived,  that  if  the  matter,  when  in 
the  constitution,  were  to  act  upon  the  same 
specific  principles,  as  that  which  is  exter- 
nally applied,  a gonorrhoea  would  arise, 
when  it  affected  a canal,  and  only  sores,  or 
chancres,  when  it  attacked  other  surfaces. 

Mr.  Hunter  found,  that  even  the  sores 
which  are  caused  in  the  throat  are  very  dif- 
ferent from  chancres.  He  says,  lhat  the 
true  chancre  produces  considerable  inflam- 
mation, often  attended  with  a great  deal  of 
pain,  and  quickly  followed  by  suppuration. 
But  the  local  effects,  arising  from  the  virus 
in  the  constitution,  are  slow  in  their  pro- 
gress, attended  with  little  inflammation, 
and  are  seldom  or  never  painful,  except  in 
particular  parts.  However,  Mr.  Hunter 
allows  that  this  sluggishness  in  the  effects  of 
the  poison  depends  on  the  nature  of  the 
parts  diseased  ; and  he  owns  that,  when 
the  tonsils,  uvula,  or  nose,  are  affected,  the 
progress  of  the  morbid  mischief  is  rapid,  and 
bears  a greater  resemblance  to  a chancre 
than  when  it  occurs  on  the  skin.  Even  in 
those  parts  Mr.  Hunter  thought  that  the 
ulcers  were  attended  with  less  inflamma- 
tion than  chancres  which  were  spreading 
with  equal  celerity. 

Before  the  time  of  Mr.  Hunter,  the  matter, 
secreted  by  sores  which  arise  from  a consti- 
tutional infection,  was  always  considered 
to  be  of  a poisonous  quality,  like  the  matter 
of  a chancre.  At  first,  one  would  expect 
that  this  must  actually  be  the  case,  because 
venereal  matter  is  the  cause,  and  mercury 
cures  chancres,  and  also  ulcers  proceeding 
from  a lues  venerea.  Mr.  Hunter  remarks, 
however,  that  the  latter  circumstance  is  not 
a decisive  proof,  since  mercury  is  capable  of 
curing  many  diseases , besides  the  venereal. 
He  also  takes  notice,  that  when  pus  is  ab- 
sorbed from  a chancre,  if  generally  produ- 
ces a bubo  ; but  that  a bubo  is  never  occa- 
sioned by  the  absorption  of  matter  from  a 
venereal  sore,  arising  from  the  virus  diffu- 
sed in  the  circulation.  For  instance,  when 
there  is  a venereal  ulcer  in  the  throat,  no 
buboes  occur  in  the  glands  of  the  neck ; 
when  there  are  syphilitic  sores  on  the  arms, 
or  even  suppurating  nodes  on  the  ulna,  no 
swellings  form  in  the  glands  of  the  armpit, 
although  these  complainis  occur  when  fresh 
venereal  matter  is  applied  to  a common 
sore  on  the  arm,  hand,  or  fingers.  No  swell- 
ing is  produced  in  1 lie  groin  in  consequence 
of  nodes,  or  blotches  on  the  legs  and 
thighs. 

Some  very  important  experiments  arc 
related  in  Mr.  Hunter’s  Treatise  on  the  Ve- 
nereal Disease,  in  order  to  prove  that  the 
matter  from  a gonorrhoea,  or  clmncrc,  is 
capable  of  affecting  a man  locally,  who  is 
already  labouring  under  a lues  venerea,  and 
that  the  matter  from  secondary  syphilitic 
sores  has  not  the  same  power.  The  parti- 


’ VENEREAL  DISEASE 


610 


culars,  however,  are  too  long  to  be  inserted 
in  this  book. 

Parts  most  susceptible  of  the  Lues  Venerea, 
fyc.  Some  parts  of  the  body  seem  to  be 
much  less  susceptible  of  the  lues  venerea 
than  others  ; indeed,  Mr.  Hunter  observes, 
that,  as  far  as  our  knowledge  extends,  cer- 
tain parts  cannot  be  affected  at  all.  The 
brain,  heart,  stomach,  liver,  kidneys,  and 
several  other  viscera,  have  never  been 
known  to  be  attacked  by  syphilis. 

The  first  order  of  parts,  or  those  which 
become  affected  in  the  early  stage  of  the 
lues  venerea,  are  the  skin,  tonsils,  nose, 
throat,  inside  of  the  mouth,  and  sometimes 
the  tongue. 

The  second  order  of  parts,  or  those  which 
are  affected  at  a later  period,  arc  the  peri- 
osteum, fasciae,  and  bones. 

Mr.  Hunter  conceived,  that  one  great  rea- 
son of  the  superficial  parts  of  the  body  suf- 
fering the  effects  of  the  lues  venerea  sooner 
than  the  deep-seated  ones,  depends  on  the 
former  being  more  exposed  to  external  cold. 
He  remarked,  that  even  the  second  order 
of  parts  do  not  all  become  diseased  at  the 
same  time,  nor  every  where  at  once. 
But.  on  tlfe  contrary,  such  as  are  nearest  the 
external  surface  of  the  body  are  first  disea- 
sed, as,  for  instance,  the  periosteum,  bones 
of  the  head,  the  tibia,  ulna,  bones  of  the 
nose,  &c.  Neither  does  the  disease  affect 
these  bones  equally  on  all  sides ; but  first 
on  that  side  which  is  next  to  the  external 
surface.  It  was  Mr.  Hunter’s  belief,  how- 
ever, that  the  susceptibility  of  particular 
bones  did  not  altogether  depend  upon  their 
nearness  to  the  skin ; but  upon  this  cir- 
cumstance and  their  hardness  together. 

The  foregoing  account  by  no  means 
agrees  with  the  results  of  modern  inquiries 
into  the  nature  of  the  venereal  disease  ; for, 
unless  mercury  be  given,  it  appears  that  the 
bones  are  very  seldom  affected  by  it.  Thus 
in  the  cases  which  were  treated  by  Mr. 
Rose  without  mercury,  he  observes,  that 
u the  constitutional  symptoms  were  evi- 
dently not  such  as  could  be  regarded  as  ve- 
nereal, if  we  give  credit  to  the  commonly 
received  ideas  on  the  subject.  Caries  of 
the  bones,  and  some  of  the  least  equivocal 
symptoms,  did  not  occur.  In  no  instance 
was  there  that  uniform  progress,  with  un- 
relenting fury,  from  one  order  of  symptoms 
and  parts  affected  to  another,  which  is  con- 
sidered as  an  essential  characteristic  of  true 
syphilis.”  (Med.  Chir.  Trans.  Vol.  8,  p.  423.) 
We  learn  also  from  Mr.  Guthrie,  that  the 
bones  were  not  affected  in  any  of  the  cases, 
cured  entirely  without  mercury  in  the  York 
Hospital,  though  there  were  several  other 
cases  admitted,  “ in  which  a few  mercurial 
pills  had  been  taken,  and  the  mouth  not 
affected,  and  in  which  the  primary  symp- 
toms were  followed  by  eruptions  both  pa- 
pular and  scaly,  by  ulcers  in  the  throat,  by 
nodes , and,  in  one  case,  by  inflammation  of 
the  periosteum  covering  the  bones  of  the 
nose,  and  ulceration  of  the  septum  nasi, 
although  mercury  was  resorted  to  for  its 
cure.”  ( Vol.  cit.  p.  560.) 


In  the  examples  treated  without  mercury, 
under  the  superintendence  of  Dr.  Henncn, 
this  gentleman  did  not  see  “ a single  case 
in  which  the  bones  of  the  nose  were  affected  : 
some  cases  of  periostitis,  and  of  pains  and 
swellings  of  the  bones  of  the  cranium  and 
ext renAties  were  met  with  ; but,  except  in 
two,  he  never  remarked  any  nodes  which 
could  be  regarded  as  unequivocally  syphili- 
ticOne  of  these  yielded  to  blisters  and 
sarsaparilla  ; the  other,  after  resisting  guaia- 
cura  and  sudorifies,  was  dispersed  by  mer- 
cury (On  Military  Surgery , Ed.  2,  p.  581.) 
Dr.  Hcnnen’s  statement  on  this  subject 
would  have  been  more  satisfactory  had  it 
comprised  his  opinion  of  the  characters  of 
an  unequivocally  syphilitic  node.  On  the 
whole,  it  appears  tolerably  certain  that 
mercury,  especially  when  employed  unmer- 
cifully, and  even  when  employed  in  mode- 
ration, and  the  patient  exposes  himself  to 
damp  and  cold,  tends  to  promote  the  fre- 
quency of  nodes,  as  a sequel  of  the  venereal 
disease,  though  as  the  long  and  abundant 
use  of  the  same  mineral  does  not  cause  the 
same  consequence  after  other  complaints, 
and  venereal  ulcers,  treated  altogether  with- 
out mercury,  rarely  lead  to  nodes,  it  would 
seem  as  if  these  swellings  were  the  product 
of  the  combined  action  of  syphilis  and  mer- 
cury together.  The  infrequency  of  nodes 
in  the  strictly  non-mercurial  practice,  is 
one  of  the  most  important  facts  yet  esta- 
blished in  its  favour,  and  it  is  curious  to  find 
from  some  quotations  made  by  Dr.  Herinen, 
that  it  was  well  known  in  former  days. 
Fallopius,  in  his  86th  chap.  De  Ossium  Cor- 
ruptione,  speaking  of  the  loss  of  the  bones 
of  the  nose  and  palate,  says  “ et  sciatis 
quod  non  in  omrii  iuveterato  gallico  hoc 
fit,  sed  tantum  in  illis,  in  quibus  inunclio 
facta  est  cum  hydrargyro And  Fernelius, 
in  speaking  of  the  injurious  effects  of  mer- 
cury, observes,  “ recidiva  raro  similis  est 
radici,  neque  iisdem  symptomatis  exercet, 
sed  fere  distillatione,  arthritide  tophis,  vel 
ossium  carie.”  (Jlphrodisiacus.  Vol.3,p  146.) 
And  Palmarius,  in  considering  the  affection 
of  the  bones,  as  Dr.  Hennen  has  noticed, 
uses  the  following  remarkable  words  : u sed 
hoc  ils  duntaxat  contingit,  qui  olim  a lue 
venerea  hydrargyrosi  vindicati  putareutur, 
non  qui  decocto  guaiacino  etalexipharmaco 
curati  fuissent.”  (De  Morb.  Contagiosis9 
Cap.  7,  lib.  2,  p.  124;  Parisiis,  1578.)  Dr. 
Hennen  expresses  his  own  conviction, 
in  which  I entirely  agree,  that  the  carious 
affections  of  the  bones,  which  are  so  com- 
mon in  persons  treated  by  long  mercurial 
courses,  proceed  not  from  the  disease,  but 
from  the  remedy  rapidly  and  irregularly 
thrown  in  while  periostitis  exists  ; and  ho 
has  not  seen  a single  case  of  carious  bone 
in  the  military  hospitals,  since  the  non- 
mercurial  treatment  was  adopted,  except 
where  mercury  has  formerly  been  used.  (On 
Military  Surgery,  Ed.  2,  p.  505,  506.) 

Nor  will  the  results  of  modern  experi- 
ence and  inquiries,  made  on  a very  expen- 
sive and  impartial  scale,  allow  us  to  consi- 
der the  venereal  disease  as  regularly  and 


VENEREAL  DISEASE. 


020 

unavoidably  leading  to  any  secondary 
symptoms,  even  though  no  medicine  at  all 
be  employed  for  their  prevention.  This  is 
fully  exemplified  in  the  official  reports  of 
the  army  hospitals.  The  particulars  of  5000 
cases,  spoken  of  by  Sir  James  M‘Grigor  and 
Dr.  Franklin,  lead  to  the  opinion,  tint  “the 
frequency  or  rarity  of  secondary  symptoms 
wotrld  seem  1o  depend  on  circumstances 
not  yet  sufficiently  understood  or  explained, 
although  the  following  fact  would  tend  to 
the  belief,  that  either  the  constitutions  of  the 
men,  or  the  mode  of  conducting  the  treat- 
ment without  mercury,  are  the  causes  that 
possess  the  greatest  influence  in  their  pro- 
duction. In  one  regiment,  4 secondary 
cases  out  of  24, treated  without  mercury,  su- 
pervened.” In  another  regiment,  68  cases 
were  treated  without  mercury,  all  bearing 
marks  of  true  venereal  disease,  (and  28  of 
them  especially  selected  for  their  decided 
characters  of  chancre)  yet  no  secondary 
symptoms  of  any  kind  had  taken  place  fif- 
teen months  after  the  treatment  had  ceased. 
The  same  document,  founded  on  the  above 
large  number  of  cases,  confirms  another 
fact,  that  no  peculiar  secondary  symptoms 
follow  peculiar  primary  sores;  a conclusion 
which  is  directly  adverse  to  Mr.  Carmi- 
chael’s opinions,  of  which  I have  taken 
more  notice  in  another  work.  (See  First 
Lines  of  the  Practice  of  Surgery , Vol.  1, 
Ed.  4.) 

According  to  Mr.  Hunter,  the  time  neces- 
sary for  the  appearance  or  production  of 
the  local  effects,  in  parts  most  susceptible 
of  the  disease,  after  the  virus  has  passed 
into  the  constitution,  is  generally  about  six 
weeks ; but  in  many  cases  the  period  is 
much  longer,  while  in  other  instances  it  is 
shorter.  Sometimes  the  local  effects  make 
their  appearance  within  a fortnight  after  the 
possibility  of  absorption. 

The  effects  on  other  parts  of  the  body, 
which  are  less  susceptible  of  the  venereal 
irritation,  or  slower  in  their  action,  says  Mr. 
Hunter,  are  much  later  in  making  their  ap- 
pearance. And  when  the  first  and  second 
order  of  parts  are  both  contaminated,  the 
effects  generally  do  not  begin  to  appear  in 
the  latter  till  after  a considerable  time,  and 
sometimes  not  till  those  affecting  the  for- 
mer parts  have  been  cured. 

Mr.  Hunter,  however,  refers  to  instances 
in  which  the  periosteum,  or  bone,  was 
affected  before  any  of  the  first  order  of  parts  ; 
but  he  was  uncertain  whether  the  skin  or 
throat  would  afterward  have  become  dis- 
eased, as  the  disorder  was  not  allowed  to 
go  on. 

Venereal  Eruptions.  The  whole  tenor  of 
Various  facts,  specified  in  the  foregoing  co- 
lumns, tends  to  prove,  that  what  is  usually 
called  the  venereal  disease  is  in  reality  seve- 
ral diseases,  modified  also  by  constitution, 
climate,  regimen,  and  mode  of  treatment. 
And  hence,*  perhaps,  the  chief  source  of  all 
the  perplexity  and  uncertainty,  which  are 
yet  so  manifest  as  fully  to  justify  the  doubt 
sometimes  entertained,  whether  any  dis- 
ease, corresponding  to  the  former  notions 


of  syphilis,  really  exists.  Were  any  proof" 
of  the  truth  of  this  reflection  needed,  in 
addition  to  the  many  other  proofs  of  it 
already  premised,  the  subject  of  venereal 
eruptions  would  at  once  furnish  it ; for  here 
no  kind  of  regularity  can  be  traced,  either 
in  the  appearances  on  the  skin  abstractedly 
considered,  nor  in  the  connexion  between 
certain  kinds  of  primary  ulcers  and  particu- 
lar forms  of  cutaneous  disease.  Nay,  as  I 
have  noticed  in  the  preceding  pages,  some- 
times, in  consequence  of  a primary  vene- 
real sore,  different  kinds  of  eruptions  form 
together,  or  successively  on  one  individual; 
and,  as  far  as  one  can  judge  by  the  eye,  ex- 
actly the' same  kind  of  chancre  may  produce 
very  different  breakings  out  in  different  per- 
sons, even  though  treated  on  precisely  the 
same  plan.  These  circumstances  are  truly 
confusing.  In  Mr.  Rose’s  paper,  however, 
there  is  a partial  confirmation  of  one  part 
of  Mr.  Carmichael’s  theory,  viz.  the  fre- 
quency of  papular  eruptions  after  simple 
primary  ulcers,  or  superficial  sores,  which 
readily  heal.  According  to  the  latter  gen- 
tleman, this  form  of  eruption  may  also  fol- 
low gonorrhoea,  and  is  generally  preceded 
by  fever,  and  ends  in  desquamation.  What- 
ever may  be  the  degree  of  truth  respecting 
the  relation  between  this  kind  of  eruption 
and  the  alleged  primary  complaints,  the 
practice  recommended  by  Mr.  Carmichael 
for  such  cases  is  judicious.  General  blood- 
letting is  recommended  when  there  is  fever, 
and  the  medicines  praised  are  antimonials 
and  sarsaparilla.  Afterward,  when  the  fever 
subsides,  and  the  eruption  desquamates,  an 
alterative  course  of  antimony  and  calomel, 
it  is  said,  will  accelerate  the  cure,  though 
not  absolutely  necessary.  In  cases  of  vene- 
real pustular  eruptions,  supposed  by  Mr. 
Carmichael  to  be  most  frequent  after  chan- 
cres with  elevated  edges,  '.vithout  indura- 
tion, bloodletting  is  also  advised  during  the 
febrile  stage,  followed  by  antimonials,  sar- 
saparilla, guaiacum,  tar-ointment,  baths  of 
sulphurated  kali,  or  the  nitro-muriatic  bath  ; 
and  after  the  pustules  have  terminated  in 
scaly  blotches,  alterative  doses  of  mercury, 
conjoined  with  sarsaparilla  or  guaiacum. 
An  eruptioq  of  tubercles,  or  spots  of  a pus- 
tular tendency,  or  of  both  intermixed,  pre- 
ceded by  fever,  and  terminating  in  ulcers 
covered  with  thick  crusts,  complaints  which 
Mr.  Carmichael  considers  a sequel  rather  of 
the  phagedenic  than  other  chancres,  he 
treats  at  first  by  bloodletting,  followed  by 
antimonials,  sarsaparilla,  guaiacum,  com- 
pound powder  of  ipecacuanha,  arseniate  of 
kali,  nitrous  acid,  and  nitro-muriatic  bath. 
Mercury  is  said  to  be  hurtful,  except  in  the 
last  stage.  To  scaly  blotches,  which  he 
conceives  to  be  a sequel  of  the  true  chan- 
cre, or  callous  ulcer,  he  applies  the  same 
local  treatment  as  to  pustular  eruptions,  and 
he  deems  the  question,  whether  sarsaparilla 
and  guaiacum  might  here  be  substituted  for 
mercury,  yet  unsettled.  (See  Obs.  on  the 
Symptoms,  tyc.  of  Venereal  Diseases , Synop- 
sis, p.  205,  fyc.)  The  investigations  made 
in  the  military  hospitals  decidedly  prove. 


venereal  disease. 


that  all  kinds  of  eruptions,  supposed  to  be 
venereal,  may  be  cured  without  mercury  ; 
but,  I believe,  the  great  and  superior  useful- 
ness of  moderate  quantities  of  mercury  for 
the  removal  of  the  scaly,  copper-coloured 
blotches,  is  still  generally  acknowledged. 
But,  even  in  these  cases  of  copper-coloured 
spots,  Mr.  Bacot’s  advice  may  be  good,  viz. 
when  the  general  health  is  much  deranged, 
the  tongue  loaded  and  furred,  and  the  appe- 
tite gone,  to  defer  mercury  “ until,  by  pro- 
per evacuations  and  attention  to  the  gfeneral 
health,’'  the  patient  has  had  the  benefit  of 
a delay,  “ which  will,  in  many  instances, 
render  all  farther  medical  treatment  unne- 
cessary. It  is  undoubtedly  true  that,  what- 
ever plan  be  pursued,  these  eruptive  symp- 
toms will  eventually  disappear  ; still,  where 
they  continue  to  linger  for  a long  time,  and 
are  attended  with^  their  usual  accompani- 
ments of  great  languor,  debility,  and  dis- 
turbed rest,  I neither  know,  nor  can  I un- 
derstand, the  advantage  of  delaying  that 
remedy,  which  repeated  experience  has 
taught  me  to  rely  upon,”  &c  ( Bacot  on 
Syphilis,  p.  99.)  Although  Mr.  Carmichael’s 
practice  seems  good,  his  theory,  about  the 
connexion  of  certain  sores  with  particular 
eruptions,  and  other  peculiar  secondary 
symptoms,  appears  to  be  nearly  refuted  by 
the  late  investigations  made  in  the  military 
hospitals.  To  some  facts,  relating  to  this 
question,  I have  already  adverted. 

There  is  as  little  certainty,  about  the 
essential  characters  of  a syphilitic  erup- 
tion, as  about  the  test  of  every  other 
symptom  of  the  venereal  disease,  or,  rather 
diseases.  While  Mr.  Hunter  describes 
the  eruption  as  generally  occurring  over 
the  whole  body,  Dr.  Bateman  states,  that 
syphilitic  affections  of  the  skin  com- 
monly make  their  first  appearance  on  the 
face,  where  they  are  usually  copious,  and 
on  the  hands  and  wrists.  ( Pract . Synopsis  of 
Cutaneous  Diseases,  p.  332,  edit.  3.)  Their 
colour,  he  says,  is  in  general  less  livid,  than 
that  of  ordinary  eruptions,  being  of  a brown- 
ish red  of  different  shades ; but  that  this  is 
not  universal ; for  some  of  the  syphilitic 
ecthymafa  have  a bright  red  base  in  the  be- 
ginning. Exposure  to  cold  accelerates  their 
progress,  and  increases  their  extent ; while, 
on  the  other  hand,  warmth  retards  and 
meliorates  them.  (P.  333.)  According  to 
Hunter,  the  discolourations  make  the  skin 
appear  mottled,  and  many  of  the  eruptions 
disappear,  while  others  continue,  and  in- 
crease with  the  disease. 

In  other  cases,  the  eruption  comes  on  in 
distinct  blotches,  which  are  often  not  ob- 
served, till  the  scurf  has  begun  to  form. 
At  other  times,  the  eruption  assumes  the 
appearance  of  small  distinct  inflammations, 
containing  matter,  and  resembling  pimples, 
not  being  however,  so  pyramidal,  nor  so  red 
at  the  base.  Mr.  Hunter  also  observes,  that 
venereal  blotches,  on  their  first,  coming  out, 
are  often  attended  with  inflammation,  which 
gives  them  a degree  of  transparency,  which 
is  generally  greater  in  the  summer,  than  the 
winter,  especially,  if  the  patient  be  kept 


02 1 

warm.  In  a little  time,  this  inflammation 
disappears,  and  the  cuticle  peels  off  in  the 
form  of  a scurf.  The  latter  occurrence 
often  misleads  the  patient  and  the  surgeon, 
who  look  upon  this  dying  away  of  the  in- 
flammation, as  a decay  of  the  disease,  till  a 
succession  of  scurfs  undeceives  them. 

The  parts  affected  next  begin  to  form  a 
copper-coloured,  dry,  inelastic  cuticle,  call- 
ed a scurf,  or  scale.  This  is  throw  n off,  and 
new  ones  are  formed,  which  spread  to  the 
breadth  of  a sixpence  or  shilling  ; but,  sel- 
dom more  extensively,  at  least,  for  a consi- 
derable time.  In  the  mean  while,  every 
succeeding  scale  becomes  thicker  and  thick- 
er, till  at  last  it  becomes  a common  scab. 
Then  the  disposition  to  the  formation  of 
matter  takes  place  in  the  cuti^  underneath, 
and  a true  ulcer  is  produced,  which  com- 
monly spreads,  although  in  a slow  way. 

When  the  affected  part  of  the  skin  is  op- 
posed by  another  portion  of  skin,  which 
keeps  it  in  some  degree  more  moist,  as  be- 
tween the  nates,  about  the  arms,  between 
the  scrotum  and  the  thigh,  in  the  angle  be- 
tween the  two  thighs,  on  the  red  part  of  the 
lip,  or  in  the  arm-pits,  the  eruptions,  instead 
of  being  attended  with  scurfs  and  scabs,  are 
accompanied  with  an  elevation  of  the  skin, 
which  is  swollen  with  extravasated  lymph 
into  a white,  soft,  moist,  flat  surface,  wrhich 
discharges  a white  matter.  {Hunter.) 

Mr.  Carlisle  has  pointed  out  what  he 
terms  an  herpetic  abrasion  of  the  cuticle  ori 
the  breast,  or  abdomen,  having  the  appear- 
ance of  venereal  blotches.  He  states,  that 
it  is  less  deep  in  the  skin  ; that  it  has  less  of 
an  inflammatory  base  ; and  that  it  is  not  so 
distinctly  pircumscribed,  as  the  true  vene- 
real blotch.  It  never  forms  a purulent  crust ; 
but  is  simply  a furfuraceous  scaling  of  the 
cuticle.  This  form  of  disease  seems  to  him 
to  be  produced  by  a disordered  stomach  and 
liver.  (See  Loud.  Med.  Deposit.  Vol.  7,  p. 
92.) 

A venereal  eruption  often  attacks  that  part 
of  the  fingers,  on  which  the  nail  is  formed. 
Here,  the  disease  renders  that  surface  red, 
which  is  seen  shining  through  the  nail ; and 
if  allowed  to  continue,  a separation  of  the 
nail  takes  place. 

When  surfaces  of  the  bod}r,  covered  with 
hair,  are  attacked,  the  hair  separates,  and 
cannot  be  re-produced  as  long  as  the  dis- 
ease lasts. 

It  must  be  allowed,  that  it  is  frequently 
very  difficult  to  say,  whether  an  eruption  is 
syphilitic  or  not,  and  an  opinion  should 
rather  be  formed  from  the  history  of  the 
case,  than  from  any  particular  appearance 
of  the  eruption  itself.  As  Dr.  Bateman  has 
remarked,  the  cutaneous  eruptions,  which 
are  the  result  of  the  venereal  poison,  are 
often  the  source  of  considerable  embarrass- 
ment to  the  practitioner.  They  assume 
such  a variety  of  forms,  that  they  bid  defi- 
ance to  any  arrangement  founded  upon  their 
external  character ; and  in  fact,  they  possess 
no  common,  or  exclusive  marks,  by  which 
their  nature  and  origin  are  indicated.  There 
is  perhaps,  no  order  of  cutaneous  appearan 


VENEREAL  DISEASE. 


ces,  and  scarcely  any  genus,  or  species  of 
tbe  chronic  eruptions,  which  these  secon- 
dary symptoms  of  syphilis  do  not  occasion- 
ally resemble.  Dr.  Bateman  admits,  how- 
ever, that  in  many  cases,  there  is  a differ- 
ence, which  a practised  eye  will  recognise, 
between  the  ordinary  diseases  of  the  skin 
and  the  syphilitic  eruptions,  to  which  the 
same  generic  appellation  might  be  given. 
This,  says  he,  is  often  observable  in  the  shade 
of  colour , in  the  situation  occupied  by  the 
eruption,  in  the  mode  of  its  distribution , and 
in  the  general  complexion  of  the  patient. 
Hence,  to  a person  conversant  with  those 
ordinary  diseases,  a degree  of  anomaly  in 
these  respects  will  immediately  excite  a sus- 
picion, which  will  lead  him  to  investigate 
the  history  of  the  progress  of  such  an  erup- 
tion, and  of  its  concomitant  symptoms. 
(See  Bateman's  Practical  Synopsis  of  Cuta- 
neous Diseases,  p.  331,  332,  Edit.  3.) 

Dr.  Hennen  in  his  valuable  book,  does  not 
pretend  to  be  able  to  discriminate  the  true 
syphilitic  eruptions  from  others,  and  indeed, 
by  what  criterion  they  are  to  be  known,  I 
am  myself  entirely  puzzled  to  comprehend, 
after  the  numerous  facts,  so  fully  established 
by  recent  experimental  inquiries.  Dr. 
Hennen  generally  approves  of  delaying 
mercury  at  first,  in  order  to  see  whether 
these  cutaneous  affections  will  yield  to  other 
means  ; “ but  (says  he)  I should  not  very 
long  postpone  the  employment  of  the  mild- 
est mercurial  alteratives,  aided  by  warm 
bathing,  and  sudorifics.  (On  Military  Sur- 
gery. Ed.  2,  p.  518.) 

Venereal  Disease  of  the  Throat,  Mouth, 
and  Tongue. — In  the  throat,  tonsils,  and  in- 
side of  the  mouth,  the  disease  is  said  by  Mr. 
Hunter  generally  to  make  its  appearance  at 
once  in  the  form  of  an  ulcer,  without  much 
previous  tumefaction.  Consequently  the 
tonsils  are  not  much  enlarged. 

A venereal  ulcer  in  the  throat  'was  suppo- 
sed by  the  same  author  to  be  in  general 
tolerably  well  marked,  though  he  confesses, 
that  it  may  not  in  every  instance  be  distin- 
guishable from  an  ulcer  of  a different  na- 
ture. Several  diseases  of  the  throat,  he  re- 
marks, do  not  produce  ulceration  on  the 
surface.  One  of  these  is  common  inflam- 
mation of  the  tonsils.  The  inflamed  place 
often  suppurates  in  the  centre,  so  as  to  form 
an  abscess,  which  bursts  by  a small  opening ; 
but  never  looks  like  an  ulcer  that  has  begun 
superficially,  like  a true  venereal  sore.  The 
case  is  always  attended  with  too  much  in- 
flammation, pain,  and  tumefaction  of  the 
parts,  to  be  venereal.  Also  when  it  suppu- 
rates and  bursts,  it  subsides  directly,  and  it 
is  generally  attended  with  other  inflamma- 
tory symptoms  in  the  constitution. 

Mr.  Hunter  then  notices  an  indolent  tu- 
mefaction of  the  tonsils,  peculiar  to  many 
persons  whose  constitutions  are  disposed 
to  scrofula.  The  complaint  produces  a 
thickness  in  the  speech.  Sometimes  coagu- 
lable  lymph  is  thrown  out  on  the  surface  of 
the  parts  affected,  and  occasions  appearan- 
ces, which  ♦are  by  some  called  ulcers;  by 
some  sloughs;  and,  by  others  putrid  sore- 


throats.  The  case  is  attended  with  too 
much  swelling  to  be  venereal,  and  with  a 
little  care,  it  may  easily  be  distinguished 
from  an  ulcer,  or  loss  of  substance.  How- 
ever, when  this  difference  is  not  obvious  at 
first  sight,  it  is  proper  to  endeavour  to 
remove  some  of  tbe  lymph,  and  if  the 
surface  of  the  tonsil  underneath  should 
appear  to  be  free  from  ulceration,  we  may 
conclude  with  certainty,  that  the  disease  is 
not  venereal.  Mr.  Hunter  states,  that  he 
has  seen  a chink  filled  with  coagulable 
lymph,  so  as  to  appear  very  much  like  an 
ulcer;  but  on  removing  that  substance,  the 
tonsil  underneath  was  found  perfectly  sound. 
He  adds,  that  he  has  seen  cases  of  a swelled 
tonsil,  having  a slough  in  its  centre,  which 
slough  before  its  detachment,  looked  very 
like  a foul  ulcer.  The  stage  of  the  com- 
plaint, he  says,  is  even  more  puzzling  when 
the  slough  has  come  out  ; for  then  the  dis- 
ease has  most  of  the  characters  of  the  vene- 
real ulcer.  Whenever  he  met  with  the  dis- 
ease in  its  first  stage,  he  always  treated  it 
as  if  it  had  been  of  the  nature  of  erysipelas, 
or  a carbuncle.  When  the  complaint  is  in 
its  second  stage,  without  any  preceding 
local  symptoms,  he  recommends  the  prac- 
titioner to  suspend  his  judgment,  and  to 
wait  a little,  in  order  to  see  how  far  nature 
is  able  to  relieve  herself.  If  there  should 
have  been  any  preceding  fever,  the  case  is 
still  less  likely  to  be  venereal.  Mr.  Hunter 
informs  us,  that,  he  has  seen  a sore-throat  of 
this  kind  mistaken  for  a venereal  case,  and 
mercury  given  till  it  affected  the  mouth, 
when  the  medicine  brought  on  a mortifica- 
tion of  all  the  parts  concerned  in  the  first 
disease. 

Another  complaint  of  these  parts,  which 
Pdr.  Hunter  represents  as  being  often  taken 
for  a venereal  one,  is  an  ulcerous  excoria- 
tion, which  runs  along  their  surface,  be- 
coming very  broad  and  sometimes  foul, 
having  a regular  termination,  but  never 
going  deeply  into  the  substance  of  the  parts, 
as  Mr.  Hunter  believes  the  venereal  ulcer 
does.  No  part,  of  the  inside  of  the  mouth 
is  exempt  from  this  ulcerous  excoriation  ; 
but,  according  to  Mr.  Hunter,  the  disease 
most  frequently  occurs  about  the  root  of 
the  uvula,  and  spreads  forward  along  the 
palatum  molle.  He  remarks,  that  the 
complaint  is  evidently  not  venereal,  since  it 
does  not  yield  to  mercury.  He  has  seen  these 
ulcerous  excoriations  continue  for  weeks, 
without  undergoing  any  change,  and  a true 
venereal  ulcer  make  its  appearance  on  the 
surface,  of  the  excoriated  part.  He  says, 
that  such  excoriations  were  cured  by  bark, 
after  the  end  of  the  mercurial  course,  by 
which  the  syphilitic  sore  was  cured. 

This  author  describes  the  true  venereal 
ulcer  in  the  throat,  as  a fair  loss  of  substance , 
part  being  dug  out,  as  it  were,  from  the  body 
of  the  tonsil : it  has  a determinate  edge,  aiul 
is  commonly  very  foul,  having  thick  while 
matter,  like  a slough,  adhering  to  it,  and  not 
admitting  of  being  washed  away. 

Here,  however,  as  in  most  other  supposed 
forms  of  syphilis,  some  test  is  wanting,  by 


VENEREAL  DISEASE. 


023 


which  the  case  may  be  certainly  distinguish- 
ed  from  other  diseases  of  the  throat,  present- 
ing similar  appearances ; for,  as  Mr.  Rose 
has  very  truly  remarked,  “ the  excavated 
ulcer  of  the  tonsils,  as  described  by  Mr. 
Hunter,  is  not,  as  Mr.  Carmichael  seems  to 
think,  a peculiar  symptom  of  the  presence  of 
the  syphilitic  virus.  I have  repeatedly  seen 
it,  as  well  as  the  scaly  blotch,  in  cases  where 
mercury  had  beeu  freely  employed  for  the 
primary  sores,  and  in  which  I considered 
the  virus  as  eradicated,  and  both  have  dis- 
appeared under  the  use  of  sarsaparilla.” 
(Med.  Chir.  Trans.  Vol.  8 , p.  421.)  In  a re- 
cent work,  Mr.  Carmichael  himself  acknow- 
ledges the  justice  of  the  preceding  observa- 
tion, and  owns,  that  since  the  publication  of 
his  Essays,  he  has  often  noticed  the  exca- 
vated ulcer  of  the  tonsils,  either  attending 
the  primary  phagedenic  ulcer,  or  the  train  of 
constitutional  symptoms  which  arise  from  it. 
( On  the  Symptoms , <^c.  of  Venereal  Diseases, 
P-  17.)  In  affections  of  the  throat,  Dr.  Hen- 
nen  states,  that  he  “ w ould  be  more  guarded 
than  in  any  others,  in  the  employment  of 
mercury,  until  all  inflammatory  disposition 
was  removed.”  Afterward  he  has  seen 
them  yield,  u as  if  by  magic,  so  soon  as  the 
local  effects  of  mercury  on  the  parts  within 
the  mouth  became  obvious.”  But  when 
mercury  was  given  earlier,  he  has  seen  a vast 
number  of  instances  in  which  irremediable 
mischief  was  done.  (On  Military  Surgery, 
Ed.  2,  p.  518.) 

According  to  Hunter  lues  venerea  some- 
times produces  a thickening  and  hardening 
of  the  tongue,  but  frequently  ulceration,  as 
in  other  parts  of  the  mouth.  He  describes 
venereal  sores  on  the  tongue,  as  generally 
more  painful  than  those  on  the  skin  ; but  less 
so  than  common  sore  throats  from  inflamed 
tonsils.  They  oblige  the  patient  to  speak 
thick,  as  if  his  tongue  were  too  large  for  his 
mouth;  with  a sits  all  degree  of  snuffling. 

Mr.  Hunter  doubted  the  reality  of  a vene- 
real.ophthalmy,  though  he  owns  that  there 
are  inflammations  of  the  eyes,  which  yield 
to  mercury  See  the  subject  of  iritis  in  the 
article  Ophthalmy. 

Symptoms  of  the  second  stage  of  Lues  Ve- 
nerea.— The  periosteum,  fascia,  tendons, 
ligaments,  and  bones,  are  the  parts  which 
Mr.  Hunter  enumerates,  as  liable  to  be  af- 
fected ir»  the  second  stage  of  lues  venerea. 
This  observation  in  its  full  extent,  however, 
seems  to  be  rendered  rather  questionable  ; 
for  it  would  appear  from  the  evidence  both 
of  ancient  and  modern  writers,  that  true 
nodes , or  venereal  swellings  of  the  bones,  and 
particularly  caries,  rarely  take  place  from 
syphilis,  unless  mercury  be  employed,  it  is 
an  observation  of  Mr.  Hunter’s,  that  we  can- 
not always  know  with  certainty  what  parts 
may  become  affected  in  this  stage  of  the 
disease.  He  says  he  has  known  the  dis- 
temper produce  a total  deafness,  some- 
times followed  by  suppuration,  and  great 
pain  in  the  ear,  and  side  of  the  head.  I 
have  already  explained,  that  it  was  one  of 
this  gentleman’s  doctrines,  that  the  second 
order  of  parts  were  generally  deep-seated. 


When  these  become  irritated  by  the  poison, 
he  observes  that  the  progress  of  the  disease 
is  more  gradual,  than  in  the  first  order  of 
parts.  It  assumes  very  much  the  character 
of  scrofulous  swellings,  or  chronic  rheuma- 
tism ; only  it  affects  the  joints  less  frequently 
than  the  latter  affection  does.  A swelling 
sometimes  makes  its  appearance  on  a bone, 
when  there  has  been  no  possible  means  of 
catching  the  infection  for  many  months ; 
and  in  consequence  of  the  little  pain  expe- 
rienced, the  tumour  rflay  be  of  some  consi- 
derable size,  before  it  is  noticed.  Some- 
times a great  deal  of  pain  is  felt ; but  no 
swelling  comes  on,  till  after  a long  while. 
According  to  Mr.  Hunter,  these  remarks  are 
also  applicable  to  swellings  of  the  tendons, 
and  fasciae.  As  tumours  of  this  kind  only 
increase  by  slow  degrees,  they  are  not  at- 
tended with  symptoms  of  much  inflamma- 
tion. When  they  attack  the  periosteum, 
they  seem  like  an  enlargement  of  the 
bone  itself,  in  consequence  of  being  very 
firm,  and  closely  connected  with  the  latter 
part.  Mr.  Hunter  also  further  observes,  that 
in  these  advanced  stages  of  the  disease,  the 
inflammation  can  hardly  gel  beyond  the 
adhesive  kind,  in  which  state,  it  contiuues 
to  become  worse  and  worse,  and  when 
matter  is  formed,  it  is  not  true  pus,  but  of  a 
slimy  description.  Some  nodes,  be  says, 
both  of  the  tendons  and  bones,  last  for 
years,  before  they  form  any  matter  at  all. 
These  cases,  he  considered,  as  not  being 
certainly  venereal,  though  commonly  consi- 
dered as  such.  Mr.  Hunter  found  it  difficult 
to  explain  the  reason  why,  when  lues  venerea 
attacks  the  bones,  or  the  periosteum,  the  pain 
should  sometimes  be  very  considerable,  and 
sometimes  very  trivial.  Venereal  pains  in  fhe 
bones  Bre  described  by  Mr.  Hunter  as  being 
of  a periodical  kind,  generally  most  severe 
in  the  night-time. 

At  the  present  day,  when  many  cases 
formerly  supposed  to  be  syphilitic,  are 
treated  without  any  mercury,  and  even 
those  which  are  reputed  to  be  venereal,  are 
cured  by  much  smaller  doses  of  that  medi- 
cine than  were  given  in  Mr.  Hunter’s  time, 
nodes  have  become  much  less  frequent,  and 
I have  already  in  a previous  part  ot  this 
article  expressed  my  decided  belief  in  the 
justness  of  the  opinion  given  by  Fallopius 
and  others,  that  a disposition  to  nodes  is 
often  occasioned  by  the  abuse  of  mercury. 

Treatment  of  Lues  Venerea.— In  Mr.  Hun- 
ter’s opinion,  the  first  order  of  parts,  or  (hose 
which  are  most  suscept  ible  of  being  affected 
in  lues  venerea,  are  also  the  most  easy  of 
cure ; while  the  second  order  of  parts  take 
more  time  to  be  remedied. 

In  the  class  of  complaints,  arising  in  the 
second  stage  of  the  lues  venerea,  Mr.  Hun- 
ter believed,  that  it  was  unnecessary  to  con- 
tinue the  employment  of  mercury,  till  all 
the  swelling  had  disappeared.  For  it  is  ob- 
served by  this  distinguished  writer,  that 
since  these  local  complaints  cannot  conta- 
minate the  constitution  by  re-absorption,  and 
since  the  venereal  disposition  and  action 
from  the  constitution  can  be  cured,  while 


VENEREAL  DISEASE. 


B24 

the  local  effects  still  remain,  and  this  even 
when  the  tumefaction,  forming  nodes  on 
the  bones,  fasciae,  kc.  has  proceeded  to  sup- 
puration, there  can  be  no  occasion  for  con- 
tinuing the  course,  after  the  venereal  action 
has  been  destroyed.  Whatever  may  be 
hereafter  decided  concerning  the  superiority 
of  mercury  as  a remedy  for  many  seconda- 
ry symptoms,  one  thing  appears  already 
well  made  out,  viz.  that  it  should  always  be 
employed  with  moderation,  lest  it  produce 
worse  effects,  and  moYe  terrible  diseases, 
than  those  which  it  is  designed  to  relieve. 
For  an  account  of  the  various  ways  of  exhi- 
biting it,  I must  refer  to  the  article  Mercury. 

To  the  following  ingenious  reasoning  on 
the  operation  of  mercury,  and  the  principles 
by  which  its  administration  should  be  regula- 
ted, surgeons  of  the  present  day  will  not  give 
more  credit  than  facts  warrant,  because  some 
of  Mr.  Hunter’s  opinions  are  manifestly  in- 
fluenced by  the  supposition,  that  mercury  is 
absolutely  necessary  for  the  cure  of  the  ve- 
nereal disease. 

In  curing  the  lues  venerea,  mercury  can 
only  have  two  modes  of  action  ; one  on  the 
poison  : the  other  on  the  constitution.  If, 
says  Mr.  Hunter,  mercury  acted  on  the  poi- 
son only  one  might  conceive  it  did  so, 
either  by  destroying  its  qualities,  by  decom- 
posing it,  or  else  by  attracting  it  and  carrying 
it  out  of  the  circulation.  If  mercury  acted 
in  the  first  of  these  ways,  one  would  expect, 
that  the  cure  would  depend  on  the  quantity 
of  the  medicine  taken  into  the  system.  If 
it  acted  in  the  second  manner,  one  would 
Infer,  that  the  progress  of  the  cure  would 
be  proportionate  to  the  quantity  of  evacu- 
ation. But,  observes  Mr.  Hunter,  if  it  act 
upon  the  principle  of  destroying  the  diseased 
action  of  the  living  parts,  and  of  counteract- 
ing the  venereal  irritation,  by  producing  one 
of  a different  kind,  then,  neither  quantity 
alone,  nor  evacuations,  will  avail  much.  He 
states,  that  the  quickness  of  the  cure  depends 
on  quantity,  joined  with  visible  effects. 
However,  it  is  added,  that  although  the  ef- 
fects which  mercury  has  upon  the  venereal 
disease,  are  in  some  degree  proponioned  to 
the  local  effects  of  the  medicine  on  some  o t 
the  glands,  or  particular  parts  of  the  body, 
as  the  mouth,  skin,  kidneys,  and  inte.  lines, 
yet  such  effects  are  not  altogether  propor- 
tioned to  these  other  circumstances.  When 
mercury  disagrees  with  the  constitution,  so 
as  to  produce  great  irritability  and  hectic 
symptoms,  this  action  of  irritation,  as  Mr. 
Hunter  explains,  is  not  a counter-irritation 
to  the  venereal  disease. 

It  was  also  noticed  by  the  same  author, 
that  the  effects  of  mercury  on  lues  venerea 
are  always  in  proportion  to  the  quantity  of 
the  remedy  exhibited  in  a given  lime,  and  the 
susceptibility  of  the  constitution  to  the  mer- 
curial irritation.  He  says  that  these  circum- 
stances require  the  most  minute  attention, 
and  that,  in  order  to  obtain  the  greatest  ac- 
tion of  mercury  with  safety,  and  in  the  most 
effectual  manner,  the  medicine  must  be 
given  till  it  produces  effects  somewhere. 
However,  it  must  not  be  exhibited  too 


quickly,  in  order  that  a sufficient  quantity 
may  be  given,  before  we  are  obliged  to  stop, 
in  consequence  of  the  effects.  Mr.  Hunter 
thinks,  that  when  the  local  effects  are  pro- 
duced too  quickly,  they  prevent  a sufficient 
quantity  of  the  remedy  from  being  taken  into 
the  system  to  counteract  the  venereal  irrita- 
tion at  large. 

Mr.  Hunter  mentions  his  having  seen  some 
cases,  in  which  mercury  acted  very  readily 
locally,  and  yet  the  constitution  was  hardly 
affected  by  it,  for  the  disease  would  not  give 
way.  He  states,  that  he  has  met  with  other 
cases,  in  which  the  mere  quantity  of  mercury 
did  not  answer,  till  it  was  given  so  quickly 
as  to  affect  the  constitution  in  such  a manner 
as  to  produce  local  irritation,  and,  conse- 
quently, sensible  evacuations.  This,  be  ob- 
serves, is  a proof  that  the  local  affects  of 
mercury  are  often  the  sign  of  its  specific 
effects  on  the  constitution  at  large,  and  it 
shows  that  the  susceptibility  of  the  diseased 
parts  to  be  affected  by  the  medicine,  is  in 
proportion  to  its  effects  on  the  mouth.  Its 
effects,  he  contends,  are  not  to  be  imputed 
to  evacuation;  but  to  its  irritation.  Hence, 
he  inculcates,  that  mercury  should  be  given, 
if  possible,  in  such  a manner  as  to  produce 
sensible  effects  upon  some  parts  of  the  body, 
and  in  the  largest  quantity  that  can  be 
given,  to  produce  these  effects  within  cer- 
tain bounds.  Mr.  Hunter  also  remarks,  that 
these  sensible  effects  should  be  the  means  of 
determining  how  far  the  medicine  maybe 
pushed,  so  as  to  have  the  greatest  effect  on 
the  disease,  without  endangering  ihe  consti- 
tution. The  practice  must  vary  according 
to  circumstances ; and  if  the  disease  is  in  a 
violent  degree,  less  regard  must  be  had  to 
the  constitution,  and  mercury  must  be  thrown 
into  the  system  in  larger  quantities  ; a very 
dangerous  precept,  as  far  as  1 can  judge, 
from  many  cases  in  which  I have  seen  it 
acted  upon. 

Mr.  Hunter  likewise  acquaints  us,  that 
when  the  disease  is  in  the  first  order  of  parts, 
a smaller  quantity  of  mercury  is  necessary, 
than  when  the  second  order  of  parts  are 
affected,  and  the  disease  has  been  oi  long 
standing,  its  first  appearances  alone  being 
cured,  and  the  venereal  disposition  still  re- 
maining in  the  secondary  parts.  For  the 
purpose  of  curing  the  venereal  disease, 
whether  in  the  form  of  chancre,  bubo,  or 
lues  venerea,  Mr.  Hunter  was  of 'opinion, 
that  probably  the  same  quantity  of  mercury 
is  necessary.  He  represents,  that  one  sore 
requires  as  much  mercury  as  fifty  sores  in 
the  same  person,  and  a small  sore  as 
much  ns  a large  one  He  thought  that 
the  only  difference,  if  there  is  any,  must 
depend  upon  th**  nature  of  the  parts  affected, 
that  is,  on.  their  being  naturally  active  or  in- 
dolent. He  conceived,  however,  that  on  the 
whole,  recent  venereal  complaints  are  gene- 
rally more  difficult  ol  cure,  than  the  symp- 
tom? of  lues  venerea,  and  that  this  may 
make  a difference,  in  regard  to  the  quantity 
of  mercurv  necessary. 

Havingnow  delivered  the  principal  gene- 
ral instructions,  relative  to  the  exhibition  ot 


VENEREAL  DISEASE. 


62o 


mercury  in  the  treatment  of  the  venerea! 
disease,  as  given  by  Mr.  Hunter,  I must  not 
quit  this  subject  without  remarking,  that 
even  this  eminent  surgeon  appears  on  the 
whole  too  partial  to  the  long  use  of  mercu- 
ry, and  sometimes  to  the  introduction  of 
immoderate  quantities  of  it  into  the  system. 
In  general,  however,  his  observations  tend 
to  condemn  all  violent  salivations.  It  is  to 
be  recollected,  that  in  his  days,  nobody  had 
a suspicion  that  truly  syphilitic  sores  (if  this 
expression  be  allowable,  while  they  cannot 
be  defined,  nor  distinguished  by  their  ap- 
pearances) would  in  the  end  spontaneously 
heal,  and  he  himself  had  no  dependence 
upon  any  medicine,  except  mercury,  for  the 
cure  of  the  true  venereal  disease.  But  mo- 
dern experience  evinces,  that  the  disorder 
seldom  now  presents  itself  in  forms  so  bad 
and  intractable  as  formerly  ; that  it  is  even 
capable  of  spontaneously  ceasing ; and  that 
Ave  hardly  ever  see  cases  in  which  it  is  re- 
quisite to  give  mercury,  except  in  very 
moderate  quantities.  Indeed,  such  is  the 
change,  that  many  surgeons  suspect  that  the 
very  nature  of  the  disease  must  have  under- 
gone a material  alteration  or  modification. 
In  England,  in  rny  opinion,  every  thing  is 
to  be  referred  to  the  improved  manner  of 
employing  mercury  only  in  moderate  doses, 
and  never  pushing  its  exhibition,  till  the 
constitution  is  so  impaired,  that  undescriba- 
ble  forms  of  diseases  ensue,  which  are 
sometimes  the  compound  effect  of  mercury 
and  syphilis  together ; and,  in  other  in- 
stances of  that  description,  which  surgeons 
now  frequently  call  syphiloid , or  pseudo- 
syphilitic, not  depending  upon  the  venereal 
poison  at  all,  but  upon  a state  of  the  system, 
which  mercury  is  known  to  aggravate  in 
the  Avorst  degree.  For  additional  informa- 
tion concerning  internal  remedies  for  the 
venereal  disease,  see  Mercury,  Guaiacum, 
Mezereon,  Muriatic  Acid , Nitrous  Acid , Sar- 
saparilla, Sulphuric  Acid,  fyc. 

With  respect  to  the  local  treatment  of 
the  symptoms  of  lues  venerea,  Mr.  Hunter 
thought  that  none  would  in  general  be  ne- 
cessary, since  the  constitutional  treatment 
Avould  commonly  effect  a cure.  However, 
he  admits,  that  sometimes  the  local  effects 
will  not  give  way,  and  the  parts  remain 
swollen  in  an  indolent  inactive  state,  even 
after  there  is  every  reason  to  believe  that 
the  constitution  is  perfectly  cured.  In  such 
cases,  he  recommends  assisting  the  consti- 
tutional treatmeat  by  local  applications  of 
mercury  to  the  part,  either  in  the  form  of 
a plaster  or  ointment.  The  latter  applica- 
tion, he  says,  is  the  best.  When  these  are 
not  sufficient,  he  advises  an  attempt  to  he 
made  to  excite  inflammation  of  another 
kind.  He  says  he  has  seen  a venereal  node, 
which  gave  excruciating  pain,  cured  by  mere- 
ly making  an  incision  down  to  the  bone,  the 
whole  length  of  the  node.  The  pain  ceased , 
the  swelling  decreased,  and  the  sore  healed 
up  kindly,  without  the  assistance  of  a grain 
of  mercury.  He  mentions,  that  blisters  have 
been  applied  to  nodes  with  success,  remo- 
ving the  pain, end  taking  away  the  swelling. 

Von. !!.  TO 


With  regard  to  these  last  cases  I may  add, 
that,  for  many  years  past,  the  idea  of  com- 
pletely dispersing  nodes  by  mercury  has 
been  entirely  abandoned  in  St.  Bartholo- 
mew’s hospital.  In  this  institution,  long 
protracted  mercurial  courses  for  the  cure 
of  such  swellings  are  totally  relinquished. 
When  small  moderate  quantities  of  mercury 
have  had  their  full  effect,  a blister  is  ap- 
plied o\Ter  the  swelling,  and  kept  open, 
under  which  plan  the  tumour  generally  sub- 
sides as  far  as  its  nature  will  allow. 

Diseases  resembling  the  Venereal.  Pseudo- 
syphilis.— Sores  on  the  glans  penis,  prepuce, 
&,c.  in  the  form  of  chancres,  as  Mr.  Hunter 
notices,  may  and  do  arise  without  any  vene- 
real infection,  and  sometimes  they  are  a 
consequence  of  former  venereal  sores, 
Avhich  have  been  cured. 

The  symptoms,  produced  by  the  \renereal 
poison  in  the  constitution,  sire  such  as  are 
common  to  many  other  diseases.  For  in- 
stance, Mr.  Hunter  remarks,  that  blotches 
on  the  skin  are  common  to  what  is  called  a 
scorbutic  habit ; pains  are  common  to  rheu- 
matism ; swellings  of  the  bones,  perios- 
teum, fasciae,  &c.  to  many  bad  habits, 
perhaps,  of  the  scrofulous  and  rheumatic 
kind.  Thus,  says  he,  most  of  the  symptoms 
of  the  venereal  disease,  in  all  its  forms,  are 
to  be  found  in  many  other  diseases.  Hence , 
the  original  cause,  and  many  leading  circum- 
stances, such  as  dates,  effects  of  the  disorder 
upon  others,  from  connexion,  when  only  local , 
the  previous  and  present  symptoms,  fyc.  must 
be  considered,  before  we  can  determine  abso- 
lutely what  the  disease  truly  is.  All  the  cir- 
cumstances and  symptoms,  taken  together, 
may  be  such  as  will  attend  no  other  disease. 
However,  Mr.  Hunter  confesses,  that  with 
all  our  knowledge,  and  with  all  the  appli- 
cation of  that  knowledge  to  suspicious 
symptoms  of  this  disease,  we  are  often  mis- 
taken, calling  distempers  venereal , which  arc. 
not  so,  and  sometimes  supposing  really  syphi- 
litic affections  to  be  of  another  nature. 

Mr.  Hunter  takes  notice,  that  in  some 
constitutions,  rheumatism,  in  many  of  its 
symptoms,  resembles  the  lues  venerea. 
The  nocturnal  pains,  swelling  of  the  ten- 
dons, ligaments,  and  periosteum,  and  pain 
in  those  swellings,  are  symptoms  both  of 
the  rheumatism,  and  also  of  the  venereal 
disease,  when  it  attacks  such  parts.  Mr. 
Hunter,  however,  did  not  know  that  he  had 
ever  seen  the  lues  venerea  attack  the  joints , 
though  many  rheumatic  complaints  of  such 
parts  are  cured  by  mercury,  and  therefore 
supposed  to  be  venereal. 

Mercury,  given  Avithout  caution,  often 
produces  the  same  symptoms  as  rheuma- 
tism. Such  complaints  Mr.  Hunter  had 
seen  mistaken  for  venereal  ones,  and  mer- 
cury continued.  He  explains,  that  some 
diseases  not  only  resemble  the  venereal  iri 
appearance,  but  in  the  mode  of  contamina- 
tion, proving  themselves  to  be  poisons  by 
affecting  the  part  of  contact ; then  produ- 
cing immediate  consequences  similar  to 
buboes ; and  also  remote  consequences  si- 
milar to  the  lues  venerea. 


VENEREAL  DISEASE 


<>■20 


Mr.  Hunter  observes,  that  it  is  nearly  as 
dangerous,  in  some  constitutions,  to  give 
mercury,  when  the  disease  is  not  venereal, 
as  to  omit  it  in  other  cases,  which  are 
really  syphilitic;  and  had  he  been  ac- 
quainted with  recent  investigations,  he 
would  undoubtedly  have  gone  further,  and 
declared  that  it  is  in  reality  far  more  dan- 
gerous. Many  of  the  constitutions,  which 
put  on  some  of  the  venereal  symptoms, 
when  the  disease  is  not  really  present,  he 
says,  are  those  with  which  mercury  seldom 
agrees,  and  commonly  does  harm.  He  had 
seen  mercury,  which  was  exhibited  for  a 
supposed  Venereal  ulcer  of  the  tonsils,  pro- 
duce a mortification  of  those  glands,  and 
the  patient  was  nearly  destroyed. 

Mr.  Abernetby,  in  his  Surgical  Observa- 
tions, 1804,  has  treated  at  some  length  of 
diseases  resembling  syphilis,  and  has  ad- 
duced several  very  interesting  cases,  which 
i advise  every  surgical  practitioner  to  read 
with  the  greatest  attention,  as  in  fact  they 
confirm  the  views  of  the  subject  lately  so 
fully  established. 

“ A gentleman  (says  he)  thought  that  he 
had  infected  a slight  cut  on  his  hand 
(which  was  situated  in  front  of,  and  just 
below  the  little  finger,)  with  the  discharge 
from  a bubo  in  the  groin,  that  he  had  occa- 
sion to  open.  The  wound  fretted  out  into 
a sore  about  the  size  of  a sixpence,  which 
he  showed  me,  and  which  1 affirmed  had 
not  the  thickened  edge  and  base,  and  other 
characters  of  a venereal  chancre.  1 there- 
fore recommended  him  to  try  the  effect  of 
local  means,  and  not  to  use  mercury. 

“ In  about  a month,  the  sore,  which  had 
spread  a little,  became  again  contracted  in 
its  dimensions,  and  assumed  an  healing  ap- 
pearance. At  this  time  pain  was  felt  ex- 
tending up  the  arm,  and  suddenly  a consi- 
derable tumour  arose  over  the  absorbing 
vessels,  which  proceed  along  the  inner  edge 
of  the  biceps  muscle.  This  tumour  became 
nearly  as  big  as  a small  orange.  As  the 
original  sore  seemed  now  disposed  to  heal, 
and  as  there  was  no  surrounding  indura- 
tion, I could  not  believe  it  venereal,  and 
therefore  recommended  him  still  to  abstain 
from  mercury,  and  apply  leeches  and  linen 
moistened  in  the  aq.  litbarg.  acet.  comp,  to 
the  tumour  formed  over  the  inflamed  ab- 
sorbents. For  it  seemed  to  me,  that  if  the 
venereal  poison  had  been  imbibed  from  the 
sore,  it  would  have  passed  on  to  one  of  the 
axillary  glands,  and  would  have  caused  in- 
duration and  inflammation  to  take  place 
there  more  slowly  than  had  occurred  on 
the  present  occasion. 

“ Under  this  treatment  the  tumour  was 
discussed,  and  the  sore  at  the  same  time 
healed.  About  three  weeks  afterward,  the 
patient  called  on  ine,  and  said  that  there 
were  venereal  ulcers  in  his  throat;  and  in 
each  tonsil  there  was  an  ulcer  deeply  exca- 
vated, with  irregular  edges,  and  with  a sur- 
face covered  by  adhering  matter  ; ulcers, 
in  short,  which  every  surgeon,  who  de- 
pends on  his  sight  as  his  guide,  would  have 
pronounced  to  be  venereal.  Shortly  after 


also  some  copper-coloured  eruptions  aj> 
peared  on  his  face  and  breast.  He*showed 
his  diseases  to  several  surgeons,  on  whose 
opinion  he  relied,  who,  without  hesitation, 
affirmed  that  they  were  venereal,  and  that 
the  mercurial  course  had  been  improperly 
delayed. 

“ While  the  patient  was  looking  out  for 
lodgings,  in  order  that  he  might  go  through 
the  mercurial  process,  a circumscribed 
thickening  and  elevation  of  the  pericra- 
nium, covering  the  frontal  bone,  appeared  ; 
it  was  of  the  circumference  of  a half-crown 
piece  ; and  was,  in  short,  what  every  sur- 
geon, who.  is  guided  only  by  his  sight  and 
touch,  would,  without  hesitation,  have 
called  a fair  corona  veneris.  I now  told 
the  patient  that  I was  more  inclined  to  be- 
lieve his  disease  was  not  syphilitic,  from 
the  sudden  and  simultaneous  occurrence  of 
this  node,  with  the  sore  throat,  &.c.  Other 
surgeons  thought  differently  ; and  I believe 
this  very  sensible  and  amiable  young  roan 
imagined  that  his  health  would  become  a 
sacrifice,  if  he  any  longer  attended  to  my 
opinion.  He  was  preparing  to  submit  fo  a 
mercurial  course,  when  very  important 
concerns  called  him  instantly  into  the 
country.  He  went  with  great  reluctance, 
taking  with  him  mercurial  ointment,  &tc. ; 
and  after  a fortnight,  I received  a letter 
from  him,  saying  that  he  found  his  com- 
plaints benefited  by  his  journey,  that  busi- 
ness had  prevented  him  from  beginning  the 
use  of  mercury  for  a few  days  ; that  he  now 
found  it  was  unnecessary,  for  his  symptoms 
had  almost  disappeared  ; and  shortly  after- 
ward he  became  perfectly  well.” 

Mr.  Abernethy  considers  this  case  as  the 
most  unequivocal  instance  extant  of  a dis- 
ease occurring,  which  could  not  from  ap- 
pearance be  distinguished  by  surgeons  of  the 
greatest  experience  from  syphilis,  and 
which,  however,  was  undoubtedly  of  a 
different  nature  ; (that  is  to  say,  it  was  of  a 
different  nature,  according  to  certain  cri- 
teria, then  generally  believed,  but  which 
recent  investigations  have  proved  to  be 
destitute  qf  foundation.)  All  the  tests  here 
alluded  to  having  been  spoken  of  in  the 
foregoing  columns,  I shall  not  here  repeat 
them. 

Some  years  ago  the  nitric  acid  was  intro- 
duced as  a remedy  for  syphilis.  (See  Ni- 
trous Jicid.)  To  the  position  of  its  efficacy 
being  as  great  in  venereal  cases  as  was  first 
alleged,  many  surgeons  have  not  acceded, 
though,  as  a sensible  writer  has  observed, 
it  has  certainly  been  allowed,  with  some 
other  medicines,  to  remain  in  a kind  of 
copartnership  with  mercury,  and  admitted 
to  be  useful  in  venereal  cases  under  certain 
circumstances.  A great  deal  of  this  want 
of  agreement,  on  the  effects  of  remedies  in 
syphilitic  cases,  is  now  explained  by  the 
imperfection  of  the  diagnosis,  and  the  im- 
portant fact,  that  the  disease  may  generally 
be  cured  iu  lime,  without  any  medicines 
whatsoever,  though  this  time  is  sometimes 
long.  Dr.  Scott,  who  first  suggested  the  use 
of  nitrous  acid,  has  attempted  to  Recount 


VENEREAL  DISEASE 


627 


for  its  alleged  occasional  failures,  by  ob- 
serving that  the  acid,  which  he  employed, 
was  not  pure  nitric  acid,  but  an  impure 
acid,  containing  an  admixture  of  muriatic 
acid.  He  therefore,  some  time  ago,  re- 
commended the  use  of  a compound  acid, 
containing  three  parts  of  nitric  acid,  and  one 
of  muriatic,  which  he  administered  inter- 
nally, and  also  applied  externally,  largely 
diluted,  as  a bath,  until  the  gums  were  af- 
fected and  ptyalism  pVoduced  ; and  he  con- 
ceived every  trial  as  quite  inconclusive, 
unless  these  constitutional  effects  occurred. 

“ The  acid  that  I have  used  of  late  (says 
Dr.  Scott)  is  the  nitro  muriatic ; and  it  is 
formed  by  mixing  together  equal  parts  of 
the  nitrous,  or  nitric  acid,  and  muriatic  acid. 
If  these  acids  be  in  the  state  of  concentra- 
tion, that  they  usually  possess  in  the  shops, 
and  if  the  quantities  be  considerable,  a 
great  volume  of  gas  is  evolved  on  their 
coming  into  contact,  which  taints  every 
part  of  a house,  is  extremely  hurtful  to  the 
lungs,  and  disagreeable  to  the  smell.  To 
avoid  this  inconvenience,  I put  a quantity 
of  water,  at  least  equal  in  bulk  to  both  the 
acids,  into  a bottle,  and  I add  the  acids  to 
it  separately.  This  method  does  not  only 
prevent  the  unpleasant  odour,  but  it  tends 
to  retain  the  chlorine,  on  which  its  effects 
depend,  it  is  well  known,  that  the  nitro- 
muriatic  acid  acts  very  readily  on  the 
metals  and  earth  ; nothing  therefore  but 
glass,  or  extremely  well  glazed  vessels  of 
porcelain,  should  be  used  to  contain  it. 
Wooden  tubs  for  bathing  answer  very  well, 
and  they  should  always  be  made  as  small  as 
; possible , compatible  with  their  holding  the 
body,  or  the  limbs  that  we  wish  to  expose 
to  the  bath.  From  their  being  small,  we 
save  acid,  and  are  able  to  heat  the  bath  with 
ease.  In  India,  I have  often  exposed  the 
whole  body  below  the  head  to  this  bath  ; 
but  here  I have  been  satisfied,  in  general, 
with  keeping  the  legs  and  feet  exposed  to 
it.  In  order  to  warm  the  bath,  after  the 
first  time,  I have  commonly  made  a third 
or  a fourth  part  of  it  to  be  thrown  away,  and 
the  loss  replaced  by  boiling  water  and  a 
proportional  quantity  of  acid.  To  save  the 
expenditure  of  acid,  I have  occasionally 
warmed  a portion  of  the  bath  in  porcelain 
vessels,  placed  near  the  fire,  but  l fear  this 
may  diminish  its  effects. 

u It  is  no  easy  matter  (continues  Dr. 
Scott,)  to  give  directions,  with  regard  to 
the  degree  of  acidity  of  the  bath.  I have 
commonly  made  it  about  as  strong  as  very 
weak  vinegar,  trusting  to  the  taste  alone. 
The  strength  should  be  regulated  by  the 
degree  of  irritability  of  the  patient’s  skin. 
1 may  say,  that  although  I like  to  know  that 
it  is  strong  enough  to  prick  the  skin  a very 
little,  after  being  exposed  to  it  from  fifteen 
to  thirty  minutes,  yet  I believe  that  even 
such  an  effect  as  this  is  unnecessary. 

1‘  The  time  too  of  remaining  in  the  bath, 
in  order  to  produce  the  greatest  effect,  is  a 
matter  of  doubt.  I have  kept  the  legs  and 
feet  exposed  to  it  for  half  an  hour  or  more  ; 
but,  with  more  delicate  people,  not  above 


one-half,  or  one-third  of  that  time.  I have 
repeated  these  baths  daily,  or  even  twice, 
or  thrice  a day.  (See  Med.  Chir.  Trans. 
Vol.  S,  p.  181.)  Dr.  Scott  adds,  that  the 
mere  sponging  the  skin  with  nitro-muriatio 
acid,  sufficiently  diluted  witli  water,  gives 
rise  to  the  very  same  effects  f.s  bathing?  and 
is  more  easily  adopted.  Fifteen  or  twenty 
minutes  may  be  employed  in  the  sponging, 
though  a much  less  time  produces  very  ma- 
terial effects. 

Dr.  Scott  has  found  the  nitro-muriatic 
acid  particularly  useful,  even  in  this  coun- 
try, in  that  description  of  syphilis,  which  is 
termed  pseudo-syphilis ; and  he  attributes 
the  beneficial  effects  to  the  chlorine,  which 
is  loosely  combined  in  this  compound. 
(See  Journal  of  Science  and  the  Arts,  Vol.  1, 
p.  205 — 211.  Lond.  Med.  Reposil.  Vol.  7,  p. 
59  ; and  Med.  and  Chir.  Trans.,  Vol.  8,  p. 
173,  et  seq.) 

The  only  important  conclusion  which  l 
venture  to  draw  from  Dr.  Scott’s  observa- 
tions, is  a confirmation  of  the  fact  of  the 
generally  curable  nature  of  syphilitic  dis- 
eases, without  the  aid  of  mercury.  And  I 
further  believe,  that  though  the  nitro-muri- 
atie  bath  may  sometimes  be  useful,  the 
surest  way  of  bringing  it  into  discredit  is 
to  represent  it  as  applicable  to  all  forms  of 
syphilis,  for  which  neither  this  remedy,  nor 
even  mercury  itself,  will  ever  suffice. 

J.  de  Vigo,  De  Arte  Chirurgica,  fol.  Lugd. 
1518.  N.  Montesaurus . De  Disposition^  us, 
quas  vulgo  Mai  Fransos  appellant,  1497.  Ki- 
col.  Massa  de  Morbo  Gallico,  Liber,  4lo.  Te- 
net. 1532,  et  1536,  auctior,  1563.  Nic.  Lco- 
nicerus  Liber  de  Epidemia  quam  ltali  morurm 
Gallicum,  Galli  ero  Xeapolitanum  vacant, 
Fol.  Papice . 1506.  Gabr.  Fallopius,  de  Tor- 
bo  Gallieof^to.  Patav.  1563.  Kic.de  Blegny, 
Zodiacus  Medico- Gallicus,  4to.  Geneves,  1680. 
Hieron.  Fracaslorius,  Syphilis  Poema;  et, 
Tractatus  de:  Syphilide ; Veronce.,  1530.  Also, 
De  Contagionc  et  Contagiosis  Morbis,  Venet. 
1546,  Casp.  Torella,  Tractatus  cum  Consiliis 
contra  Pudendagram,  Romes,  1497.  Also , 
Dialogus  de  Dolore  et  de  Ulceribus  in  Pu- 
dendagra  ; Romes,  1500.  Ant.  Francantia - 
nus,  de  Morbo  Gallico,  8 to.  Patav.  1563. 
Jul.  Palmarius , De  Morbis  Contagiosis,  4 io. 
Paris , 1578.  Guil.  Rondeletius,  de  Morbo 
Gallico,  1576.  J.  Fernelius,  Universa  Me- 
dicina,  4 to.  Venet.  1564,  p.  584,  593, 

Ulric  de  Hulten,  de  Morbo  Gallico . Mogun! 
1531.  R.  Rostinio,  Trattato  di  Mai.  Fran - 
cess,  \2mo.  Venet,  1556.  Al.  Luisinus,  Aphro- 
disiacus,  Venet.  1566,  et  in  2 Tom.  fol.  Lugd. 
Bat.  1728,  one  of  the  most  valuable  collections 
of  the  Works  of  ancient  writers  on  Syphilis. 
Diaz  de  Isla,  Tratado  contra  las  Bubas.  1527. 
Wm.  Clowes,  a new  and  approved  Treatise , 
concerning  the  Cure  of^the  French  Poclces,  by 
the  Unctions,  8va.  Lond.  1575  ; said  to  be  the 
earliest  English  book  on  Syphilis.  J.  Aslruc, 
de  Morbis  Venereis ; Lutet.  Paris , 1740.  Le 
Blond,  (Jbs.  sur  la  Fitvre  Jaunt,  Chap.  4. 
Leo  Africanus,  Descriptio  A f rices,  L.  1 , p.  86. 
The  last  two  authors  mention:  the  fad  of  the 
nature  of  the  Venereal  Di&af j If  get  wet! 
spontaneously  in  hot  climates.  I?r. Ah,- 


VENEREAL  DISEASE. 


62S 

cromby , Tula  or.  effienx  Luis  Venerece , scepe 
absque.  Mercurio,  ac(  semper  absque  Saliva- 
Hone  Mercurial! Ciirandw  Methodus,  Land. 
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Venus  and  Mercury , represenled  in  a Treatise 
an  the  Venereal  Disease,  giving  a succinct  Ac- 
count of  that  Dreadful  Distemper,  and  the 
fatal  Consequences  arising  from  mercurial 
Cures , <y c.  iciih  the  true  Way  of  curing  the 
Mercurial  Pox,  found  to  be.  more  dangerous 
than  Pox  itself  Lond.  1709.  Morgagni,  de 
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Method  of  curing  all  the  Stages  of  that  Dis- 
temper will  be  communicated,  without  the  help 
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cases  will  be  avoided , 8 vo.  Lond.  1737.  Lu- 
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Vencrecc  symptomata  non  sinl  affect  us  morbi, 
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C.  Willoughby,  The  Practice  of  Salivation 
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ments, with  regard  to  Ihc  Use  of  Sarsaparilla, 
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of  Pie  nek's  Method  of  Cure,  S vo.  Lond.  1770. 
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the  Venereal  Disease,  8 vo.  Dublin,  1783.  P. 
Clare,  a New  Method  of  curing  Lucs  Venerea 
by  the  introduction  of  Mercury  through  the 
Orifices  of  the  absorbent  Vessels  on  the  Inside 
of  the  Mouth,  3 Ed.  Lond.  1780.  Jesse  Foote, 
Gbs.  on  the  New  Opinions  of  John  Hunter , 
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the  New  Opinions  of  Hunter,  Svo.  Lond.  1787. 
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and  Lues  Venerea,  Ed.  3.  Lalouetle,  A'ou- 
vtlle  Mdthode  de  trailer  les  Maladies  V6neri- 
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of  the  Materia  Medica,  in  the  Cure  of  Lues 
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Enfaris  nouveaux-n6s,  <fc.  fyc.  des  Maladies 
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the  Effects  of  Nitrous  Acid,  and  other  analo- 
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Propri6l6s  Medicinales  de  TOxygtue,  et  sur 
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02a 


vertebrae,  disease  of 


. ibslinence , rid.  Huf eland  and  Harlc's  Journ. 
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Opinion  about  the  Venereal  Disease,  rid. 
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michael, Essays  on  the  Venereal  Diseases , 
which  have  been  confounded  with  Syphilis,  fyc. 
4to.  1S14  ; also,  Obs.  on  the  Symptoms  and 
specific  Distinctions  of  Venereal  Diseases,  fyc. 
Svo.  Lond.  1818.  T.  Rose,  Obs.  on  the 
Treatment  of  Syphilis,  with  an  Account  of 
several  Cases,  in  which  a Cure  was  effected, 
without  the  Use  of  Mercury , in  Med.  Chir. 
Trans.  Vol.  8.  G.  J.  Guthrie , on  the  Treat- 
ment of  the  Venereal  Disease,  without  Mercu- 
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and  J.  Henntn , in  Edinb.  Med.  and  Surgical 
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1820.  J.Bacol,  Obs.  on  Syphilis,  principally 
with  reference  to  the  use  of  Mercury,  Sr o. 
Lond.  1821.  James  Evans,  Pathological  and 
Practical  Remarks  on  Ulcerations  of  the  Geni- 
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De  Methodis  alque  mtdicamenlis  antisyphiliti- 
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existence  de  la  Maladie  Venerienne,  <£*c.  Svo. 
Paris,  1811. 

VENESECTION,  (from  vena,  a vein, 
and  sectio,  a division.)  The  operation  of 
opening  a vein.  Phlebotomy.  See  Bleed- 
ing. 

VERRUCA.  A Wart.  See  Wart. 

VERTEBRAE,  DISEASE  OF.  The  case, 
here  to  be  considered,  is  a disease  of  the 
spine,  sometimes  originating  in  an  ulceration 
of  the  intervertebral  cartilages,  sometimes  in 
a morbid  condition  of  the  cancellous  struc- 
ture of  the  bodies  of  the  vertebrae  ( Brodit  on 
Diseases  of  the  Joints,  p.  259,)  followed  by  a 
more  or  less  complete  loss  of  the  power  of 
using  the  legs. 

Formerly,  the  affection  of  the  limbs  was 
generally  called  a palsy,  and  treated  as  a 
paralytic  affection  ; to  vvhicli  it  is  in  almost 
every  respect  perfectly  unlike. 

In  the  true  paralysis,  (says  Mr.  Pott)  from 
whatever  cause,  the  muscles  of  the  affected 
limb  are  soft,  flabby,  unresisting,  and  inca- 
pable of  being  put  into  even  a tonic  state  ; 
the  limb  itself  may  be  placed  in  almost  any 
position,  or  posture  ; if  it  be  lifted  up,  and 
then  let  go,  it  falls  down,  and  it  is  not  in  the 
power  of  the  patient  to  prevent,  or  even  to 
retard,  its  fall ; the  joints  are  perfectly  and 
easily  moveable  in  any  direction  ; if  the  af- 
fection be  of  the  lower  limbs,  neither  hips, 
knees,  rior  ankles,  have  any  degree  of  ri- 
gidity, or  stiffness  ; but  permit  the  limb  to  be 
turned,  or  twisted,  in  almost  any  manner. 

In  the  present  case,  the  muscles  are  in- 
deed lessened,  hut  they  are  rigid,  and  al- 
ways at  least  in  a tonic  state,  by  which  the 
knees  and  ankles  acquire  a stiffness  not  very 
easy  to  overcome.  By  means  of  this  stiff- 
ness, mixed  with  a kind  of  spasm,  the  legs 
of  the  patient  are  either  constantly  kept 
stretched  out  straight,  in  which  case  consi- 
derable force  is  required  to  bend  the  knees, 
or  they  are,  by  the  action  of  the  stronger 
muscles,  drawn  across  each  other,  in  such 


manner  as  to  require  as  much  to  separate 
them.  When  the  leg  is  in  a straight  position, 
the  extensor  muscles  act  so  powerfully,  as 
to  require  a considerable  degree  of  force  to 
bend  the  joints  of  the  knees  j and,  when  they 
have  been  bent,  the  legs  are  immediately, 
and  strongly,  drawn  up  with  the  heels  to- 
ward the  buttocks.  By  the  rigidity  of  the 
ankle  joints,  joined  to  the  spasmodic  action 
of  the  gastrocnemii  muscles,  the  patient’s 
toes  are  pointed  downward,  in  such  manner 
as  to  render  it  impossible  for  him  to  put  his 
foot  flat  to  the  ground  : which  makes  one  of 
the  decisive  characteristics  of  the  distemper. 

The  majority  of  those  who  labour  under 
this  disease,  are  infants,  or  young  children  : 
adults  are  by  no  means  exempt  from  it ; but 
Mr.  Pott  never  saw  it  at  an  age  beyond 
forty  ; and  Mr.  Baynton  never  met  with 
more  than  three  instances,  which  approach- 
ed that  period  of  life.  (On  Diseases  of  the 
Spine,  p.  4.) 

In  one  case,  however,  recited  by  Mr.  Bro- 
die,  the  patient  was  forty-five  years  old. 
(On  Diseases  of  Joints,  p.  268.)  By  Pott, 
Baynton,  and  several  other  writers,  a belief 
is  entertained,  that  the  disease  is  most  dis- 
posed to  happen  in  scrofulous  subjects,  in 
which  opinion  I am  also  disposed  to  join. 
There  can  also  be  no  doubt  of  the  fact,  sta- 
ted by  Mr.  Pott,  that  it  most  frequently  hap- 
pens in  weak  and  delicate  children. 

According  to  Mr.  Pott,  if  the  patient  be  a 
child,  the  account,  most  frequently  given  is, 
that  for  some  time  previous  to  the  incapa- 
city of  using  its  limbs,  it  bad  been  observed 
to  be  languid,  listless,  and  very  soon  tired  ; 
that  it  was  unwilling  to  move  much,  or 
briskly ; that  it  had  been  observed  fre- 
qucnly  to  trip  and  stumble,  although  no  im- 
pediment lay  in  its  way  ; that  when  it  mov- 
ed hastily,  or  unguardedly,  its  legs  would 
cross  each  other  involuntarily  by  which  it 
was  often  and  suddenly  thrown  down  ; that 
if  it  endeavoured  to  stand  still,  and  upright, 
unsupported  by  another  person,  its  knees 
would  totter  and  bend  under  it ; that  it  could 
not,  with  any  degree  of  precision  or  certain- 
ty, steadily  direct  either  of  its  feet  to  any 
particular  point,  but,  that  in  attempting  so  to 
do,  they  would  be  suddenly,  and  involunta- 
rily, brought  across  each  other ; that  soon 
after  this,  it  complained  of  frequent  pains 
and  twifebings  in  its  thigh s,  particularly 
when  in  bed,  and  of  an  uneasy  sensation  at 
the  pit  of  the  stomach  ; that  when  it  sat  on 
a chair,  or  a stool,  its  legs  were  almost  al- 
ways found  across  each  other,  and  drawn 
up  under  the  seat ; and  that  in  a little  time 
after  these  particulars  had  been  observed,  it 
totally  lost  the  power  of  walking. 

The  same  author  observes,  that  if  the  in- 
curvation be  of  the  neck,  and  to  a consider- 
able degree,  by  affecting  several  vertebrae, 
the  child  finds  it  inconvenient  and  painful  to 
support  its  own  head,  and  is  always  desirous 
of  laying  it  on  a table  or  pillow,  or  any  thing 
to  take  off  the  weight.  If  the  affection  be  of 
the  dorsal  vertebrae,  it  is  soon  attended  with 
loss  of  appetite,  hard  dry  cough,  laborious 


630  YERTKBR/E, 

respiration,  quick  pulse,  and  disposition  to 
hectic. 

Mr.  Pott  states,  that  an  adult,  in  a case 
where  no  violence  has  been  committed  or 
received,  will  tell  you  that  his  first  intima- 
tion was  a sense  of  weakness  in  his  back- 
bone, accompanied  with  what  he  will  call  a 
heavy  dull  kind  of  pain,  attended  with  such 
a lassitude  as  rendered  a small  degree  of 
exercise  fatiguing  ; that  this  was  soon  fol- 
lowed by  an  unusual  sense  of  coldness  in  his 
thighs,  not  accountable  for  from  the  weather, 
and  a palpable  diminution  of  their  sensibili- 
ty. That,  in  a little  time  more,  his  limbs 
were  frequently  convulsed  by  involuntary 
twitchings,  particularly  troublesome  in  the 
night;  that  soon  after  this,  he  not  only  be- 
came incapable  of  walking,  but  that  his 
power  either  of  retaining  or  discharging  his 
urine  and  feces  was  considerably  impaired, 
and  his  penis  became  incapable  of  erection. 

The  adult  also  finds  all  the  offices  of  his 
digestive  and  respiratory  organs  much  af- 
fected, and  complains  constantly  of  pain 
and  tightness  at  his  stomach. 

The  true  cause  of  the  disease  is  a morbid 
state  of  the  spine,  and  of  some  of  the  parts 
connected  with  it ; which  distempered  state  of 
parts  will , upon  careful  inquiry , he  always 
found  to  have  preceded  the  deformity  some 
length  of  time ; in  infants,  this  is  the  sole 
cause,  and  external  violence  has  nothing  to 
do  with  it.  “ In  the  adult  (says  Mr.  Pott)  I 
will  not  assert,  that  external  mischief  is  al- 
ways and  totally  out  of  the  question  ; but  I 
will  venture  to  affirm,  what  is  equal,  as  far 
as  regards  the  true  nature  of  the  case,  which 
is,  that  although  accident  and  violence  may, 
in  some  few  instances,  be  allowed  to  have 
contributed  to  its  more  immediate  appear- 
ance, yet  the  part  in  which  it  shows  itself, 
must  have  been  previously  in  a morbid 
state,  and  thereby  predisposed  for  the  pro- 
duction of  it.  I do  not  by  this  mean  to  say, 
that  a violent  exertion  cannot  injure  the' 
spine,  nor  produce  a paralytic  complaint : 
that  would  be  to  say  more  than  I know  ; 
but  I will  venture  to  assert,  thal  no  degree 
of  violence  whatever  is  capable  of  produ- 
cing such  an  appearance  as  lam  now  speak- 
ing of,  unless  the  bodies  of  the  vertebrae 
were  by  previous  distemper  disposed  to  give 
way;  and  that  no  supposable  dislocation, 
caused  by  mere  violence  done  to  the  bones 
of  the  back,  which  bones  were,  before  the 
receipt  of  the  injury,  in  a sound  state,  can 
possibly  be  attended  with  the  peculiar  symp- 
toms of  a curved  spine.” 

For  some  observations,  connected  with 
this  point,  I refer  the  reader  to  C.  Bell’s 
Surgical  Observations,  Vol.  1. 

Mr.  Brodie  agrees  with  Mr.  Pott,  and 
other  writers  on  the  fact,  that  the  actual 
curvature  must  be  preceded  by  a disease  of 
the  parts,  unaccompanied  with  any  visible 
deformity,  and  “ cannot  take  place  until  the 
caries  has  made  considerable  progress.”  In 
the  early  stage  of  the  case,  therefore,  when, 
as  Mr.  Brodie  justly  observes,  the  diagnosis 
is  of  the  most  importance,  no  information 
can  be  obtained  from  the  appearance  of  the 


DISEASE  OF. 

spine  itself,  the  shape  of  which  is  yet  un 
changed;  and  frequently  the  symptoms, 
which  do  take  place  early,  are  not  unequi- 
vocal ; they  are,  according  to  this  writer, 
“ a pain,  and  some  degree  of  tenderness  in 
thal  part  of  the  spine  where  the  disease  has 
begun;  a sense  of  constriction  of  the  chest; 
an  uneasy  feeling  at  the  pit  of  the  stomach, 
and  of  the  whole  abdomen ; a disturbed 
state  of  the  functions  of  the  alimentary  ca- 
nal, and  of  the  urinary  bladder;  a sense  of 
weakness  and  aching, and  occasional  cramps 
of  the  muscles  of  the  extremities.”  But,  as 
Mr.  Brodie  confesses,  very  similar  symptoms 
may  arise  from  other  causes,  and  sometimes 
no  particular  complaints  are  made  previ- 
ously to  the  actual  discovery  of  the  curva- 
ture. (On  Diseases  of  Joints,  p.  279,  280.) 

I have  already  mentioned  Mr.  ^rodie’s 
opinion,  deduced  from  dissection,  that,  in 
many  instances,  caries  of  the  spine  has  its 
origin  in  an  ulceration  of  the  intervertebral 
cartilages,  beginning  in  tbeir  centre,  and  ex- 
tending to  their  circumference,  and  after- 
ward affecting  the  bodies  of  the  contiguous 
vertebra  ; but  that,  in  other  cases,  the  dis- 
ease has  its  origin  in  the  bodies  of  the  verte- 
bra themselves,  which  are  liable  to  the  same 
peculiar  disease  of  the  cancellous  structure, 
which  is  noticed  in  the  articulating  extremi- 
ties of  other  bones.  (Brodie  on  Diseases  of 
Joints , p.  267.)  This  gentleman  suspects 
that  the  disease,  which  begins  in  the  cancel- 
lous structure  of  the  vertebra,  is  more  im- 
mediately followed  by  suppuration,  than 
that  which  commences  in  the  intervertebral 
cartilages  ; and  that  the  first  form  of  the  dis- 
ease seldom  occasions  so  extensive  a des- 
truction of  the  vertebrae,  as  the  last.  “ But 
(says  Mr.  Brodie)  farther  than  this,  nothing 
which  I have  hitherto  observed,  enables  me 
to  point  out  any  circumstances,  in  which 
the  symptoms  of  these  different  diseases 
differ.”  (P.276.)  Respecting  another  state- 
ment, that  when  the  lumbar  vertebra  are 
alone  affected,  the  symptoms  dependent 
on  pressure,  or  irritation,  of  the  spinal  mar- 
row, are  absent,  1 cannot  say  tbatit  accords 
with  several  cases  which  have  fallen  under 
my  own  notice,  that  is  to  say,  if  the  affection 
of  the  lower  limbs  is  to  be  received  as  a test 
of  such  irritation  or  pressure. 

According  to  Mr.  Pott,  the  true  curvature 
is  invariably  uniform,  in  being  from  within 
outward  ; but  it  varies  in  situation,  in  extent, 
and  in  degrees ; it  affects  the  neck,  the  back, 
or  the  loins  ; it  comprehends  one  vertebra 
only,  or  two,  or  more  ; and  as  few  or  more 
are  affected,  or  as  these  are  more  or  less 
morbid,  and  consequently  give  way  more  or 
less,  the  curve  must  be  different. 

In  these  cases,  as  Mr.  Brodie  remarks,  “the 
distortion  of  the  spine  is  usually  of  a pecu- 
liar kind,  and  such  as  nothing  can  produce, 
except  the  destruction  of  the  bodies  of  one 
or  more  vertebra.  Tbe  spine  is  bent  for 
ward,  so  as  to  form  an  angle  posteriorly ; 
and  although  the  destruction  of  the  vertebra? 
may  be  the  same,  it  is  more  obvious  in  some 
parts  of  the  spine  than  it  is  in  others.  For 
example-  the  spinous  processes  in  the  middle 


VERTEBRAE,  DISEASE  OF. 


631 


of  the  back  being  long,  and  projecting 
downwards,  the  elevation  of  one  of  these 
must  occasion  a greater  prominence  than 
that  of  one  of  the  spinous  processes  of  the 
neck,  which  are  short,  and  stand  directly 
backwards. 

“ Curvature  of  the  spine,  in  the  direction 
forwards,  may  arise  from  other  causes,  as  a 
"weak  condition  of  the  muscles,  or  a rickety 
affection  of  the  bones.  In  general,  in  such 
cases,  the  curvature  occupies  the  whole 
spine,  which  assumes  the  form  of  a segment 
of  a circle.  At  other  times,  however,  it 
occupies  only  a portion  of  the  spine,  usually 
that  which  is  formed  by  the  superior  lumbar 
and  inferior  dorsal  vertebrae.”  But  here, 
as  Mr.  Brodie  has  found,  the  curvature  is 
always  gradual,  and  never  angular  ; a cir- 
cumstance by  which  it  is  distinguishable 
from  the  curvature  produced  by  caries. 
The  cases,  however,  he  thinks,  have  often 
been  confounded,  and  some  speedy  and 
complete  cures  of  carious  spine  on  record, 
he  infers,  must  have  been  cases  of  an  entire- 
ly different  nature.  (On  Diseases  of  Joints, 
p.  282,  <$/•<:.  and  Earle , in  Edinb.  Med.  Journ. 
Jan.  1815.) 

Lateral  curvatures  of  the  spine  are  alleged 
generally  to  incline  to  the  right  side ; and 
the  fact  is  referred  (with  what  correctness 
I know  not,)  to  the  undue  power,  which  is 
acquired  by  the  more  general  use  of  the 
right  arm,  and  of  other  muscles,  in  the  per- 
formance of  the  voluntary  actions.”  (Boyn- 
ton on  Diseases  of  the  Spine,  p.  43.)  It  is 
admitted,  however,  that  exceptions  are  met 
with,  and  that  the  lateral  curvature  some- 
times tends  to  the  left,  and  occasionally 
resembles  the  letter  S reversed.  On  this 
subject,  I have  also  another  rare  exception 
to  specify,  which  is  explained  by  Mr.  Bro- 
die, viz.  that  though  lateral  distortions  of 
the  spine  generally  arise  from  causes  inde- 
pendent of  caries,  a slight  degree  of  lateral 
curvature  is,  in  some  instances,  produced 
by  the  bodies  of  ihe  vertebras  having  been 
destroyed  on  one  side  by  caries  in  a greater 
degree  than  on  the  other.  (Brodie  on  Joints, 
p.  284.) 

In  general,  the  lower  limbs  alone  usually 
feel  the  effect.  Mr.  Pott,  however,  had 
seen  two  cases,  in  one  of  which  the  arms 
only  were  affected  ; in  the  other,  both  legs 
and  arms.  Mr.  Ford  showed  him  a lad, 
who  hadfost  the  use  of  both  arms  and  legs 
from  a eif.Vature.  An  account  of  two  simi- 
lar examples  was  also  communicated  to  Mr. 
Pott  by  Mr.  Parke,  of  Liverpool. 

Mr.  Brodie  has  never  known  the  paralysis 
affect  the  muscles  of  the  arms,  when  the 
disease  was  at  the  lower  or  middle  part  of 
the  spine  ; but  he  agrees  with  Mr.  Cope- 
land, that  the  symptoms  are  not  always 
confined  to  parts  below  the  disease,  and 
that  it  is  not  uncommon  for  pains  in  the 
upper  extremities  to  accompany  the  para- 
lytic affection  of  the  legs  and  thighs.  (Bro- 
die, p.  285.  Copeland,  Obs.  on  Diseased 
Spine,  fyc.) 

Very  soon  after  tue  curvature,  some  pa- 
tfrhts  are  rendered  totally  and  absolutely 


incapable  not  only  of  walking,  but  of  using 
their  legs  in  any  manner  ; others  can  make 
shift  to  move  about  with  the  help  of  crutch- 
es, or  by  grasping  their  thighs  just  above 
the  knees  with  both  hands ; some  can  sit 
in  an  armed  chair,  without  much  trouble 
or  fatigue  ; others  cannot  sit  up  with  any 
help;  some  retain  such  a degree  of  power 
of  using  their  legs  as  to  be  able  to  shift, 
their  posture  when  in  bed;  others  have  no 
such  power,  and  are  obliged  to  be  moved 
upon  all  occasions. 

I have  been  present  at  the  dissection  of 
persons  who  died  of  lumbar  abscesses,  and 
who,  while  they  lived,  never  suffered  the 
peculiar  loss  of  the  use  of  the  lower  ex- 
tremities, so  well  described  by  Mr.  Pott,, 
though  the  vertebrae  were  found  to  be  dis- 
eased. However,  in  other  instances  of 
such  abscesses,  attended  with  caries  of  the 
spine,  the  legs  are  deprived  of  their  power. 
But,  whether  the  difference  is  to  be  ex- 
plained by  the  consideration,  that,  in  some 
cases,  the  disease  of  the  bone  may  be  se- 
condary and  the  abscess  itself  the  primary 
complaint,  I cannot  determine.  At  all 
events,  suppuration  is  frequently  only  an 
effect,  the  curvature  existing  long  before 
the  abscess;  and,  in  such  cases,  the  legs 
are  effected.  A few  weeks  ago,  Mr.  Dunn, 
of  Scarborough,  consulted  me  about  a case 
in  which  the  latter  facts  were  exemplified. 
Mr.  Brodie’s  opinion,  that  suppuration  takes 
place  at  an  earlier  period  in  cases  where 
the  disease  begins  in  the  cancellous  struc- 
ture of  the  bones,  has  been  already  noticed. 
In  having  a tendency  to  excite  suppuration, 
and  in  producing  the  weakness  of  the 
lower  extremities,  the  present  disease  of 
the  spine  appears  to  be  materially  different 
from  the  absorption  of  the  vertebras,  some- 
times caused  by  the  pressure  of  aneurisms, 
and  other  tumours.  (Hodgson  on  Diseases  of 
Arteries,  fyc.  p.  80.) 

Mr.  Pott  observes : — When  a child  ap- 
pears to  be  what  the  common  people  call 
naturally  weakly,  whatever  complaints  it 
may  have  are  supposed  to  be  caused  by  its 
weak  state,  and  it  is  generally  believed,  that 
time  and  common  care  will  remove  them  ; 
but  when  a curvature  has  made  its  appear 
ance,  all  these  marks  bf  ill  health,  such  as 
laborious  respiration,  hard  cough,  quick 
pulse,  hectical  heat  and  flushing,  pain  and 
tightness  of  the  stomach,  fcc.  are  more  at- 
tentively regarded,  and  set  to  the  account 
of  the  deformity  consequent  to  the  curve, 
more  especially  if  the  curvature  be  of  the 
dorsal  vertebra?,  in  which  case  the  deformi- 
ty is  always  greatest ; but  whoever  will 
carefully  attend  to  all  the  circumstances  of 
this  disorder,  will  be  convinced,  that  most, 
if  not  all  the  complaints  of  children,  labour 
ing  under  this’infirmity,  precede  the  curva- 
ture, and  that  a morbid  state  of  the  spine, 
and  of  the  parts  connected  with  it,  is  the 
original  and  primary  cause  of  both. 

Among  many  other  reasons  for  thinking, 
that  an  effect  was  mistaken  for  a cause,  Mr 
Pott  enumerates  the  following  : 

I That  he  did  not  remember  ever 


VERTEBKyE,  DldEASE  01'. 


o3  2 

have  seen  this  useless  state  of  the  limbs 
from  a mere  malformation  of  the  spine, 
however  crooked  such  malformation  might 
have  made  it. 

2.  “ That  none  of  those  deviations  from 
right  shape,  which  growing  girls  are  so  liable 
to,  however  great  the  deformity  might  be, 
was  ever  attended  with  this  effect.” 

With  respect  to  the  treatment  of  diseased 
spine,  I think  one  principle  laid  down  by 
Mr.  Pott,  must  receive  approbation  ; viz. 
that  the  primary  and  sole  cause  of  all  the 
symptoms  is  a distempered  state  of  the 
parts,  composing,  or  in  immediate  connex- 
ion with  the  spine,  tending  to,  and  most 
frequently  ending  in  a caries  of  the  verte- 
bra?. Hence,  says  he,  all  the  ills,  whether 
general  or  local,  apparent  or  concealed  ; 
the  ill  health  of  the  patient,  and  in  time  the 
curvature.  As  the  disease  does  not  origi- 
nate in  the  limbs,  no  application  to  them 
can  be  of  any  use,  and  the  great  indication 
must  be  to  stop  the  progress  of  the  disease 
in  the  affected  part  of  the  spine. 

The  first  suggestion  of  the  probability  that 
issues  might  prove  serviceable  in  this  dis- 
ease, appears  to  have  been  made  to  Mr. 
Pott  by  Dr.  Cameron,  of  Worcester,  who 
told  him,  that  having  remarked  in  Hippo- 
crates, an  account  of  paralysis  of  the  lower 
limbs,  cured  by  an  abscess  in  the  back,  he 
had  in  a case  of  useless  limbs,  attended  with 
a curvature  of  the  spine,  endeavoured  to 
imitate  this  act  of  nature,  by  exciting  a pu- 
rulent discharge,  and  that  it  had  proved  very 
beneficial : which  was  confirmed  to  Mr. 
Pott  by  Mr.  Jeffreys,  of  Worcester,  who 
had  made  the  experiment  with  the  same 
success. 

The  practice  which  Pott  recommends, 
consists  merely  in  procuring  a large  dis- 
charge of  matter  from  the  integuments  on 
each  side  of  the  distempered  bones  forming 
the  curvature,  and  in  maintaining  such  dis- 
charge until  the  patient  shall  have  recovered 
his  health  and  the  use  of  his  limbs.  They 
who  are  little  conversant  with  matters  of 
this  sort  (says  Mr.  Pott)  will  suppose  the 
means  very  inadequate  to  the  proposed 
end  ; but  they  who  have  been  experimen- 
tally acquainted  with  the  very  wonderful 
effects  of  purulent  drains,  made  from  the 
immediate  neighbourhood  of  diseases,  will 
not  be  so  much  surprised  at  this  particular 
one  ; and  will  immediately  see  how  such 
kind  of  discharge,  made  and  continued 
from  the  distempered  part,  checks  the  fur- 
ther progress  of  the  caries,  gives  nature  an 
opportunity  of  exerting  her  own  powers  of 
throwing  off  the  diseased  parts,  and  of  pro- 
ducing, by  incarnation,  an  union  of  the 
bones  (now  rendered  sound,)  and  thereby 
establishing  a cure. 

Mr.  Pott  considers  it  a matter  of  very 
little  importance  towards  the  cure,  by  what 
means  the  discharge  be  procured,  provided 
it  be  large,  that  it  come  from  a sufficient 
depth,  and  that  it  be  continued  for  a suffi- 
cient length  of  time.  He  tried  setons, 
issues  by  incision,  and  issues  by  caustic,  and 
found  the  last  in  general  preferable,  being 


least  painful,  most  cleanly,  most  easily  ma- 
nageable, and  capable  of  being  longest  con 
tinued. 

The  caustics,  he  observes,  should  be  ap- 
plied on  each  side  of  the  curvature  in  such 
a manner  as  to  leave  the  portion  of  skin, 
covering  the  spinal  processes  of  the  protru- 
ding bones  entire  and  unhurt,  and  so  large, 
that  the  sores  upon  the  separation  of  the 
eschars,  may  easily  hold  each  three  or  four 
peas,  in  the  case  of  the  smallest  curvature  ; 
but  in  large  curves,  at  least  as  many  more. 

The  issues  which  modern  surgeons  usually 
make,  for  the  relief  of  the  symptoms  arising 
from  diseased  vertebra?,  are  larger  than  such 
as  Mr.  Pott  himself  was  in  the  habit  of 
forming.  They  now  commonly  prefer 
making  an  issue  on  each  side  of  the  spinous 
processes,  about  three  or  four  inches  long, 
and  half  an  inch  broad. 

The  size  of  the  issue  intended  to  be  made 
being  determined,  the  place  where  it  is  to  be 
made  should  be  accurately  marked  out  with 
ink.  All  the  skin  immediately  around  should 
then  be  covered  with  adhesive  plaster,  in  or- 
der that  it  may  be  protected  from  the  action 
of  the  caustic.  Let  the  surgeon  next  take  a 
piece  of  caustic  potassa,  or  of  potassa  cum 
calce,  and  wrap  a little  tow  round  one  end 
of  it,  so  that  he  may  take  hold  of  it  with 
safety  and  convenience.  The  other  end  of 
the  caustic  should  then  be  moistened  a little, 
and  rubbed  very  quickly  on  the  portion  of 
the  integuments,  which  is  to  be  converted 
into  an  eschar.  The  caustic  is  to  be  rubbed 
in  this  manner,  till  the  part  turns  of  a dull 
brown  colour,  when  the  caustic  should  be 
carefully  washed  off  with  a little  wet  tow, 
and  a poultice  applied. 

As  soon  as  the  eschars  admit  of  being  re- 
moved, a row  of  peas,  or  beans,  connected 
together  with  thread,  should  be  laid  on  the 
sore,  and  confined  there  with  sticking  plas- 
ter. A compress,  containing  a piece  of 
pasteboard,  or  sheet-lead,  is  then  to  be  bound 
over  the  peas  or  beans  with  a roller.  In 
consequence  of  the  continued  pressure,  the 
peas  or  beans  soon  form  little  hollows  for 
themselves,  in  which  they  should  be  regu- 
larly placed  every  day.  When  the  pressure 
is  not  duly  maintained,  the  granulations  are 
apt  to  rise  so  high,  that  the  peas  cannot  be 
well  kept  on  the  part.  In  this  circumstance, 
the  surgeon  must  try  to  repress  the  high 
surface  of  the  sore,  by  sprinklin'*  on  it  a 
little  savine  powder  and  subacetat?  of  cop- 
per, mixed  together  in  equal  proportions. 
When  this  plan  is  unavailing,  the  reappli- 
cation of  the  caustic  becomes  indispensable. 

Whatever  time  may  be  requisite  to  restore 
the  health,  as  well  as  the  use  of  the  limbs, 
Mr.  Pott  thinks,  that  the  issues  should  be 
kept  open  until  these  objects  are  completely 
fulfilled;  and  even  longer,  especially  in 
growingchildren.  Heownsthat  nothing  can 
be  more  uncertain,  than  the  time  required 
for  the  cure.  He  has  seen  it  perfected  in 
two  or  three  months  ; and  he  has  known  it 
require  two  years  ; two-thirds  of  which  time 
passed  before  there  was  any  visible  amend- 
ment 


VERTEBRA,  DISEASE  01 


03o 


Alter  the  discharge  has  been  made  some 
time,  the  patient  is  found  to  be  better,  in  all 
general  respects,  and  if  of  age  to  distinguish, 
will  acknowledge,  that  he  feels  himself  to 
be  better  in  health  ; he  begins  to  recover 
his  appetite,  gets  refreshing  sleep,  and  has  a 
more  quiet  and  less  hectical  pulse  ; but  the 
relief  which  lie  feels  above  all  others*  is 
from  having  got  rid  of  that  distressing  sen- 
sation of  tightness  about  the  stomach  ; in  a 
little  time  more  a degree  of  warmth,  and  a 
sensibility  are  felt  in  the  thighs*  which  they 
had  been  strangers  to  for  some  time  ; and 
generally  much  about  the  same  time  the 
power  of  retaining  and  discharging  the  urine 
and  feces  begins  to  be  in  some  degree  exerted. 

The  first  return  of  the  power  of  motion 
in  the  limbs,  says  Mr.  Pott,  is  rather  disa- 
greeable ; the  motions  being  involuntary, 
and  of  the  spasmodic  kind,  principally  in 
the  night;  and  generally  attended  with  a 
sense  of  pain  in  all  the  muscles  concerned. 

At  this  point  of  amendment,  if  it  may  be 
so  called,  it  is  no  uncommon  thing,  espe- 
cially in  bad  cases,  for  the  patient  to  stand 
some  time  without  making  any  farther  pro- 
gress ; this,  in  adults,  occasions  impa- 
tience, and  in  parents,  despair;  but  in  the 
milder  kind  of  case,  the  power  of  voluntary 
motion  generally  soon  follows  the  involun- 
tary. 

The  knees  and  ankles,  by  degrees,  lose 
their  stiffness,  and  the  relaxation  of  the 
latter  enables  the  patient  to  set  his  feet  flat 
upon  the  ground,  the  certain  mark  that  the 
power  of  walking  will  soon  follow ; but 
those  joints  having  lost  their  rigidity,  be- 
come exceedingly  weak,  and  are  not  for 
sometime  capable  of  serving  the  purpose  of 
progression. 

An  attentive  examination  of  the  morbid 
appearances,  and  their  effects  in  different 
subjects,  led  Mr.  Pott  to  conclude,  among 
other  things,  that  the  disease  which  produ- 
ces these  effects  on  the  spine,  and  the  parts 
in  its  vicinity,  is  what  is  in  general  called 
scrofula. 

That  ulceration  or  caries  of  the  bodies  of 
the  vertebras  affected,  is  the  common  morbid 
change,  and  not  enlargement. 

That  when  the  attack  is  made  upon  the 
dorsal  vertebrae,  the  sternum  and  ribs,  for 
want  of  proper  support,  necessarily  give 
way,  and  deformity,  additional  to  the  curve, 
is  produced. 

That  this  kind  of  caries  is. always  confined 
to  the  bodies  of  the  vertebae,  seldom  or 
never  affecting  the  articular  processes. 
Two  cases  were  seen  by  Pott,  in  which  the 
bodies  of  the  vertebrae  were  completely  de- 
tached from  their  processes,  so  as  to  leave 
the  membrane  of  the  spinal  marrow  per- 
fectly bare. 

That  without  this  destruction  of  the  bodies 
of  the  vertebrae,  there  can  be  no  curvature 
of  the  kind  here  treated  of ; or  in  other 
words,  that  erosion  is  the  sine  qud  non  of 
this  disease  ; that  although  there  can  be  no 
true  curve  without  caries,  yet  there  is,  and 
that  not  infrequently,  caries  without  curve. 

That  the  caries  with  curvature  and  useless 
fVoL.1T.  SO 


limbs,  is  most  frequently  of  the  cervical  or 
dorsal  vertebrae,  the  caries  without  curve, 
of  the  lumbal,  though  this  is  by  no  means 
constant  or  necessary. 

That  in  the  case  of  carious  spine  without 
curvature,. it  most  frequently  happens,  that 
internal  abscesses,  and  collections  of  matter 
are  formed,  which  matter  makes  its  way 
outward,  and  appears  in  the  hip,  groin,  or 
thigh  ; or  being  detained  within  the  body, 
destroys  the  patient : the  real  and  immedi- 
ate cause  of  whose  death  is  seldom  known, 
or  even  rightly  guessed  at,  unless  the  dead 
body  be  examined. 

That  what  are  commonly  called  lumbal 
and  psoas  abscesses,  are  not  infrequently 
produced  in  this  manner,  and  therefore, 
when  we  use  these  terms,  we  should  be 
understood  to  mean  only  a description  of 
the  course,  which  such  matter  has  pursued 
in  its  way  outward,  or  the  place  where  it 
makes  its  appearance  externally,  the  terms 
really  meaning  nothing  more,  nor  convey- 
ing any  precise  idea  of  the  nature,  seat,  or 
origin  of  a distemper  subject  to  great  varie- 
ty, and  from  which  variety  its  very  different 
symptoms  and  events  in  different  subjects, 
can  alone  be  accounted  for. 

That  contrary  to  the  general  opinion,  a 
caries  of  the  spine  is  more  frequently  a 
cause,  than  an  effect  of  these  abscesses. 

That  the  true  curvature  of  the  spine  from 
within  outward,  of  \yhich  the  paralytic,  or 
useless  state  of  the  lower  limbs,  is  a too  fre- 
quent consequence,  is  itself  but  one  effect  of 
a distempered  spine  ; such  case  being  al- 
ways attended  with  a number  of  complaints, 
which  arise  from  the  same  cause  : the  gene- 
rally received  opinion,  therefore,  that  all  the 
attending  symptoms  are  derived  from  the 
curvature,  considered  abstractedly,  is  by  no 
means  founded  in  truth,  and  may  be  pro- 
ductive of  very  erroneous  conduct. 

That  when  two  or  more  vertebrae  are  af- 
fected, forming  a large  curve,  however  per- 
fect the  success  of  the  treatment  may  be 
with  regard  to  the  restoration  of  health  and 
limbs,  yet  the  curvature  will  and  must  re- 
main, in  consequence  of  the  union  of  the 
bones  with  each  other. 

That  the  useless  state  of  the  limbs  is  by  no 
means  a consequence  of  the  altered  figure 
of  the  spine,  or  of  the  disposition  of  the 
bones  with  regard  to  each  other,  but  merely 
of  the  caries : of  this  truth  there  needs  no 
other  proof,  than  what  may  be  drawn  from? 
the  cure  of  a large  and  extensive  curvature, 
in  which  three  or  more  vertebras  were  con- 
cerned : in  this  the  deformity  always  remains 
unaltered  and  unalterable,  notwithstanding 
the  patient  recovers  both  health  and  limbs. 

Pott  contends,  that  a morbid  state  of  the 
parts,  previous  to  deformity,  caries,  or  curve, 
must  be  allowed.  All  the  general  complaints 
of  persons  afflicted  with  this  disorder,  he 
says,  will,  upon  careful  inquiry,  be  found  to 
have  preceded  any  degree  of  deformity,  to 
hatfe  increased  as  the  curve  became  appa- 
rent, and  to  have  decreased  as  the  means 
used  for  relief  took  place;  the  pain  and 
tightness  about  the  stomach,  the  indigestion 


VERTEBR/E,  DISEASE  OF. 


cm 


(he  want  of  appetite,  the  disturbed  sleep,  &c. 
&c.  gradually  disappear,  and  the  marks  of 
returning  health  become  observable  before 
the  limbs  recover  the  smallest  degree  of  their 
power  of  moving. 

On  the  other  hand,  is  admitted  to  be  as 
true,  that  when  from  extent,  or  degree,  or 
inveteracy  of  the  caries,  the  issues  are  found 
to  be  unequal  to  the  wished-for  effect,  the 
general  complaints  receive  no  amendment  ; 
but  increase  until  the  patient  sinks  under 
them. 

If  all  this  be  true,  says  Mr.  Pott,  and  it 
be  found  that  the  issues  are  capable  of  ef- 
fecting a perfect  cure,  even  after  a caries 
has  taken  place,  and  that  to  a considerable 
degree,  is  it  not  reasonable  to  conclude,  that 
the  same  means,  made  use  of  in  due  time, 
might  prove  a preventive  ? 

Besides  the  forms  of  disease  of  the  spine 
treated  of  in  this  article,  the  observations  of 
Mr.  Wilson  prove,  that  the  distemper  may 
sometimes  begin  within  the  theca  vertebralis, 
and  thence  extend  to  the  bones.  He  also 
demonstrated,  at  the  College  of  Surgeons, 
scrofulous  tumours  in  the  spinal  marrow. 
Such  diseases  would  create  a loss  of  power 
in  the  parts  below  them,  without  any  curva- 
ture of  the  spine.  {Lectures  on  the  Skeleton , 
fyc.p.  397.) 

In  France,  the  same  indication  is  followed 
as  that  on  which  Mr.  Pott  lays  stress,  viz.  to 
endeavour  to  arrest  the  disease  of  the  spine 
hy  means  applied  in  the  vicinity  of  the  mor- 
bid parts.  But  instead  of  employing  caustic 
issues,  the  tnoxa  is  used,  and  sometimes  re- 
peated cupping  near  the  affected  bones ; 
both  which  means  were  particularly  re- 
commended by  Desault. 

Another  practice,  which  yet  lias  partisans, 
though  it  was  strongly  disapproved  of  by 
Pott,  is  that  of  supporting  the  spine  with  ma- 
chinery. Perhaps  the  latter  author  may  have 
carried  his  objections  to  this  method  beyond 
all  reason,  and  with  the  exception  of  Dr. 
Harrison,  (see  Lond.  Med.  and  Physical 
Journ.  JYov.  1820,)  I believe  no  modern 
practitioner  now  ever  advises  it  on  t »e  sup- 
position of  there  being  any  dislocation;  an 
error  which  formerly  prevailed.  As  Mr. 
Biodie  observes, certainly  no  machines  ought 
ever  to  be  employed  for  the  purpose  of  elon 
gating  the  spine  and  correcting  the  deformi- 
ty : but  if  they  be  used  simply  to  take  off 
the  weight  of  the  head,  chest,  and  upper  ex- 
tremities, from  the  diseased  part  of  the  spine, 
they  may  sometimes  be  of  service.  The 
late  Sir  James  Earle  had  a very  favourable 
opinion  of  their  utility.  I believe,  with  Mr. 
Brodie,  that  they  ought  never  in  the  iirst  in- 
stance to  supersede  the  constant  mainte- 
nance of  the  horizontal  position  ; but  that 
they  may  be  advantageous,  when  circum- 
stances make  it  desirable  that  the  patient  be- 
gin to  sit  up  a part  of  the  day.  (On  Diseases 
cf  the  Joints,  p.  291.) 

From  Mr.  Poll’s  own  account,  it  will  be 
seen,  that  he  never  pretended  that  issues, 
kept  open  in  the  vicinity  of  the  disease,  were 
infallible;  and  a late  eminent  surgeon  has 
actually  referred  the  good  which  Pott 


thought  accrued  from  them,  to  the  Song  ob 
servance  of  the  horizontal  posture.  Mr, 
Baynton,  the  gentleman  to  whom  I allude, 
also  mentions,  that  M.  David  is  the  only 
writer  who  has  suggested  that  rest  would 
affect  the  cure  of  diseases  of  the  spine.  On 
this  point,  however,  Mr.  Baynton  was  en- 
tirely mistaken,  as,  about  eighteen  years 
ago,  Loder  wrote  some  remarks,  particularly 
directed  to  the  object  of  recommending  quie- 
tude in  the  present  disease,  as  the  best  means 
of  promoting  anchylosis.  (See  Med.  Chir . 
Beobachlungen,  p.  251  ; 8 vo.  Weimar , 1794.) 

Now,  although  I fully  concur  in  the  pro- 
priety of  keeping  the  patient  as  quiet  as  pos- 
sible in  the  recumbent  position,  inasmuch 
as  motion  must  be  hurtful  to  t he  diseased 
part  of  the  spine,  it  does  not  follow,  that  be- 
cause this  admission  is  made,  that  issues 
should  be  rejected,  and  that  rest  must  do 
every  thing.  In  one  part  of  Mr.  Baynton’s 
reasoning,  an  error  prevails,  which  I shall 
here  notice,  as  it  seems  greatly  to  have  influ 
enced  his  opinions;  and  as  far  as  I know  it 
has  not  been  remarked  by  the  critical  exa- 
miners of  that  gentleman’s  book.  The  mis 
take  is  in  supposing,  that  the  process  by 
which  the  diseased  part  of  the  spine  is  to  be 
restored  and  united,  should  be  conducted 
exactly  on  the  same  principles  as  the  union 
of  bones  free  from  disease.  In  fact,  there  is 
an  additional  indication,  which  is  to  stop  the 
progress  of  the  disease,  for  which  purpose, 
experience  proves  that  issues,  aided  by  rest , 
are  the  means  affording  the  best  chances  of 
success.  I have  attended  several  children 
myself,  who,  from  the  effect  of  issues,  reco- 
vered the  use  of  their  lower  extremities, 
even  though  they  could  not  be  kept  constant- 
ly at  rest.  1 must  also  give  my  testimony 
to  the  truth  of  Mr.  Brodie's  statement,  that 
many  patients  are  benefited  almost  immedi- 
ately the  issues  are  made,  or  uniformly  -find 
themselves  better  after  each  application  of 
the  caustic.  {On  Diseases  of  Joints,  p.  282.) 
In  some  cases,  however,  caustic  issues  fail 
to  affosd  relief;  and  when  they  are  of  no 
use,  rest  in  the  horizontal  posture,  below 
ground,  I believe  must  soon  be  the  patient’s 
doom.  Whether  the  occasional  failure  of 
issues. is  to  be  ascribed  to  the  advanced  pro- 
gress which  the  disease  has  made,  or  to  its 
having  begun  in  the  cancellous  structure  of 
the  vertebrae,  as  suggested  by  Mr.  Brodie, 
future  observation  must  decide. 

Consult  Pott's  Chirurgical  Works,  Vol.  8. 
G.  Gebb,  Select  Cases  of  the  Disorder , com- 
monly  termed  Paralysis  of  the  Lover  Extre- 
mities, 8 vo.  Lond.  1782.  C.  H.  Wilkinson , 
Essays  on  Distortion  of  the  Spine , fyc.  8 vo. 
Lond.  179S.  Loder , Med.  Chir.  Beobachlun- 
gen, B.  1 ,p.  247,  fyc.  8 vo.  Weimar,  1794.  J. 
C.  Frank,  Oralio  de  Vertebralis  Columnar  in 
Morbis  Dignilale ; Pavia,  1791.  C.  Van 
Boy,  De  Scoliasi,  Alo.  Lugd.  1774.  Sir  J 
Earle,  Observations  on  the  Cure  of  Curved 
Spine  ; in  which  the  effect  of  Mechanical  As- 
sistance is  considered,  Svo.  Loud.  1803.  Gius- 
eppe Bergamaschi,  Osservazioni  sulla  Injlam- 
mazione  dello  Spinale  Medollo  e dellc  sue 
Membrane  ; 4to  Par.  1810.  T.  Baynton.  Jh- 


WAR 


win 


<>35 


Account  of  a Successful  Method  of  Treating 
Diseases  of  the  Spine ; Sro.  Bristol , 1813. 
11.  Earle , in  Edinb . Med.  and  Surg.  Jo  urn. 
for  January , 1815.  J.  L.  Chbulant , Decas 
Pelvium  Spinarumquc  Deformatarum  ; 4/o. 

1818.  G.  Malseh,  de  nova  Machina 
Graefiana  Distortiones  Spince  Dorsi  ad  Sanan- 
das,  necnon  Disquisitio  DeformHatum  ista- 
rum ; 4to.  Berol.  1818.  Abercrombie , in 
Edinb . Med.  and  Surg.  JournJ  for  January , 
1818.  Kapeler,iu  Annuaire  Mcd.Ckir.  dcs 
Hdpitaux  de  Paris,  T.  i , p.  390  ; 4 to.  Paris, 
3819.  T.  Copeland,  Obs.  on  the  Symptoms 
and  Treatment  of  Diseased  Spine  ; Svo.  B.  C. 
Brodie,  Pathological  and  Surgical  Observa- 
tions on  the  Joints p.  257,  fyc.  Svo.  Bond. 


1818.  James  Wilson , Lectures  on  the  Struc- 
ture and  Physiology  of  the  Skeleton,  and  on 
the  Diseases  of  the  Bones  and  Joints  ; p.  395, 
8 vo.  Bond.  1820. 

VINEGAR.  (Sec  Acetic  Acid.) 

^ VINUM  0111.  Take  of  extract  of  opium 
^i,  cinnamon  bark  bruised,  cloves  bruised, 
of  each  3j ; wine  a pint.  Macerate  for 
eight  days,  and  filter.  The  thebaic  tincture, 
or  liquid  laudanum  of  Sydenham,  in  sur- 
gery, it  is  often  preferred  to  the  common 
tincture  of  opium,  as  an  application  to  tiie 
eye. 

VIPER,  BITE  OF.  See  Wounds. 

VOLVULUS,  (from  voivo.  to  roll  up.'* 
See  Intussusception. 


w. 


~Wf  ART.  Mr.  Hunter  observes,  that  a 

V ▼ wart  appears  to  be  an  excrescence 
from  the  cutis,  or  a tumour  formed  upon  it, 
by  which  means  it  becomes  covered  with  a 
cuticle,  which  is  either  strong  and  hard,  or 
thin  and  soft;  just  as  the  cuticle  is  which 
covers  the  parts,  from  which  the  excres- 
cence arises.  Warts  are  radiated  from  their 
basis  to  their  circumference.  The  surface 
of  the  radii  appears  to  be  pointed,  or  granu- 
lated, like  the  surface  of  healthy  granula- 
tions, with  the  exception  of  being  harder, 
and  rising  higher.  The  surface  on  which 
the  wart  is  formed,  seems  only  to  be  capa- 
ble of  producing  one;  for  the  surrounding 
and  connecting  surface  does  not  throw  out 
a similar  substance.  Thus,  when  a wart  has 
once  begun  to  grow,  it  rises  higher  and 
higher,  without  becoming  larger  at  its  basis. 
Such  excrescences  seem  to  have  within 
themselves  the  power  of  growing ; for,  as 
Hunter  remarks,  after  they  have  risen  above 
the  surface  of  the  skin,  on  which  their  basis 
cannot  grow  larger,  they  swell  out  into  a 
round  thick  substance,  which  becomes 
rougher  and  rougher. 

In  consequence  of  this  structure,  warts 
are  very  liable  to  be  hurt  by  bodies  rubbing 
against  them,  and  from  such  a cause,  they 
often  bleed  very  profusely,  and  are  rendered, 
sore  and  painful.  (On  the  Venereal  Disease, 
p.  250,  Edit.  2.) 

As  warts  are  adventitious  substances,  and 
not  any  part  of  the  original  structure  of  the 
body,  their  powers  of  life  are  weak.  Hence 
when  stimulated,  they  generally  become 
smaller,  and  at  length  altogether  disappear, 
or  drop  off. 

On  this  principle,  warts  may  frequently 
be  cured  by  the  application  of  the  sulphate 
of  copper,  or  a powder,  composed  of  the 
powders  of  savine  leaves,  and  the  subace- 
tate of  copper,  in  equal  proportions. 

However,  the  employment  of  stronger 
escharotics,  like  the  nitrate  of  silver,  or  the 
concentrated  acetic  acid  ; the  removal  of 
such  excrescences  with  a knife,  or  pair  of 
scissors;  or  tying  their  necks  with  a liga- 


ture, is  a mode  frequently  preferred,  be- 
cause the  cure  is  sooner  accomplished. 

The  two  last  methods  are  eligible,  when 
the  wart  has  a narrow  neck;  but  after  the 
removal  of  the  excrescence,  it  is  still  proper 
to  touch  the  root  with  the  caustic,  or  the 
acetic  acid;  for  unless  the  whole  be  com- 
pletely destroyed,  the  wart  will  inevitably 
grow  again. 

Warts  on  the  pudenda,  and  about  the 
anus,  scarcely  ever  withstand  the  effect  of 
the  powder  of  savine,  and  subacetate  of 
copper,  though  they  will  sometimes  resist 
a course  of  mercury,  adequate  to  cure  lues 
venerea  ; a consideration,  which  led  Mr. 
Hunter  to  believe  them  not  to  be  syphilitic. 
In  this  opinion,  I believe  all  the  best  sur- 
geons of  the  present  day  concur.* 

WHITLOW.  ( Panaris , Onychia,  Pana- 
ritium, Paronychia.)  A whitlow  is  an  in- 
flammation, about  the  end  of  the  finger, 
exceedingly  painful,  and  very  much  disposed 
to  suppurate.  The  toes  are  also  sometimes 
the  seat  of  the  disease. 

Writers  usually  divide  Whitlows  into  four 
kinds.  In  the  first,  or  mildest,  a vesicle, 
filled  with  matter,  commonly  arises  near  the 
root,  or  side  of  the  nail,  after  a superficial 
inflammation  of  trivial  extent.  The  matter 
is  situated  immediately  under  the  cuticle. 
Sometimes  the  abscess  takes  place  under  the 
nail,  in  which  case,  the  pain  is  severe,  and 
not  unfrequently  shoots  upward,  as  far  as 
the  external  condyle. 

* The  ligature  is  as  effectual  and  convenient  as  any 
method  recommended,  for  the  removal  of  warts. 
But  as  warts  have  seldom  necks  sufficient  to  retain  the 
thread,  I have  been  in  the  habit  of  resorting  to  a plan 
which  1 have  always  found  successful,  to  the  entire 
removal  of  warts.  Take  a fine  sewing  needle,  armed 
with  strong  silk,  and  pass  it  through, the  centre  of  the 
tumour  at  its  base,  taking  care  to  go  deep  enough,  that 
the  whole  disease  may  be  included,  then  by  tying  this 
at  each  side,  of  sufficient  tightness  to  interrupt  the  cir- 
culation, the  wart  will  dropoff  within  the  w'eek,  without 
inconvenience  to  the  patient.  From  the  manner  in 
which  the  ligatures  are  applied,  there  is  no  possibility 
of  their  coming  off,  until  the  disease  come  with  it.  In 
this  way,  I have  freed  a hand  from  a dozen  at  one 
time,  to  the  great  satisfaction  of  the  individual  ; and 
when  removed  in  this  manner,  I have  never  found 
them  recur-  Am.  Ed. 


636 


WHITLOW 


The  second  kind  of  whitlow  is  chieGy  situ- 
ated in  the  cellular  substance  under  the 
cutis,  and,  for  the  most  part,  occurs  at  the 
very  end  of  the  finger.  In  this  sort  of  case, 
the  inflammatory  symptoms,  especially  the 
pain,  are  far  more  violent  than  in  other 
common  inflammations  of  net  greater  extent. 
However,  although  the  pain  is  thus  severe, 
it  does  not  in  general  extend  far  from  the 
part  affected.  Writers  usually  impute  the 
violence  of  the  pain,  and  the  considerable 
degree  of  inflammation  attending  the  com- 
plaint, to  the  hard  and  unyielding  nature  of 
the  skin  on  the  finger.  To  the  same  cause 
they  also  ascribe  the  difficulty  of  perceiving 
any  fluctuation  after  matter  is  formed  ; and 
the  slowness  with  which  the  pus  makes  its 
Way  outward. 

The  third  kind  of  whitlow  is  distinguish- 
able from  the  others  by  the  following  cir- 
cumstances. With  the  most  excruciating 
pain,  there  is  very  little  swelling  in  the 
affected  finger,  but  a vast  deal  in  the  hand, 
particularly  about  the  wrist,  and  over  the 
whole  fore-arm.  The  pain  extends  to  the 
hand,  wrist,  elbow,  and  even  the  shoulder. 
When  suppuration  takes  place,  a fluctuation 
can  never  be  felt  in  the  finger,  though  it 
may  very  often  be  distinctly  perceived  in 
the  hand,  at  the  wrist,  or  even  somewhere 
in  the  fore-nrrn.  The  case  is  frequently  ac- 
companied with  considerable  fever.  The 
disease  is  seated  in  the  tendons  and  their 
sheaths,  and  the  power  of  moving  the  fin- 
gers, and  even  the  whole  hand,  is  lost. 

Authors  describe  the  fourth  kind  of  whit- 
low as  arising  principally  from  an  inflamma- 
tion of  the  periosteum.  The  case  is  attend- 
ed with  one  peculiarity,  which  is,  that,  how- 
ever violent  the  pain  may  be,  it  never  ex- 
tends to  the  hand  and  fore-arm,  nor  is 
there  any  external  swelling  of  the  affected 
finger.  Suppuration  generally  follows  very 
soon,  the  usual  consequence  of  which  is  a 
caries,  or  rather  a necrosis,  of  the  subjacent 
finger-bones. 

Whitlows  commonly  begin  on  the  inside 
of  the  fingers ; but  they  do  occasionally 
Commence  on  the  back  of  these  parts,  and 
even  on  that  of  the  hand.  Though  pain 
about  the  wrist  is  usually  the  effect  of  in- 
flammation in  the  finger,  Acrel  mentions  a 
case  in  which  the  disorder  was  altogether 
confined  to  the  hand  itself.  ( Vorfalle , 2 
B.  p.  191.) 

Mr.  Wardrop  has  favoured  the  public 
with  an  account  of  a particular  species  of 
whitlow,  which,  from  its  malignant  cha- 
racter, he  has  denominated  the  onychia  ma- 
ligna. “The  commencement  of  this  dis- 
ease is  marked  by  a degree  of  swelling,  of 
a deep  red  colour,  in  the  soft  parts  at  the 
root  of  the  nail.  An  oozing  of  a thin  ichor 
afterward  takes  place  at  the  cleft  formed 
between  the  root  of  the  nail  and  soft  parts, 
and  at  last  the  soft  parts  begin  to  ulcerate. 
The  ulcer  appears  on  the  circular  edge  of 
the  soft  parts  at  the  root  of  the  nail ; it  is  ac- 
companied with  a good  deal  of  swelling, 
and  the  skin,  particularly  that  adjacent  to 
the  nicer,  ha®  a deep  purple  colour.  The 


appearance  of  the  ulcer  is  very  unhealthy, 
the  edges  being  thin  and  acute,  and  its  sur- 
face covered  with  a dull  yellow,  or  brown- 
coloured  lymph, 'and  attended  with  au  ichor- 
ous and  very  fetid  discharge.  The  growth 
ol  the  nail  is  interrupted,  and  loses  its  na- 
tural colour,  and  at  some  places  appears  to 
have  but  little  connexion  with  the  soft  parts. 
In  this  state  (says  Mr.  Wardrop)  l have 
seen  the  disease  continue  for  several  years, 
so  that  the  toe,  or  finger,  became  a deform- 
ed bulbous  mass.  The  pain  is  sometimes 
very  acute  ; but  the  disease  is  more  com- 
monly indolent,  and  accompanied  with  lit- 
tle uneasiness.  The  disease  affects  both  the 
toes  and  the  fingers.  I have  only  observed 
it  on  the  great  toe,  and  more  frequently  on 
the  thumb,  than  any  of  the  fingers.  It  occurs, 
too,  chiefly  in  young  people  •,  but  I have 
also  seen  adults  affected  with  it.”  (IVar- 
drop , in  Med.  Chir.  Trans.  Vol.  5,  />.  135, 
136.) 

The  causes  of  whitlows  are  generally  of  a 
local  nature.  Writers  enumerate  the  fol- 
lowing as  the  most  common  : a contusion  ; 
suddenly  warming  the  finger  when  it  is  ex- 
ceedingly cold  ; pricks  with  needles, . or 
other  sharp  instruments  ; and  the  insinua- 
tion of  irritating  matter  into  scratches  on  the 
finger.  A surgeon,  in  operating  lor  a fistula 
in  ano,  has  been  known  to  cut  his  finger, 
and  have,  in  consequence  of  the  accident, 
a very  severe  and  dangerous  kind  of  whit- 
low. Richter  also  mentions  a person  who 
had  a most  obstinate  whitlow,  in  conse- 
quence of  a slight  wound  on  the  finger,  in 
examining  the  head  of  a horse  that  had  the 
glanders.  Sometimes  the  cause  of  a whit- 
low depends  on  a splinter,  or  thorn,  which 
continues  lodged  in  the  part.  Very  often, 
no  particular  cause  whatever  can  he  assign- 
ed for  the  complaint. 

The  first  case,  which  occurs  about  the 
root  of  the  n§il,  ought  to  be  opened  as 
soon  as  possible.  When  this  plan  is  not 
adopted,  the  matter  is  apt  to  penetrate  more 
deeply,  reach  the  root  of  the  nail,  and  occa- 
sion a loss  of  this  part.  When  an  effectual 
opening  is  not  made,  the  matter  collects 
again.  In  general,  a detachment  of  the  cu- 
ticle takes  place  as  far  as  the  abscess  extends. 
When  the  inflammation  has  been  very  vio- 
lent, and  the  matter  has  made  its  way  as  far 
as  the  root  of  the  nail,  the  nail  itself  is  in 
general  gradually  detached,  while  the  denu- 
ded portion  of  the  root  of  the  nail  acts  on 
the  sore  as  a foreign  body,  and  hinders  it 
from  healing.  Hence  the  surgeon  should 
repeatedly  cut  away  as  much  of  the  lower 
edge  of  the  nail  as  he  can,  and  insinuate  a 
little  soft  lint  between  the  margin  of  the 
nail  and  the  sore,  in  order  to  keep  the  latter 
from  being  irritated  by  the  former.  In  pro- 
portion as  the  old  nail  gradually  separates, 
a new  one  makes  its  appearance. 

When  matter  lies  under  the  nail,  an  open- 
ing should  be  made  through  the  part  as 
speedily  us  possible,  for  the  discharge  of  the 
abscess.  In  order  to  perform  this  operation, 
Richter  advises  the  surgeon  to  scrape  the 
naj!  with  a piece  of  glass,  till  it  is  as  thin  ns 


whitlow. 


637 


a can  well  be,  when  it  may  be  cut  through 
with  a bistoury. 

In  the  secoml  species  of  whitlow,  suppu- 
ration may  sometimes  be  prevented,  and 
the  inflammation  be  resolved,  by  the  timely 
employment  of  proper  means.  When  the 
pain  is  violent,  and  acute  fever  prevails,  it 
may  be  adviseable  to  bleed  the  patient.  In 
a few  severe  cases,  the  application  of  three 
or  four  leeches  to  the  affected  finger  has 
been  known  to  procure  prompt  relief. 

( Schmucker .)  Theden  thinks,  that  applying 
a roller  round  the  finger,  hand,  and  arm, 
and  frequently  wetting  the  first  two  parts 
with  a lotion,  the  most  certain  means  of 
resolving  the  inflammation.  Platner  advi- 
ses the  finger  to  be  for  some  time  immersed 
in  water  as  warm  as  the  patient  can  bear. 
Some  recommend  the  external  use  of  cam- 
phorated spirit,  or  the  volatile  alkali : while 
others  advise  the  affected  finger  to  be  plun- 
ged in  a warm  solution  of  soap,  or  kali. 
When  the  whitlow  is  occasioned  by  a prick, 
particular  care  must  be  taken  that  no  extra- 
neous substance  remain  in  the  puncture. 

When  the  symptoms  do  not  lessen  by  the 
fourth  day,  Richter  recommends  an  open- 
ing to  be  made.  Even  when  no  fluctuation 
is  discovered,  he  approves  of  making  a cru- 
cial incision  in  the  seat  of  the  pain,  and  he 
states,  that  although  no  matter  may  be  dis- 
charged, the  patient  always  derives  infinite 
relief  from  the  operation.  The  benefit,  he 
says,  may  either  be  imputed  to  the  bleeding, 
or  to  the  division  of  the  hard  tense  skin 
which  compresses  the  subjacent  inflamed 
parts.  Sometimes  the  collection  of  matter 
can  be  plainly  felt,  and,  in  this  case,  there 
can  be  no  hesitation  about  the  place  where 
the  opening  should  be  made.  However,  it 
may  lie  proper  to  remark,  that  the  opening 
should  always  be  made  sufficiently  large. 
When  the  surgeon  makes  a small  puncture, 
it  soon  closes  again,  and  a repetition  of  the 
operation  become^  necessary.  When  open- 
ing the  abscess  is  delayed,  the  theca  of  the 
flexor  tendons  easily  becomes  affected,  or 
the  matter  may  spread  to  a considerable  exr 
tent  under  the  skin.  Sometimes  it  makes 
its  way  through  the  cutis  by  ulceration,  and 
raises  up  the  cuticle.  In  this  case,  as  soon 
as  the  cuticle  has  been  opened,  a director 
should  he  introduced  into  the  aperture  in 
the  skin,  and  the  latter  opening  be  enlarged 
with  a bistoury. 

The  third  species  of  whitlow  seldom 
affects  the  last  phalanx  of  the  fingers;  but, 
generally,  the  second  or  third.  In  this  case, 
Richter  enjoins  us  never  to  defer  making  an 
opening  longer  than  the  third  day.  If  we 
wait  till  suppuration  happens,  we  shall  wait 
till  the  tendons  are  destroyed,  and  the  use 
of  the  finger  lost.  In  the  case  under  consi- 
deration, the  matter  is  always  of  bad  qua- 
lity, and  very  small  in  quantity.  A fluctua- 
tion in  the  finger  can  seldom  be  felt.  How- 
ever, in  a few  instances,  the  matter  is  per- 
ceptible at  the  extremity  of  the  finger,  or 
about  the  finger-joints,  but,  more  often,  in 
the  palm  of  the  hand,  or  near  the  wrist. 
In  these  circumstances,  the  tendons  are  in 


general  already  destroyed,  and  a stiffness 
of  the  finger  and  hand  is  to  be  apprehended 
When  the  complaint  is  the  consequence  of 
a puncture,  the  best  plan,  according  to 
Richter,  is  at  once  to  enlarge  the  wound; 
for,  in  this  sort  of  case,  all  other  methods 
are  unavailing.  It  is  not  enough,  however, 
to  cut  through  the  skin  ; the  tendinous  theca 
itself  must  be  laid. open. 

When  a collection  of  matter  forms  to- 
wards the  wrist,  attended  with  violent  pain 
in  that  situation,  an  opening  must  also  be 
made  there.  If  an  opening  should  have 
been  already  made  in  the  hand,  a probe 
may  be  introduced  into  the  wound,  and  ano- 
ther aperture  made  in  an  eligible  situation, 
by  cutting  on  the  end  of  the  instrument. 
In  the  same  way,  Richter  advises  an  open- 
ing to  be  made  in  any  part  of  the  fore-arm, 
where  great  pain,  or  the  symptoms  of  sup- 
puration, may  indicate  its  propriety. 

In  the  fourth  kind  of  whitlow,  early  inci- 
sions, made  down  to  the  bone,  are  the  most 
certain  means  of  obviating  the  danger. 
When  such  incisions  are  not  made  early 
enough,  suppuration  takes  place,  and  the 
bone  becomes  carious.  The  cut  is  to  be 
made  iu  the  place  where  the  pain  is  most 
severe.  When  the  first  phalanx  is  affected, 
the  incision  may  be  made  in  front  of  the 
finger  : but  when  the  second  or  third  is  the 
seat  of  the  complaint,  the  opening  should  be 
made  on  one  side.  However,  in  order  that 
the  opening  may  be  useful,  it  is  absolutely 
necessary  to  make  it  down  to  the  bone. 
When  the  incision  is  delayed  too  long,  a 
small  quantity  of  unhealthy  matter  is  usually 
detected,  and  the  bone  is  found  in  the  state 
of  necrosis.  As  $an  exfoliation  can  hardly 
be  expected  in  this  situation,  it  is  best  to 
remove  at  once  the  diseased  piece  of  bone. 
When  the  last  phalanx  alone  is  affected,  the 
finger  retains  its  form,  with  the  exception  of 
its  end  being  a little  shorter  and  flatter. 
When  the  disease,  however,  is  situated  in 
the  third  phalanx,  Richter  thinks  it  better 
to  amputate  the  finger  than  remove  the 
diseased  bone,  as  the  finger,  if  left,  would 
always  remain  stiff  and  unserviceable. 
fSce  Anfangsgr.  dcr  IVundarmeykunst , 
Pol.  7.) 

With  regard  to  the  treatment  of  the  spe- 
cies of  whitlow,  named  by  Mr.  Wardrop, 
onychia  maligna , all  local  applications  have, 
in  many  instances,  proved  quite  ineffectual, 
and  the  part , been  amputated.  The  only 
local  treatment,  which  Mr.  Wardrop  has 
ever  seen  relieve  this  complaint  has  been 
the  evulsion  of  the  nail,  and  afterward  the 
occasional  application  of  escharotics  to  the 
ulcerated  surface.  I have  myself  Seen  a 
similar  plan  occasionally  succeed,  and  the 
applications  which  appeared  to  answer  best 
were  arsenical  lotions,  Plunket’s  caustic,  or 
a veiy  strong  solution  of  the  nitrate  of  sil- 
ver. Nothing,  however,  will  avail,  till  the 
nail  is  removed,  and  its  total  separation 
sometimes  takes  up  a good  deal  of  time, 
unless  the  patient  submit  to  the  great  pain 
of  having  it  cut  away. 

Mr.  Wardrop  tried  with  success  the  exhi 


cm  WOUNDS. 


Coition  of  mercury  in  four  cases  of  the  ony- 
chia maligna.  The  medicine  was  given  in 
small  doses  at  first,  and  afterward  increa- 
sed, so  as  to  affect  the  gums  in  about  twelve 
or  fourteen  days.  When  the  system  was  in 
this  state,  the  sores  in  general  soon  assumed 
a healing  appearance,  and  the  bulbous 
swelling  gradually  disappeared.  (See  Med. 
C/nr.  Trans.  Vol.  5,  p.  138.) 

WOUNDS.  A great  deal  of  the  subject 
of  wounds  has  been  already  considered  in 
the  articles,  Gunshot  Wounds ; Head,  Inju- 
ries of ; Hemorrhage;  Hydrophobia;  Paro- 
tid Duct ; Sutures  ; Tetanus ; Throat  >'  he. 

A wound  may  be  defined  to  be  a recent 
solution  of  continuity  in  the  soft  parts,  sud- 
denly occasioned  by  external  causes,  and 
generally  attended  at  first  with  a greater  or 
lesser  degree  of  hemorrhage. 

Wounds  in  general  are  subject  to  a consi- 
derable variety  in  their  nature,  degree  of 
danger,  facility  of  cure,  and  the  consequen- 
ces which  are  to  be  apprehended  from 
them.  Some  wounds  are  perfectly  trivial, 
not  extending  more  deeply  than  the  skin 
and  cellular  membrane ; while  others  are 
more  serious,  penetrating  the  muscles,  ten- 
dons, large  blood-vessels,  and  nerves,  of  im- 
portance. There  are  also  certain  wounds 
which  are  not  confined  to  the  soft  parts, 
but  injure  even  the  bones;  such  are  many 
sabre-wounds,  which  frequently  separate 
at  once  both  a portion  of  the  scalp  and  the 
subjacent  part  of  the  skull.  Many  wounds 
of  the  head,  chest,  and  abdomen,  injure  the 
organs  contained  in  those  cavitjes.  in  short, 
the  varieties,  and  the  degree  of  danger,  at- 
tending wounds  in  general,  depend  very 
much  upon  some  of  the  following  circum- 
stances. The  extent  of  the  injury  ; the  kind 
of  instrument  with  which  it  has  been  inflict- 
ed ; the  violence  which  the  fibres  of  the 
part  have  suffered  in  addition  to  their  divi- 
sion ; the  size  and  importance  of  the  blood- 
vessels and  nerves  which  happen  to  be  in- 
jured ; the  nature  of  the  wounded  part  in 
respect  to  its  general  power  of  healing 
favourably  or  not ; whether  the  operations 
of  the  system  at  large,  “and  life  itself,  can 
be  well  supported  or  not,  while  the  func- 
tions of  the  wounded  part  are  disturbed, 
interrupted,  or  suspended  by  the  accident ; 
the  youth  or  old  age  of  the  patient ; the 
goodness  or  badness  of  his  constitution ; and 
the  opportunities  which  there  may  be  of 
administering  proper  surgical  aid,  and  assist- 
ance of  every  kind. 

Wounds  are  distinguished  by  surgical  wri- 
ters into  several  kinds  ; viz.  incised,  punc- 
tured, contused,  lacerated, poisoned,  and  gun- 
shot wounds.  They  also  make  another  equal- 
ly important,  division  into  Wounds  of  the 
Head,  Thorax,  Abdomen,  fyc. 

Of  gunshot  wounds,  and  wounds  of  the 
bead,  an  account  has  already  been  given. 
(See  Gunshot  Wounds,  and  Head,  Injuries 
of.)  The  other  cases  I shall  now  proceed  to 
consider. 

Incised  Wounds.  As  a general  observa- 
tion, it  may  be  stated,  that,  center  is  paribus,  a 
wound,  which  is  made  with  a sharp  cutting 


instrument,  which  is,  in  short,  a mere  inci 
sion,  is  attended  with  less  hazard  of  danger- 
ous consequences,  than  any  other  kind  of 
wound  whatever.  The  fibres  have  only  been 
simply  divided  ; they  have  suffered  no  con- 
tusion nor  laceration  ; consequently,  they 
are  less  likely  to  inflame  severely,  or  to  sup- 
purate, or  slough  ; and  they  commonly  ad- 
mit of  being  united  again  in  a very  expedb 
tious  manner. 

Generally  simple  incised  wounds  bleed 
more  freely,  then  contused  and  lacerated 
ones,  which  at  first  sometimes  scarcely  pour 
out  any  blood  at  all,  although  considerable 
blood-vessels  may  be  injured.  But  this  cir- 
cumstance, apparently  diminishing  the  dan- 
ger of  contused  and  ' lacerated  wounds,  is 
deceitful,  and  serves  rather  to  render  the 
case  in  reality  more  perilous,  by  inducing 
the  inexperienced  practitioner  to  be  off  his 
guard  against  hemorrhage.  Thus,  in  gun- 
shot wounds,  it  often  happens,  that  on  their 
first  occurrence,  the  bleeding  is  trivial ; but 
the  side  of  some  large  artery  having  suffer- 
ed great  violence  at  the  time  of  the  accident, 
it  may  ulcerate  or  siough,  a week  or  ten  days 
afterward,  and  an  alarming  and  even  fatal 
effusion  of  blood  be  the  result. 

In  cases  of  simple  incised  wounds,  the 
bleeding  which  at  onre  takes  place  from  all 
the  divided  vessels,  is  a source  of  very  use- 
ful information  to  the  surgeon,  inasmuch  as 
it  enables  him  to  judge,  what  danger  is  to 
be  apprehended  from  the  hemorrhage,  whe- 
ther the  cut  vessels  are  large  enough  to  de- 
mand the  ligature,  or,  on  the  contrary,  whe- 
ther they  are  such  as  will  cease  to  bleed, 
either  by  slight  pressure,  or  of  their  own 
accord. 

In  a recent  simple  incised  wound,  ihere 
are  three  objects  which  the  surgeon  should 
endeavour  to  accomplish,  without  the  least 
delay.  The  first,  and  that  which  requires 
his  immediate  interference,  is  the  bleeding, 
which  must  be  checked.  The  sbeond  is 
the  removal  of  all  extraneous  matter  from 
the  surface  of  the  wound.  The  third  is 
the  reunion  of  the  opposite  sides  of  the 
injury. 

When  the  divided  vessels  are  not  above  a 
certain  size,  the  bleeding  soon  spontaneous- 
ly ceases,  and  no  surgical  measures  need  be 
taken  on  this  particular  account.  When  the 
wounded  vessels  are  even- somewhat  larger, 
and  their  situation  is  favourable  for  com- 
pression with  a bandage,  it  is  often  ndvisea- 
ble  to  close  the  wound  and  apply  compresses 
and  a roller,  rather  than  have  recourse  to 
ligatures,  which  always  create  a certain  de- 
gree of  irritation  and  suppuration.  However, 
though  l have  made  this  observation,  I 
should  be  exceedingly  sorry  to  appear  at  all 
against  the  general  preference  lo  ligatures, 
whenever  the  wounded  arteries  are  above  a 
certain  .magnitude.  In  this  circumstance, 
tying  the  bleeding  vessels  is  the  only  safe 
mode  of  proceeding.  When  the  artery  is  ot 
considerable  size,  and  its  mouth  can  be 
readily  seen,  the  most  proper  instrument  for 
taking  hold  of  it  is  a pair  of  forceps.  In 
applying  the  ligature,  the  surgeon  must  take 


WOUNDS.  639 


care  lo  puli  its  cuds  in  such  a manner,  that 
the  noose  will  not  rise  above  the  mouth  of 
the  vessel,  and  for  the  purpose  of  altering 
the  direction  of  the  force  employed  in 
tightening  the  ligature,  the  ends  of  the 
thumbs  are  generally  made  use  of.  The 
tenaculum  is  commonly  employed  for  ta- 
king up  arteries,  which  are  not  large  and 
distinct. 

Very  fine  ligatures,  of  sufficient  strength, 
are  at  present  often  applied,  as  \vell  to  large 
as  small  vessels.  One  half  of  each  ligature 
should  always  be  cut  off,  before  the  wound 
is  closed,  and  there  are  some  surgeons,  who 
prefer  the  method  of  cutting  off’  all  the  liga- 
ture, except  what  forms  the  noose  immedi- 
ately round  the  artery.  (Delpech,  M6m . sur  la 
Pourriture  d' Hdpital,  p.  29;  Lawrence  in  Med. 
Chir.  Trans.  Vol.  6,  p.  156.)  To  the  latter 
plan,  however,  a lew  surgeons  have  addu- 
ced objections,  particularly  Mr.  Guthrie, 
who  only  admits  the  utility  of  it  in  cases 
where  the  wound  will  not  unite  by  the 
first  intention;  ( On  Gunshot  Wounds,4  p. 
94.)  and  Mr.  Cross,  of  Norwich.  (Bee  the 
London  Medical  Repository , Vol.  7,  p.  353.) 
The  experiments  of  Mr.  Cross  lend  to  the 
following  conclusions : 

First,  If  the  wounds  do  not  unite  by  the 
first  intention,  the  ligatures  may  escape  with 
the  discharge,  without  any  inconvenience. 

Secondly,  If  common  ligatures  of  twine 
are  cut  short,  the  wound  may  unite  over 
them,  and  they  may  be  found  in  abscesses 
after  an  interval  of  many  weeks. 

Thirdly,  If  the  finest  dentist’s  silk  be  em- 
ployed in  the  same  way,  and  the  wound 
unite  over  it,  the  ligature  may  be  detached 
from  the  vessel,  and  remain  buried  in  an  ab- 
scess, where  it  will  be  found  at  different  pe- 
riods, from  one  to  seven  months;  and  this 
may  happen,  whether  the  vessel  be  firmly 
compressed  with  a single  ligature,  or  divided 
between  two  ligatures,  so  as  to  imitate  the 
circumstances  under  which  vessels  are  tied 
after  operations. 

Fourthly,  If  Indian  silk,  fine  as  hair,  be 
put  round  a vessel  so  as  to  diminish  its  dia- 
meter, or  to  effect  its  obliteration,  by  just 
compressing  its  sides  together,  it  may  remain 
in  this  situation,  without  exciting  abscess,  or 
producing  any  inconvenience.  The  ligature 
may  be  thus  applied  to  compress  an  artery 
for  the  cure  of  aneurism  ; but  not  to  secure 
vessels  divided  in  operations.  If  a thin  liga- 
ture be  drawn  sufficiently  tight  upon  a ves- 
sel on  the  face  of  a stump  to  be  secure,  Mr. 
Cross  is  persuaded,  that  the  extremity  of  the 
vessel  which  becomes  insulated,  as  it  were, 
must  die.  (See  Lond.  Med.  Reposit.  Vol.  .7,  pi 
363.)  Jt  deserves  attention,  that  the  preced- 
ing inferences  are  chiefly  founded  on  experi- 
ments mode  upon  asses  and  dogs.  For  fur- 
ther observations,  s oo.  Aneurism, Hemorrhage, 
Ligature,  Surgery,  4"C. 

The  bleeding  having  been  suppressed,  the 
next  object  is  to  remove  any  extraneous 
matter,  such  as  dirt,  bits  of  glass,  clots  of 
blood.  &.c.  from  the  surface  of  the  wound. 
Were  this  circumstance  neglected,  the  plan 
of  uniting  the  opposite  sides  of  the  cut  by 


the  adhesive  inflammation,  or  by  wbat  is 
more  frequently  termed,  union  by  the  first  in  - 
tention,  would  in  general  be  frustrated. 

As  soon  as  attention  has  been  paid  to  the 
foregoing  indications,  the  surgeon  must  put 
the  lips  of  the  wound  in  contact,  and  take 
measures  for  keeping  them  in  this  state, 
until  they  have  grown  firmly  together.  The 
sides  of  incised  wounds  are  kept  in  a state 
of  apposition  by  means  of  adhesive  plaster, 
a proper  position,  the  pressure  of  a roller, 
and  in  a few  particular  instances,  by  the  em- 
ployment cf  sutures. 

With  respect  to  sutures,  as  they  create 
pain,  irritation,  and  some  degree  of  suppu- 
ration, they  ought  never  to  be  employed 
when  the  parts  can  be  kept  in  contact  with- 
out them.  However,  certain  cases  require 
them,  and  it  is  admitted  by  many  experienced 
surgeons,  that  in  sabre-wounds  of  the  ears, 
eyelids,  nose,  and  lips,  it  is  proper  to  use 
them.  (See  Assalini's  Manuale  di  Chir, 
Parte  Seconda,  p.  10.)  An  account  of  the 
several  kinds  of  sutures,  with  remarks  on 
their  employment,  will  be  found  in  the  arti- 
cle Sutures. 

The  best  and  most  common  method  of 
keeping  the  surfaces  of  divided  parts  in  con- 
tact is  by  means  of  strips  of  adhesive  plaster. 
When  they  are  to  be  applied,  the  surgeon 
should  pul  the  wounded  limb  or  parts  in  the 
position,  which  is  most  favourable  to  bring- 
ing the  lips  of  the  wound  together.  With  this 
view,  a position  should  generally  be  chosen 
which  relaxes  the  skin  and  subjacent  mus- 
cles. An  assistant  should  tiien  place  the 
edges  of  the  wound  as  evenly  together  as 
possible,  and  hold  them  in  this  state,  until 
the  surgeon  has  secured  them  in  this  condi 
tion  by  strips  of  adhesive  plaster,  applied 
across  the  line  of  the  wound.  In  general.it 
is  deemed  adviseable  to  leave  a small  inter- 
space of  about  a quarter  of  an  inch  between 
each  two  strips  of  plaster,  by  which 
means  the  matter  cannot  be  confined  in  case 
of  suppuration.  Over  these  first  strips,  lint  is 
to  be  applied,  and  kept  in  its  place  with 
oilier  pieces  of  adhesive  plaster.  Then,  if 
necessary,  a pledget  and  compresses  are  to  be 
put  on  the  part,  and,  lastly,  the  bandage,  or 
roller  is  to  be  applied. 

In  this  manner,  the  fresh-cut  surfaces  are 
brought  into  contact,  and  to  preserve  them 
quietly  in  this  state,  is  the  next  great  aim 
which  the  surgeon  should  have  in  view. 
The  wounded  part  should  be  laid  in  the  pos 
lure  which  was  found  the  most  favourable 
for  approximating  the  sides  of  the  cut  at  the 
time  of  applying  the  dressings,  and  the  patient 
should  be  directed  to  keen  the  part  in  a per 
fectly  quiet  state. 

When  attention  is  paid  to  these  circuit 
stances,  it  often  happens  that  the  two  oppo 
site  surfaces  of  the  wound  grow  together 
again  in  the  course  of  forty-eight  hours, 
without  any  degree  of  suppuration.  The 
process  by  which  this  desirable  event  is  ac- 
complished, is  well  known  among  surgeons, 
by  the  name  of  union  by  the  first  intention. 
Besides  the  advantage  of  the  cure  bein'-- 
effected  in  this  way  with  the  greatest  exn <?■ 


WOUND# 


t349 


dition  possible,  there  is  still  another  thing 
much  in  favour  of  constantly  promoting  this 
method  of  healing  wounds,  which  is,  that 
the  scar  is  much  less  than  after  any  other 
mode  of  cicatrization,  and  the  part  is  cover- 
ed with  original  skin,  which  is  always  much 
stronger  than  any  which  can  be  formed  as  a 
substitute  for  it. 

It  is  wonderful  with  what  celerity  union 
by  the  first  intention  takes  place  under 
favourable  circumstances.  In  the  course 
of  three  days,  the  large  wound  made  in  the 
operation  of  amputation,  is  frequently  all 
healed,  except  just  where  the  ligatures  are 
Situated. 

When  the  two  sides  of  the  wound  have 
been  brought  together,  before  the  oozing  of 
blood  has  entirely  ceased,  Mr.  Hunter  con- 
ceives that  blood  itself  becomes  the  first 
bond  of  union  ; but  on  this  point,  Professor 
Thomson,  of  Edinburgh,  entertains  a doubt ; 
and  all  practical  surgeons  agree,  that  the 
lodgment  of  blood  on  the  surface  of  a 
wound,  is  more  likely  to  prevent  than  pro- 
mote. the  union  of  the  parts.  In  all  com- 
mon instances,  what  Mr.  Hunter  calls  the 
adhesive  inflammation  takes  place.  In  this 
process,  coagulating  lymph  either  issues 
from  the  half  closed  mouths  of  the  vessels, 
or  from  the  surface  of  the  opened  cells  of  the 
cellular  substance.  This  becomes  the  first 
uniting  medium,  and  very  soon  afterward,  in 
some  inexplicable  manner,  a vascular  inter- 
course is  established  between  the  opposite 
sides  of  the  wound. 

The  power  which  parts  of  the  animal 
body  have,  of  thus  growing  together,  is  stri- 
kingly evinced  by  the  possibility  of  remo- 
ving a part  of  one  body,  and  then  uniting  it 
to  some  part  of  another.  In  this  latter  case 
there  can  be  no  assistance  given  to  the 
union  on  one  side,  since  the  detached  part, 
as  Mr.  Hunter  observes,  can  hardly  do  more 
than  just  preserve  its  own  living  principle, 
and  accept  of  union.  In  this  way,  says  the 
same  writer,  the  spurs  of  the  young  cock 
can  be  made  to  grow  on  his  comb,  or  on 
that  of  another  cock ; and  its  testicles, 
after  having  been  removed,  may  be  made 
to  unite  to  the  inside  of  any  cavity  of  an 
animal. 

Every  one  initiated  in  surgery  has  heard 
of  the  feats  of  Taliacotius,  Garengeot,  and 
others,  who  are  said  to  have  succeeded  in 
effecting  the  union  of  parts,  which  were 
completely  severed  from  the  body.  Several 
other  not  less  extraordinary  performances  by 
modern  surgeons  are  recorded.  (See  Obser- 
7: aliom  on  Adhesion,  with  two  Cases , demon - 
slralive  of  the  Powers  of  Nature  to  reunite 
parts,  which  have  been  by  accident  totally  sepa- 
rated from  the  animal  System,  by  fVm.  Bal- 
four, S vo.  Edinb.  1814.)  Indeed  the  well- 
known  practice  of  transplanting  the  teeth, 
the  experiments  of  Duhamel  and  Hunter; 
and  the  number  and  respectable  character  of 
the  testimonies  upon  this  subject,  fully  con- 
vince me  of  the  occasional  success,  which 
may  attend  the  endeavour  to  bring  about 
such  an  union.  Experience  also  fully  proves 
*he  frequent  success  which  attends  an  en- 


deavour to  unite  a part,  which  retains  only 
the  slight  connexion  of  a small  piece  of  flesh, 
or  even  a tew  fibres.  My  friend,  Mr.  Lav;- 
rence,  lately  had  a case  which  illustrates  the 
truth  of  this  statement.  A man  on  the  top 
of  a stage-coach,  was  carried  underagateway 
which  did  not  leave  sufficient  room  for  him 
to  pass  without  injury,  and  bis  head  was  so 
much  wounded,  that  one  of  his  ears  was  entire- 
ly separated,  with  the  exception  of  an  attach- 
ment by  a trivial  piece  of  integuments. 
Mr.  Lawrence  assented  to  the  man’s  wish  of 
not  having  the  separation  completed,  and 
fixed  the  part  in  its  situation  with  a few  suj 
tures.  The  consequence  was  that  the  ear 
soon  united  again,  and  the  patient  escaped 
all  disfigurement.  Of  the  knowledge  of  the 
disposition  of  living  cut  surfaces  to  grow 
together  with  considerable  expedition,  sur- 
geons, both  of  ancient  and  modern  times, 
have  availed  themselves  not  only  in  the 
treatment  of  accidental  wounds,  but  also  in 
the  removal  of  deformity,  as  exemplified  in 
the  cure  of  fissures  in  the  palate  or  lips,  (see 
Harelip ,)  but  most  particularly  in  the  curi- 
ous and  interesting  art  of  forming  new 
under-lips  and  noses,  and  closing  largo  defi- 
ciences  in  the  urethra  with  flaps  of  flesh, 
raised  from  the  adjacent  parts,  shaped  ac- 
cording to  circumstances,  and  laid  directly 
down  upon  a fresh-cut  surface  purposely- 
prepared,  where  it  is  steadily  confined  for  a 
certain  time  with  sutures,  or  simple  adhesive 
plaster  and  pressure,  as  the  nature  of  the 
case  may  indicate.  Nay,  sometimes,  the 
flesh  for  the  formation  of  the  organ  to  be 
restored  has  even  been  taken  from  a distant 
part,  as  for  instance,  from  the  arm  for  the 
restoration  of  parts  of  the  face.  When  this 
was  done,  the  limb  was  confined  in  close 
contact  with  the  raw  surface  formed  on  the 
face,  until  a union  between  them  had  been 
effected ; a division  was  now  performed 
with  the  scalpel,  and  the  opportunity  taken 
to  shape  the  portion  of  the  limb  which  was 
to  be  left  behind,  according  as  the  part  to  be 
restored  might  he  the  ear,  nose,  or  lip.  At 
the  present  day,  the  flesh  is  usually  taken 
from  the  adjacent  parts;  a connexion  of 
the  flap  with  the  rest  of  the  body  is  retained, 
so  as  to  ensure  some  circulation  of  blood  in 
it,  and  it  is  turned  into  any  position  which 
the  circumstances  may  demand.  (See  Gas- 
par  Taliacotius , Chirurgia  Nova  de  Narium , 
Aurium,  Labiorumque  Defectu,per  insilionem 
cutis  ex  humero  sarciendo,  fye.  8 vo.  Francof. 
1598.  J.  C.  Carpue,  an  Account  of  Two 
successful  Operations  for  restoring  a lost  Nose 
from  the  Integuments  of  the  Forehead,  4to. 
Lond.  1816.  Giuseppe  Baronio,  Degli  Inncsti 
Animali,  8 vo.  Milan.  C.  F.  Graefe,  De  Rhi~ 
noplastice,  site  Arte  curtum  Nasum  ad  Vivum 
restituendi,  cemmentaiio , quA  prisca  illius  ratio 
iterum  experimenlis  illustratur  novisque  me- 
thodis  ad  majorem  pcrfeclionem  perducilur , 
4/o.  Berol.  1818.  Sir  A. Cooper,  on  Unnatural 
Apertures  in  the  Urethra;  Surgical  Essays,  Part 
2.  H. Earle,  on  the  Re-establishment  of  a Canal 
in  the  place  of  a portion  of  the  Urethra,  in  Phil. 
Trans,  for  1821.  A Case  of  restored  Nose,  by 
Mr.  C.  Hutchison.  A Case  of  artificial  Anus 


WOUNDS. 


o*U 


cured  by  U.  F.  Collier,  in  Med.  and  Physical 
Journ.  for  June,  1820. 

Mr.  John  Bell  describes  the  process  of 
adhesion  to  be  this : either  the  arteries  of 
the  opposite  surfaces  inosculate  mouth  to 
mouth,  orjrather  each  cut-surface  throws  out 
a gluten  ; the  gluten  fills  up  the  intermediate 
space ; into  that  gluten  the  lesser  arteries 
of  each  cut-surface  extend  themselves,  and 
it  is  thus,  perhaps,  by  the  generation  of  a 
new  intermediate  substance,  that  the  con- 
tinuity and  entireness  of  the  part  are  so 
quickly  restored.  If  any  one  point  fail  to 
adhere,  there  the  wound  must  run  into 
suppuration  ; because,  says  Mr.  J.  Bell,  at 
that  point  there  is  a separation  of  parts, 
which  is  equivalent  to  a loss  of  substance. 

The  same  writer  observes,  that  there  are, 
no  doubt,  accidents,  both  of  the  constitution 
and  the  wound, which  will  prevent  adhesion. 
If  the  patient  be  of  a bad  habit  of  body ; if 
he  be  lying  in  afoul  hospital,  in  the  midst  of 
putrid  sores,  and  breathing  a contagious  air  ; 
if  he  be  ill  of  a fever,  or  flux,  or  any  general 
disease  ; then  the  properties  of  the  body 
being  less  perfect,  the  wound  will  not  ad- 
here. Mr.  J.  Bell  also  notices,  that,  if  the 
wound  be  foul,  made  with  a poisoned 
weapon,  or  left  with  foreign  bodies  lodged 
in  it ; or  if  a considerable  quantity  of  blood 
be  poured  out  into  the  cavity  of  the  wound, 
or  if  there  be  a wounded  lymphatic,  or  a 
wounded  salivary  duct,  a. wounded  intestine, 
or  a bleeding  artery  or  vein,  the  immediate 
adhesion  of  the  whole  of  the  wound  may  be 
prevented.  However,  I cannot  help  re- 
marking, that,  though  Mr.  John  Bell,  in 
imitation  of  most  surgical  writers,  sets  do  wn 
the  wound  of  a lymphatic  as  preventive  of 
the  union  of  w ounds,  I eannot  say,  that  I 
ever  saw  such  an  effect  imputable  to  the 
cause  just  mentioned.  Also,  when  an  artery 
or  vein  is  cut,  and  requires  to  be  tied,  the 
adhesion  of  the  wound  would  be  prevented 
only  just  wdiere  the  ligature  lies,  and  at  no 
other  point. 

There  is  no  wound,  observes  Mr.  John 
Bell,  in  wdiich  we  may  not  try  with  perfect 
safety  to  procure  this  adhesion  ; for  nothing 
can  agree  better  with  one  surface  of  the 
wound,  than  the  opposite  one,  which  has 
been  just  separated  from  it.  They  may 
immediately  adhere  together,  and  even  if 
they  should  not  do  so,  no  harm  is  done,  and 
the  wound  will  yet  suppurate  as  favourably, 
as  if  it  had  been  roughly  dressed  with  dry 
caddis,  or  some  vulnerary  balsam,  or  acrid 
ointment.  If  one  part  should  suppurate, 
while  one  half  adheres,  then,  says  Mr.  John 
Bell,  one  half  of  our  business  is  done.  In 
short,  this  simple  duty  of  immediately 
closing  a wound  is  both  natural  and  safe. 
(Discourses  an  the  Nature  and  Cure  of  Wounds , 
Vol.  1.) 

Upon  this  interesting  topic  of  the  advan- 
tages of  union  by  the  first  intention,  the 
most  enlightened  surgeons  of  all  Europe 
now  begin  to  entertain  only  one  opinion. 
The  practice  is  generally  adopted  both  in 
the  treatment  of  accidental  cuts,  and  of  the 
wou,nds  resulting  from  surgical  operations. 

Vol.IL  * 81 


Thus  Assalini,  one  of  the  best  modern  sur 
geons  in  Italy,  begins  his  Manual  of  Surgery 
with  the  following  axiom  : “ Wounds  and 
injuries  of  the  soft  parts,  produced  by  cut- 
ting instruments,  from  the  trilling  wouq^jf 
a vein,  made  for  the  purpose  of  discharging 
a few  ounces  of  blood,  to  the  incision  in  the 
uterus  for  the  extraction  of  the  foetus,  inclu- 
sively, should  all  be  united  by  the  first  inten- 
tion. (See  Manual e di  Chirurgia ; Discorso 
Primo.  Milano , 1812.) 

British  surgeons  have,  indeed,  been  ac- 
cused by  M.  Roux  of  indiscriminate  par- 
tiality to  the  plan  of  uniting  all  incised 
wounds  by  the  first  intention,  and  his  coun- 
tryman Baron  Larrey  has  wished  the  me- 
thod to  be  discontinued  after  amputation,  in 
order  (as  he  states)  to  lessen  the  chance  of 
tetanus.  But  the  exceptions  which  these 
surgeons  wish  to  make,  are  fewT,  and  few  as 
they  are,  they  are  not  likely  to  be  establish- 
ed, since  several  of  the  circumstances,  al- 
leged as  reasons  for  limiting  so  beneficial 
a practice,  are  hypothetical,  and  far  from 
being  clearly  proved.  (See  Roux , Mtmoire 
el  Obs.  sur  la  Reunion  immediate  de  la  Plaie 
apr&s  V Amputation  circulaire  des  Membres, 
8t •£>.  Paris,  1814.  Larrey,  M6m.  de  Chir.  Mil- 
Tome  4,  8 to.  1812—17.) 

Sometimes  the  attempt  to  procure  union 
by  the  first  intention  fails,  even  in  cases  of 
incised  wounds  : but,  in  this  circumstance, 
no  harm  arises  from  the  kind  of  practice 
which  has  beeirfollowed.  The  case,  in  fact, 
now  falls  into  nearly  the  same  state,  as 
would  have  occurred,  had  no  attempt  at 
union  been  made  at  all.  The  patient  has 
taken  the  chance  of  a quicker  mode  of  cure  ; 
but  he  has  not  been  successful,  and  he  must 
now  be  cured  by  a process,  w hich  on  ac- 
count of  its  slowness  he  at  first  wished  to 
avoid.  It  is  to  be  observed  also,  that  union 
by  the  first  intention,  if  not  spoiled  by  sutures, 
rarely  fails  so  completely,  that  there  is  not 
a partial  adhesion  of  some  points  of  the 
wound.  The  moment  when  we  observe 
pain,  inflammation,  and  swelling  of  the 
wound,  a separation  or  gaping  of  its  lips,  the 
stitches  tense  (when  these  have  been  used,) 
and  the  points  where  the  stitches  pass  parti- 
cularly inflamed,  Mr.  John  Bell  advises  us 
to  undo  the  bandages,  draw  out  the  sutures, 
and  take  away  every  thing,  w^hich  acts  like 
a stricture  on  the  w'ound.  These  prudent 
measures,  he  observes,  may  abate  the  rising 
inflammation,  and  prevent  the  total  separa- 
tion of  the  skin,  while  an  endeavour  may 
still  be  made  to  keep  the  edges  of  the 
wound  tolerably  near  each  other  by  the 
more  gentle  operation  of  sticking-plasters. 

However,  when  the  inflammation  rises 
still  higher,  and  it  is  evident,  that  a total 
separation  of  the  sides  of  the  wound  cannot 
be  avoided,  Mr.  John  Bell  wisely  recom- 
mends leaving  the  parts  quite  loose,  and  ap- 
plying a large  soft  poultice ; for,  says  he, 
should  you  in  this  critical  juncture,  persist  in 
keeping  the  parts  together  with  sutures,  the 
inflammation,  in  the  form  oferysipelas,  would 
extend  over  the  whole  limb,  attended  with  a 
fetid  and  bloody  suppuration  the 


WOlviND.S. 


u.4-2 


\vound  has  been  brought  into  a favourable 
state,  '•another  attempt  may  be  made  to 
bring  the  edges  near  each  other,  not  with 
sdfltres,  but  strips  of  adhesive  plaster,  or  the 
gentle  application  of  a bandage. 

Mr.  John  Bell  concludes  with  remarking, 
that  the  suppuration,  production  of  granula- 
tions, and  all  that  follows,  are  the  work  of 
nature.  The  only  thing  that  the  surgeon 
can  usefully  do,  is  to  take  care  of  the  health. 
When  the  wound  does  not  suppurate  favour- 
ably, the  discharge  generally  becomes  pro- 
fuse, thin,  and  gleety.  This  state  is  to  be 
amended  by  bark,  wine,  rich  diet,  and  good 
air. 

1 shall  conclude  this  subject  of  union  by 
the  first  intention,  with  an  extract  from 
the  writings  of  Mr.  Hunter,  who  observes, 
that 

et  It  is  with  a view  to  this  principle  of 
union,  that  it  has  been  recommended  to 
bring  the  sides  (or  lips)  of  wonnds  together  ; 
but,  as  the  natural  elasticity  of  the  parts 
makes  them  recede,  it  has  been  found  ne- 
cessary to  employ  art  for  that  purpose.  This 
necessity  first  suggested  the  practice  of  sew- 
ing wounds,  and  afterward  gave  rise  to  va- 
rious inventions  in  order  to  answer  this  end, 
such  as  bandages,  sticking-plasters,  and  liga- 
tures. Among  these,  the  bandage  common- 
ly called  the  uniting  bandage  is  preferable  to 
all  the  rest,  where  it  can  be  employed  ; but 
its  application  is  very  confined,  from  being 
only  adapted  to  parts  wThere  a roller  can  be 
used.  A piece  of  sticking-plaster,  which  has 
been  called  the  dry  suture,  is  more  general 
in  its  application  than  the  uniting  bandage, 
and  is  therefore  preferable  to  it  on  many  oc- 
casions. 

“ I can  hardly  suppose  (says  Mr.  Hunter,) 
a wound,  in  any  situation,  where  it  may  not 
be  applied,  excepting  penetrating  wounds, 
where  we  wish  the  inner  portion  of  the 
wound  to  be  closed  equally  with  the  outer, 
as  in  the  case  of  hare-lip.  But  even  in  such 
wounds,  if  the  parts  are  thick,  and  the  wound 
not  large,  the  sides  will  seldom  recede  so 
far  as  to  make  any  other  means  necessary. 
The  dry  suture  has  an  advantage  overstitches 
by  bringing  a larger  surface  of  the  wound  to- 
gether, by  not  inflaming  the  parts  to  which 
it  is  applied,  and  by  neither  producing  in 
them  suppuration  nor  ulceration,  which 
stitches  always  do.  When  parts,  therefore, 
can  be  brought  together,  and  especially 
where  some  force  is  required  for  that  purpose, 
from  the  skin  not  being  in  large  quantity, 
the  sticking-plaster  is  certainly  the  best  ap- 
plication. This  happens  frequently  to  be 
the  case  after  the  removal  of  tumours,  in 
amputation,  or  where  the  sides  of  the  wound 
are  only  to  be  brought  together  at  one  end, 
as  in  the  hare-lip  ; and  I think  the  difference 
between  Mr.  Sharp’s  cross-stitch,  after  ampu- 
lion,  as  recommended  in  his  Critical  Inquiry, 
and  Mr.  Allanson’s  practice,  shows  strongly 
he  superiority  of  the  sticking-plaster  (or  dry 
suture,)  In  those  parts  of  the  body  where 
t.ue  skin  recedes  more  than  in  others,  this 
''routine  nt  becomes  most  necessary  ; and  as 
!*><•  y-*vlp  probably  recedes  as  little  a-s  rtu.y,  *t 


is  therefore  seldom  iieceasary  to  app^y  any 
thing  in  wounds  of  that  part  ; the  practice 
will  certainly  answer  best  in  superficial 
wounds,  because  the  bottom  is  in  these  more 
within  its  influence. 

“ The  sticking-plasters  should  be  laid  on 
in  strips,  and  these  should  be  at  small  dis- 
tances from  each  other,  viz.  about  a quarter 
of  an  inch  at  most,  if  the  part  requires  close 
confinement ; but  when  it  does  not,  they 
may  be  at  greater  distances.  This  precaution 
becomes  more  necessary  if  the  bleeding  is 
not  quite  stopped  ; there  should  be  passages 
left  for  the  exit  of  blood,  as  its  accumula- 
tion might  prevent  the  union,  although  this 
does  not  always  happen.  If  any  extraneous 
body,  such  as  a ligature,  should  have  been 
left  in  the  wound,  suppuration  will  take 
place,  and  the  matter  should  be  allowed  to 
vent  at  some  of  these  openings,  or  spaces, 
between  the  slips  of  plaster.  1 have  known 
a very  considerable  abscess  formed  in  con  - 
sequence of  this  precaution  being  neglected, 
by  which  the  whole  of  the  recently  united 
parts  has  been  separated. 

“ The  interrupted  suture,  which  has  gene- 
rally been  recommended  in  large  wounds, 
is  still  in  use,  but  seldom  proves  equal  to 
the  intention.  This  we  may  reckon  to  be 
the  only  one  that  deserves  the  name  of  su- 
ture ; it  was  formerly  used,  but  is  now  in  a 
great  measure  laid  aside  in  practice,  not 
from  (he  impropriety  of  uniting  parts  by 
this  process,  but  from  the  ineffectual  mode 
of  attempting  it.  In  what  manner  better 
methods  could  be  contrived^  1 have  not  been 
able  to  suggest.  It  is  to  be  understood,  that 
the  above  methods  ofsbringing  wounded 
parts  together,  in  order  to  unite  them,  are 
only  to  be  put  in  practice  in  such  cases  as 
will  admit  of  it}  for  if  there  was  a method 
known,  which  in  all  cases  would  bring  the 
wounded  surfaces  into  contact,  it  would,  in 
many  instances,  be  improper,  as  some 
wounds  are  attended  with  contusion,  by 
which  the  parts  have  been  more  or  less 
deadened ; in  such  cases,  as  was  formerly 
observed,  union  ^cannot  take  place  accord- 
ing to  our  first  principle,  and  therefore  it  is 
improper  to  attempt  it. 

“In  many  wounds,  which  are  not  attend- 
ed willi  contusion,  when  we  either  know, 
or  suspect,  that  extraneous  bodies  have  been 
introduced  into  the  wound,  union  by  the 
first  intention  should  not  be  attempted,  but 
they  should  be  allowed  to  suppurate,  in  or- 
der that  the  extraneous  matter  may  be  ex- 
pelled. Wounds  which  are  attended  with 
laceration,  although  free  from  contusiou, 
cannot  always  be  united  by  the  first  inten- 
tion, because  it  must  frequently  be  impossi- 
ble to  bring  the  external  parts,  or  skin,  so 
much  in  contact,  as  to  prevent  that  inflam- 
mation which  is  naturally  produced  by  ex- 
posure. But  even  in  cases  of  simple  lacera 
tion,  where  the  external  influence  is  but 
slight,  or  can  be  prevented  (as  we  observed 
in  treating  of  the  compound  fracture,)  we 
find  that  union  by  the  first  intention  often 
takes  place  ; the  blood,  which  fills  up  the 
hiterstvw  of  the  lacerated  parts,  having  prf  • 


WOfcJNliS 


■'vented  the  siiuiuius  ot  imperfection  in  them, 
and  prevented  suppuration,  muy  afterward 
be  absorbed. 

te  Many  operations  may  be  so  performed 
as  to  admit  of  parts  uniting  by  the  first  in* 
tention  ; but  the  practice  should  be  adopted 
with  great  circumspection  : the  mode  of 
operating  with  that  view,  should  in  all  cases 
be  a secondary,  and  not  a first  considera- 
tion, which  it  has  unluckily  been  too  often 
among  surgeons.  In  cases  of  cancer,  it  is 
a most  dangerous  attempt  at  refinement  in 
surgery. 

“ In  the  union  of  wounded  parts  by  the 
first  intention,  it  is  hardly  or  never  possible 
to  bring  them  so  close  together  at  the  expo- 
sed edges,  as  to  unite  them  perfectly  by 
these  means;  such  edges  are  therefore 
obliged  to  take  another  method  of  heuiing. 
If  kept  moist,  they  will  inflame  as  deep  be- 
tween the  cut  surfaces  as  the  blood  fails  in 
the  union,  and  there  suppurate  and  granu- 
late ; but  if  the  blood  be  allowed  to  dry  and 
form  a scab  between,  and  along  the  cut 
edges,  then  inflammation  and  suppuration 
of  those  edges  will  be  prevented,  and  (his 
\vill  complete  the  union,  as  will  be  descri- 
bed by  and  by. 

“ As  those  effects  of  accidental  injury, 
which  can  be  cured  by  the  first  inteution, 
call  up  none  of  the  powers  of  the  constitu- 
tion to  assist  in  the  reparation,  it  is  not  the 
least  affected  or  disturbed  by  them  ; the 
parts  are  united  by  the  extravasated  blood 
alone,  which  was  thrown  out  by  the  injury, 
either  from  the  divided  vessels,  or  in  conse- 
quence of  inflammation,  without  a single 
action  taking  place,  even  in  the  part  itself, 
except  the  closing  or  inosculation  of  the 
vessels  : for  the  flowing  of  the  blood  is  to 
be  considered  as  entirely  mechanical.  Even 
in  cases  where  a small  degree  of  inflamma- 
tion comes  on,  it  is  merely  a local  action, 
and  so  inconsiderable,  that  the  constitution 
is  not  affected  by  it ; because  it  is  an  opera- 
tion, to  which  the  powers  belonging  to  the 
parts  themselves  are  fully  equal.  The  in- 
flammation may  produce  a small  degree  of 
pain,  but  the  operation  of  union  gives  no 
sensation  of  any  kind  whatever.’1  ( Hunter 
on  the  Blood , Inflammation,  and  Gunshot 
Wounds .) 

Contused  and  Lacerated  Wounds. — Lace- 
rated wounds  are  those,  in  which  the  fibres, 
instead  of  being  divided  by  a cutting  instru- 
ment, have  been  torn  asunder  by  some  vio- 
lence, capable  of  overcoming  their  force  of 
adhesion.  The  edges  of  such  wounds,  in- 
stead of  being  straight  and  regular,  are  jag- 
ged and  unequal. 

The  term  contused  is  applied  to  those 
wounds  which  are  occasioned  by  some  blunt 
instrument,  or  surface,  which  has  violently 
struck  a part  of  the  body. 

These  two  species  of  wounds  greatly  re- 
semble each  other,  and  astheyrequire  nearly 
the  same  kind  of  treatment,  writers  usually 
treat  of  them  together. 

Lacerated  and  contused  wounds  differ 
from  simple  incised  ones,  in  appearing,  at 
first  view,  much  less  alarming  than  the  tat- 


bd3 

ter,  while,  in  reality,  they  are  infinitely 
more  dangerous.  In  simple  cut  wounds,  the 
retraction  of  the  parts,  and  the  hemorrhage, 
are  generally  much  more  considerable  than 
in  a lacerated  wound  of  the  same  size. 
However,  notwithstanding  these  circum 
stances,  they  commonly  admit  of  being 
healed  with  far  greater  ease.  It  is  worthy 
of  particular  notice,  that  lacerated  and  con- 
tused wounds  are  not  in  general  attended 
with  any  serious  effusion  of  blood,  even 
though  large  blood-vessels  may  be  injured. 

I say  in  general,  because  in  the  year  1813, 

I saw  a soldier,  whose  death  was  occasioned 
by  a sudden  effusion  of  a very  large  quan- 
tity of  blood  from  the  internal  jugular  vein, 
which  vessel  had  been  injured  by  a muskel- 
ba.Il,  that  first  entered  the  integuments  be- 
hind the  mastoid  process,  and  passed  ob- 
liquely downwards  and  forwards  towards 
the  sternum.  The  blood  did  not  issue  ex- 
ternally; but  formed  betwixt  the  integu- 
ments and  the  trachea,  a large  dark-coloured 
swelling,  which  produced  almost  immediate 
suffocation.  At  the  memorable  siege  of 
Saragossa,  Professor  Assalini  saw  a surgeon 
whose  left  carotid  artery  had  been  injured 
by  a musket-bail,  perish  of  hemorrhage  in 
a few  seconds.  (See  Assalini’s  Manuale  di 
Chirurgia,  p.  32,  Milano,  1812.) 

In  most  cases,  however,  there  is  little  or 
no  hemorrhage  from  lacerated  and  contused 
wounds,  and  it  is  a circumstance,  which 
often  leads  inexperienced  practitioners  to 
commit  great  mistakes,  by  inducing  them 
to  promise  too  much  in  the  prognosis  which 
they  make.  Surgeons  versed  in  practice, 
however,  do  not  allow  themselves  to  be  de- 
ceived by  the  absence  of  hemorrhage,  and, 
in  proportion  as  there  is  little  bleeding,  they 
apprehend  that  the  violence  done  to  the 
fibres  and  vessels  has  been  considerable. 
What  is  it,  but  the  contused  and  lacerated 
nature  of  the  wound,  that  prevents  hemor 
rhage  from  the  umbilical  arteries,  u'hen  ani 
mals  divide  the  navel-string  with  their  teeth  ? 
Whole  limbs  have  frequently  been  torn  from 
the  body,  without  any  hemorrhage  of  con- 
sequence taking  place. 

In  the  Phil.  Trans.  Cheselden  has  recorded 
a very  remarkable  case,  in  which  a man’s 
arm  was  suddenly  torn  from  his  body. 
Samuel  Wood,  a miller,  had  round  his  arm 
a rope,  which  got  entangled  with  the  wheel 
of  the  mill.  He  was  lifted  off  the  ground, 
and  then  stopped  by  a beam,  which  pre 
vented  his  trunk  from  passing  further  ; at 
this  instant,  the  wheel,  which  was  moving 
with  immense  force,  completely  tore,  and 
carried  away,  his  arm  and  scapula  from  his 
body.  The  appearance  of  a wound,  occa- 
sioned in  this  manner,  must  of  course  be 
horrible,  and  the  first  idea,  thence  arising, 
must  naturally  be  that  the  patient  cannot 
possibly  survive.  Samuel  Wood,  however, 
escaped  with  his  life.  The  limb  had  been 
torn  off  with  such  velocity,  that  he  was  un- 
aware of  the  accident,  till  he  saw  his  arm 
moving  round  on  the  wheel.  He  immedi- 
ately descended  by  a narrow  ladder  from 
the  mill,  and  even  walked  some  pacers,  with 


WOUNDS. 


I >tt  d 


a view  of  seeking  assistance.  He  now  fell 
^lowii  from  weakness.  The  persons  who 
first  came  to  his  assistance,  covered  the 
wound  with  powdered  sugar.  A surgeon, 
\vno  afterward  arrived,  observing  that  there 
was  no  hemorrhage,  was  content  with 
bringing  down  the  skin,  which  was  very 
loose,  so  as  to  make  it  cover  the  surface  of 
the  wound.  For  this  purpose  he  used  two 
cross  stitches.  The  patient  was  conveyed 
the  next  day  to  St.  Thomas’s  Hospital,  and 
put  under  the  care  of  Mr.  Fern.  This  prac- 
titioner employed  the  usual  means  for  pre- 
venting the  bad  symptoms  most  to  be  ex- 
pected in  this  sort  of  case.  The  first  dress- 
ings came  away  without  any  bleeding;  no 
alarming  consequences  ensued  ; and  the 
patient,  in  two  months,  completely  reco- 
vered. 

When  the  arm  was  examined,  it  was 
found,  that  the  muscles,  inserted  into  the 
scapula,  were  torn  through  near  their  inser- 
tions ; while  other  muscles,  arising  from 
this  bone,  were  carried  away  w ith  it.  The 
skin,  covering  the  scapula,  had  remained  in 
its  natural  situation,  and  seemed  as  if  it  had 
been  divided  precisely  at  the  insertion  of 
the  deltoid  muscle. 

In  La  Motte’s  Trait6  des  Accouchemtns, 
may  be  found  an  account  of  a little  boy, 
who,  while  playing  near  the  wheel  of  a 
mill,  got  his  hand,  fore-arm,  and  arm,  suc- 
cessively entangled  in  the  machinery,  and 
the  limb  was  violently  torn  away  at  the 
shoulder  joint,  in  consequence  of  the  lad’s 
body  not  being  able  to  pass  in  the  direction 
Id  which  the  arm  w as  drawn.  The  bleed- 
ing was  so  trivial,  that  it  was  stopped  with 
a Tittle  lint,  and  tiie  boy  very  soon  reco- 
vered. 

In  the  fifth  vol.  of  the  Edinb.  Med.  Com- 
mentaries, may  also  be  perused  the  history 
of  a child,  three  years  and  a half  old,  whose 
arm  was  torn  off  by  the  wheel  of  a mill. 
Mr.  Carmichael,  who  saw  the  child  about 
an  hour  after  the  accident,  found  it  almost 
in  a dying  state,  with  cold  extremities,  small 
faltering  pulse,  and  all  the  right  side  of  the 
body  convulsed.  However,  there  was 
hardly  any  bleeding.  The  arm  was  broken 
about  an  inch  and  a half  above  the  elbow ; 
the  stump  had  a dreadful  appearance  ; all 
the  soft  parts  were  in  a contused  and  lace- 
rated stale,  and  the  humerus  was  laid  bare 
as  high  as  the  articulation,  which  was  itself 
exposed.  The  skin  and  muscles  were  lace- 
rated to  a much  greater  extent,  and  in  dif- 
ferent directions.  The  remainder  of  the 
humerus  was  removed  from  the  shoulder- 
joint  by  amputation,  only  as  much  skin  and 
tnuscle  being  left  as  was  sufficient  to  cover 
the  wound.  In  two  months  the  child  was 
well. 

In  the  M6m.  de  VAtad.  de  Chir.  T.  2,  is 
an  account  of  a leg  being  torn  away  at 
the  knee-joint  by  a cart  wheel.  The  pa- 
tient was  a boy,  about  nine  or  ten  years  of 
age.  This  accident,  like  the  foregoing  ones, 
was  accompanied  with  no  hemorrhage. 
The  lower  portion  of  the  os  femoris,  whieh 
was  exposed,  was  amputated,  together  with 


such  portion  ot  the  soil  parts,  as  was  in  a 
contused  and  lacerated  state.  The  patien; 
experienced  a perfect  recovery. 

The  preceding  cases  strikingly  confirm 
the  observation,  which  I have  already  made, 
in  regard  to  the  little  bleeding,  which  usu- 
ally arises  from  contused  and  lacerated 
wounds. 

In  these  instances,  the  pain  is  also  in  an 
inverse  ratio  to  the  cause  of  the  accident; 
it  is  generally  very  severe,  when  the  wound 
is  only  moderately  contused  : and,  on  the 
other  hand,  the  patient  scarcely  suffers  any 
pain  at  all,  where  there  has  been  so  violent 
a degree  of  contusion,  as  at  once  to  destroy 
the  organization  of  the  part. 

When  the  bruised  fibres  have  not  been 
injured  above  a certain  degree,  the  part 
suppurates  ; but  such  portions  of  the  wound 
as  have  suffered  greater  violence,  inevitably 
die,  and  are  cast  off  in  the  form  of  sloughs. 
Granulations  are  afterward  formed,  arid 
the  breach  of  continuity  is  repaired  by  the 
process  of  cicatrization.  (See  this  word.) 

When  a still  greater  degree  of  violence 
has  been  done,  and,  especially,  when  arte- 
ries of  a certain  magnitude  have  been  in 
jured,  a mortification  is  too  frequently  the 
consequence.  However,  if  the  constitution 
be  good,  and  the  mischief  not  too  extensive, 
the  case  may  still  end  well.  But,  in  other 
instances,  the  event  is  alarmingly  dubious  ; 
for  the  mischief  is  then  not  limited  to  the 
wounded  parts,  which  have  suffered  the 
greatest  degree  of  contusion  ; but,  too  fre- 
quently, extends  over  such  parts  as  were 
not  at  all  interested  by  the  wound  itself. 

The  mortification  arising  directly  from  the 
impaired  organization  of  parts,  is  not  what 
is  the  most  alarming  circumstance.  A still 
more  dangerous  kind  of  mortification,  is  that 
which  is  apt  to  originate  from  the  violent  in- 
flammation occasioned  by  the  accident.  This 
consequence  demands  the  utmost  attention 
on  the  part  of  the  surgeon,  who  must  let  no 
u«eful  means  be  neglected,  with  a view  of 
diminishing  the  inflammation  before  it  has 
attained  too  high  a degree,  and  very  danger- 
ous symptoms  have  commenced.  In  the 
first  instance,  he  should  not  be  afraid  of  let- 
ting the  wound  bleed  a little,  if  it  should  be 
disposed  t:*  do  so.  The  ediies  of  the  wound 
should  then  be  gently  drawn  towards  each 
other  with  a few  strips  of  sticking-plaster,  so 
as  to  lessen  the  extent  of  the  exposed  sur- 
face. hut  no  sutures  are  proper.  Indeed, 
the  plan  of  diminishing  the  exposed  surface 
of  a contused  wound  with  strips  of  adhe- 
sive plaster,  is  not  invariably  right  ; because 
their  application  creates  a hurtiul  degree  ot 
irritation.  The  method  is  chiefly  advisenble 
when  there  is  a large  loose  flap  of  skin, 
which  can  be  conveniently  brought  over  the 
wound.  In  other  cases,  it  is  best  to  leave 
the  parts  free,  uncompressed,  and  unconfined 
With  any  adhesive  plaster,  because  if  it  were 
applied  its  irritation  would  do  barm,  and 
could  not  possibly  procure  any  union  of  The 
parts.  Under  the  most  favourable  circum- 
stances, hardly  any  part  of  the  wound  can 
be  expected  to  unite  by  the  first  intention 


WOUNDS. 


Ine  whole  or  the  greater  part  of  it  will  neces- 
sarily suppurate,  after  the  detachment  of  the 
sloughs.  The  surface  will  then  granulate, 
new  skin  will  be  formed,  and  the  part  heal 
just  like  a common  wound.  Perhaps,  until 
the  sloughs  separate,  the  best  application  is 
a soft  poultice,  which  should  be  put  on 
cold,  lest  it  bring  on  too  great  an  oozing  of 
blood. 

Nothing,  indeed,  is  so  proper  for  checking 
any  tendency  to  hemorrhage  as  cold  applica- 
tions, which  are  also  the  most  effectual  in 
preventing  and  diminishing  the  great  degree 
of  inflammation,  which  is  one  of  the  most 
dangerous  consequences  of  this  description 
of  wounds. 

No  surgical  writer,  I think,  has  given 
more  rational  advice,  respecting  contused 
wounds,  than  that  published  by  Professor 
Assalini.  In  general,  says  he,  the  treatment 
of  contused  wounds,  whether  they  be  simple 
and  slight,  or  complicated  and  severe,  re- 
quires the  active  employment  of  debilitating 
means  in  order  to  prevent  inflammation. 
Cold  water,  and  ice  ; and  general  and  topi- 
cal bleeding,  are  the  things  usually  resorted 
to  with  success.  Vulnerary  lotions,  campho- 
rated spirit,  and  other  spirituous  applications, 
are  improper,  and  if  their  pernicious  effects 
are  not  always  very  evident,  it  is  only  be- 
cause the  contused  injuries  have  been  trifling, 
and  in  their  nature  perfectly  easy  of  cure.  In 
these  cases,  as  well  as  in  those  of  extravasa- 
tions and  glandular  swellings,  Assalini  gives 
a preference  to  cold  applications.  The  in- 
ternal remedies  and  regimen,  (says  he) 
should  also  be  adapted  to  the  condition  of 
the  patient.  A cannon-ball,  at  the  end  of 
its  course,  may  come  into  contact  with  a 
limb,  and  fracture  the  bones,  while  the  inte- 
guments have  the  appearance  of  being  unin- 
jured. Such  cases  are  often  attended  with 
dreadful  mischief  in  the  soft  parts  around 
the  bone,  which  generally  sphacelate.  This 
is  an  accident  for  which  immediate  amputa- 
tion is  mostly  indispensable  (see  Gunshot 
Wounds;)  but  if  any  thing  be  capable  of  pre- 
venting inflammation  and  gangrene,  it  is  an 
active  debilitating  plan  of  treatment,  assisted 
with  cold  applications  to  the  injured  part. 
In  such  cases,  the  internal  and  external  use 
of  stimulants  is  approved  of  by  many  sur- 
geons. But,  Assalini  prefers  considering  the 
state  of  the  injured  limb,  just  like  what  it  is 
when  affected  with  frost ; and  he  thinks  that 
the  employment  of  stimulants  will  neces- 
sarily produce  the  same  effect  as  caloric 
prematurely  applied  to  parts  deadened  with 
cold.  On  the  contrary,  from  the  outward 
employment  of  ice  and  cold  lotions  in  tb.ese 
cases,  and  in  contused  injuries  in  general,  he 
has  seen  the  greatest  benefit  derived. 

Assalini  conceives,  that  reason  will  be 
found  to  support  this  practice.  The  opera- 
tion of  cold,  he  says,  retards  the  course  of 
the  blood,  which  meeting  with  only  dama- 
ged vessels,  augments  the  extravasation  as 
it  continues  to  flow.  By  lessening  the  tem- 
perature of  the  part,  cold  applications  like- 
wise diminish  the  danger  of  inflammation 
and  sphacelus,  at  the  same  time  that  they 


o4o 

have  the  good  effect  Of  rendering  the  suppu 
ration,  which  must  qnsue,  less  profuse,  than 
it  would  be,  were  not  extravasation  of  blood, 
and  violence  of  the  inflammation,  lessened 
by  such  applications,  and  a lowering  plan  of 
treatment. 

Why,  says  Assalini,  should  not  this  me- 
thod, which  is  generally  adopted  to  prevent 
the  effects  of  concussion  of  the  brain  after 
blows  on  the  head, be,  for  analogous  reasons, 
employed  in  examples  of  extravasation  and 
commotion  in  other  parts  of  the  body  ? 

( Manuale  de  Chirurgia,  Parte  Primatp  17.) 
Cold  applications,  however,  in  cases  of  con- 
tused wounds,  are  chiefly  to  be  preferred,  for 
the  first  day  or  two,  in  order  to  check  the 
increase  of  extravasation  and  inflammation. 
After  this  period,  l give  a decided  preference 
to  an  emollient  linseed  poultice,  which  will 
be  found  the  most  easy  dressing  during  those 
processes,  by  which  the  slougii3  are  detached, 
the  surface  of  the  wound  cleansed,  and  the 
origin  of  granulations  established.  When 
these  changes  have  happened,  the  remaining 
sore  is  to  be  treated  on  the  same  principles 
as  ulcers  in  general.  See  Ulcers. 

Punctured  Wounds. — A punctured  wound 
signifies  one,  made  with  a narrow-pointed 
instrument,  the  external  orifice  of  the  injury 
being  small  and  contracted,  instead  of  being 
ofasize  proportionate  to  its  depth.  A wound, 
produced  by  a thrust  of  a sword,  or  bayonet, 
affords  us  an  example  of  a punctured  wound. 

Wounds  of  this  description  are  in  general 
infinitely  more  dangerous  than  cuts,  notwith- 
standing the  latter  have  the  appearance  of 
being  by  far  the  most  extensive.  In  cases 
of  stabs,  the  greatest  degree  of  danger  al- 
ways depends  on  the  injury,  and  rough  vio- 
lence which  the  fibres  have  suffered,  in  ad- 
dition to  their  mere  division.  Many  of  the 
disagreeable  consequences  are  also  to  be 
imputed  to  the  considerable  depth,  to  which 
these  wounds  extend,  whereby  important 
parts  and  organs  are  frequently  injured. 
Sometimes  the  'treatment  is  rendered  per- 
plexing, by  the  difficulty  of  removing  ex- 
traneous substances, as  forinstancea  piece  of 
the  weapon,  which  has  been  left  in  the 
wound.  Lastly,  experience  proves,  that 
punctured  wounds  and  stabs  are  particularly 
liable  to  be  followed  by  a great  deal  of  in- 
flammation, fever,  deep  seated  abscesses,  si- 
nuses, fee. 

A strange  notion  seems  to  pervade  the 
writings  of  many  systematic  authors,  that  all 
the  danger  and  disagreeable  consequences 
of  punctured  wounds  are  entirely  owing  to 
the  narrowness  of  their  orifices,  which  pre- 
vents suitable  applications  from  being  made 
to  their  bottom.  Hence,  it  is  absurdly  re- 
commended to  dilate  th*  opening  of  every 
slab,  with  the  view,  as  is  generally  added, 
of  converting  the  accident  into  a simple  inci- 
sed wound.  Some  of  these  writers  are  advo- 
cates for  making  the  dilatation  with  a cutting 
instrument,  while  others,  with  equal  absurdi- 
ty, propose  to  enlarge  the  opening  with  tents. 

Certain  authors  regard  a punctured  'wound, 
as  a recent  sinus,  and  in  order  to  make  the 
inner  surfaces  unite,  they  recommend  ex- 


IYOUjSUs. 


<>4i> 

citing  a degree  of  inflammation  in  them, 
either  l>y  means  of  setons,  or  injections. 

In  the  earliest  edition  of  The  First  Lines  of 
the  Practice  of  Surgery,  I have  taken  parti- 
cular pains  to  expose  the  folly  and  errors, 
which  prevail  in  most  writings  on  this  part 
of  practice.  In  the  above  work,  I have  re- 
marked, that  if  the  notion  were  true,  that 
an  important  punctured  wound,  such  as  the 
stab  of  a bayonet,  could  be  actually  chan- 
ged into  a wound,  partaking  of  the  mild 
nature  of  an  incision,  by  the  mere  enlarge- 
ment of  its  orifice,  the  corresponding  prac- 
tice would  certainly  be  highly  commenda- 
ble, however  painful.  But  the  fact  is  other- 
wise : the  rough  violence,  done  to  the  fibres 
of  the  body  by  the  generality  of  stabs,  is 
little  likely  to  be  suddenly  removed  by  an 
enlargement  of  the  wound.  Nor  can  the 
distance,  to  which  a punctured  wound  fre- 
quently'penetrates,  and  the  number  and  na- 
ture of  the  parts  injured  by  it,  be  at  all 
altered  by  such  a proceeding.  These,  which 
are  the  grand  causes  of  the  collections  of 
matter,  that  often  take  place  in  the  cases 
under  consideration,  must  exist,  whether  the 
mouth  and  canal  of  the  wound  be  enlarged 
or  not.  The  time  when  incisions  are  pro- 
per, is  w’hen  there  are  foreign  bodies  to  be 
removed,  abscesses  to  be  opened,  or  sinuses 
to  be  divided.  To  make  painful  incisions 
sooner  than  they  can  answer  any  end,  is 
both  injudicious  and  hurtful.  They  are 
sometimes  rendered  quite  unnecessary,  by 
the  union  of  the  wound  throughout  its 
whole  extent,  without  any  suppuration  at 
all. 

Making  a free  ineision  in  the  early  stage 
of  these  cases,  undoubtedly  seems  a reasona- 
ble method  of  preventing  the  formation  of 
sinuses,  by  preventing  the  confinement  of 
matter,  and  were  sinuses  an  inevitable  con- 
sequence of  all  punctured  wounds,  for 
which  no  incisions  had  been  practised  at  the 
moment  of  their  occurrence,  it  would  un- 
doubtedly be  unpardonable  to  omit  them. 
Fair,  however,  as  this  reason  may  appear,  it 
is  only  superficially  plausible,  and  a small 
degree  of  reflection  soon  discovers  its  want 
of  real  solidity.  Under  what  circumstances 
do  sinuses  form  ? Do  they  not  form  only 
where  there  is  some  cause  existing  to  pre- 
vent the  healing  of  an  abscess  ? This  cause 
may  either  be  the  indirect  way,  in  which 
the  abscess  communicates  externally,  so 
that  the  pus  does  not  readily  escape  ; or  it 
maybe  the  presence  of  some  foreign  body, 
or  carious  bone  ; or  lastly,  it  may  he  an  in- 
disposition of  the  inner  surface  of  the  ab- 
scess to  form  granulations,  arising  from  its 
long  duration,  but  removable  by  laying  the 
cyst  completely  open  to  the  influence  of 
the  air.  Thus  it  becomes  manifest,  that  the 
occurrence  of  suppuration  in  punctured 
wounds  is  followed  by  sinuses  only  when 
the  surgeon  neglects  to  procure  a free  issue 
for  the  matter,  after  its  accumulation  ; or 
when  he  neglects  to  remove  any  extraneous 
bodies.  But  as  dilating  the  wound  at  first 
can  only  tend  to  augment  the  inflammation, 
nnd  render  the  suppuration  more  extensive. 


it  ought  never  to  be  practised  in  tnese  casev. 
except  for  the  direct  objects  of  giving  free 
exit  to  matter  already  collected,  and  of 
being  able  to  remove  extraneous  bodies 
palpably  lodged.  I shall  once  more  repeat, 
that  it  is  an  erroneous  idea  to  suppose  the 
narrowness  of  punctured  wounds  so  princi- 
pal a cause  of  the  bad  symptoms,  with 
which  they  are  often  attended,  that  the 
treatment  ought  invariably  to  aim  at  its,  re- 
moval. 

Recent  punctured  wounds  have  absurdly 
had  the  same  plan  of  treatment  applied  to 
them  as  old  and  callous  fistuhe.  Setons  and 
stimulating  injections,  which  in  the  latter 
cases,  sometimes  act  beneficially,  by  exci- 
ting such  inflammation  as  is  productive  of 
the  effusion  of  coagulating  lymph,  and  of 
the  granulating  process,  never  prove  ser- 
viceable when  the  indication  is  to  moderate 
an  inflammation,  which  is  too  apt  to  rise  to 
an  improper  height.  The  counter-opening, 
that  must  be  formed  in  adopting  the  use  oi 
a seton,  is  also  an  objection.  However, 
what  good  can  possibly  arise  from  a setou 
in  these  cases?  Will  it  promote  the  dis- 
charge of  foreign  bodies,  if  any  are  present : 
By  occupying  the  external  openings  of  the 
wound,  will  it  not  be  more  likely  to  prevent 
it  ? In  fact,  will  it  not  itself  act  with  all  the 
inconveniences  and  irritation  of  an  extra- 
neous substance  in  the  wound  ? Is  it  a likely 
means  of  diminishing  the  immoderate  pain, 
swelling,  and  extensive  suppuration,  so  often 
attending  punctured  wounds  ? It  will  un- 
doubtedly prevent  the  external  openings 
from  healing  too  soon  ; but  cannot  this  ob- 
ject be  effected  in  a better  way?  If  the  sur- 
geon observes  to  insinuate  a piece  of  lint 
into  the  sinus,  and  pass  a probe  through  its 
track  once  a day,  the  danger  of  its  closing 
too  soon  will  be  removed. 

The  practice  of  enlarging  punctured 
wounds  by  incisions,  and  of  introducing  se- 
tons, is  often  forbidden  by  the  particular 
situation  of  these  injuries. 

In  the  first  stage  of  a punctured  wound, 
the  indication  is  to  guard  against  the  attack 
of  violent  inflammation.  When  no  con- 
siderable quantity  of  blood  has  been  lost, 
general  and  topical  bleeding  should  be  prac 
tised.  In  short,  the  antiphlogistic  plan  is  tu 
be  followed.  As  no  man  can  pronounce, 
whether  such  wounds  will  unite  or  not,  and 
as  no  harm  can  result  from  the  attempt,  the 
orifice  ought  to  be  closed,  and  covered  with 
simple  dressings.  In  such  cases,  cold  appli- 
cations are  also  highly  commendable.  Whe- 
ther gentle  compression  might  be  made  to 
promote  the  adhesive  inflammation  or  not, 
may  be  doubtful  : l confess,  that  I should 
not  haVe  any  reliance  upon  its  usefulness. 
Perfect  quietude  is  to  be  observed.  When 
the  pain  is  severe,  opium  is  to  be  adminis- 
tered. 

Sometimes  under  this  treatment,  the  sur 
geon  is  agreeably  surprised  to  find  the  con- 
sequent inflammation  mild,  and  the  wound 
speedily  united  by  the  first  intention.  u Nu- 
merous are  the  examples  ol  wounds,  which 
penetrate  the  lapge  ravifies.  being  healed  by 


wu 


the  iVrkt  intention,  tiial  is,  ui-tiiout  any  sup- 
puration. Even  wounds  of  the  chest  itself, 
with  injury  of  the  lungs  (continues  an  ex- 
perienced military  surgeon  and  professor,) 
ought  to  be  united  by  the  first  intention. 
(Jlssalini,  in  Mnnuale  di  Chirurgia,  parte 
Scconda , p.  13.)  More  frequently,  however, 
in  cases  of  deep  stabs,  the  pain  is  intolera- 
ble; and  the  inflammatory  symptoms  run 
so  high  as  to  leave  no  hope  of  avoiding  sup- 
puration. In  this  condition,  an  emollient 
poultice  is  the  best  local  application  ; and 
when  the  matter  is  formed,  the  treatment  is 
like  that  of  abscesses  in  general.  See  Sup- 
puration. 

Poisoned  IVounds:  Bite  of  ike  Viper. — If 
we  exclude  from  present  consideration  the 
bites  of  mad  dogs,  and  other  rabid  animals, 
which  subject  is  fully  treated  ot  in  the  ar- 
ticle Hydrophobia,  wounds  of  this  descrip- 
tion are  not  very  eommon  in  these  islands. 
In  dissections,  pricks  of  the  hand  sometimes 
occur,  and  they  are  in  reality  a species  of 
poisoned  wound,  frequently  causing  consi- 
derable pain  and  irritation  in  the  course  of 
the  absorbents ; swelling  and  suppuration 
of  the  lymphatic  glands  of  the  arm  or  axilla; 
and  severe  fever  and  constitutional  irrita- 
tion. An  instance  of  the  fatal  consequences 
of  such  an  injury  must  still  be  fresh  in  the 
recollection  of  the  profession  ; and  some 
others  of  yet  more  reoent  date  have  taken 
place  in  this  metropolis.  (See  London  Me- 
dical Repository,  Vol.  7,  p ■ 288.) 

In  many  instances,  however,  surgeons 
wound  their  fingers  in  dissecting  bodies, 
and  no  particular  ill  consequences  ensue. 
The  healthy  and  robust  are  said  to  suffer 
less  frequently  after  such  accidents,  than 
persons,  whose  constitutions  have  been 
weakened  by  hard  study,  excesses,  pleasure, 
or  previous  disease.  It  is  remarked,  also, 
that  pricks  of  the  lingers,  met  with  in  open- 
ing the  bodies  of  persons  who  have  died  of 
contagious  diseases,  and  where  a virus  or 
infectious  matter  might  be  expected  to  exist 
in  such  bodies,  do  not  communicate  the  in- 
fection. Doubtless  (observes  Richerand) 
the  activity  of  certain  animal  poisons,  from 
which  the  venereal  and  several  other  dis- 
eases arise,  is  extinguished  with  life.  (JVb- 
sographie  Chir.  T.  1 ,p.  102,  103.  Edit.  4.) 

With  regard  to  the  treatment  of  the 
pricks  of  dissecting  scalpels,  the  surgeons  of 
the  continent  recommend  the  immediate 
cauterization  of  the  little  wounds  with  a 
grain  of  caust  ic  potassa,  or  the  liquid  muri- 
ate of  ammonia.  Tonic  remedies,  particu- 
larly wine,  is  prescribed,  and  great  atten- 
tion paid  to  emptying  the  bowels. 

The  stings  of  bees,  wasps,  and  hornets, 
are  also  poisoned  wounds,  though  ^ftey  are 
.seldom  important  enough  to  require  the 
assistance  of  a surgeon.  The  hornet  is  not 
found  in  Scotland;  but  it  is  an  inhabitant  of 
several  of  the  woods  in  England.  Its  sting, 
which  is  more  painful  than  that  of  a bee, 
or  wasp,  is  not,  however,  often  the  occa- 
sion of  any  serious  consequences.  1'he 
stings  of  all  these  insects  are  attended  with 
a vhn-ro  pain  in  the  part,  very  muckly  suc- 


ceeded by  an  inflammatory  swelling,  which, 
after  a short  time,  generally  subsides  of  it- 
self. When  the  eye  is  stung,  as  sometimes 
has  happened,  the  e fleets  may  be  very  se- 
vere, as  is  elsewhere  noticed.  (See  Ophthal’ 
my.)  It  has  been  lately  observed,  that  the 
pain  of  the  stings  of  venomous  insects,  like 
the  bee,  depends  less  upon  the  introduction 
of  the  sting  into  the  part,  than  upon  that  of 
the  venomous  fluid.  The  experiments  of 
Professor  Dumeril  tend  to  prove,  that  when 
the  little  poison  bladder,  situated  at  the 
base  of  the  sting,  has  been  cut  off,  a wound 
with  the  sting  then  produces  no  pain.  The 
poison  flows  from  the  vesicle  through  the 
sting  at  the  instant  when  this  passes  into  the 
flesh.  The  exact  nature  of  this  venomous 
fluid  is  not  known.  When  applied  to  mu- 
cous surfaces,  or  even  to  the  surface  of  the 
conjunctiva  of  the  eye,  it  causes  no  dis- 
agreeable sensation  ; but  when  it  is  intro- 
duced into  the  skin,  by  means  of  a needle, 
it  immediately  excites  very  acute  pain. 

Oil,  honey,  spirits  of  wine,  the  juice  of 
the  plantain,  and  a variety  of  other  local 
applications,  have  been  extolled  as  specifics 
lor  the  relief  of  the  stings  of  insects.  Mo- 
dern experience,  however,  does  not  sanc- 
tion their  claim  to  this  character.  In  fact, 
none  of  these  applications  either  neutralize 
the  poison,  or  appease  with  superior  efficacy 
the  pain  of  the  sting 

These  cases  should  all  be  treated  on  com- 
mon antiphlogistic  principles,  and  the  most 
rational  plan  is  to  extract  the  sting,  taking 
care,  in  the  first  instance,  to  cut  oft*  the  little 
poison  vesicle  with  scissors,  lest  in  the  at- 
tempts to  withdraw  the  sting  more  of  the 
virus  be  compressed  into  the  part.  The 
stung  part  should  then  be  immersed  for  a 
time  in  ice-cold  water,  anc!  afterward  co- 
vered with  linen,  wet  with  the  liquor  plumbi 
acetatis  dilutus.  Were  the  inflammation  to 
exceed  the  usual  degree,  leeches  and  aperi- 
ent medicines  would  be  proper.  In  short, 
as  there  is  no  specific  for  the  cure  of  these 
cases,  they  are  to  be  treated  with  common 
antiphlogistic  means. 

With  regard  to  the  bites  of  serpents, 
those  inflicted  by  the  rattle-snake  of  Ame- 
rica, and  the  cobra  di  capello  of  the  East 
Indies,  are  the  most  speedily  mortal.  In- 
deed, this  is  so  much  the  case,  that  some- 
times there  is  scarcely  an  opportunity  of 
trying  any  remedies ; and  even  when  the 
patient  is  not  destroyed  thus  rapidly,  there 
is  such  general  disorder  of  the  nervous  sys- 
tem, with  repeated  faintings  arid  sickness, 
that  medicines  cannot  well  be  retained  in 
the  stomach,  at  least  for  some  time. 

Mr.  Catesby,  in  the  Preface  to  his  Natural 
History  of  Carolina,  informs  us,  that  the 
Indians,  who,  by  their  constant  wanderings 
hi  the  woods,  are  liable  to  be  bit  by  snakes, 
know,  as  soon  as  they  receive  the  injury, 
whether  it  will  prove  mortal  or  not.  If  it 
be  on  any  part  at  a dislance  from  largo 
blood-vessels,  or  where  the  circulation  is 
not  vigorous,  they  apply  their  remedies ; 
but  if  any  vein  of  considerable  magnitude 
be  hurt,  they  qnietlv  resign  themselves  to 


WB  WOUNDS. 


their  fate,  knowing  that  nothing  can  then 
be  of  service.  Among  the  remedies  on 
which  they  chiefly  depend  are  seneka  root, 
volatile  alkali,  and  particularly  strong  doses 
of  arsenic,  as  will  be  presently  noticed 
again. 

If  we  put  out  of  consideration  animals 
affected  with  rabies,  the  viper  inflicts  the 
'worst  poisoned  wound  ever  met  with  in 
these  islands.  In  fact  it  is  an  animal  which 
inserts  into  the  part  w hich  it  bites  a poison 
capable  of  exciting  very  serious  conse- 
quences. The  jaws  of  the  viper  are  fur- 
nished with  teeth,  two  of  which  in  the 
upper  jaw  are  very  different  from  the  rest. 
These,  w hich  are  about  three  lines  long,  are 
covered  for  about  two-thirds  of  their  length, 
with  a membranous  coat  or  sheath,  are  of  a 
curved  shape,  and  articulated  with  the  jaw- 
bone. When  the  animal  is  tranquil,  and 
his  mouth  shut,  they  lie  dowm  with  their 
points  turned  backwards  3 but  they  instantly 
project  forwards  when  it  is  irritated,  and 
about  to  bite.  In  them  are  canals,  which 
terminate  by  a very  narrow  fissure  on  their 
convex  sides,  a little  way  from  their  points. 
The  rest  of  these  fangs  is  very  hard  and 
solid  ; and  the  canal  is  usually  filled  with  a 
transparent,  yellowish  fluid,  the  poison  of 
the  viper. 

This  venomous  fluid  is  secreted  by  two 
glands,  or  rather  by  two  clusters  of  glands, 
one  on  each  side  of  the  head,  placed  on  the 
front  of  the  forehead,  directly  behind  the 
eye-ball,  under  the  muscle,  which  serves  to 
depress  the  upper  jaw.  Thus  the  muscle 
cannot  act  without  pressing  upon  them,  and 
promoting  the  secretion  of  the  fluid,  which 
they  are  destined  to  prepare.  A little  bag, 
or  vesicle,  connected  to  the  base  of  the  first 
bone  of  the  upper  jaw,  as  well  as  to  the  end 
of  the  second,  covers  also  the  roots  of  the 
curved  fangs,  and  forms  a receptacle  for  the 
venom. 

The  viper  is  chiefly  found  in  hilly,  stony, 
and  wroody  districts,  and  seldom  in  flat  or 
marshy  places.  It  is  not  its  nature  to  at- 
tack man,  or  large  animals,  except  when 
provoked.  Its  venom  is  only  employed  for 
the  destruction  of  smaller  animals,  such  as 
mice,  frogs,  k.c.  which  are  usually  swallow- 
ed w hole,  and  to  the  digestion  of  which  the 
venomous  secretion  is  by  some  writers  sup- 
posed to  contribute.  When,  however,  a 
viper  is  pursued,  trod  upon,  taken  hold  of, 
or  hurt,  it  immediately  bites,  and  were  it 
only  on  account  of  the  shape  of  the  fangs, 
the  wound  might  be  attended  w ith  very  un- 
pleasant effects;  but  it  is  certain  of  being 
so,  by  reason  of  the  species  of  inoculation 
which  complicates  it,  and  of  which  the 
mechanism  is  as  follows : 

When  a viper  is  about  to  bite,  it  opens  its 
mouth  very  wide.  The  two  curved  fangs, 
which  had  previously  lain  flat  down  in  the 
cavity  of  the  membrane  attached  to  their 
base,  now  project,  and  become  perpendicu- 
lar to  the  low  er  jaw.  When  the  bite  takes 
place,  the  poison  is  propelled  through  the 
fangs,  by  t lie  contraction  of  the  muscles, 
and  the  closure  of  the  mouth,  and  is  in- 


jected into  the  wound  with  a force  propor- 
tioned to  its  accidental  quantity  at  the 
time,  and  the  vigour  of  the  animal. 

The  bite  of  a viper  is  quickly  followed  by 
severe  effects,  some  of  w'hich  are  local,  and 
the  others  general ; but  it  is  with  the  former 
that  the  disorder  invariably  commences. 
At  the  instant  of  the  bite,  the  bitten  part  is 
seized  with  an  acute  pain,  which  rapidly 
shoots  over  the  whole  limb,  and  even  affects 
the  viscera  and  internal  organs.  Soon  after- 
ward the  w’ounded  part  swells  and  reddens. 
Sometimes  the  tumefaction  is  confined  to 
the  circumference  of  the  injury  ; but  most 
frequently  it  spreads  extensively,  quickly 
affecting  every  part  of  the  limb,  and  even 
the  trunk  itself.  A sanious  fluid  is  often 
discharged  from  the  wound,  around  which 
phlyctenas  arise,  similar  to  those  of  a burn. 
After  a short  time,  however,  the  pain  abates 
considerably ; the  inflammatory  tension 
changes  into  a doughy,  or  oedematous  soft- 
ness ; the  part  grow's  cold;  and  the  skin 
exhibits  large  livid  spots,  like  those  of  gan- 
grene. The  general  symptoms  also  come 
on  with  celerity ; the  patient  is  troubled 
with  anxiety,  prostration  of  strength,  diffi- 
culty of  breathing,  and  cold  profuse  sweats 
Vomiting  frequently  occurs,  and  sometimes 
copious  bilious  evacuations  from  the  bowels 
These  symptoms  are  almost  constantly  at- 
tended with  an  universal  yellowness,  and 
excruciating  pain  about  the  navel. 

The  effects  occur  in  the  same  way  in 
nearly  all  subjects,  with  some  differences 
depending  upon  the  particular  irritability 
and  constitution  of  the  patient ; the  high  or 
low  temperature  of  the  atmosphere ; the 
greater  or  lesser  anger  of  the  viper ; the 
number  of  its  bites;  the  size  of  the  reptile 
itself  ; the  depth  to  which  the  fangs  have 
penetrated  ; and  whether  the  bitten  part 
happens  to  be  one  of  great  sensibility,  or 
w as  naked  or  not  at  the  time  of  the  acci- 
dent. In  general,  weak,  pusillanimous 
persons,  of  bad  constitutions,  and  loaded 
stomachs,  suffer  more  sudden  and  alarming 
ill  consequences,  than  strong,  healthy  sub 
jects,  wdio  view7  the  danger  without  fear 
Several  bites  are,  of  course,  more  danger- 
ous than  a single  one  ; and,  lastly,  it  has 
been  remarked,  that  the  venom  of  the  viper 
is  more  active  in  summer  than  the  spring. 

A year  or  two  ago,  however,  the  news 
papers  recorded  the  death  of  a servant, 
from  the  inadvertent  application  of  the  poi- 
son to  a scratch  on  his  hand,  as  he  was  exa- 
mining the  fangs  and  venomous  organs  of  a 
viper  perfectly  torpid  in  the  winter  season. 

Severe,  however,  as  the  effects  of  the 
bite  of  a viper  may  be,  they  are  far  from 
being  so  perilous  as  they  are  commonly 
supposed  to  be.  Indeed,  the  injury  rarely 
proves  fatal  to  an  adult,  even  when  inflicted 
by  a viper  in  the  middle  of  summer,  the 
period  when  the  animal  is  mo3t  active  and 
vigorous.  Exceptions  to  this  common  be- 
lief, however  are  upon  record.  Thus  in 
the  year  1816,  a vvomaD,  in  France,  aged 
sixty-four,  was  bit  ou  the  thigh  by  a viper, 
and.  died  in  thirty-seven  hours,  notwith- 


WOUNDS. 


standing  the  internal  use  of  the  liquor  am- 
monite, and  the  enlargement  of  the  wound, 
and  cauterization  of  it  with  this  fluid.  In 
this  case,  it  is  to  be  observed,  that  an  hour 
elapsed  before  any  thing  was  done.  (See 
Annalts  du  Cercle  Medicate , T.  1,  P-  43,  S vo. 
Paris,  1820.) 

Fontana,  therefore,  was  not  exactly  cor- 
rect in  concluding,  that  the  bite  of  an  ordi- 
nary viper  will  not  prove  fatal  to  a full- 
grown  person,  nor  even  to  a large  dog, 
though  it  does  so  to  smaller  animals.  Five 
bites  from  three  strong  and  healthy  vipers 
were  not  able  to  kill  a dog  weighing  sixty 
pounds;  and  as  this  dog  was  little  more 
than  a third  part  of  the  weight  of  an  ordi- 
nary man,  Fontana  supposed  that  a single 
bite  could  never  be  fatal  to  an  adult.  He 
says,  that  he  had  seen  a dozen  cases  himself, 
and  had  heard  of  fifty  more,  only  two  of 
which  ended  fatally.  Concerning  one  of 
these  cases,  he  could  get  no  information  ; 
the  other  patient  perished  of  gangrene, 
twenty  days  after  the  bite.  The  mortifica- 
tion began  three  days  after  the  accident, 
the  bitten  place  having  been  deeply  scarified 
almost  as  soon  as  the  injury  was  received. 
Fontana  believes,  that  much  of  the  faint- 
ness, &.c.  which  ensues  upon  the  bite  of  a 
viper,  are  the  mere  effects  of  terror.  “ Upon 
a person’s  being  bit  (says  he;  the  fear  of 
its  proving  fatal  terrifies  himself  and  the 
whole  family.  From  the  persuasion  of  the 
disease  being  mortal,  and  that  not  a mo- 
ment is  to  be  lost,  they  apply  violent  or 
hurtful  remedies.  The  fear  increases  the 
complaint.  I have  known  a person  that 
was  imperceptibly  bit  in  the  hands  or  feet, 
and  who,  after  seeing  the  blood,  and  ob- 
serving a viper  near  him,  suddenly  fainted 
away  ; one,  in  particular,  continued  in  a 
swoon  for  upwards  of  an  hour,  until  he  was 
accidentally  observed,  and  recovered  out 
of  it  by  being  suddenly  drenched  in  cold 
water.  We  know  that  death  itself  may  be 
brought  on  by  very  violent  affections  of  the 
mind,  without  any  internal  disease.  Why 
may  not  people,  that  are  bit,  die  from  a dis- 
ease, produced  entirely  from  fear,  and  who 
would  not  otherwise  have  died  from  any 
complaint  produced  by  the  venom  ?”  Al- 
though it  must  be  owned,  that  Fontana  be- 
stowed a great  deal  of  attention  upon  this 
subject,  the  above  reasoning  is  hypothetical 
and  inconclusive.  If  it  were  to  be  granted, 
that  some  very  timid,  delicate,  or  nervous 
people,  die  from  fear  alone,  it  could  not  be 
admitted,  that  the  generality  of  people,  bit 
by  snakes,  perish  also  from  the  violent 
effect  of  mental  alarm. 

Whenever  the  patient  dies,  the  catastro- 
phe is  always  ascribable  to  the  quantity  of 
venom  inserted  in  the  wound  ; the  number 
of  bites  ; their  situation  near  important  or- 
gans ; and  the  neglect  of  proper  means  of 
relief.  In  ordinary  cases  of  a single  bite 
upon  the  extremities,  the  patients  would  get 
well  even  without  any  assistance  ; but  the 
symptoms  would  probably  be  more  severe, 
and  the  cure  slower. 

Vox..  IF 


649 

From  some  facts,  recorded  by  Sir  Everard 
Home,  and  observations  made  on  the  opera 
tiou  of  the  poisons  of  the  black  spotted 
snake  of  St.  Lucia,  the  cobra  di  Capello,  and 
the  rattlesnake,  it  appears,  that  u the  effects 
of  the  bite  of  a snake,  vary  according  to  the 
intensity  of  the  poison.  When  the  poison 
is  very  active,  the  local  irritation  is  so  sud- 
den, and  so  violent,  and  its  effects  on  the 
genera!  system  are  so  great,  that  death  soon 
takes  place.  When  the  body  is  afterward 
inspected,  the  only  alteration  of  structure 
met  with,  is  in  the  parts  close  to  the  bite, 
where  the  cellular  membrane  is  completely 
destroyed,  and  the  neighbouring  muscles 
very  considerably  inflamed.  • When  the  poi- 
son is  less  intense,  the  shock  to  the  general 
system  does  not  prove  fatal.  It  brings  on  a 
slight  degree  of' delirium,  and  the  pain  in  the 
part  bitten  is  very  severe  : in  about  half  an 
hour,  swelling  takes  place  from  an  effusion  of 
serum  in  the  cellular  membrane,  which  con- 
tinues to  increase,  with  greater  or  less  ra- 
pidity, for  about  twelve  hours,  extending, 
during  that  period,  into  the  neighbourhood 
of  the  bite.  The  blood  ceases  to  flow  in  the 
small  vessels  of  the  swollen  parts  ; the  skin  over 
them  becomes  quite  cold ; the  action  of  the 
heart  is  so  weak,  that  the  pulse  is  scarcely  per- 
ceptible, and  the  stomach  is  so  irritable  that 
nothing  is  retained  by  it.  In  about  sixty  hours , 
these  symptoms  go  off ; inflammation  and  sup- 
puration take  place  in  the  injured  parts;  and 
when  the  abscess  formed  is  very  great,  it 
proves  fatal.  When  the  bite  has  been  in 
the  finger,  that  part  has  immediately  mortified. 
When  deaih  has  taken  place,  under  such  cir- 
cumstances, the  absorbent  vessels,  and  their 
glands  have  undergone  no  change,  similar  to 
the  effects  of  morbid  poisons,  nor  has  any  part 
lost  its  natural  appearance,  except  those  im- 
mediately connected  with  the  abscess.  In 
those  patients,  who  recover  with  difficulty 
from  the  bite,  the  symptoms,  produced  by 
it,  go  off  more  readily,  and  more  complete- 
ly, than  those  produced  by  a morbid  poi 
son,  which  has  been  received  into  the  sys- 
tem.'’ ( Sir  E.  Home,  Case  of  a Man  who  died 
in  Consequence  of  the  Bite  of  a Rattle  Snake, 
in  Phil.  Trans.  1810.) 

Numerous  remedies  for  the  bites  of  com 
mon  vipers  have  obtained  celebrity.  Ac 
cording  to  certain  writers,  each  of  these  re 
medies  has  effected  wonderful  cures ; and 
yet,  as  Boyer  well  remarks,  every  one  of 
them  has  been  in  its  turn  relinquished  for 
another,  the  sole  recommendation  of  which 
has  frequently  consisted  in  its  novelty.  Any 
of  these  boasted  medicines,  though  of  oppo 
site  qualities,  cured,  or  at  least  seemed  to 
cure,  the  patients,  and  the  partisans  of  each 
considered,  that  he  had  a right  to  extol  his 
own  remedy  as  a specific,  when  the  patient, 
to  whom  he  administered  it,  was  seen  to  re- 
cover perfectly,  after  suffering  a train  of  se- 
vere symptoms.  But  the  reason  of  this  pre- 
tended efficacy  becomes  obvious,  when  one 
knows  that  the  bite  of  a viper  is  of  itself 
rarely  mortal  to  the  human  subject,  and  that 
the  severity  of  the  symptoms  materially  de- 
pends upon  the  quantity  of  the  venom  in  the 


82 


WOUNDS 


wound.  {Boyer,  TraiU  des  .Maladies  Chir. 
T.  1 ,p.  428.) 

The  treatment  of  the  bite  of  a viper  is  di- 
vided into  local  and  general  means.  . 

The  local  treatment  has  for  its  principal 
object  the  destruction  of  the  venom  ; the 
prevention  of  its  entrance  into  the  vessels, 
or  the  removal  of  it  from  the  wound. 

Ot  scarifying  the  wound,  I shall  only  say, 
that  it  promises  no  utility,  if  it  be  practised 
with  a view  of  letting  such  dressings  be  ap- 
plied, as  are  extolled  as  specifics  ; for  we 
know,  that  there  is  no  local  application, 
which  is  entitled  to  this  character.  Fontana 
was  an  advocate  for  applying  a ligature 
round  the  lirnb,*in  order  to  check  the  ingress 
of  the  venom  into  the  circulation  ; and  he 
thought,  that  he  had  seen  much  good  result 
from  this  practice.  Sir  Everard  Home  is 
also  of  opinion,  that  “ the  only  rational  lo- 
cal treatment,to  prevent  the  secondary  mis- 
chief, is  making  ligatures  above  the  tumefied 
part,  to  compress  the  cellular  membrane, 
and  set  bounds  to  the  swelling,  which  only 
spreads  in  the  loose  parts  under  the  skin ; and 
scarifying  freely  the  parts  already  swoln, 
that  the  effused  serum  may  escape,  and  the 
matter  be  discharged  as  soon  as  it  is  formed. 
Ligatures  (he  says)  are  employed  in  Ameri- 
ca, but  with  a different  view,  viz.  to  prevent 
the  poison  being  absorbed  into  the  system.” 
(Phil.  Trans,  for  1810,  p.  87.)  At  all  events, 
if  compression  be  employed,  it  should  be 
so  regulated  as  not  to  create  any  risk  of 
gangrenous  mischief,  by  its  interruption  of 
the  circulation. 

Suction  of  the  wound  has  been  proposed, 
and  seems  founded  on  reason  ; but  experi- 
ence, I believe,  has  determined  little  in  its 
favour.  A cupping-^lass  might  be  employed, 
but,  probably,  no  mode  of  suction  would 
succeed  in  extracting  the  whole  of  the  poi- 
son. 

The  most  certain  method  of  removing  the 
virus  consists  in  the  excision  of  the  bitten 
part.  This  operation, however,  would  hardly 
be  proper,  unless  done  immediately  after  the 
injury,  before  much  inflammation  had  come 
on.  It  is  likewise  a practice  to  which  many 
patients  would  not  assent,  and  even  some 
surgeons  may  deem  the  proceeding  too  se- 
vere, in  relation  to  the  bite  of  the  viper  of 
this  country.  The  bite  might  also  be  incon- 
veniently situated  for  the  excision  of  the 
parts. 

Another  plan,  more  commonly  preferred 
is,  that  of  destroying  the  envenomed  part 
with  caustic,  or  the  actual  cautery.  When 
this  is  done  in  time,  the  poison  is  prevented 
from  extending  its  irritation  over  the  ner- 
vous system,  through  the  medium  of  which 
all  the  worst  symptoms  are  usually  excited. 
The  caustic  and  cautery  may  also  have  the 
effect  of  chymically  destroying  the  venom 
itself,  while  they  must  tend  to  hinder  its 
passage  into  the  circulation,  inasmuch  as 
they  destroy  the  neighbouring  absorbent 
vessels.  The  caustic,  which  Fontana  pre- 
ferred, was  potassa.  But,  as  Boyer  sensibly 
' remarks,  every  caustic,  of  equal  strength, 
must  infallibly  have  the  same,  effect,  n«  its 


mode  of  operating  is  that  of  destroying  the 
point  of  irritation,  viz.  the  seat  of  the  ve 
nom.  In  France,  liquid  caustics  are  pre- 
ferred, the  fluid  muriate  of  antimony,  the 
liquor  ammonia?,  or-dhe  sulphuric,  or  nitric 
acid,  because  their  action  is  quicker,  and 
they  more  certainly  penetrate  to  the  bottom 
of  the  wound.  {Traits  des  Mai.  Chir.  T.  1, 
p.  429.)  Either  of  these  liquids  may  be 
applied  by  means  of  a slender  pointed  bit  of 
wood,  which  is  to  be  dipped  in  it,  and  then 
introduced  into  the  punctures,  made  by  the 
fangs  of  the  reptile.  The  piece  of  wood 
should  be  withdrawn,  wret  once  more,  and 
applied  again.  If  a drop  of  the  caustic  can 
be  inserted,  so  much  the  better.  When  the 
bite  is  very  narrow  and  deep,  the  caustic  can- 
not well  be  introduced,  before  the  mouth  of 
the  wound  is  somewhat  enlarged  with  a lan- 
cet. A little  bit  of  lint  may  then  be  wet  in 
one  of  the  above  fluids,  and  be  pressed  deep- 
ly into  the  wound. 

After  the  caustic  has  produced  an  eschar4 
the  best  application  is  an  emollient  poul- 
tice. 

It  is  not,  however,  every  bite  of  a viper, 
that  requires  local  treatment,  even  of  this 
degree  of  severity.  As  Boyer  observes, 
when  the  wound  is  superficial,  the  viper 
benumbed  with  cold;  its  poison  considera- 
bly exhausted  by  its  having  previously  bit- 
ten other  animals  ; the  swelling  inconsider- 
able ; and  the  patient  neither  affected  with 
prostration  of  strength,  nor  pain  about  the 
praecordia  ; a few  drops  of  ammonia  may  be 
introduced  into  the  wound,  and  a small 
compress  wet  with  the  same  fluid  applied. 
Formerly,  olive  oil  was  considered,  in  Eng- 
land, one  of  the  best  applications  for  the 
bites  of  snakes,  and  its  virtues  were  after 
ward  extolled  in  France  by  Pouteau  ; but, 
says  Boyer,  it  possesses  no  specific  efficacy, 
as  the  experiments  of  Hunaud  and  G6otfroi 
have  decidedly  proved.  ( Traitd  des  Mala- 
dies Chir.  T.  l,p.  431.) 

With  respect  to  the  general  treatment,  if 
we  exclude  emetics,  of  which  Dr.  Mead  had 
a high  opinion,  when  the  patient  was  much 
jaundiced  the  favourite  medicines  are  cor- 
dials, ammonia,  and  arsenic.  The  ancients 
employed  theriaca,  Mithridates,  salt,  and 
the  carbonate  of  ammonia.  Of  all  stimulants, 
however,  the  liquor  ammonia?  is  that  which 
now  obtains  the  greatest  confidence ; or 
else,  the  eau  de  luce , which  only  differs  from 
the  fluid  ammonia,  in  containing  a small 
quantity  of  the  oleum  succinatum.  In 
France,  this  remedy  is  even  at  the  present 
time  regarded,  as  having  the  best  claim  to 
the  title  of  a specific  for  the  bite  of  a viper 
{Boyer,  op.  cit.) 

In  France,  Bernard  de  Jussieu  first  tried 
ammonia  in  the  year  1747  (see  Hist,  de 
VAcad.  des  Sciences , 1747 ;)  since  which  time 
it  has  been  extensively  employed  for  the 
cure  of  the  bites  of  vipers,  both  as  an  inter- 
nal and  external  remedy.  It  had,  however, 
been  highly  praised  by  Dr.  Mead  at  a much 
earlier  period. 

A few  drops  of  the  remedy  are  to  be  ex- 
hibited every  two  hours  : but.  as  it  is  very 


W0Li\b& 


boi 


powerful,  it  must  always  be  diluted  with  tea, 
or  some  other  drink,  or  the  mistura  cam 
phora?.  The  dose,  however,  must  depend 
upon  the  age  and  constitution  of  the  patient, 
and  the  intensity  of  the  symptoms.  Four 
or  five  drops  suffice  for  a person  of  weak, 
delicate,  irritable  habit ; but  twelve-  or  fif- 
teen may  be  given  to  stronger  subjects, 
when  the  symptoms  are  violent.  With  am- 
monia, some  practitioners  order  wine. 

In  St.  George’s  Hospital,  the  man  who 
was  bit  by  the  rattle-snake,  kept  for  exhibi- 
tion, took  aperient  medicines,  the  liquor 
ammonias,  aither,  the  spiritus  ammonias, 
comp,  opium,  and  other  stimulants ; but 
without  any  apparent  benefit.  The  disease 
followed  that  course  which  Sir  E.  Home 
has  described  as  usual  when  the  shock  on 
the  system  is  not  directly  fatal,  and  the 
mischief  in  the  arm  ultimately  produced  the 
man’s  death.  (See  Phil.  Trans.  1810.) 

From  the  following  passage,  in  relation 
to  the'  bites  of  snakes  in  general,  it  seems 
that  Sir  Everard  Home,  in  1810,  had  no 
confidence  in  any  medicines  which  had  then 
been  duly  tried.  The  violent  effects, 
which  the  poison  produces  on  the  part  bit 
ten,  and  on  the  general  system,  and  the 
shortness  of  their  duration,  where  they  do 
not  terminate  fatally,  (says  he)  have  fre- 
quently induced  the  belief,  that  the  recove- 
ry depended  on  the  medicines  employed  ; 
and,  in  the  East  Indies,  eau  de  luce  is  con- 
sidered as  a specific. 

There  does  not  appear  to  be  any  founda- 
tion for  such  an  opinion  ; for  when  the  poi- 
son is  so  intense  as  to  give  a sufficient  shock 
to  the  constitution,  death  immediately  takes 
place,  and  where  the  poison  produces  a lo- 
cal injury  of  sufficient  extent,  the  patient 
also  dies,  while  all  slighter  cases  reco- 
ver. The  effect  of  the  poison  on  the  con- 
stitution is  so  immediate,  and  the  irritability 
of  the  stomach  so  great,  that  there  is  no  op- 
portunity of  exhibiting  medicines  till  it  has 
fairly  taken  place,  and  then  there  is  little 
chance  of  beneficial  effects  being  produced. 
(Sir  E.  Home,  in  Phil.  Trans.  1810.) 

Fontana  also  had  little  faith  in  reputed 
antidotes;  but  it  is  to  be  noticed,  that  his 
observations  refer  only  to  the  bites  of*vipers. 
u In  no  country  (says  he)  through  which  I 
passed,  could  I ever  find  any  two  people  or 
persons,  bit  by  the  viper,  either  in  the  moun- 
tains or  valleys,  that  used  the  same  reme- 
dies. Some  used  theriaea  alone,  either  ex- 
ternally or  internally  applied  ; others  com- 
mon oil  ; a third  set  used  stimulants,  such 
as  the  strongest  spirituous  liquors  ; whilst 
others,  on  the  contrary,  tried  every  different 
kind  of  sedative.  In  short,  there  is  hardly 
any  active  kind  of  medicine  that  has  not 
been  tried  as  a cure  in  this  disease  ; while, 
at  the  same  time,  it  is  certain  that,  under  all 
the  varieties  of  application,  none  of  the  pa- 
tients died.”  Hence  Fontana  concluded, 
that  none  of  the  remedies  had  any  effect  in 
curing  the  disease. 

Later  observations,  however,  tend  to 
raise  our  hopes,  that  a medicine  is  now 
known  which  really  seems  to  possess  consi- 


derable efficacy  against  Uie  bite,  even  of  a 
very  formidable  kind  of  snake.  From  some 
facts  recorded  in  Dr.  Russell’s  History  oi  In- 
dian Serpents,  on  the  authorities  of  Mr.  Duf- 
fin  and  Mr.  Ramsay,  it  appears  that  the  Tan  - 
jure  pill,  of  which  arsenic  is  the  chiefingre- 
dient,  is  exhibited  with  considerable  success 
in  India  after  the  bites  of  venomous  serpents 
this  information  led  Mr.  Chevalier  to  pro- 
pose the  fair  trial  of  arsenic. 

Mr.  Ireland,  surgeon  to  the  60th  regt.  had 
formerly  heard  Mr.  Chevalier  recommend 
the  trial  of  arsenic,  and  he  was  resolved  to 
make  the  experiment  whenever  an  oppor- 
tunity offered.  On  his  arrival  in  the  island 
of  St.  Lucia,  he  was  informed  that  an  officer, 
and  several  men,  belonging  to  the  6Sth  re- 
giment, had  died  from  the  bites  of  serpents, 
supposed  to  be  the  coluber  earinatusof  Lia- 
na?^. 

The  reader  will  find  some  interesting  ac 
count  of  the  serpent  here  alluded  to,  in  a 
tract,  which  I have  lately  read,  entitled  Mo- 
nographic du  Trigonocephale  des  Antilles , on 
Grand  Vipere  Fcr-de- Lance  de  la  Martinique, 
par  A.  Moreau  de  Jonnes,  8 vo.  Paris,  1816. 

Mr.  Ireland  also  learnt,  that  every  thing 
had  been  tried  by  the  attending  medical  men 
to  no  purpose,  as  all  the  patients  had  died, 
some  in  six,  and  others  in  about  twelve 
hours  from  their  receiving  the  wound. 

A case,  however,  soon  came  under  Ml'. 
Ireland’s  own  observation,  and  as  nothing 
that  had  been  done  before,  seemed  to  have 
been  of  any  service,  he  was  determined  to 
give  arsenic  a full  trial. 

“ Jacob  Course,  a soldier  in  the  York  light 
infantry  volunteers,  was  bitten  in  the  left 
hand,  and  the  middle  finger  was  so  much 
lacerated,  that  I found  it  necessary  to  am- 
putate it  immediately  at  the  joint  with  the 
metacarpal  bone. 

“ I first  saw  him  about  ten  minutes  after 
he  had  received  the  wound,  and  found  him 
in  a torpid,  senseless  state  ; the  hand,  arm, 
and  breast  of  the  same  side  were  much 
swelled  and  mottled,  and  of  a dark  purple, 
and  livid  colour.  He  was  vomiting,  and  ap- 
peared as  if  much  intoxicated.  Pulse  quick 
and  hard  : he  felt  little  or  no  paini  during 
the  operation. 

u The  wound  being  dressed,  and  the  pa- 
tient put  to  bed,  I ordered  a cathartic  clys- 
ter, and  the  following  medicine  to  be  taken 
immediately.  Liquor  Arsenic.  3ij.  Tinct. 
Opii,  gt.  x.  Aq.  Menth.  Pip.  j§iss.  which  was 
added  to  half  an  ounce  of  lime-juice,  and 
as  it  produced  a slight  effervescence,  it  was 
given  in  that  state ; this  remained  on  his 
stomach,  and  was  repeated  every  half  hour 
for  four  successive  hours.  In  the  mean 
time,  the  parts  were  frequently  fomented 
with  common  fomentations,  and  rubbed 
with  a liniment  composed  of  01.  Terebinth, 
^ss.  Liquor  Ammon. |ss.  and  01.  Oliv.  Jiss\ 
The  cathartic  clyster  was  repeated  twice, 
when  the  patient  began  to  be  purged  ; and 
the  arsenical  medicine  was  now  disconti- 
nued. He  had  become  more  sensible  when 
touched,  and  from  that  time  he  gradually 


WOUNDS 


C&2 

recovered  his  faculties ; he  took  some  nou-  ner  two  cavities  aye  formed,  which  have  rid' 
vishment,  and  had  several  hours  sleep.  sort  of  communication  with  each  other 

“ The  next  day  he  appeared  very  weak,  By  the  two  pleura1,  touching  and  lying 
and  fatigued  ; the  fomentation  and  liniment  against  each  other,  a middle  partition  is 
were  repeated.  The  swelling  diminished  formed,  called  the  mediastinum.  These  two 
gradually  ; the  natural  colour  and  feeling  membranes  are  intimately  adherent  to  each 
returned,  and  by  proper  dressings  to  the  other,  in  front,  the  whole  length  of  the  ster- 
wound,  and  attention  to  the  state  of  his  num;  but  behind,  where  they  approach  the 
bowels,  he  soon  recovered  and  returned  to  vertebrae,  they  separate  from  each  other, 
his  duty.”  so  as  to  leave  room  for  the  aorta,  cesopha- 

Mr.  Ireland  recites  about  four  other  ex-  gus,  &z.c.  The  heart,  enclosed  in  the  peri- 
amples,  in  which  arsenic  was  exhibited  with  cardium,  occupies  a considerable  space  on 
similar  success.  the  left  of  the  mediastinum,  and  all  the  rest 

It  deserves  particular  notice,  that  the  li-  of  the  chest  is  filled  with  the  lungs,  except 
quor  arsenici  employed  by  Mr.  Ireland,  was  behind,  w here  the  large  blood-vessels, 
prepared  according  to  Dr.  Fowler’s  pre-  nerves,  tbpracic  duct,  and  (Esophagus,  are 
scription,  which  directs  sixty  four  grains  of  situated.  In  the  perfectly  healthy  state,  the 
arsenic,  and  as  many  of  the  fixed  vegetable  lungs  do  not  adhere  to  the  pleura ; but  in 
alkali,  to  be  dissolved  in  a sand  heat,  and  ‘the  majority  of  subjects,  at  least  in  this 
the  solution  to  be  made  an  exact  pint,  so  climate,  who  are  examined  after  death,  such 
that  two  drachms  contain  one  grain  of  arse-  adhesions  are  found  in  a greater  or  lesser 
jiie  in  solution.  (See  Med.  Chir.  Trans.  Vol.  degree.  The  disease  may  probably  be  oc- 
2,  p.  393,  fyc.)  casioned  by  very  slight  inflammation  ; and 

IVounds  of  the  Thorax. — The  thorax  is  a as  the  surface  of  the  lungs  is  naturally  des- 
cavity  of  an  irregularly  oval  figure,  bounded  tined  to  be  always  in  close  contact  with  the 
in  front  by  the  sternum,  laterally  by  the  pleura,  and  patients  are  frequently  not  sus- 
ribs,  posteriorly  by  the  vertebrae  of  the  back,  pected  to  have  any  thing  wrong  in  the  tho 
above  by  the  clavicles,  and  below  by  the  rax,  this  morbid  change  being  often  acci 
diaphragm,  a very  powerful  muscle,  which  dentally  discovered  after  death, in  lookingfoi 
forms  a kind  of  partition  between  the  cavity  something  else  ; it  may  be  concluded,  tha' 
of  the  thorax,  and  that  of  the  abdomen.  it  does  not  produce  any  serious  effects. 

The  diaphragm  is  not  stretched  across,  in  The  thorax  is  subject  to  all  kinds  of 
a straight  direction,  from  one  side  of  the  wounds  ; but  their  importance  particularly 
chest  to  the  other ; but  on  the  contrary,  depends  on  their  depth.  Those  which  do 
descends  much  further  in  some  places  than  not  reach  beyond  the  integuments  do  not 
in  others.  If  the  cavity  of  the  thorax  be  differ  from  common  wounds,  and,  when 
opened  by  a transverse  section,  about  the  properly  treated,  are  seldom  followed  by 
middle  of  the  sternum,  the  diaphragm  ap-  any  bad  consequences.  On  the  contrary, 
pears,  on  examination,  to  be  very  promi-  those  which  penetrate  the  cavity  of  the 
nent  and  convex  towards  its  centre,  while  pleura,  even  by  the  slightest  opening,  may 
it  sinks  downward  at  its  edges,  towards  all  give  rise  to  alarming  symptoms.  Lastly, 
the  points  to  which  the  muscle  is  attached,  wounds  injuring  any  of  the  thoracic  viscera, 
At  its  anterior,  and  most  elevated  pajt,  it  is  are  always  to  be  considered  as  placing  the 
fixed  to  the  ensiform  cartilage,  whence,  de-  patient  in  a state  of  considerable  danger, 
scending  obliquely  to  the  right  and  left,  it  is  From  what  has  been  said,  it  appears  that 
inserted,  on  both  sides,  into  the  seventh  rib,  wounds  of  the  thorax  are  very  properly  di- 
all  the  lower  ribs,  and  lastly,  into  the  lower  visible  into  three  kinds;  viz.  1.  such  as 
dorsal  vertebrae.  According  to  this  descrip-  affect  only  the  skin  and  muscles;  2.  such 
tion,  it  is  obvious,  that  the  cavity  of  the  as  enter  the  cavity  of  the  chest,  but  injure 
thorax  has  much  greater  depth  and  capacity  none  of  the  viscera  ; 3.  others,  which  in 
behind,  than  in  front;  a circumstance  which  jure  the  lungs,  or  some  other  viscus. 
surgeons  ought  to  be  well  aware  pf,  or  else  Superficial  Wounds  of  the  Thorax. — Im- 
they  will  be  liable  to  give  most  erroneous  mediately  a surgeon  is  called  to  a recent 
opinions  concerning  wounds  of  the  chest,  wound  of  the  chest,  his  first  care  should  be 
For  instance,  a practitioner  deficient  in  ana-  to  ascertain,  whether  the  w eapon  has  pene- 
tomical  knowledge,  might  imagine  that  a trated  the  pleura  or  not.  In  order  to  form 
weapon,  pushed  from  above  downward  into  a judgment  on  this  circumstance,  surgical 
the  front  of  the  chest,  could  never  reach  the  writers  recommend,  1.  Placing  the  wound- 
lungs,  after  having  penetrated  the  cavity  of  ed  person  in  the  same  posture  in  which  he 
the  abdomen.  It  is  a fact,  however,  that  was  when  he  received  the  wound,  and  then 
no  instrument  could  pass  in  this  direction,  carefully  examining  with  a finger,  or  probe, 
even  some  inches  below  the  highest  part  of  the  direction  and  depth  of  the  stab.  2.  The 
the  abdomen,  without  entering  the  chest.  examination,  if  possible,  of  the  weapon,  so 
The  whole  cavity  of  the  thorax  is  lined  as  to  see  how  much  of  it  is  stained  with 
with  a membrane  named  the  pleura,  which  blood.  3.  The  injection  of  fluid  into  the 
is  every  where  adherent  to  the  bones  which  wound,  and  attention  to  whether  it  regur 
form  the  parietes  of  this  cavity,  and  to  the  gitates  immediately,  or  lodges  in  the  part 
diaphragm.  Each  side  of  the  thorax  has  a 4.  The  colour  and  quantity  of  the  blood, 
distinct  pleura.  The  two  membranes  meet  discharged  from  the  wound,  are  to  be  no- 
in the  middle  of  the  chest,  and  extend  from  ticed,  and  whether  any  is  coughed  up.  6. 
the  sternum  to  the  vertebrae.  In  this  man-  We  are  to  examine . whether  air  escape* 


WOUNDS. 


boo 


from  (lie  wound  in  respiration,  and  whether 
there  is  any  emphysema.  6.  Lastly,  the 
state  of  the  pulse  and  breathing  must  be 
considered. 

In  wounds  of  the  chest,  however,  sur- 
geons should  not  be  too  officious  with  their 
probes,  merely  for  the  sake  of  gratifying 
their  curiosity,  or  appearing  to  be  doing 
something.  No  judicious  surgeon  can 
doubt  that  authors  have  dwelt  too  much  on 
the  subject  of  probing  wounds  of  the  abdo- 
men and  thorax  ; for  they  would  really  lead 
their  readers  to  believe,  that,  until  the 
wound  has  been  traced  with  the  finger  or 
probe,  to  its  very  bottom  and  termination, 
surgeons  are  not  qualified  to  institute  any 
mode  of  treatment.  The  only  advantage 
of  knowing  that  a wound  penetrates  the 
chest,  is,  that  the  practitioner  immediately 
feels  himself  justified  in  having  recourse  to 
bleeding  and  other  antiphlogistic  means, 
with  the  view  of  preventing  inflammation 
of  the  pleura  and  lungs,  which  affection,  if 
not  controlled  in  time,  often  proves  fatal. 
However,  there  can  be  little  doubt,  that  if 
the  nature  and  depth  of  the  wound  cannot 
be  readily  detected  with  the  eye,  the  finger, 
or  a probe,  or  by  the  discharge  of  air,  or 
blood,  it  is  much  safer  to  bleed  the  patient 
than  to  put  him  to  useless  pain  with  the 
probe,  and  waste  opportunities  of  doing 
good,  which  too  frequently  can  never  be 
recalled  In  short,  generally  speaking,  it  is 
better,  and  more  advantageous  for  all  pa- 
tients, that  some  of  them  should  lose  blood, 
perhaps  unnecessarily,  than  that  any  of 
them  should  die  in  consequence  of  the  eva 
euation  being  omitted  or  delayed. 

Almost  all  writers,  who  have  taken  pains 
to  direct  how  wounds  of  the  thorax  should 
be  probed,  conclude  with  remarking,  that, 
however  advantageous  a knowledge  of  the 
direction  and  depth  of  the  wound  may  be, 
much  harm  has' frequently  been  done  by 
pushing  the  attempts  to  gain  such  informa- 
tion too  far.  It  is,  perhaps,  of  greater  im- 
portance to  learn,  by  some  kind  of  exami- 
nation, the  extent  of  a wound,  which  does 
not  reach  beyond  the  integuments,  or  in- 
tercostals,  than  to  know  whether  the  w ound 
extends  into  the  cavity  of  the  chest.  For, 
even  when  the  pleura  is  found  to  be  divided, 
if  the  xvound  be  attended  with  no  urgent 
symptoms,  the  information  is  of  no  practical 
use,  if  we  make  it  a rule  to  adopt,  without 
the  least  delay,  a strict  antiphlogistic  plan  of 
treatment,  in  all  cases  in  which  there  is 
any  doubt  or  chance  of  the  parts  within  the 
chest  being  wounded,  and  likely  to  inflame. 
Besides,  frequently,  the  symptoms  are  more 
urgent  and  alarming  than  they  could  be 
were  only  parts  on  the  outside  of  the  thorax 
injured  ; and,  under  such  circumstances, 
it  is  manifest  that  a probe  cannot  be  neces- 
sary for  discovering  that  the  wound  extends 
into  the  chest. 

With  respect  to  the  injection  of  luke- 
warm water,  or  any  other  fluid,  and  the  cir- 
cumstance of  its  regurgitation,  as  a criterion 
of  the  wound  being  only  superficial,  the 
plan  i?  more  objectionable  than  the  employ- 


ment of  a probe  ; for,  if  the  liquid  be  pro- 
pelled  with  force,  it  may  be  injected  into 
the  cellular  substance,  and  seem  to  be  pass- 
ing through  the  track  of  the  w ound  into  the 
chest,  w hile,  in  reality,  not  a drop  does  so. 
Besides,  is  it  a warrantable  proceeding  to 
try  to  insinuate  any  quantity  or  kind  of 
liquid  whatever  between  the  pleura  and 
lungs, into  a situation  in  which  it  must  neces- 
sarily obstruct  the  important  function  of 
respiration,  and  cause  serious  inconve- 
nience ? 

When  air  issues  from  the  wound  in  expira- 
tion, there  is  ground  for  suspecting  that  the 
lungs  are  wounded.  But  I believe,  that 
such  authors  as  represent  this  circumstance 
as  an  infallible  criterion  of  the  nature  of  the 
accident,  labour  under  a mistake  ; for  when 
there  is  simply  an  opening  in  the  chest,  with- 
out any  injury  of  the  lungs  whatever,  the 
same  symptom  may  occur.  The  air,  which 
is  discharged  through  the  wound  in  expira- 
tion, has  previously  entered  the  bag  of  the 
pleura  through  the  same  wound  in  inspira- 
tion. In  order  to  remove  all  doubt,  the  pa- 
tient should  be  requested  to  expire, as  strong- 
ly as  he  can,  so  as  to  force  out  whatever  air 
may  have  accumulated  in  the  chest.  At  the 
end  of  each  expiration  of  this  kind,  care 
must  be  taken  to  bring  the  skin  closely  over 
the  orifice  of  the  w ound,  and  to  keep  it  thus 
applied,  during  each  following  inspiration, 
for  the  purpose  of  preventing  the  external 
air  from  entering.  In  this  way,  if  there  be 
no  wound  of  the  lungs,  all  the  air  will  soon 
be  expelled ; but  if  it  still  continues  to  be  dis- 
charged in  expiration,  the  lungs  must  be 
wounded. 

Sometimes,  an  emphysematous  swelling 
takes  place  round  wounds  of  the  thorax,  in 
consequence  of  a quantity  of  air  diffusing  it- 
self in  the  cellular  substance.  In  wounds, 
which  are  straight  and  ample,  this  symptom 
is  very  uncommon  ; but,  in  cases  of  narrow 
oblique  stabs,  and  where  the  lungs  are 
wounded  by  the  points  of  broken  ribs,  it  is 
by  no  means  unfrequent.  (See  Emphysema.) 
When  a considerable  quantity  of  blood 
flows  from  the  wound,  there  is  reason  for 
conjecturing,  not  only  that  the  w'eapon 
has  penetrated  the  cavity  of  the  thorax,  but 
that  some  of  the  thoracic  viscera  are  injured. 
Excepting  the  intercostal  arteries,  which 
run  along  the  lower  edges  of  the  ribs,  and 
the  trunks  of  the  thoracic  arteries,  all  the 
other  vessels,  on  the  outside  of  the  chest, 
are  very  inconsiderable.  The  effects  of  com- 
pression will  indicate,  whether  the  blood 
escapes  from  an  artery  on  the  outside  of  the 
cavity  of  the  pleura  ; and  sometimes,  the 
situation  and  direction  of  a wound  at  once 
denotes,  that  the  hemorrhage  cannot  pro- 
ceed from  the  trunks  of  the  thoracic  ar- 
teries. 

Even  the  appearance  of  the  blood,  which 
comes  from  the  wound,  may  lead  to  some 
conjectures,  concerning  the  depth  of  the 
injury.  The  blood,  which  flow  s from  wounds 
of  the  lungs,  is  of  a brighter  scarlet  colour, 
and  more  frothy,  than  that  which  is  dis 


WOUNDS. 


664 


charged  from  the  vessels  of  any  other 
part. 

There  can  be  no  doubt  of  the  lungs  being 
wounded,  when  the  patient  is  observed  to 
spit  up  blood  ; but,  the  absence  of  this  symp- 
tom is  not  a positive  proof  of  their  being 
untouched,  though  unquestionably,  a very 
important  circumstance  in  the  diagnosis, 
and,  generally  speaking,  a correct  criterion 
of  the  lungs  having  escaped  injury.  At  all 
events,  when  no  blood  is  spit,  or  coughed 
up,  the  lungs  can  never  be  deeply  pene- 
trated. 

The  state  of  the  pulse,  and  that  of  respira- 
tion ought  to  be  particularly  attended  to  by 
the  practitioner.  Neither  one,  nor  the  other, 
seems  altered,  at  least  at  first,  when  wounds 
do  not  reach  more  deeply  than  the  integu- 
ments; but  those  which  penetrate  the  cavity 
of  the  thorax,  and  especially  such  as  injure 
the  viscera,  may  frequently  be  distinguished, 
from  the  very  first  moment  of  their  occur- 
rence, by  their  effects  on  the  sanguiferous 
system,  and  the  function  of  respiration. 
When  the  lungs  are  wounded,  at  a point 
where  they  adhere  to  the  pleura,  no  air  can 
be  effused  in  the  thorax,  and  the  functions  of 
those  organs  may,  on  this  account,  suffer 
less  disturbance  than  would  be  the  conse- 
quence of  an  equal  degree  of  injury  at  some 
other  unadherent  portion  of  the  lungs. 
Experience  proves,  that  when  either  air  or 
blood  insinuates  itself  between  the  lungs 
and  the  pleura,  the  lungs  become  immedi- 
ately oppressed,  the  breathing  is  attended 
with  great  difficulty,  the  pulse  is  weak,  con- 
tracted, and  intermittent. 

Wounds  of  the  integuments  and  muscles 
of  the  thorax,  are  not  attended  with  any 
particular  danger  ; they  heal  with  the  same 
readiness,  and  by  the  same  means,  as  com- 
mon superficial  wounds  in  any  other  part  of 
the  body. 

When  the  case  is  a punctured,  or  a gun- 
shot wound,  some  writers  are  advocates  for 
laying  open  the  track  of  the  injury  from 
one  end  to  the  other,  if  its  course  should  not 
be  too  extensive,  and  they  then  recommend 
dressing  the  cavity  down  to  its  bottom. 
When  the  track  of  the  wound  was  too  exten- 
sive, a seton  was  sometimes  introduced. 
The  aim  of  such  exploded  practices  was  to 
prevent  the  outer  part  of  the  wound  from 
healing  too  soon,  and.  thus  give  time  for  the 
xvhole  of  it  to  heal  in  an  equal  degree. 
When  a seton  was  used,  the  thickness  of  the 
skein  was  gradually  diminished,  and,  after 
the  whole  of  it  had  been  removed,  a slight 
compression  was  kept  up  for  a few  days, 
with  the  view  of  completing  the  cure. 

The  French  surgeons  have  the  discredit  of 
having  brought  setons  into  fashion  in  this 
branch  of  surgery,  and  I am  particularly 
glad,  that  a late  writer  has  well  exposed  the 
absurdity  of  the  practice.  “We  find  (says 
Mr.  John  Bell)  the  history  of  it  to  he  plainly 
this  : that  as  Guy  de  Chauliac,  JPar6,  and  ail 
the  older  surgeons,  did  not  know  how  to 
dilate  gunshot  wounds,  they  found  these 
same  setons  useful  in  bringing  the  eschar 
sooner  away,  and  in  preserving  an  open 


wound  ; and,  as  they  believed  the  wounds  to 
be  poisoned,  they  took  the  opportunity  of 
conducting,  by  these  setons,  whatever  acrid 
medicines  might,  according  to  the  prevailing 
doctrines  of  that  .time,  have  any  chance  of 
correcting  the-poison.”  Mr.  J.  Bell  notices, 
howsurprisingitistoseethe  cruelty,  and  per- 
severance, with  which  some  modern  prac- 
titioners, particularly  French,  draw  these 
cords  through  wounded  limbs  ; and  when 
the  ^roughness  of  such  a cord,  or  the  acri- 
mony of  the  drugs  conveyed  by  it,  produces 
a copious  suppuration,  these  men  are  de- 
lighted with  such  proofs  of  their  success. 
The  setons  have  been  introduced  by  the 
French  surgeons,  across  the  thickest  parts  of 
the  limbs,  along  the  whole  length  of  the 
fore-arm,  and,  at  the  same  time,  frequently' 
through  the  wrist-joint.  The  setons  have 
also  been  covered  with  stimulating  applica- 
tions. Profuse  suppurations,  and  dreadful 
swellings  of  course  ensued  ; still,  as  Mr.  J 
Beil  has  remarked,  these  cruelties  were  con- 
tinued, till  the  wound  healed  almost  in  spite 
of  the  pain  ; or  till  the  coming  on  of  very 
dreadful  pain,  great  suppurations,  convul- 
sions, &,c.  made  the  surgeon  discontinue  the 
method,  or  even  amputate  the  limb.  The 
French  have  become  so  familiarized  to 
setons,  that  they  do  not  restrict  their  use  to 
flesh  wounds,  they  pass  them  quite  across  the 
thorax,  across  the  abdomen,  and  even 
through  wounds  of  the  knee-joint. 

When  we  wish  to  excite  inflammation, 
in  the  cavity  of  the  tunica  vaginalis,  for 
the  purpose  of  radically  curing  a hydro- 
cele, we  either  pass  a seton  through  the 
part ; lay  it  open  with  an  extensive  inci- 
sion ; cram  a tent  into  it  ; or  injgct  some 
irritating  fluid  into  it.  While  the  animal 
machine  continues  the  same,  says  Mr.  John 
Bell,  the  same  stimuli  will  produce  the  same 
effects,  arid  a seton,  injection,  or  long  tent, 
if  they  produce  pain  and  inflammation  in 
the  scrotum,  will  not  be  easy  in  the  chest  : 
and,  unless  we  can  use  them  in  the  chest, 
with  the  same  intentions  with  which  we  use 
them  in  the. hydrocele,  (in  other  words)  un- 
less we  are  justified  in  inflaming  the  chest, 
and  causing  an  adhesion  of  all  the  parts,  we 
cannot  use  them  with  any  consistency  or 
good  sense. 

With  regard  to  the  cases  which  the 
French  adduce  in  confirmation  ot  the  good! 
effects  of  their  plans,  1 am  entirely  of 
opinion  with  Mr.  J.  Bell,  that  the  facts  only 
prove,  that  ike  patients  recovered  in  spite  of 
the  setons.  “ It  is  like  (adds  this  author) 
what  happened  to  a surgeon,  who  was  dab- 
bing in  the  thorax  with  a piece  of  caustic 
which  fell  directly  into  the  cavity  oi  the 
ciiest,  where  it  caused  very  large  suppura- 
tions, and  yet  the  patient  was  saved,  l'he 
patient  recovered,  in  spite  of  the  caustic, 
just  as  M.  Guerin’s  patient,  and  many  other 
poor  unhappy  souls,  who  lived  in  spite  ot 
the  setons.  One  would  think,  that  people 
took  a pleasure  in  passing  setons  across  the 
eyeball,  the  chest,  the  knee-joint,  &c. 
merely  to  make  tools  stare,  when  the  bust- 


WOUNDS. 


troll 


fciess  might  be  as  effectually  done  with  an 
abscess  lancet.” 

Mr.  John  Bell,  in  his  usual  lively  style, 
makes  the  employment  of  tents,  in  wounds 
of  the  chest,  seem  equally  ridiculous  and 
improper.  Indeed,  he  says,  he  knows  of' no 
occasion  in  all  surgery,  in  which  tents  can  be 
useful,  except  in  the  single  one  of  a narrow 
opening,  which  we  desire  t<>  dilate,  in  order  to 
g t at  the  bottom  of  the.  wound ; and  where 
either,  on  account  of  some'great  artery , or  the 
fearful  temper  of  our  patient,  ive  dare  not  use 
the  knife.  (See  J.  Bell  on  Wounds.  Dis- 
course 2,  Vol.  2.) 

Having  hitherto  been  engaged,  rather  in 
pointing  out  what  ought  not  to  be  done, 
than  what  ought,  I shall  next  make  some  re- 
marks on  the  line  of  conduct,  which  should 
be  adopted,  in  cases  of  wounds  of  the  pa- 
rietes  of  the  chest. 

When  the  wound  is  a common  cut,  the 
sides  of  the  division  are  to  be  brought  into 
contact,  and  maintained  in  this  position 
with  strips  of  adhesive  plaster,  compresses, 
and  a bandage,  until  they  have  grown  toge- 
ther. If  the  surgeon  take  care  to  relax  such 
muscles  as  happen  to  be  cut,  or  to  be  situated 
immediately  under  the  wound  of  the  integu- 
ments, there  will  rarely  be  any  need  of 
sutures. 

As  cut  wounds  seldom  or  never  .penetrate 
the  chest,  and  there  is  generally  no  reason 
why  they  should  not  unite  by  the  first  inten- 
tion, without  being  followed  by  extensive 
inflammation  and  abscesses,  antiphlogistic 
means  should  be  employed  with  moderation. 
Bleeding  will  not  often  be  requisite.  The 
grand  objects  are,  to  keep  the  patient  in  a 
quiet  state,  on  rather  a low  diet,  and  to  hin- 
der him  from  taking  wine,  porter,  spirits,  or 
any  other  stimulating  beverages. 

If  the  wound,  instead  of  healing  favoura- 
bly, should  inflame,  the  treament  should  be 
regulated  by  the  principles  laid  down  in  the 
article  Inflammation.  If  it  suppurate  over 
its  whole  surface,  but  without  a great  deal  of 
surrounding  swelling  and  inflammation,  one 
or  two  strips  of  sticking-plaster,  may  still  be 
used  with  advantage  ; for,  in  this  way,  the 
cavity,  which  must  now1  be  filled^up  by  gra- 
nulations, will  be  rendered  much  smaller 
than  it  otherwise  would  be.  Some  very  soft 
lint  may  be  laid  in  the  cavity  of  the  wound, 
which  the  sticking-plaster  does  not  entirely 
remove,  and  over  the  whole  a pledget  of 
some  mild,  unirritating  ointment.  No  pres- 
sure is  now  proper,  until  the  inflammation 
diminishes ; and  if  the  discharge  should  be 
profuse,  or  the  surrounding  inflammation 
considerable,  the  best  application  would  be 
an  emollient  poultice.  In  this  state  of  things, 
the  patient  should  also  be  bled,  and  leeches 
be  applied  near  the  inflamed  parts. 

When  the  case  is  a stab,  or  punctured 
wound,  the  fibres  of  the  divided  parts  are 
not  simply  cut,  they  are  also  considerably 
stretched,  bruised,  and  otherwise  injured. 
Hence,  generally  they  will  not  admit  of 
being  united  so  readily,  as  the  sides  of  a 
clean  incision,  made  with  a sharp  instru- 
ment, However,  the  possibility  of  uniting 


the  opposite  sides  of  punctured  wounds  must 
depend  very  much  on  the  shape  of  the 
weaponrand  the  suddenness,  roughness,  and 
violence,  with  which  it  was  driven  into  the 
part.  \ prick  with  a needle  is  a punctured 
wound  ; so  is  that  often  made  by  surgeons 
with  their  lancets  ; yet,  these  injuries  do  not 
frequently  bring  on  violent  inflammation,, 
and  abscesses,  as  other  wounds  frequently 
do,  which  are  inflicted  with  bayonets,  and 
pikes. 

Let  us  suppose  a man  to  have  received 
a thrust  of  a bayonet,  which  has  run  into 
the  skin  and  muscles,  covering  one  side 
of  the  thorax  : what  plan  can  the  surgeon 
follow,  with  the  greatest  .advantage  to  his 
patient  ? 

Instead  of  laying  open  the  whole  track  of 
such  a wound  with  a knife,  as  is  barbarously 
recommended  in  many  of  the  principal 
works  on  surgery ; instead  of  drawing  a 
seton  through  its  whole  course,  or  of  cram- 
ming into  the  part  a hard,  irritating  tent ; 
the  practitioner  should  take  whatever  chance 
there  may  be  of  uniting  the  wound  without 
suppuration.  For  this  purpose,  he  should 
recollect  that  the  great  degree  of  violence 
done  to  the  parts  in  punctured  wounds  is 
the  reason  why  they  are  so  apt  to  inflame 
and  suppurate.  Hence- the  expected  inflam  - 
mation is  to  be  counteracted  in  the  very  first 
instance  ; and  immediately  the  wound  is 
dressed,  the  patient  should  be  freely  bled, 
and  take  some  saline  purgative  medicines. 
With  regard  to  the  dressings,  the  orifice  of 
the  wound  may  be  lightly  closed  with  sticking- 
plaster,  or  covered  with  any  mild  superficial 
applications.  Over  and  around  these,  the 
surgeon  may  apply  linen,  kept  continually 
wet  with  cold  water,  or  the  liquor  plumbi 
acetalis  dilutes.  As,  however,  many  pa- 
tients have  a strong  dislike  to  cold  applica- 
tions to  any  wounds  upon  their  bodies,  it 
is  often  necessary  {^dispense  with  this  prac- 
tice. The  dressings  are  to  be  retained 
with  a roller ; but  it  is  not  to  be  tight, 
as  pressure  is  more  likely  to  do  harm, 
than  good.  Thus  the  inflammation  of  the 
wound  will  be  moderated  ; the  extravasa- 
tion of  blood  prevented-,  the  chance  ofunkm 
by  the  first  intention  taken  ; and  all  p^rfM 
operations  avoided.  And,  nothing  is  morlf 
certain  than  the  fact,  that,  if  antiphlogistic 
means  be  strictly  employed,  many  stabs  heal 
without  abscesses,  or  any  very  severe  symp- 
toms, when  no  hope  could  be  entertained  of 
their  doing  so  under  other  treatment.  But, 
if  suppuration  should  happen,  and  a col- 
lection of  matter  take  place,  would  the 
patient  suffer  more,  or  -be  put  into  greater 
danger,  by  having  a proper  depending 
opening,  of  just  sufficienffsize,  now  made 
into  the  abscess  in  an  eligible  place,  than 
if  he  had  submitted  to  have  the  formidable 
operation  of  laying  open  the  whole  extent 
of  a stab,  performed  in  the  first  instance  ? In 
short,  will  he  suffer  half  so  much,  be  half  so 
long  in  getting  well,  or  have  to  encounter 
half  the  danger  ? With  all  this  advantage,  he 
will  have  taken  a certain  chance,  which 
attends  all  these  cases,  if  the  wonnd  be- 


WOUNDS. 


050 

coming  united  by  what  is  called  the  first 
intention,  that  is  to  say  without  any  suppu- 
ration. I need  not  enlarge  upon  this  subject, 
but  refer  the  reader  to  what  has  been  said  in 
the  preceding  columns  on  the  subject  of 
Punctured  Wounds,  and  to  the  treatment  of 
abscesses,  in  the  article  Suppuration.  Gun- 
shot wounds,  merely  injuring  the  parietes 
of  the  chest,  are  to  be  treated  according  to 
principles  elsewhere  explained.  (See  Gun- 
shot Wounds.) 

Of  Wounds  penetrating  the  Cavity  of  the 
Thorax. — Penetrating  wounds  of  the- chest 
are  always  dangerous,  and  claim  the  utmost 
attention  of  the  practitioner.  I shall  first 
treat  of  such  wounds  as  enter  the  cavity  of 
the  thorax,  but  without  injuring  the  viscera. 

In  the  healthy  state,  the  lungs  so  complete- 
ly fill  the  thorax,  that,  both  in  inspiration  and 
expiration,  they  are  always  in  close  contact 
w«h  the  pleura  ; and  whenever  air,  blood, 
or  any  other  matter,  insinuates  itself  between 
the  pleura  costalis  and  pleura  pulmonalis, 
more  or  less  oppression  and  difficulty  of 
breathing  immediately  take  place.  In  all 
wounds  attended  with  a division  of  the 
pleura  costalis,  and  occurring  in  a situation 
where  there  happens  to  be  no  adhesion  be- 
tween this  membrane  and  the  lungs,  some  of 
the  external  air,  ora  small  quantity  of  blood, 
or  both,  can  hardly  fail  to  get  into  the  cavity 
of  the  thorax.  If  one  of  the  intercostal  ar- 
teries be  wounded,  and  the  external  orifice 
be  very  narrow,  the  blood  furnished  by  this 
vessel  may  pass  into  the  chest,  and  immedi- 
ately produce  oppression  of  the  breathing, 
and  other  symptoms  of  pressure  on  the  lungs. 
Of  what  is  to  he  done  in  this  case,  l shall 
presently  speak. 

When  a wound  is  known  to  have  entered 
the  pleura,  and  there  is  no  symptom  leading 
to  a suspicion  that  the  lungs,  or  any  large 
vessel,  is  wounded,  the  injury  is  to  be  dress- 
ed according  to  common  principles,  and  the 
more  superficially  the  better.  Authors  also 
usually  direct  us,  just  before  we  close  the 
opening,  to  tell  the  patient  to  make  a deep 
inspiration,  for  the  purpose  of  expelling  as 
much  of  the  air  as  possible,  which  may  have 
passed  into  the  cavity  of  the  pleura.  At  the 
end  of  such  inspiration,  the  edges  of  the 
wound  in  the  skin  are  to  be  brought  together, 
and  kept  so  with  sticking-plaster,  com- 
presses, and  a roller.  The  other  indications 
are  to  prevent  inflammation  of  the  pleura 
and  lungs  by  rigorous  antiphlogistic  reme- 
dies, particularly  bleeding,  which  should  be 
copious,  and  repeated  as  circumstances  may 
require. 

Penetrating  wounds  of  the  chest  may  be 
complicated  with  some  of  the  following  cir- 
cumstances: 1.  Foreign  bodies.  2.  Injury 
of  one  of  the  intercostal  arteries.  3.  Pro- 
trusion of  a portion  of  the  lungs.  4.  Em- 
physema. 5.  Extravasation  of  blood  in  the 
thorax. 

1.  Almost  all  these  wounds  occasion  pain 
and  difficulty  of  breathing.  Many  of  them 
are  also  followed  by  an  emphysematous 
swelling  around  the  w ound  ; the  patient  fre- 
quently coughs  up  blood  : and  after  having 


had  for  some  time  a small,  contracted,  irre- 
gular pulse,  with  a pallid  countenance  and 
cold  extremities,  he  is  too  often  seized  with 
severe  fehrile  symptoms,  the  effect  of  inflam 
mation  of  the  lung3  and  parts  within  the 
chest.  These  symptoms  should  be  counter 
acted  by  bleeding,  a very  low  regimen,  open 
ing  saline  medicines,  the  use  of  leeches,  or 
cupping,  and  the  strict  observance  of  qui- 
etude. If  such  indisposition  should  con- 
tinue longer  than  a few  days,  without  dimi 
nation,  writers  inform  us,  that  there  is  ground 
for  suspecting  that  they  depend  upon  the 
presence  of  some  foreign  body.  However, 
it  may  be  doubted  whether  Sabatier’s  advice, 
iramediaiely  to  make  search  after  the  extra- 
neous substance,  is  proper  under  these,  cir- 
cumstances. For  tny  owrn  part,  I cannot 
think  the  symptoms  above  related  by  any 
means  unequivocal,  and  even  were  they  so, 
the  practice  would  -dill  be  questionable. 
(See  Medecine  Opiratoire,  Tom.  2,  p.  244.) 

Sabatier  has  quoted  the  two  following 
ca^es,  for  the  purpose  of  showing  what  may 
be  attempted  in  these  cases. — “ A man,  twen- 
ty-seven years  of  age,  was  struck  very  vio- 
lently with  a knife  on  the  outer  part  of  the 
fourth  true  rib.  Simple  dressings  were  ap- 
plied tor  the  first  few7  days;  but  a considera- 
ble coughing  and  spitting  of  blood  ensuing 
M Gerard  was  consulted,  wdio  found,  that 
the  symptoms  depended  on  the  presence  of 
a piece  of  the  knife,  which  had  pierced  the 
rib,  and  was  projecting  some  way  into  the 
thorax.  So  little  of  the  foreign  body  w7as  on 
the  outside  of  the  rib,  and  it  was  so  fixed  in 
the  bone,  that  it  could  neither  be  extracted 
with  any  kind  of  forceps,  nor  even  moved 
in  the  least  with  a leader,  mallet,  he.  Al- 
though the  only  expedient  seemed  now  to 
be  that  of  sawing  orcutting  out  the  portion  of 
the  rth,  Gerard  conceived  that  an  attempt 
might  first  be  made  to  extract  the  foreign 
body,  by  pushing  it  from  within  outward. 
For  this  purpose,  having  put  a steel  thimble 
on  his  index  finger,  he  introduced  it  into  the 
cavity  of  the  thorax,  and  thus  succeeded  in 
pushing  out  the  piece  of  the  knife. 

A spicula  of  the  bone  was  afterward  felt  , 
but  it  wa^too  firmly  connected  with  the  rest 
of  the  i ib  to  admit  of  being  completely  taken 
out.  Gerard  was  absurd  enough  to  surround 
the  whole  rib  at  the  splintered  part  with  a li- 
gature.. To  these  ingenious  proceedings,  as 
the  French  term  them,  was  imputed,  not  only 
the  cessation  of  all  the  bad  symptoms,  but 
a speedy  recovery.  (See  la  Faye's  Notes  to 
the  Trait 6 des  Operations  de  Dionis.) 

An  officer  was  shot  in  the  left  side  of  the 
chest.  The  ball  entered  about  where  the 
bone  and  cartilage  of  the  seventh  true  rib 
unite,  and  came  out  in  the  situation  of  the 
angle  of  the  same  bone,  which  was  broken 
in  tw7o  places.  The  posterior  part  of  the 
first  false  rib  was  also  broken  Incisions 
were  made,  which  enabled  the  surgeon  to 
take  away  several  splinters  of  bone,  and  fa- 
cilitated (that  mischievous  French  practice) 
the  introduction  of  a seton.  Soft  mild  dress 
ings  were  applied.  The  patient  was  bled 
twenty-six  times,  with  the  view  of  relieving 


WOUNDS. 


the  fever,  difficulty  of  breathing,  and  spitting 
of  blood.  On  the  fifth  day,  suppuration 
commenced,  and  the  seton  could  be  easily 
drawn.  In  about  a fortnight,  the  patient’s 
sufferings  considerably  abated,  and  he  passed 
som*  of  the  ensuing  days  in  a tolerably  easy 
state.  Circumstance*,  however,  made  it 
necessary  to  move  him  to  another  place,  and 
on  the  twenty-fourth  day,  he  had  a bad 
night ; febrile  symptoms  came  on  ; and  the 
discharge  was  not  of  its  usual  consistence. 
He  was  bled  twice  more,  and  hia  critical 
state  led  the  surgeon  to  examine  the  wounds 
again.  On  passing  a finger  into  the  posterior 
wound,  a foreign  body  was  felt,  an  i easily 
extracted.  It  was  a piece  of  the  patient’s 
coat.  A spicula  of  bone  was  also  felt  more 
deeply  lodged,  which  required  the  wound  to 
be  dilated.  Partial  relief  followed  the  re- 
moval of  these  extraneous  substances. 

On  the  thirtieth  day,  the  bad  symptoms 
recurred,  two  more  bleedings  were  practised, 
and  as  fears  were  entertained  that  ike  seton 
zvas  doing  harm , it  was  suppressed.  The  pa- 
tient now  first  made  complaint  ot  feeling 
something  which  pricked  him,  in  a deep  situ- 
ation between  the  two  openings  of  the 
wound.  It  was  therefore  determined  to  di- 
vide all  the  parts  intervening  between  the 
two  orifices,  and  occupying  an  extent  of 
seven  or  eight  inches.  Guerin  cut  the  parts 
between  the  two  ribs,  from  within  outward, 
under  the  guidance  of  his  finger  introduced 
into  the  posterior  wound,  care  being  taken 
not  to  cut  near  the  lower  edge  of  the  upper 
rib.  In  this  way,  the  whole  track  of  the 
ball  was  laid  open,  and  in  the  middle  of  it.  a 
very  sharp  splinter  was  found,  projecting 
into  the  substance  of  the  lungs.  It  was  re- 
moved, and  the  wound  dressed  with  simple 
applications.  From  this  day  all  the  bad 
symptoms  ceased.  (06s.  de  Guerin  in  Mem. 
de  I’Acad.  de  Chir.  T.  2 ; 41c.) 

Mr.  John  Bell  has  taken  notice  of  the  pre- 
ceding case  ; he  observes,  that  some  of  Gue- 
rin’s steps  were  bold  and  good,  as  well  as 
successful;  but  that  the  employment  of  the 
seton  was  wrong.  The  example  teaches  us 
several  important  circumstances  : 1.  The 
propriety  of  making  very  free  dilatations  for 
the  extraction  of  splinters  of  bone.  2.  The 
utility  of  repeated  copious  bleedings,  which 
in  the  above  case,  indeed,  had  the  greatest 
effect  both  in  preventing  such  hemorrhage  in 
the  chest  as  would  probably  have  produced 
suffocation,  and  also  in  averting  a degree  of 
pulmonary  inflammation,  which  would  have 
proved  fatal. 

Mr.  John  Bell  judiciously  condemns  the 
seton : “ Had  M.  Guerin  (says  he)  been 
asked  what  good  it  was  to  do,  it  would  have 
been  difficult  for  him  to  have  invented  even 
a plausible  apology  for  the  practice  which, 
if  it  was  not  doing  good,  could  not  fail  to  do 
harm.  Was  this  seton  nece  sary  for  keeping 
the  wound  open  ? No,  ureiy  ; for  the  wound 
could  not  have  closed  while  il  was  irritated 
and  kept-in  suppuration  by  splinters  of  bone, 
and  a piece  of  cloth  within  the  breast.  Was 
it  to  draw  the  piece  of  cloth  out  ? Surely,  in 
the  course  of  twentr  days,  a piece  of  cloth 
Vo;,.  II  ' S3 


657 

would  have  had  some  chance  at  least  of  be- 
ing floated  towards  the  wound,  either  by  the 
natural  flux  of  the  matter,  or  by  the  help  of 
a mild  injection.  Was  it  uspful  in  support- 
ing the  discharge  ? This  would  have  been  a 
sore  question  lor  M Guerin  ; for  it  support- 
ed the  suppuration  only  by  inflaming  the 
chest ; and  where  inflammation  of  the  chest, 
or  high  cough,  or  bloody  expectoration,  or 
a profuse  discharge,  were  the  chief  dangers, 
a great  seton  could  hardly  be  a comfortable 
inmate  in  the  breast.  1 think  one  might 
very  boldly  promise  to  produce  bloody  ex- 
pectoration and  terrible  cough,  profuse  sup- 
purations, and  oppression,  to  any  degree,  by 
drawing  such  a cord  across  a sound  thorax.” 

Mr.  John  Bell  next  censures  M.  Guerin  for 
not  having  discovered  the  pricking  piece  of 
bone  before  the  thirty-eighth  day;  a disadvan- 
tage which  he  partly  ascribes  to  the  seton, 
the  pain  of  drawing  which  across  the  chest 
deadened  every  lesser  pain,  and,  consequent- 
ly, the  patient  could  not  feel  the  trilling 
pricking  of  the  bone,  (ill  his  greater  suffer- 
ings from  the  seton  were  allayed.  “ In  short, 
(says  Mr.  John  Bell,)  M.  Guerin  passes  a 
a great  strap  of  coarse  linen  across  the  cavi- 
ty of  the  chest,  and  when  it  causes  inflam- 
mation, he  thinks  to  subdue  it  by  bleeding  ; 
when  M.  Guerin  continued  for  thirty  days 
drawing  a coarse  seton  through  the  breast 
every  morning,  and  bleemng  for  the  cough 
every  night,  what  did  he  do  but  raise  inflam- 
mation with  his  left  hand,  to  show  how  well 
he  could  cure  it  w ith  his  right  ?”  (See  John 
Bell  on  Wounds , Vol.  2,  p.  .36 — 38.) 

The  liability  of  wounds  of  the  chest  to  be 
complicated  with  the  lodgement  of  foreign 
bodies,  is  a circumstance  of  which  the  prac- 
titioner should  ever  be  mindful.  u In  the 
examinations  of  the  bodies  of  soldiers  who 
have  died  from  these  injuries,  (says  Dr. 
Hennen,)  I have  frequently  found  pieces  of 
wadding  or  clothes,  spiculae  of  bone,  and 
balls,  and,  in  one  case,  some  charpie  used  as 
a dressing  ; either  loose  in  various  parts  of 
the  lungs,  or  lying  in  sacs,  which  the  exer- 
tions of  the  constitution  to  free  itself  had 
thrown  round  them  by  the  medium  of  the 
coagulating  lymph.  Iu  the  more  fortunate 
few  who  have  recovered,  these  matters  have 
been  discharged  from  the  wounds,  or  ex- 
tracted from  them  by  the  surgeon.  In  some 
lucky  cases,  they  have  been  ejected  by  the 
convulsive  efforts  to  cough,  which  their  irri- 
tation has  occasioned.”  ( On  Military  Sur- 
gery, Ed.  2,  p.  367  ) For  an  account  of  the 
dexterity  with  which  Larrey  has  sometimes 
traced  balls  in  ihe  chest,  and  extracted  them 
by  bold  operations,  I must  refer  to  his  valua- 
ble writings.  (See  Mem.  de  Chir.  Mil . T.  4 ,p. 
250,  fyc.)  Balls  have  sometimes  lodged  and 
remained  encysted  in  the  lungs  for  upwards 
of  twenty  years,  without  the  health  beins;  at 
all  disturbed  by  their  presence  (See  Percy, 
Manuel , fyc  p.  125  ; Boyer , Trait 6 des  Mai. 
Chir.  T.  7,p.  310,  fyc.) 

2.  When  one  of  the  intercostal  arteries  is 
wounded  by  a narrow  oblique  stab,  the  ac- 
cident cannot  at  first  be  known.  In  this 
case,  the  blood  commocly  make?  its  way 


WOUNDS. 


6-58 

into  the  cavity  of  the  chest,  where  it  causes 
a more  or  less  considerable  extravasation. 
But  when  the  wound  is  ample,  and  direct, 
the  effused  blood,  which  has  all  the  charac- 
ters of  arterial  blood,  leaves  no  doubt  con- 
cerning the  injury  of  an  intercostal  artery. 
However,  if  any  uncertainty  prevail,  it  may 
easily  be  dispelled,  by  introducing  a finger 
into  the  wound,  and  making  pressure  with 
it  on  the  lower  edge  of  the  rib,  which  cor- 
responds to  the  vessel  suspected  to  be  in- 
jured. 

Gerard  proposed  to  stop  hemorrhage  from 
the  intercostal  artery,  by  means  of  a liga- 
ture. His  plan  was  to  enlarge  the  external 
wound,  as  far  as  the  upper  edge  of  the  rib, 
corresponding  to  the  wounded  intercostal 
artery,  and  then  to  introduce  into  the  chest 
a common  curved  needle,  armed  with  a 
ligature,  to  which  was  attached  a dossil  of 
lint.  The  needle  was  passed  behind  the 
rib,  rather  higher  than  the  superior  edge  of 
the  bone.  The  point  of  the  instrument  was 
then  pushed  from  within  outward,  and 
brought  out  through  the  external  wound, 
together  with  the  ligature.  When  the  dossil 
had  come  into  contact  with  the  artery,  the 
two  ends  of  the  ligature  were  tied  over  a 
thick  compress,  placed  on  the  outside  of  the 
rib.  In  this  manner,  the  bone  was  sur- 
rounded with  the  ligature,  and  the  artery 
compressed. 

Goulard,  of  Montpelier,  having  found  dif- 
ficulty in  passing  a common  needle,  whose 
shape  little  corresponded  to  the  track, 
through  which  it  had  to  pass,  being  curved 
towards  its  point,  and  straight  towards  the 
eye,  invented  one  expressly  for  this  opera- 
tion. He  also  objected  to  the  common 
bent  needles,  as  he  conceived  that  they 
might  wound  the  lungs  with  their  sharp 
points  and  edges.  Goulard’s  needle  formed 
three-fourths  of  a circle,  and  was  fixed  on  a 
long  handle,  which  facilitated  its  introduc- 
tion. The  eye,  in  which  the  ligature  was 
put,  was  situated  near  the  point,  which  was 
a little  blunted,  and  the  ligature  lay  in  a 
groove,  in  the  convexity  of  the  instrument. 
When  the  needle  had  passed  through  the 
intercostal  muscles,  and  its  point  had  made 
its  appearance  over  the  rib,  which  was 
above  the  artery,  the  ligature  was  untied, 
and  held,  while  the  needle  was  withdrawn 
at  the  place  where  it  had  entered.  The 
ligature  was  then  tied,  as  in  Gerard’s  me- 
thod. 

It  was  afterward  thought,  that  com- 
pression might  answer  better  than  the  fore- 
going use  of  the  ligature.  Lottery,  professor 
of  anatomy  in  the  university  of  Turin,  con- 
structed, for  this  purpose,  a steel  plate, 
which  is  described,  and  engraved  in  the 
second  volume,  4to.  of  the  Metnpires  de 
1’Acad.  de  Chir.  This  plate  was  narrow  at 
one  end  ; broad  at  the  other  ; and  curved 
in  two  directions  at  its  narrow  part,  where 
there  were  some  holes,  by  means  of  which 
a compress  for  the  artery  was  fastened  ori 
the  instrument.  The  broad  end  of  the  plate 
bad  two  long  parallel  slits,  through  which  a 


riband  was  passed,  with  which  the  instru- 
ment was  secured. 

When  the  wound,  corresponding  to  the 
intercostal  artery,  was  sufficiently  extensive 
in  the  transverse  direction,  the  narrow,  bent 
end  of  the  instrument  was  so  introduced, 
that  the  lower  edge  of  the  rib  above  was 
placed  in  the  concavity  of  the  curvature, 
while  the  compress  acted  on  the  edge  of 
the  bone,  and,  of  course,  011  the  artery. 
The  rest  of  the  instrument  appiied  itself  to 
the  side  of  the  thorax,  in  which  situation  it 
was  fastened.  When  the  wound  was  not 
ample  enough,  a sufficient  dilatation  of  it 
was  first  made  for  the  introduction  of  the 
instrument. 

Quesnay  employed  a piece  of  ivory,  which 
he  covered  with  lint,  Lc.  and  then  intro- 
duced within  the  chest.  The  instrument 
was  then  drawn  from  within  outward,  by 
means  of  a riband,  and  thus  the  necessary 
compression  was  produced. 

Quesnay’s  plan  is  somewhat  like  that  in- 
vented by  Lottery.  But,  to  have  introduced 
the  compress  entirely  into  the  thorax,  to- 
gether with  the  ivory,  which  was  the  basis 
of  it,  and  then  to  have  drawn  the  contri- 
vance from  within  outward,  as  was  probably 
intended,  a very  large  wound  would  have 
been  indispensable.  This  was  also  one  of 
the  many  strong  objections  to  Lbttery’s 
instrument,  which,  in  fact,  could  only  be 
employed  when  there  was  a free  and  ample 
opening. 

Belloque,  seeing  the  inefficacy  of  all  the 
compressing  means  used  before  his  time, 
and  their  inconveniefices,  invented  an  in- 
strument, which,  he  says,  is  calculated  for 
making  proper  pressure,  and  following  the 
motion  of  the  ribs,  without  hindering  the 
escape  of  extravasated  blood.  The  machine 
is  engraved,  and  described,  in  2 T.  of  Mem. 
de  1’Acad.  de  Chir.  4to.  It  is  composed  of 
two  plates,  which  are  wadded,  and  capable 
of  being  brought  towards  each  other  by 
means  of  a screw.  This  instrument,  as  Sa- 
batier observes,  may  indeed  answer  ; but  it 
is  complicated  and  awkward,  and  its  utility 
is  founded  on  the  supposition  of  the  wound 
being  larger,  than  wounds  are,  which  are 
made  with  common  weapons. 

Justly  averse  to  any  unnecessary  multi- 
plication of  surgical  instruments,  modern 
practitioners  reject  all  particular  contrivan- 
ces for  stopping  hemorrhage  from  the  inter- 
costal arteries.  Indeed,  as  the  accident  is 
very  rare,  it  is  probable,  that,  if  the  best  in- 
strument possible  were  devised,  it  would 
hardly  ever  be  at  hand,  when  required. 

A common  dossil  of  lint  (says  Sabatier,) 
fastened  to  a strong  ligature,  and  introduced 
between  the  two  ribs,  or  even  quite  into 
the  chest,  and  then  drawn,  from  within  out- 
ward, like  Quesnay’s  compress,  would  fulfil 
every  desirable  purpose.  The  ■ external 
wound  should  then  be  covered  with  simple 
dressings,  and  a bandage  applied  round  the 
body.  The  patient  should  be  freely  and 
repeatedly  bled,  and  treated  on  the  most 
rigorous  antiphlogistic  plan. 

Professor  Assalini  joins  all  the  best,  mo- 


WOUNDS. 


659 


dern  surgeons  in  reprobating  the  introduc- 
tion of  the  preceding  contrivances  and  ex- 
traneous substances  into  the  chest,  in  order 
to  stop  hemorrhage  from  the  intercostal  ar- 
tery. All  these  methods,  he  remarks,  .are 
calculated  to  excite  a dangerous  degree  of 
inflammation  in  the  chest.  Hence  he  pre- 
fers simply  cutting  the  artery  across,  so  as 
to  allow  it  to  retract,  and  if  this  plan  fail,  he 
recommends  the  wound  to  be  elosed. 
Should  the  blood  find  its  way  into  the  chest, 
it  is  true,  the  consequences  will  be  serious, 
but  not  fatal ; and,  if  the  symptoms  require 
it,  the  operation  of  empyema  may  after- 
ward be  done.  A small  quantity  of  effused 
blood,  however,  may  be  absorbed,  and  no 
such  proceeding  be  requisite.  ( Manuale  di 
Chirurgia , p.  58,  59.) 

Dr.  Hennen  conceives,  that  whenever  the 
tenaculum  can  be  used  for  an  injured  inter- 
costal artery,  the  practice  should  be  adopted. 
He  states,  that  cases  are  reported  in  which 
the  vessel  was  thus  secured  ; but  that  he  has 
never  seen  the  method  adopted  himself. 
“ Unfortunately,  (says  he)  we  but  too  often 
are  disappointed  in  finding  the  source  of  the 
hemorrhage,  and  here  judicious  pressure  is 
our  only  resource.  In  some  very  slight 
cases,  I have  used  the  graduated  compress 
with  success;  but  if  the  sloughing  is  exten- 
sive, nothing  but  the  finger  of  an  assistant, 
relieved  as  often  as  occasion  may  require, 
aud  pressure  direct  upon  a compress  placed 
along  the  course  of  the  vessel,  or  so  dispo- 
sed as  to  operate  upon  its  bleeding  orifice, 
will  be  of  any  avail.  (, Military  Surgery,  Ed. 
2,  p.  377.) 

3.  The  protrusion  of  a portion  of  the 
lungs,  in  consequence  of  wounds  penetra- 
ting the  tfhest,  is  a very  unusual  case  : but 
there  are  some  instances  recorded  by  wri- 
ters : and  one  case  l attended  myself  after 
the  battle  of  Waterloo.  Sehenckius  relates 
an  example,  taken  from  Rolandus,  The 
latter  was  called  to  a man,  who  had  been 
wounded  in  the  thorax,  six  days  before.  A 
portion  of  the  lungs  protruded  in  a state  of 
mortification.  Rolandus  extirpated  it,  and 
the  patient  soon  recovered. 

Tulpius  has  recorded  a similar  fact.  A 
man  received  an  extensive  wound,  just  be- 
low his  left  nipple.  His  naturally  gay  dis- 
position, however,  led  him  to  neglect  the 
injury;  and  on  the  third  day  a piece  of  the 
lung3,  three  inches  in  length,  protruded. 
The  patient  went  to  Amsterdam,  whence  he 
was  distant  two  days’  journey,  for  the  pur- 
pose of  receiving  succour  in  one  of  the  hos- 
pitals of  that  city.  The  protruded  piece  of 
lung,  which  was  already  mortifying,  was 
tied,  and  cut  off  with  scissors.  It  weighed 
three  ounces.  The  wound  healed  in  a fort- 
night, and  the  patient  experienced  no  com- 
plaint afterward,  except  a slight  cough,  with 
which  he  was  occasionally  troubled.  He 
survived  the  accident  six  years,  leading  a 
wandering,  drunken  life.  After  death,  no- 
thing particular  was  observed  in  the  thorax, 
except  that  the  lungs  had  become  adherent 
to  the  pleura,  in  the  situation  of  the  wound, 
Hildanus  relates  another  case : a man  wa? 


wounded  with  a knife,  between  the  fifth 
and  sixth  ribs,  near  the  sternum.  As  a piece 
of  lung  protruded  through  the  opening,  and 
had  a livid  colour,  it  was  extirpated  with 
the  actual  cautery.  The  wound  was  then 
dilated,  and  the  ribs  kept  apart,  with  a 
wooden  wedge,  under  which  plan,  the  por- 
tion of  lung,  girt  by  the  opening,  shrunk 
within  the  chest.  The  patient  was  soon 
completely  well. 

A fourth  example  of  a protrusion  of  a 
piece  of  lung  through  a wound  in  the  tho- 
rax, is  among  the  cases  recorded  by  Ruysch. 
The  servant  of  a seafaring  man  was  wound- 
ed in  the  anterior  and  inferior  part  of  the 
chest,  and  was  immediately  attended  by  a 
surgeon,  who  mistook  the  protruded  piece 
of  lung  for  a portion  of  omentum,  and  ap- 
plied a tight  ligature  round  it.  Ruysch,  who 
was  consulted,  soon  detected  the  mistake 
which  had  been  made,  but  he  delivered  his 
opinion,  that  the  wound  would  heal  very 
well,  as  soon  as  the  tied  piece  of  lung  was 
detached.  The  event  justified  his  prognosis, 
and  the  patient  recovered. 

When  the  protruded  portion  of  lung  is 
sound,  the  reduction  ought  to  be  made 
without  the  least  delay.  It  should  be  done 
on  the  same  principles  as  those  on  which 
protruded  pieces  of  intestine,  or  omentum, 
are  reduced.  (See  Wounds  of  the  Abdomen .) 
A recurrence  of  the  accident  is  to  be  pre- 
vented by  closing  the  wound,  and  placing 
a compress  over  it.  But  when  the  piece  of 
lung  is  already  in  a mortified  state,  in  con- 
sequence of  the  constriction  which  it  has 
suffered,  or  when  its  large  size  prevents  re 
duction,  Sabatier  is  of  opinion,  that  the  only 
resource  is  to  extirpate  the  part,  after  apply- 
ing a ligature  round  its  base.  If  the  latter 
step  were  not  taken,  a dangerous  hemor- 
rhage might  follow,  or  even  an  extravasa- 
tion in  the  thorax.  (Midecine  Optratoire , 
Tom.  2,  p.  224.)  However,  the  practice 
recommended  by  Sabatier  appears  ques- 
tionable in  the  instance  of  mortification,  be- 
cause the  dead  part  will  naturally  be  thrown 
off  by  a spontaneous  process  ; and  when 
the  wound  is  too  small  to  allow  the  part  to 
be  returned,  its  dilatation  might  be  more 
adviseable  than  the  removal  of  a consider- 
able portion,  or  even  any,  of  the  lung. 

After  the  battle  of  Waterloo,  I had  a pa- 
tient with  a protrusion  of  a piece  of  lung, 
four  or  five  inches  in  length.  The  part  was 
much  bruised,  and  coitld  not  be  easily  re- 
duced. I therefore  applied  a ligature  round 
its  base,  and  cut  it  off.  Previously,  how- 
ever, I made  an  incision  in  it,  in  order  to 
ascertain  ^whether  it  would  bleed  freely, 
which  being  the  case,  induced  me  to  use  a 
ligature.  I was  afterward  informed  by  my 
friend  Mr.  Collier,  that  the  man  died. 

4.  Emphysema  is  another  symptom  with 
which  penetrating  wounds  of  the  chest  are 
frequently  complicated,  especially  when 
they  are  small,  and  indirect.  When  such 
wounds  are  small,  and  not  straight  in  their 
course ; when  their  track  is  rendered  im- 
pervious either  by  change  in  the  situation 
of  the  muscles,  the  swelling  of  the  parts. 


WOUNDS. 


liOU 


clots  of  blood,  or  any  extraneous  substan- 
ces ; air  may  insinuate  itself  into  the  cellu- 
lar substance,  so  as  to  cause  a great  deal  of 
tumour  and  distention.  Emphysema  is 
easily  distinguishable  by  the  tumefaction  of 
the  part  affected,  without  any  pain,  or 
change  of  colour  in  the  skin,  and  by  the 
crepitation  which  is  perceptible  on  pressing 
the  air  from  one  part  of  the  cellular  sub- 
stance into  another.  Emphysema  may  take 
place,  where  the  lungs  are  not  wounded, 
but  in  this  case  it  can  never  be  of  much  ex- 
tent. Here  the  emphysematous  swelling  is 
caused  by  the  air,  which  insinuates  itself 
into  the  cavity  of  the  thorax  through  the 
wound,  during  the  first  inspirations  which 
follow  the  accident,  and  the  same  air  is 
expelled  in  the  subsequent  acts  of  expira- 
tion. But  when  the  lungs  are  wounded,  the 
emphysema  arises  from  the  escape  of  air 
from  those  organs,  during  inspiration,  first 
into  the  cavity  of  the  thorax,  and  thence, 
through  the  inner  opening  of  the  external 
wound,  into  the  cellular  substance. 

I should  have  deemed  it  unnecessary  to 
have  said  any  thing  in  this  part  of  the  work, 
on  the  present  subject,  and  have  contented 
myself  with  referring  to  the  article  Emphy- 
sema, were  not  the  cause  of  this  symptom 
rather  perplexing,  and  did  I not  hope  that 
the  following  extract  from  Sir  A.  Halliday’s 
publication  will  tend  to  facilitate  the  com- 
prehension of  these  cases.  This  gentleman 
menlions  the  following  circumstances,  under 
which  air  may  escape  from  the  lungs,  or 
emphysema  arise. 

1st.  u An  injury  or  disease  of  the  pleura 
pulmonalis,  causing  a wound  or  ulceration 
of  that  membrane,  and  thus  allowing  the  air 
to  escape  from  the  lungs,  as  in  oblique  ex- 
ternal wounds,  where  the  outer  opening, 
and  that  of  the  pleura  costalis  have  healed, 
or  closed  up,  and  in  ulcers  of  the  surface  of 
the  lungs. 

2dly.  “ The  pleura  pulmonalis,  and  pleura 
costalis,  may  be  wounded  or  ulcerated  when 
there  is  no  external  opening,  as  when  the 
ends  of  fractured  ribs  penetrate  through  both 
into  the  substance  of  the  lungs;  and  it  is 
from  this  accident,  fcc.  that  emphysema  most 
commonly  takes  place. 

3d!y.  “The  common-  integuments  of  the 
parietes  of  the  chest,  the  intercostal  muscles, 
and  the  pleura  costalis  may  be  wounded, 
while  the  plura  pulmonalis  and  the  lungs 
remain  uninjured,  so  that  the  air  admitted 
from  without,  and  collected  in  the  cavity  of 
the  thorax,  may  be  pressed  into  the  cellular 
membrane,  so  as  to  occasion  emphysema.” 

The  same  writer  remarks,  “ that  the  lungs 
in  the  thorax  have  often,  and  not  unaptly, 
been  compared  to  a bladder  in  a close  pair 
of  bellows;  but  if  we  suppose  the  bellows 
to  be  divided  into  two  compartments,  and 
each  of  these  to  contain  a bladder,  which 
mutually  communicate  with  each  other,  and 
with  the  external  air,  by  means  of  a tube 
which  is  exactly  adapted  to  the  nozzle  of 
the  bellows,  arid  which  admits  the  air  only 
into  the  cavity  of  the  bladders,  and  not  into 
the  space  betwixt  the  bladders  and  bellows. 


we  shall  then  have  a perfect  representation 
of  the  mechanical  structure  of  the  thorax 
The  bellows  will  represent  the  thorax,  divi- 
ded in  the  middle  by  the  mediastinum  ; the 
bladders  will  represent  the  lungs  of  the  right 
and  left  sides;  and  the  tube,  which  com- 
municates with  the  bladders  and  with  the 
external  air,  will  represent  the  trachea.  The 
only  thing  which  is  wanting  to  render  this 
mechanical  representation  perfect*  is,  that 
the  bladders  should  exactly  fill  (he  bellows, 
so  as  to  leave  no  air  betwixt  them  and  the 
bellows.” 

It  is  explained  by  Sir  A.  Halliday,  that 
when  the  handle  of  the  bellows  is  lifted  up, 
the  bladders  become  filled  by  the  external 
air,  which  rushes  in  through  the  tube  which 
communicates  with  both  of  them.  When  the 
handle  is  depressed,  the  air  is  expelled  again. 
In  the  like  manner  the  lungs  are  filled  with 
air,  and  emptied  again  when  the  capacity  of 
the  chest  is  enlarged  by  the  inspiratory  rnus° 
cles,  and  then  diminished  by  the  expiratory 
ones. 

When  emphysema  arises  from  a wound, 
or  ulceration  of  the  pleura  pulmonalis,  on 
one  side  of  the  thorax,  the  case  is  nearly  the 
same  as  if  an  opening  were  made  in  one  of 
the  bladders,  which  opening  would  form  a 
communication,  as  the  same  gentleman  ob- 
serves, with  the  bellows  and  bladder  on  one 
side.  It  this  should  happen  while  the  handle 
of  the  bellows  is  depressed,  no  sooner  is  the 
handle  raised,  than  air  rushes  into  the 
space  betwixt  the  bladder  and  bellows,  and 
on  keeping  up  the  handle  a little  while,  the 
bladder  will  become  quite  collapsed,  and  the 
place  which  it  occupied,  while  distended, 
will  now  be  occupied  by  the  air.  If  now, 
says  Sir  A.  Halliday,  u we  attempt  to  force 
out  the  air,  by  depressing  the  handle  of  the 
bellows,  we  shall  find  that  this  cannot  be 
done  ; for  there  is  no  direct  communication 
between  the  bellows  and  the  external  air  ; 
and  as  the  effused  air  presses  equally  on  all 
parts  of  the  collapsed  bladder,  it  cannot  es 
cape  through  it.” 

When  the  thorax  is  expanded  in  inspira- 
tion, the  pressure  is  taken  off  the  surface  of 
the  wounded  lung,  and  the  air  which  now 
enters  this  organ,  instead  of  distending  its 
cells,  passes  through  its  wound  into  the 
space  between  the  pleura  pulmonalis,  and 
pleura  costalis.  The  lung  will,  indeed,  be 
partially  expanded,  as  long  as  inspiration  on 
that  side  goes  on  ; the  more  so,  the  smaller 
its  wound  is.  At  every  expiration,  however, 
when  the  thorax  is  diminished,  the  effused 
air  will  be  compressed  against  the  wounded 
lung;  but  none  of  the  air  which  has  escaped 
can  re-enter  the  lung  again  ; “ because  (as 
the  preceding  writer  accurately  remarks)  the 
whole  of  the  air  contained  in  the  lung,  must 
be  forced  out,  and  then  (lie  pressure  (of  the 
air)  against  every  part  of  the  collapsed  lung 
being  6qual,  will  prevent  its  separating  any 
part,  so  as  to  make  a passage  for  itself  into 
the  trachea.”  Thus  fresh  air  accumulates  at 
every  inspiration  in  the  space  between  the 
pleura?,  while  none  can  escape  from  the  same 
situation  during  expiration,  and  the  quantity 


W#UNDS 


661 


accumulated  will,  at  last,  eqaal  that  which  is 
received  into  the  other  lung,  during  the  most 
powerful  inspiration. 

When  the  pleura  pulmonalis,  and  pleura 
costalis  are  both  wounded,  the  same  effusion 
of  air  between  them  continues  from  the 
above-mentioned  causes,  till  the  lung  collap- 
ses. Vyben  an  attempt  is  now  made  to  ex- 
pire, the  injufed  side  of  the  thorax  must  con- 
tinue distended,  notwithstanding  every  el- 
fort  of  the  patient.  In  this  expiratory  act, 
however,  if  the  capacity  of  the  thorax  be 
diminished,  and  the  air  compressed,  a part 
of  it  finds  its  way  through  the  wound  in  the 
pleura  costalis,  into  the  common  cellular, 
substance  of  the  parietes  of  the  chest. 

The  passage  of  air  into  the  cavity  of  the 
thorax  during  the  inspiration  is,  as  Sir  A. 
HaUiday  observes,  now  more  easy  than  the 
return  of  that  already  effused  in  the  cellular 
membrane,  and  consequently,  the  subcuta 
neons  emphysema  continues  to  increase  with 
a rapidity  which  is  remarkable,  as  long  as 
the  patient  lives. 

To  explain  the  origin  of  emphysema,  in 
cases  of  wounds,  which  only  enter  the  chest, 
and  do  not  injure  the  lungs  at  all,  this  writer 
has  recourse  to  the  simile  of  the  bellows  and 
bladders.  Were  an  opening  made  into  the 
bellows,  without  injuring  the  contained 
bladders,  and  the  access  of  air  by  this  open- 
ing more  free  than  that  by  the  nozzle,  com- 
municating with  the  cavity  of  the  bladder, 
more  air  would  enter  by  the  opening,  than 
by  the  pipe,  on  the  handle  being  raised,  so 
that  the  bladder  would  not  rise  as  usual, 
when  no  opening  in  the  side  of  the  bellows 
existed.  If  the  latter  opening  be  smaller  than 
that  of  the  pipe,  the  bladder  will  only  be  par- 
tially filled,  and  on  depressing  the  handle  of 
the  bellows,  the  air  contained  in  the  bladder, 
and  that  between  the  bladder  and  the  bel- 
lows, will  be  expelled  in  the  same  propor- 
tion to  each  other,  as  that  in  which  they 
were  formerly  filled.  This  process  would 
continue  to  go  on  in  the  same  way,  did  not 
the  bladder  naturally  collapse  more  and 
more  from  its  gravitation.  Let  us  now  stop 
the  mouth  of  the  pipe,  while  the  handle  of 
the  bellows  is  raised,  and  the  bladder  par- 
tially filled.  On  trying  next  to  depress  the 
handle,  it  results,  that  as  no  air  can  escape 
from  the  pipe,  the  air  contained  between 
the  bladder  and  the  bellows  must  be  first 
evacuated,  while  that  contained  in  the  blad- 
der of  the  sound  side,  will  be  forced  into 
the  bladder  on  the  injured  side,  and  either 
distend  it,  so  as  to  rupture  it,  or  cause  it  to 
protrude. 

Hence,  in  the  case  of  a wound  penetra- 
ting the  chest,  without  injuring  the  lungs,  if 
the  air  can  enter  more  freely  by  the 
wound  than  by  the  trachea,  more  of  it 
will  enter,  in  the  act  of  inspiration,  into 
the  cavity  of  the  thorax,  than  into  the  lungs. 
On  the  contrary,  when  the  opening  of  the 
wound  is  not  so  large  as  that  of  the  tra- 
j chea,  less  air  will  enter  the  thorax  than  the 
lungs. 

In  the  expiration,  the  air  will  be  forced 
from  the  two  different  situations,  in  pro- 


portion to  the  quantity  which  enters  each 
of  them  in  inspiration,  and  no  air  at  all 
would  accumulate  in  the  thorax,  did  not 
the  lungs  always  tend  to  collapse  from  their 
gravitation.  Should,  however,  the  patient, 
in  making  an  effort  to  expire,  contract 
the  glottis,  the  air  contained  in  the  lungs 
of  the  sound  side,  may  be  propelled  into  the 
bronchia  and  air-cells  of  the  lungs,  on 
the  same  side  as  the  wound,  so  as  to  distend 
them,  and  even  make  them  protrude  at  the 
wound. 

Dr.  HaUiday  remarks,  that  such  a pro- 
trusion often  happens,  when  wounds  are 
made  in  dogs,  and  has  been  erroneously 
adduced  as  an  argument  against  the  col- 
lapse of  the  lungs,  when  an  opening  is  made 
into  the  thorax  of  the  human  subject.  (See 
Obs.  on  Emphysema , by  Sir  A.  HaUiday, 
1807.) 

For  information  concerning  the  treatment 
of  this  affection,  see  Emphysema. 

5.  I have  already  noticed,  that  wounds  of 
the  thorax  may  injure  one  of  the  intercostal 
arteries,  and  when  the  blood  cannot  flow 
outward,  it  may  be  extravasated  in  the 
chest.  The  same  consequence  may  follow 
wounds  of  the  pulmonary  vessels,  those  of 
the  heart,  or  of  the  heart  itself.  And  here  I 
may  take  the  opportunity  of  remarking, that 
sometimes  wounds  of  the  heart  do  not 
prove  instantaneously  fatal.  A case  in  which 
a bayonet  passed  through  the  colon,  sto- 
mach, diaphragm,  part  of  the  lungs,  and  the 
right  ventricle  of  the  heart,  and  yet  the  pa- 
tient lived  nine  hours  after  the  receipt  of  the 
injury,  is  recorded  by  Dr.  Babbington.  (See 
Med.  Records  and  Researches , Lond.  1798  ; 
also  a case  by  Ckastenet  in  Jour,  de  Med. 
Mil.  T.  2.)  In  almost  all  cases,  however, 
such  injuries  prove  instantly  fatal ; and  the 
same  remark  will  extend  to  cases  of  hemor- 
rhage from  vessels  above  a certain  size, 
but  when  they  are  less  considerable,  the  pa- 
tient may  live  for  a greater  or  less  time,  and 
receive  the  aid  of  surgery. 

The  following  are  the  symptoms  which 
denote  an  extravasation  of  blood  in  the 
thorax.  The  patient  feels  great  oppression, 
and  such  uneasiness  as  will  not  let  him  long 
continue  in  one  position.  Unless  he  bend 
his  body  very  much  forward,  in  which  posi- 
tion, the  diaphragm  is  relaxed,  and  not  so 
much  dragged  by  the  weight  of  the  extrava- 
sated fluid,  he  feels  great  difficulty  in  stand- 
ing or  sitting  up.  When  the  thighs  are 
bent,  the  patient  can  lie  with  tolerable 
ease  on  his  back ; be  is  also  not  averse  to 
lying  on  the  side,  on  which  the  wound  is 
situated  ; but  he  cannot  place  himself  on  the 
opposite  side,  without  feeling  very  acute  pain 
in  the  situation  of  the  mediastinum. 

His  respiration  is  short,  frequent,  and  in- 
terrupted by  sighs ; his  veins  become  emp- 
ty ; a cadaverous  paleness  spreads  over  his 
countenance  ; his  extremities  become  cold  ; 
a viscid  perspiration  covers  his  neck  and 
temples;  his  teeth  chatter;  his  pulse  be- 
comes weak  ; and  if,  as  most  frequently 
happens,  the  lungs  are  wounded,  he  spit?- 


WOUNDS. 


up  frothy  blood,  end  air  issues  from  the 
wound. 

Though  one  might  suppose  (he  above 
class  of  symptoms  always  attendant  on  a 
considerable  effusion  of  blood  in  the  thorax, 
this  is  not  the  case.  Wounded  persons 
have  been  known  to  die  of  such  an  extrava- 
sation, whose  respiration  was  tolerably  free, 
and  who  did  not  complain  of  suffering  more 
inconvenience  in  one  posture  than  another. 
Sabatier  says,  that  several  facts  of  this  kind 
have  fallen  under  his  own  observation. 
Olher  wounded  persons,  also,  who  suffered 
most  of  the  complaints  ascribable  to  extra- 
vasations of  blood  in  the  thorax,  have  been 
cured  by  ordinary  means.  Mery  gives  an 
account  of  a young  man,  wounded  in  the 
anterior  and  superior  part  of  the  chest,  about 
two  o’clock  in  the  morning,  who  had  such 
difficulty  of  breathing,  and  fever,  five  hours 
afterward,  that  an  extravasation  was  sup- 
posed to  exist,  and  Mery  was  thinking  of 
making  an  opening  for  its,  evacuation.  A 
tumour  near  the  great  pectoral  muscle,  pre- 
senting neither  t lie  feel  of  fluctuation,  nor 
that  of  emphysema,  made  him  suspend  his 
decision.  The  tumour  was  dispersed  by 
bleeding,  and  the  application  of  compresses, 
dipped  in  a mixture  of  spirit  of  wine  and 
water. 

However,  even  the  assemblage  of  the 
above  symptoms  did  not  deceive  Petit. 
Having  been  requested  to  assist  at  an  ope- 
ration, which  was  about  to  be  done  on  a 
wounded  man,  about  whose  armpit,  pecto- 
ralis  major,  and  latissimus  dorsi  muscles  a 
prodigious  emphysematous  swelling  had  ta- 
ken place  ; whose  respiration  was  painful 
and  difficult ; and  who  spit  up  frothy  blood  ; 
Petit  gave  it  as  his  opinion,  ihat  it  was  unne- 
cessary to  make  an  opening  into  the  chest. 
He  thought  it  would  be  sufficient  to  enlarge 
the  wound,  which  was  at  a little  distance 
from  the  armpit,  near  the  edge  of  the  latis- 
simus dorsi,  so  as  to  give  vent  to  the  effused 
air.  This  advice  was  followed,  th§  emphy- 
sema soon  disappeared,  and  the  patient  re- 
covered. 

The  equivocal  nature  of  the  symptoms  of 
extravasations  of  blood  in  the  thorax,  has 
induced  practitioners  to  pay  the  most  scru- 
pulous attention  to  every  circumstance  at- 
tendant on  these  cases.  In  several  instan- 
ces, Valentin  remarked,  that  an  ecchymosis 
occurred,  at  the  angle  of  the  false  ribs,  and 
spread  towards  the  loins.  The  ecchymosis 
is  described  as  being  of  a clear  purple 
colour,  like  the  spots  which  sometimes 
form  on  the  abdomen,  a little  while  after 
death.  In  a case,  in  which  most  of  the 
symptoms  of  extravasation  were  combined 
with  the  above  sort  of  ecchymosis,  Valen- 
tin advised  a counter-opening  to  be  made. 
The  advice  was  overruled,  and  the  patient 
soon  afterward  died  : more  than  six  pints 
of  blood  were  found  extravasated  in  the 
thorax. 

Sabatier  remarks,  that  we  cannot  too 
highly  applaud  the  zeal  of  those  practi- 
tioners, who  endeavour  to  dispel  the  doubts 
which  still  prevail  in  several  parts  of  sur- 


gery. At  the  same  time,  he  thinks,  that  ail 
who  take  interest  in  the  improvement  of 
this  science,  should  endeavour  to  ascertain 
the  truth  of  any  new  observations  which 
are  offered.  Hence,  he  deems  it  proper  to 
relate  a case  which  was  communicated  to 
him  by  M.  Saucerotte  (the  father,)  an  emi- 
nent military  surgeon,  and  which  shows 
that  the  ecchymosis,  observed  by  Valentin, 
is,  at  least,  not  invariably  attendant  on  ex- 
travasations of  blood  in  the  chest.  A light- 
horseman,  who  had  received  a thrust  with 
a sabre  in  the  right  side  of  the  thorax, 
above  the  tendon  of  the  pectoralis  major, 
appeared  to  be  going  on  very  well  for  the 
first  four  days  after  the  accident.  On  the 
fifth,  he  complained  of  difficulty  of  breath- 
ing, uneasiness,  and  an  inability  of  lying  on 
the  left  side,  without  aggravating  his  com- 
plaints. He  complained  of  a great  deal  of 
pain  in  the  region  of  the  liver,  and  at  the 
top  of  the  shoulder.  His  pulse  was  small 
and  contracted,  and  rather  hard  than  weak. 
The  right  side  of  the  chest  seemed  larger 
than  the  left.  On  the  eight  and  ninth  day, 
the  symptoms  became  more  urgent,  and  the 
patient  found  no  ease,  except  in  leaning  on 
his  right  side,  and  supporting  himself  on  a 
chair,  placed  across  his  bed.  This  assem- 
blage of  symptoms  indicated  an  extravasa- 
tion of  blood  in  the  right  cavity  of  the 
thorax ; but  as  the  ecchymosis,  which  Va- 
lentin has  described,  was  not  apparent, 
doubts  were  entertained  about  the  real  na- 
ture of  the  case.  When  a counter-opening 
was  made  on  the  dead  body,  a pint  of  pu- 
trid blood  flowed  out. 

When  the  surgeon  feels  assured,  that  an 
extravasation  of  blood  in  the  thorax  has 
really  occurred,  and  the  symptoms  are  very 
urgent,  the  discharge  of  the  confined  fluid 
appears  to  promise  benefit.  However,  be- 
fore the  operation  is  done,  the  revived  state 
of  the  pulse,  the  return  of  warmth  in  the 
extremities,  and  the  cessation  of  great  faint- 
ness, ought  to  denote,  that  the  hemorrhage 
no  longer  continues  from  the  vessels ; for, 
if  this  be  not  the  case,  a fresh  quantity  of 
blood  must  soon  be  extravasated  again,  and 
the  patient  die  exhausted. 

Authors  mention  five  methods  of  dis- 
charging blood  from  the  thorax  ; viz.  1st. 
By  placing  the  patient  in  a posture,  which 
favours  the  escape  of  the  blood.  2dly.  By 
introducing  a syringe  for  the  purpose  of 
sucking  it  out,  or  a mere  cannula,  through 
which  it  is  to  flow.  3dly.  By  enlarging  the 
wound.  4thly.  By  employing  injections. 
Stilly  By  making  an  opening  in  a depend- 
ing part  of  the  thorax. 

1.  Success  cannot  be  expected  from 
merely  placing  the  patient  in  a posture, 
which  is  favourable  to  the  escape  of  the  ex- 
travasated blood,  except  when  the  wound 
is  situated  at  the  inferior  part  of  the  chest, 
and  is  large  and  direct  in  its  course.  Parc 
successfully  adopted  this  method  in  the 
case  of  a soldier,  who  was  stabbed  in  three 
places  with  a sword  ; one  of  the  wounds, 
which  entered  the  chest,  being  situated 
under  the  right  nipple.  The  man  was  fire* 


WOUNDS 


Otje 


dressed  by  a surgeon,  who  made  several 
sutures.  The  patient  was  soon  afterward 
attacked  with  considerable  difficulty  of 
breathing,  fever,  coughing,  spitting  of  blood, 
and  acute  pain  in  the  side.  Par6,  who  was 
consulted  the  next  day,  suspected  that  an 
extravasation  had  happened  ; consequently 
he  cut  out  the  sutures,  and  placed  the  pa- 
tient in  a position,  in  which  his  feet  were 
much  more  raised  than  the  head.  Pare  also 
recommended  him  to  hold  his  breath,  and 
then  introduced  his  finger  into  the  wound, 
in  order  to  take  away  some  clots  of  blood, 
which  appeared  at  its  orifice.  By  these 
steps,  the  discharge  of  seven  or  eight  ounces 
of  fetid  coagulated  blood  was  effected. 

2.  The  idea  of  drawing  out  of  the  thorax 
extravasated  blood  with  a syringe  is  rather 
ancient.  The  pipes  of  all  syringes,  for  this 
purpose,  should  have  blunt  ends,  lest  they 
injure  the  lungs.  Mere  tubes,  containing  a 
stilet,  have  also  frequently  been  employed. 
Scultetus  relates  a case,  in  which  an  instru- 
ment of  the  latter  sort  was  successfully 
employed.  No  syringe,  nor  any  suction 
with  the  mouth/  was  requisite.  It  was 
found  necessary  merely  to  introduce  the 
tube,  and  then  withdraw  the  stilet. 

Lamotte  used  only  a simple  cannula, 
which  he  introduced  into  the  centre  of  the 
extravasation.  Then  having  placed  the 
patient  in  what  he  conceived  to  be  the  most 
favourable  posture,  and  requested  him  to 
hold  his  breath,  he  drew  &ff  the  collection 
of  fluid.  The  cases  numbered  216, 217,  218, 
show  the  success  which  attended  this  me 
thod.  Although  it  might  also  have  answered 
very  well  in  case  219,  Lamotte  saw  that  the 
high  situation  of  the  wound  w ould  not  have 
allowed  all  the  blood  to  be  discharged,  and 
therefore  he  made  a counter-opening. 
Thus  the  thorax  was  completely  emptied, 
and  a recovery  ensued.  When  a cannula 
is  employed,  authors  recommend  it  to  be 
introduced  every  day  till  the  bad  symptoms 
cease,  and  no  more  fluid  escapes  through 
the  cavity  of  the  instrument  Alter  having 
given  vent  to  blood,  it  allow's  a bloody  se- 
rous fluid  to  escape,  and  at  a later  period 
pus,  w hich  becomes  of  a thicker  and  thicker 
consistence,  the  nearer  the  patient  is  to  a 
recovery. 

3.  The  cases  in  which  a wound,  compli- 
cated with  an  extravasation  in  the  chest, 
should  be  dilated,  are  those  in  which  the 
situation  of  the  opening  is  favourable  to 
the  escape  of  the  blood.  The  operation  is 
performed  with  a curved  bistoury,  and  a 
director.  The  integuments,  and  external 
muscles,  are  to  be  divided  in  a perpendicu- 
lar direction,  and  the  intercostal  muscles 
in  a line  parallel  to  the  ribs.  Care  is  also 
to  be  taken  not  to  cut  loo  near  the  lower 
edge  of  the  upper  rib,  lest  the  intercostal 
artery  be  wounded.  Dionis  practised  such 
an  operation  on  a soldier,  who  was  wound- 
ed at  Befort,  in  1703,  with  a sword  below 
the  right  nipple,  whereby  a direct  opening 
was  made  into  the  thorax.  When  the  ex- 
travasated fluid  had  been  let  out,  Dionis 
made  the  patient  lie  on  the  wounded  side 


during  the  night,  and  in  proportion  as  the 
blood  continued  to  be  thus  evacuated,  the 
breathing  became  free  from  oppression. 

4.  The  methods,  above  explained,  may  be 
of  use  when  the  blood  retains  its  natural 
state  of  fluidity;  but,  when  it  is  coagulated, 
as  often  happens,  they  can  be  of  no  avail. 
In  tins  circumstance,  most  authors  direct  a 
proper  opening  to  oe  made,  and  tepid  water 
then  to  be  thrown  into  the  chest,  with  the 
view  of  loosening  and  dissolving  the  coa- 
gula  and  washing  them  out  Of  the  wound. 
The  French  writers,  even  the  modern  ones, 
( Sabatier ) most  absurdly  recommend  the 
injection  of  various  detergent  vulnerary  de- 
coctions, and  of  solutions  of  honey  of  roses, 
soap,  salt,  fcc.  What  idea  these  authors  can 
entertain  of  the  great  tendency  to  inflam 
mation  of  the  lungs  and  pleura,  or  what 
good  they  can  expect  from  such  applica- 
tions, is  difficult  of  conception.  1 am  firmly 
convinced,  that  the  meanest  scribbler  on 
surgery,  in  this  country,  would  be  ashamed 
of  offering  such  advice. 

5.  When  the  wound  is  narrow,  and  situ- 
ated at  the  upper  part  of  the  chest,  the  ex- 
travasated blood  cannot  be  discharged,  un- 
less a counter-opening  be  made  at  the  lower 
part  of  this  cavity.  The  best  place  for  mak- 
ing the  opening,  and  the  proper  manner  of 
executing  the  operation,  are  described 
under  the  head  of  Paracentesis.  As  soon  as 
the  opening  has  been  made,  the  blood  flows 
out.  Its  discharge  is  then  to  be  promoted 
by  such  a posture  as  will  render  the  open  - 
ing depending. 

The  old  surgeons,  who  had  much  more 
fear  than  the  moderns  of  letting  the  opening 
heal  up,  sometimes  employed  tents  for  the 
purpose  of  preventing  this  event,  until  all 
danger  of  another  collection  of  blood  or 
matter  seemed  to  be  over.  However,  as 
in  these  cases  tents  are  apt  to  bring  on  in- 
flammation of  the  pleura  and  lungs,  hinder 
the  escape  of  whatever  fluid  is  contained  in 
the  chest,  and  cause  great  irritation,  pain, 
and  even  exfoliations  from  (be  ribs,  their 
use  is  now  relinquished. 

As  large  tents  had  the  effect  of  hindering 
the  discharge  of  blood,  or  matter  from  the 
cavity  of  the  chest,  some  of  the  old  French 
surgeons  employed  a kind  of  wick  ; but,  in 
the  present  state  of  surgery,  I do  not  con- 
sider that  it  would  be  at  all  edifying  to  enter 
into  a comparison  of  these  contrivances. 
If  any  means  be  ever  requisite  for  keeping 
the  opening  from  closing,  there  cannot  be  a 
better  thing  for  the  purpose  than  a short 
cannula,  with  a rim  to  keep  it  from  slipping 
into  the  thorax,  and  two  little  rings  for  con’- 
fining  it  in  its  situation  with  a riband. 
This  should  only  just  enter  deeply  enough 
to  have  its  inner  orifice  on  a level,  or  a very- 
little  further  inward  than  the  pleura  costa- 
lis,  so  that  it  may  not  irritate  the  lungs. 

When  the  patient  has  been  dressed,  he  is 
to  be  kept  in  bed,  with  his  head  and  chest 
somewhat  elevated,  and  his  thighs  bent,  in 
which  position  the  breathing  will  be  least 
oppressed.  It  is  usual  also  to  recommend 
him  to  lie,  as  much  as  possible,  on  the  siffe 


WOUNDS. 


Bu4 


on  which  the  operation  has  been  done.  He 
is  to  keep  himself  in  as  quiet  a condition  as 
he  can.  He  is  to  be  put  on  very  low  diet, 
and.,  if  his  strength  allows,  he  is  to  be  bled 
from  the  arm  ; and  this  evacuation  must  be 
repeated,  with  other  antiphlogistic  means, 
as  often  as  the  urgency  of  the  fever  and  in- 
flammatory symptoms  indicates,  and  the 
strength  allows.  Bleeding  from  the  arm, 
besides  counter-acting  inflammation  in  the 
chest,  which  is  a principal  source  of  danger, 
does  good  by  lessening  the  force  of  the  cir- 
culation in  the  wounded  vessels,  and  thus 
diminishing  the  tendency  to  internal  hemor- 
rhage. 

The  old  practice  of  keeping  open  wounds 
of  the  chest  is  now  nearly  exploded  ; but,  if 
it  ever  be  adviseable,  particular  caution  must 
be  used  not  to  let  the  tents,  and  pieces  of 
the  dressings,  glide  into  the  cavity  of  the 
pleura.  Tulpius  speaks  of  a Danish  gentle- 
man who  had  been  under  a careless  sur- 
geon, on  account  of  a wound  in  the  thorax, 
and  who  coughed  up,  six  months  afterward, 
a large  tent.  A similar  fact  is  recorded  by 
Hildanus.  A man  was  stabbed  in  the  right 
side  of  the  chest,  near  the  axilla,  between 
the  second  and  third  ribs.  Fora  fortnight, 
a great  deal  of  blood  was  discharged  both 
from  the  wound  and  the  mouth.  The 
wound  healed ; but  the  patient  continued 
to  be  afflicted  with  considerable  difficulty  of 
breathing,  an  incessant  cough,  and  to  spit 
up  a greenish,  fetid  matter.  Three  months 
afterward  he  coughed  up  two  tents,  which 
had  slipped  into  the  cavity  of  the  thorax. 

A relaxation  of  the  antiphlogistic  regimen 
must  be  made  with  very  great  circumspec- 
tion. Too  much  nourishment,  talking  too 
frequently,  and  any  exertion,  are  circum- 
stances which  may  induce  a renewal  of 
the  hemorrhage,  and  extravasation.  Vesa- 
lius  saw  an  accident  of  this  nature  happen 
a fortnight  after  the  wound,  and  eleven 
days  after  the  operation  for  empyema.  A 
soldier,  who  had  been  stabbed  in  two  places 
with  a sword  above  the  right  nipple,  was 
attacked  with  fever,  difficulty  of  breathing, 
restlessness,  and  acute  pain  at  the  bottom  of 
the  chest.  These  symptoms  induced  Vesa- 
lius  to  infer,  that  an  extravasation  had  taken 
place  ; but  he  was  afraid  of  making  an  open- 
ing in  the  chest  for  fear  the  hemorrhage 
should  still  continue  from  the  wounded 
vessels.  However,  as  the  patient  remained 
in  the  same  state  the  fourth  day  after  the 
receipt  of  the  wounds,  and  he  still  had 
strength  enough,  Vesalius  undertook  the 
operation,  by  which  a considerable  quan- 
tity of  extravasated  blood  was  discharged. 
The  patient  felt  great  relief  at  the  instant. 
The  oozing  of  blood  continued  for  a few 
days,  after  which  a favourable  suppuration 
took  place  in  all  the  three  wounds,  and  the 
case  was  expected  to  end  well.  But  the 
patient  having  regained  his  strength,  and 
taken  too  much  food,  the  recurrence  of  he- 
morrhage caused  his  death.  Lombard  saw' 
a soldier  die  instantaneously  of  internal 
hemorrhage,  brought  on  by  throwing  a 


bowl  at  some  nine  pins,  two  months  after 
he  had  been  cured  of  a wound  of  the  lungs  . 

When  the  edges  of  a penetrating  wound 
of  the  chest  are  to  be  brought  together, 
writers  state,  that  the  patient  should  be  re- 
quested to  make  a strong  inspiration,  with 
the  wound  closed,  and  then  a long,  slow 
expiration  with  it  open,  and  so  on,  till  as 
much  of  the  air  is  discharged  from  the  tho- 
rax as  possible,  and  then  the  wound  is  to 
be  accurately  closed  w ith  sticking-plaster. 
From  what  has  been  observed,  however,  in 
the  article  Emphysema , it  will  appear,  that 
when  there  is  a direct  opening  into  the 
thorax,  so  as  to  admit  the  external  air,  the 
lungs  on  one  side  coilapse,  and  remain  so 
till  the  wound  is  healed,  and  the  air  absorb- 
ed. When  one  of  these  organs  is  wounded, 
a collapsed  state  is  indeed  the  best  condi- 
tion in  which  it  can  possibly  be  for  a cer- 
tain time,  that  is,  till  the  breach  of  conti- 
nuity in  it  is  healed.  Schemes  for  making 
the  lung  expand,  by  exhausting  the  air  from 
the  cavity  of  the  pleura,  may  be  amusing 
on  paper,  but,  1 apprehend,  they  will  never 
be  of  real  use  in  practice. 

Fistulse  sometimes  continue  a long  while 
after  w ounds  of  the  thorax.  Platner  men- 
tions an  instance  in  which  there  was  a fistu- 
lous opening,  out  of  which  the  air  rushed 
with  sufficient  force  to  blow  out  a candle. 
The  patient  lived  a long  while  in  this  state 
without  suffering  any  particular  inconve- 
nience. 

Another  occasional  consequence  of  a 
wound  of  the  chest,  is  a hernia  of  the  lungs,, 
an  affection  of  which  Sabatier  met  with  an 
example.  A soldier,  thirty  years  of  age, 
W'as  wounded  with  a bayonet  in  the  right 
side  of  the  chest,  between  the  middle  part 
of  the  fifth  and  sixth  true  ribs.  The  wound 
healed  ; but,  as  the  intercostal  muscles  had 
been  divided  to  a great  extent,  and  could 
not  be  approximated  with  precision,  an 
empty  space  was  left  under  the  integuments, 
which  a!lowred  a piece  of  the  lungs,  as  large 
as  a walnut,  to  protrude  between  the  ribs. 
The  swelling  enlarged  at  the  time  of  inspi- 
ration, and  grew  smaller  when  expiration 
took  place,  occasioning  merely  a slight  pain 
without  any  oppression  in  the  chest. 

Though  so  much  has  been  written  on  the 
subject  of  discharging  blood  from  the  chest, 
in  cases  of  extravasation  within  that  cavity, 
the  operation  is  very  rare.  During  the  last 
twenty-four  years,  I have  never  heard  of  its 
being  done  by  any  of  the  surgeons  in  Lon- 
don. In  military  surgery,  however,  the 
practice  is  occasionally  exemplified.  (Lar- 
rey,  M6m.  dc  Chir.  Mil.  T.  2,  p.  158,  8pc.) 
No  doubt,  the  true  reason  of  the  operation 
being  uncommon,  is  the  obscurity  in  the 
diagnosis,  the  symptoms  being  all  of  an 
equivocal  nature  Even  Larrey,  generally 
so  partial  to  operations,  recommends  the 
immediate  closure  of  all  wounds  of  the 
chest,  excepting  such  as  are  complicated 
with  injury  of  the  intercostal  artery,  be- 
cause, (says  he)  unless  very  considerable 
vessels  of  the  lungs  are  injured,  (in  which 
case  nothing  cam  bo  of  any  use)  either  no 


WOUNDS 


C(*j 


extravasation,  or  only  a trivial  one,  happens, 
which,  under  the  employment  of  rigorous 
♦antiphlogistic  treatment,  may  be  dispersed 
by  absorption.  (P.  127.)  In  the  general 
propriety  of  closing  all  wounds  of  the  chest, 
I entirely  concur  with  Larrey,  Pelletan^ 
t Boyer,  and  Dr.  Hennen.  ( On  Military 
L Surgery,  ed.  2,  p.  373.) 

Consult  Sabatier,  De  la  MMecine  Opera- 
toire,  T.  2.  Joum.  de  Med.  Militaire,  7 
Tomes.  Schmucker,  Wahrnehmungen,  2 B. 
Berlin,  1774 — 89.  J.  Bell , on  the  JVa'ure 
I and  Cure  of  Wounds,  Ed.  3.  D.  J Larrey, 
Mdm.  de  Chir.  Militaire,  8 vo.  Paris,  1812 — 
1817,  in  various  places.  John  Hennen, 
Principles  of  Military  Surgery,  Ed.  2,  8 vo. 
Edinb.  1820.  Wm.  Maiden,  an  Account  of 
a Case  of  Recovery,  after  an  extraordinary 
Accident,  4/o.  Lond.  1812.  The  injury  here 
referred  to  is  one  of  the  most  extraordinary  on 
record ; the  shaft  of  a gig  having  been  driven 
with  the  greatest  violence  between  the  sternum 
and  lungs.  Sir  A.  Halliday,  in  Edinb.  Med. 
and  Surg.  Joum.  Vol,  1 1,  p.  140  ; a Recovery 
from  a Gunshot  Injury,  in  which  a great  part 
of  the  Shoulder  was  carried  away , and  the 
Lungs  and  Pericardium  were  exposed  : to 
the  authenticity  of  this  Case  / can  bear  wit- 
ness myself,  having  been  at  the  Field  Hospital, 
when  the  Soldier  arrived  from  the  Trenches, 
near  Antwerp. 

Wounds  of  the  Abdomen. — Here  one  of  the 
chief  causes  of  danger  is  the  tendency  of 
the  peritoneum  to  inflame.  Every  pene- 
trating wound  of  the  belly  is  apt  to  excite 
this  inflammation,  which  too  often  extends 
itself  over  all  the  viscera,  and  terminates  in 
the  death  of  the  patient. 

There  are  (says  Mr.  John  Bell)  a thousand 
occasions,  on  which  the  delicacy  of  the 
peritoneum  may  be  observed.  The  wound 
of  the  small  sword,  and  the  stab  of  the  sti- 
letto, explain  to  us,  how  quickly  the  perito- 
neum, and  all  its  contained  bowels,  inflame 
from  the  most  minute  wound,  although  the 
injury  be  almost  too  small  to  be  visible  on 
the  outside,  and  scarcely  within  ; for  often, 
upon  dissection,  no  intestines  are  discover- 
ed wounded,  and  no  feces  have  escaped  into 
the  abdomen.  In  subjects  who  die  after 
lithotomy,  we  find  the  cavity  of  the  perito- 
neum universally  inflamed.  The  operation 
of  the  Caesarean  section  is  fatal,  not  from 
any  loss  of  blood,  for  there  is  little  bleed- 
ing; nor  from  the  parts  being  exposed  to 
the  air,  for  patients  also  die  in  whom  the 
womb  bursts,  and  where  the  air  has  no  pos- 
sible opportunity  of  insinuating  itself ; but 
the  case  proves  fatal  from  the  inflamma- 
tion which  is  always  disposed  to  originate 
from  wounds  of  the  peritoneum,  small  as 
I well  as  great.  ( Discourses  on  the  Nature  and 
♦ Cure  of  Wounds,  p.  310,  edit.  3.) 

But  although  there  can  be  no  doubt  that 
the  wound,  abstractedly  considered,  is  the 
most  frequent  occasion  of  this  dreaded  in- 
flammation ; yet  it  sometimes  happens  that 
the  inflammatory  consequences  must  be 
ascribed  to  another  kind  of  cause.  If  an 
intestine  be  wounded,  its  contents  may, 
under  certain  circumstances,  be  effused  in 
Voi..  IT.  84 


the  abdomen  ; it  the  fiver,  spleen,  kidney, 
or  any  large  vessel  be  injured,  blood  may 
be  poured  out  among  the  viscera ; if  the 
gall-bladder  be  wounded,  bile  may  be  effu- 
sed ; and  if  the  bladder  be  pierced,  the 
urine  may  escape  into  the  abdomen.  Now 
all  these  fluids  are  extraneous  substances 
with  respect  to  the  surfaces,  with  which 
they  often  come  into  contact,  and,  as  such, 
they  give  rise  to  inflammation  of  the  peri- 
toneum and  viscera. 

Wounds  of  the  belly  are  divided,  by  almost 
all  writers,  into  such  as  penetrate  the  cavity 
of  the  abdomen,  and  into  others,  which 
only  interest  the  skin  and  muscles. 

The  former  differ  very  much  in  their  na- 
ture, and  degree  of  danger,  according  as 
they  do,  or  do  not,  injure  parts  of  impor- 
tance, contained  in  the  peritoneum.  The 
latter  are  not  remarkably  different  from  the 
generality  of  other  superficial  wounds. 
The  chief  indications  are  to  lower  inflam- 
mation, and  to  prevent  collections  of  mat- 
ter. A few  particularities,  however,  in  the 
treatment  of  superficial  wounds  of  the  ab- 
domen, merit  attention. 

Superficial  Wounds. — The  most  ancient 
surgeons,  and  their  successors,  down  to  the 
present  day,  have  recorded,  that  wounds  of 
tendinous  parts  frequently  give  rise  to  very 
unpleasant  consequences.  Almost  the 
whole  front  of  the  abdomen  is  covered  with 
tendinous  expansions,  and,  on  this  account, 
-it  is  not  unusual  to  see  punctured  wounds 
in  this  situation  followed  by  extensive  in- 
flammation, and  the  formation  of  abscesses. 
At  the  same  time,  the  patient  is  affected 
with  a great  deal  of  inflammatory  fever. 
He  suffers  aedte  pain,  sickness,  hiccough, 
and  considerable  disturbance  of  the  ner- 
vous system.  ( Callisen , Syst.  Chirurg.  Ho- 
diernce , Vol.  1 ,p.  698,  Hafniee,  1798.)  When 
the  tension  and  swelling  of  the  abdomen 
abate,  shiverings  sometimes  occur,  and  in- 
dicate the  occurrence  of  suppuration.  The 
matter  sometimes  accumulates  in  the  tendi- 
nous sheath  of  the  rectus  muscle,  and,  when 
the  collection  in  this  situation  remains  un- 
discovered until  a pointing  appears,  no 
sooner  does  the  abscess  burst,  or  it  is  open- 
ed, than  an  extraordinary  quant  ity  of  matter 
is  discharged.  The  surgeon  ^should  care- 
fully remember  the  nature  of  this  kind  of 
case,  as  there  is  frequently  not  sufficient 
alteration  in  the  appearance  of  the  integu- 
ments to  denote  either  the  existence  or  the 
extent  of  the  suppuration. 

Such  an  abscess  forms  one  remarkable 
exception  to  the  excellent  general  rule  of 
allowing  acute  phlegmonous  abscesses  to 
burst  of  their  own  accord.  In  the  present 
instance,  there  is  an  aponeurotic  expansion, 
intervening  between  the  abscess  and  the 
skin,  and  nothing  retards  the  natural  pro- 
gress of  the  matter  to  the  surface  of  the 
body  so  powerfully  as  the  interposition  of  a 
tendinous  fascia.  But,  even  in  this  circum- 
stance, the  propensity  of  pus  to  make  its 
way  outward  is  often  seen  to  have  immense 
influence.  Though  there  is  only  a thin 
membrane  (viz.  the  peritoneum^  between 


666 


WOUNDS. 


matter  so  situated*  and  the  cavity  of  the 
abdomen,  the  abscess  after  a time  mostly 
points  externally. 

Tiie  proper  treatment  of  this  case  is  to 
prevent  the  surprising  accumulation  of  mat- 
ter, and  rapid  increase  of  mischief,  by 
making  a depending  opening,  sometimes  at 
the  very  lowest  part  of  the  sheath  of  the 
rectus  muscle,  and  this,  as  soon  as  the  lodge- 
ment of  matter  is  clearly  ascertained. 

If  ever  there  be  a case  in  which  it  is  ad- 
vantageous and  justifiable  to  make  an  early, 
dilatation  of  a punctured  wound,  in  order 
to  prevent  the  above-described  ill  conse- 
quences, it  is  unquestionably  the  present 
one.  Such  practice,  indeed,  is  particularly 
recommended  by  Callisen,  in  addition  to 
the  strictest  antiphlogistic  means.  (See 
Syst.  Cliir.  Hodiernce,  Vvl.1,p.  698,  edit. 
1798.) 

Sometimes  the  matter  is  formed  between 
the  external  and  internal  oblique  muscles, 
and  spreads  to  a great  extent.  The  pus 
may  even  insinuate  itself  into  the  abdomen, 
and  the  case  end  fatally.  Such  an  example 
is  recorded  by  Dr.  Crowther,  of  Wakefield. 
In  this  instance,  however,  the  disease  pro- 
ceeded from  a contusion,  not  a wound. 
(See  Edinb.  Med.  and  Surgical  Journal tVol. 
2 ,p.  129.) 

Superficial  wounds  of  the  abdomen  are 
to  be  treated  on  the  same  principles  as  simi- 
lar wounds  in  other  situations.  The  indica- 
tions are  to  prevent  inflammation  as  much 
as  possible,  and,  if  suppuration  should  be 
inevitable,  to  let  out  the  matter  by  a de- 
pending opening  as  soon  as  the  abscess  is 
known  to  exist.  The  inflammation  is  to  be 
checked  by  general  and  topical  bleeding, 
low  diet,  emollient  clysters,  diluent  beve- 
rages, quietude,  opening  medicines,  cold 
applications,  or  fomentations  and  poultices, 
and  the  mildest  and  most  simple  dressings. 
(See  Inflammation.) 

Whenever  the  abdominal  muscles  are 
wounded,  they  should  be  relaxed,  and  the 
patient  kept  quiet  in  bed.  A very  impor- 
tant point  in  the  treatment  of  wounds  of 
the  parietes  of  the  abdomen,  is  to  afford  a 
degree  of  support  to  the  wounded  parts,  so 
that  the  pressure  of  the  viscera  may  be  re- 
sisted. The  sides  of  the  abdomen  are  almost 
wholly  composed  of  soft  parts,  which  easily 
yield.  No  part  of  the  front,  or  sides  of  the 
abdomen,  is  supported  by  a bony  structure, 
and  as  the  viscera  are  for  the  most  part, 
more  or  less  moveable,  and  closely  com- 
pressed by  the  abdominal  muscles,  and  dia- 
phragm, they  are  liable  to  protrude,  when- 
ever the  resistance  of  the  containing  part3  is 
not  sufficiently  powerful.  Hence  all  wounds 
of  the  abdomen,  especially  those,  in  which 
both  the  integuments  and  muscles  have  been 
cut,  demand  strict  attention  to  the  precau- 
tion of  supporting  the  wounded  part,  and 
this,  though  the  peritoneum  itself  should 
not  happen  to  be  divided.  The  patient 
ought  to  keep  as  much  as  possible  in  a 
horizontal  position,  and  suitable  compresses 
and  bandages  should  be  applied.  And,  in 
order  to  guard  against  hernia?,  the  parts 


should  be  supported,  in  this  way,  a consi- 
derable time  after  the  wound  is  healed. 

’I'he  peritoneum  being  connected  by  means 
of  cellular  substance  with  the  inner  surface 
of  the  abdominal  muscles,  there  is  always 
some  risk  of  the  inflammation  of  these 
parts  extending  to  that  membrane.  The 
danger  must  be  averted  by  the  rigorous  em- 
ployment of  antiphlogistic  treatment.  What 
renders  the  event  still  more  dangerous,  is, 
that  when  one  point  of  the  peritoneum  is 
affected,  the  inflammation  usually  spreads 
with  immense  rapidity  over  its  whole  ex- 
tent, and  too  often  proves  fatal. 

As  superficial  wounds  of  the  abdomen  are 
to  be  treated  on  the  general  principles,  ap- 
plicable to  all  resembling  wrounds  in  other 
situations,  it  is  hardly  necessary  to  state, 
that  union  by  the  first  intention,  if  possible, 
is  always  to  be  attempted. 

Of  Wounds  penetrating  the  Cavity  of  the 
Abdomen — The  first  thing  which  the  surgeon 
is  generally  anxious  to  know,  when  he  is 
called  to  a wound  of  the  belly  is,  whether 
the  wound  penetrates  the  cavity  of  the  ab- 
domen, and  whether  any  of  the  viscera  are 
injured. 

When  the  wound  is  extensive,  and  the 
bowels  protrude,  the  first  part  of  the  ques- 
tion is  at  once  decided.  But  when  the 
wound  is  narrow,  and  the  viscera  do  not 
protrude,  it  is  more  difficult  to  know,  whe- 
ther the  cavity  of  the  abdomen  is  penetra- 
ted or  not.  An  opinion,  however,  may  be 
formed,  by  carefully  examining  the  wound 
with  a linger  or  a probe  ; by  observing,  if 
possible,  how  ranch  of  the  weapon  is  stain- 
ed with  blood  -,  considering  the  direction  in 
which  it  was  pushed  ; the  quantity  of  blood 
lost,  the  state  of  the  pulse,  and  whether  any 
bile,  feces,  or  other  fluids,  known  to  be  na- 
turally contained  in  some  of  the  abdominal 
viscera,  have  been  discharged  from  the  ori- 
fice of  the  injury. 

When  the  wound  is  sufficiently  large  to 
admit  the  finger,  a surgeon  can  always  learn, 
whether  the  injury  extends  into  the  abdo- 
men, because  the  smooth  lining  of  that 
cavity,  and  the  contained  bowels,  may  be 
easily  felt.  There  is  one  chance  of  decep- 
tion, however,  arising  from  the  possibility 
of  mistaking  the  inside  of  the  sheath  of  the 
rectus  muscle  for  the  cavity  of  the  perito- 
neum ; and  when  the  examination  is  made 
with  a probe,  particular  caution  should  be 
used  in  forming  a judgment  of  the  nature  of 
the  case  ; for  the  parts  are  so  soft  and  yield- 
ing, that  a very  little  force  will  make  the 
instrument  pass  a considerable  way  inward. 
Every  examination  of  this  kind  should 
always  be  undertaken,  if  possible,  when  the 
patient  is  exactly  in  the  same  position,  iu 
which  he  was  at  the  time  of  receiving  the 
wound.  Formerly,  injections  were  some- 
times employed  as  tests  of  the  penetration 
of  the  cavity  of  the  abdomen.  This  absurd 
experiment  is  now  very  rightly  exploded. 
It  is  well  known  to  the  moderns,  that  the 
space,  termed  the  cavity  of  the  abdomen, 
is,  in  fact,  completely  filled  with  the  various 
viscera,  and  that  in  general,  an  injected 


WOUND; 


067 


fluid  would  not  so  easily  find  its  way  into 
the  bog  of  the  peritoneum,  as  an  unreflect- 
ing person  might  suppose.  And  if  it  were 
propelled  with  much  force,  it  would  be  quite 
us  likely  to  insinuate  itself  into  the  cellular 
substance  of  the  parietes  of  the  abdomen, 
or  perhaps,  into  the  sheath  of  the  rectus 
muscle.  The  least  tortuosity  of  the  wound, 
or  a piece  of  bowel,  or  omentum,  lyiug 
against  the  internal  orifice  of  the  injury, 
would  also  completely  prevent  an  injection 
from  passing  into  the  abdomen. 

When  a considerable  quantity  of  blood 
issues  from  a wound  of  the  abdomen,  we 
may  pronounce,  almost  with  certainty,  that 
some  large  vessel,  within  its  cavity,  is  inju- 
red. Excepting  the  epigastric  artery,  which 
runs  on  the  forepart  of  the  abdomen,  along 
the  inner  surface  of  the  rectus  muscle,  no 
large  vessel  is  distributed  to  the  muscles 
and  integuments.  At  the  same  time,  it  is 
deserving  of  particular  notice,  that  a large 
artery  may  be  opened  in  the  abdomen,  and 
not  a drop  of  blood  be  discharged  from  the 
wound. 

In  such  cases,  the  consequent  symptoms 
quickly  lead  to  a suspicion  of  what  has  hap- 
pened. The  patient  complains  of  extreme 
debility  and  faintness ; his  pulse  falters  ; 
he  has  cold  sweats;  and  if  the  bleeding 
should  not  speedily  cease,  these  symptoms 
are  soon  followed  by  death. 

Sometimes,  the  extension  of  the  wound 
into  the  cavity  of  the  abdomen,  is  from  the 
first  quite  manifest,  being  indicated  by  the 
escape  of  chyle,  bilious  matter,  feces,  or 
other  fluids.  The  vomiting  up  of  a consi- 
derable quantity  of  blood,  or  its  discharge 
by  stool,  affords  also  the  same  information. 
The  urine  however,  may  flow  from  a wound, 
which  does  not  actually  penetrate  the  abdo- 
men, for  the  kidneys,  ureter,  and  bladder 
may  be  said  to  be  out  of  the  abdomen,  be- 
cause they  are  really  on  the  outside  of  the 
cavity  of  the  peritoneum. 

When  none  of  the  above  symptoms  occur : 
when  neither  the  finger  nor  probe  can  be 
introduced  ; when  none  of  the  fluids,  known 
to  be  contained  in  the  various  receptacles 
in  the  abdomen,  are  discharged  from  the 
wound;  when  the  pulse  remains  natural, 
and  the  pain  is  not  excessive  ; there  is  rea- 
son to  hope,  that  the  wound  has  not  injured 
parts  of  greater  consequence,  than  the  in- 
teguments and  muscles.  (Encyclopedic 
Mtthodique,  Partie  Chir.  Art.  Abdomen.) 

I have  now  taken  a survey  of  the  criteria, 
commonly  noticed  by  writers,  for  the  pur- 
pose of  enabling  surgeons  to  discriminate 
a wound,  which  penetrates  the  abdomen, 
from  one  which  is  more  superficial.  My 
next  duty  is  to  warn  the  practitioner,  that 
too  much  solicitude  to  determine  this  point, 
is  very  frequently  productive  of  serious 
harm.  It  may  be  set  down,  as  an  axiom  in 
surgery,  that  in  general , whenever  the  probing 
of  a wound  is  not  rendered  absolutely  neces- 
sary by  some  particular  object  in  view,  it  may 
be  judiciously  omitted.  A narrow,  oblique 
wound  may  enter  the  cavity  of  the  abdo- 
men, without  there  being  any  particular 


method  of  ascertaining,  whether  it  has  done 
so,  or  not.  However,  this  want  of  positive 
information  is  of  no  practical  importance; 
for,  when  there  are  no  urgent  symptoms, 
evincing  the  nature  of  the  case,  the  treat- 
ment ought  obviously  to  resemble  that  of  a 
simple  wound  ; and  whether  the  wound  be 
deep,  or  superficial,  antiphlogistic  remedies 
are  indicated. 

The  edges  of  a wound,  penetrating  the 
abdomen,  but  unattended  with  injury  of  the 
viscera,  arc  to  be  brought  together  with 
sticking-plaster,  in  the  same  way  as  commoa 
wounds.  Sutures  are  not  generally  neces- 
sary. Numerous  cases  may  be  found  in  the 
records  of  surgery,  proving  that  wounds  of 
the  abdomen  may  be  easily  united  without 
sutures,  provided  the  surgeon  take  care  to 
avail  himself  of  the  assistance,  which  may 
be  derived  from  a suitable  position  and  a 
proper  bandage.  But  such  cases  are  less 
decisive,  than  relations  of  the  Ca?sarean 
operation,  the  extensive  wound  of  which 
admits  of  being  healed  by  the  same  simple 
means.  It  is  not  my  intention  to  assert, 
that  in  the  majority  of  these  examples, 
sutures  were  altogether  dispensed  with; 
but,  the  ligatures  frequently  cut  their  way 
through  the  skin  and  muscles,  and  the  ap- 
plication of  others  was  impossible,  either 
on  account  of  the  particular  state  of  the 
case,  or  the  patient’s  aversion  to  them.  Still 
the  union  of  such  wounds  was  accomplish- 
ed. A bandage,  made  on  the  same  plan,  as 
that  with  eighteen  tails,  would  be  extremely 
convenient  for  longitudinal  wounds  of  the 
abdomen.  (See  Pibrac  in  Mtm.  de  VAcad. 
de  Chir.  T.  3, 4/o.) 

In  the  treatment  of  wounds  of  the  abdo- 
men, sutures  may  generally  be  relinquished, 
not  only  without  harm,  but  with  benefit; 
for  their  employment  is  sometimes  the  cause 
of  bad  symptoms.  In  one  instance,  the  hic- 
cough and  vomitihg  could  not  be  appeased 
by  any  remedy  which  was  tried.  On  the 
fourth  day,  the  wound  was  inflamed  and 
painful,  and  it  was  judged  proper  to  cut 
away  two  sutures,  and  employ  only  simple 
dressings,  with  the  view  of  diminishing  the 
pain  and  swelling.  The  symptoms  quickly 
abated,  and  in  a week,  were  entirely  cured, 
the  wound  healing  up  very  well.  (Op.  cit.) 

However,  there  are  circumstances,  in 
which  it  would  be  impossible  to  dispense 
with  sutures.  If,  for  instance,  the  belly 
were  torn  open  from  one  side  to  the  other 
with  a bullock’s  horn  ; or  if  it  were  exten- 
sively divided  with  the  tusks  of  a wild  boar, 
a stag’s  horn,  a razor,  &c.  and  the  inflated 
intestine  could  not  be  kept  from  protru- 
ding ; some  stitches  would  be  absolutely 
necessary,  but  even  then,  they  should  be  as 
few  as  possible.  (Sabatier,  Mtdecine  Optra- 
toire,  T.l,  p.  214,  edit.  2.) 

“ Oufgood  old  surgeon  Wiseman  (observes 
Mr.  John  Bell)  has  said  with  great  simplici- 
ty, as  a great  many  have  said  after  him, it 
frequently  happenetb,  that  a sword  passetli 
through  the  body,  without  wounding  any 
considerable  part.’  He  means, that  a rapier, 
or  ball,  often  passes  quite  across  the  belly, 


WOUNDS. 


60S 

in  at  the  navel,  anti  out  at  the  back,  and  that 
without  one  bad  sign,  the  patient  recovers, 
and  as  has  very  often  happened,  walks 
abroad  in  good  health,  in  eight  days;  which 
speedy  cure  has  been  supposed  to  imply  a 
simple  wound,  in  which  all  the  bowels  have 
escaped.  But  we  see  now,  how  this  is  to  be 
explained  ; for  we  know,  that  in  a thrust 
across  the  abdomen,  six  turns  of  intestine 
may  be  wounded, — each  wound  may  ad- 
here ; adhesion,  we  know,  is  begun  in  a 
few  hours,  and  is  perfected  in  a few  days  ; 
and  when  it  is  perfect,  all  danger  of  inflam- 
mation is  over;  and  when  the  danger  of  in- 
flammation is  over,  the  patient  may  walk 
abroad ; so  that  we  may  do,  just  as  old 
Wiseman  did  in  the  case  here  alluded  to, 
( P . 98,  the  case  of  a man,  who  was  wound- 
ed across  the  belly,  and  well  and  abroad  in 
seven  days,)  ‘ Bleed  him,  and  advise  him  to 
keep  his  bed  and  be  quiet.’  In  short,  a man, 
thus  wounded,  if  he  be  kept  low,  has  his 
chance  of  escaping  by  an  adhesion  of  the 
internal  wounds.”  ( Discourses  on  the  Nature 
and  Cure  of  Wounds , p.  329,  330,  edit.  3.) 

The  truth  of  these  observations  is  well 
illustrated  in  a case  mentioned  by  Dr.  Hen* 
nen,  in  which  a soldier  recovered,  whose 
abdomen  uTas  pierced  with  a ramrod,  which 
stuck  so  fast  in  the  vertebrae,  that  some 
force 'was  required  to  disengage  it.  ( On 
Military  Surgery , p.  402,  ed.  2.) 

When  a man  is  stabbed  or  shot  in  the  belly, 
and  none  of  the  bowels  protrude,  the  wisest 
plan  is  to  keep  the  patient  as  quiet  as  possible, 
have  recourse  to  copious  and  repeated  bleed- 
ing, prescribe  anodynes,  and  the  lowest  fluid 
diet,  and  apply  light  superficial  unirritating 
dressings.  In  the  event  of  severe  pain  and 
swelling  of  the  belly  coming  on,  leeches, 
fomentations,  the  warm  bath,  and  emollient 
poultices,  will  be  necessary,  and  nothing 
will  now  avail,  except  the  most  rigorous 
employment  of  antiphlogistic  remedies.  As 
Dr.  Hennen  observes,  the  best  means  of 
emptying  the  bowels  are  oleaginous  clysters, 
and  if  any  internal  medicine  be  given,  as  a 
purgative,  it  should  be  of  the  mildest  nature. 
(On  Military  Surgery,  p.  402,  ed.  2.)  Castor 
oil  is  perhaps  the  best;  but,  on  the  whole, 
for  some  few  days,  I would  hardly  venture 
beyond  the  use  of  clysters  for  procuring 
evacuations  from  the  bowels. 

Suppuraiionin  the  Abdomen,  in  consequence 
of  Wounds. — Abscesses  within  the  bag  of 
the  peritoneum  are  far  from  being  common. 
As  a late  writer  well  observes,  "the  con- 
taining and  contained  parts  of  the  abdomen 
present  to  each  other  an  uniform  and  con- 
tinuous surface  of  membrane.  This  mem- 
brane is  of  the  serous  class,  and  the  species 
of  inflammation,  to  wdiich  it  is  especially 
subject,  is  that,  which  has  been  denominated 
the  adhesive.  The  membrane,  lining  the 
intestinal  canal,  is  of  the  mucous  elffs,  and 
the  ulcerative  inflammation  is  the  species, 
to  which  this  class  is  liable.  This  benefi- 
cent provision  is  an  irresistible  evidence  of 
the  operation  of  a salutary  principle  in  dis- 
ease. If  the  inflamed  peritonfeurn  had  run 
directly  into  suppuration  : ulceration  of  the 


surrounding  parts  would  have  been  required 
for  an  outlet ; and  if  the  inlernal  surface  of 
the  irritated  bowel  had  tended  to  form  ad- 
hesions, the  canal  would  have  been  in  con- 
stant danger  of  obliteration.”  (Travers  on 
Injuries  of  the  Intestines,  Ipc.  p.  10.) 

That  collections  of  matter,  however,  do 
sometimes  take  place  in  the  cavity  of  the 
abdomen,  in  consequence  of  wounds,  is  a 
fact,  of  which  there  are  too  many  proofs  on 
record  for  the  possibility  of  the  case  to  be 
doubted.  At  this  moment,  be  it  sufficient  to 
refer  to  two  examples  of  the  occurrence,  as 
related  by  Mr.  B.  Bell.  (System  of  Surgery , 
Vol.  5,  p.  256.) 

If  the  abscess  were  in  any  other  part  of 
the  body,  and  did  not  readily  point,  the 
wisest  practice  would  undoubtedly  be  to 
make  an  opening  sufficient  for  the  evacua- 
tion of  the  matter.  But  suppuration  in  the 
abdomen  can  seldom  be  known  with  cer- 
tainty in  an  early  stage  of  the  case  : for  the 
abscess  is  so  deep,  that  no  fluctuation,  nor 
swelling,  is  perceptible,  until  the  quantity 
of  pus  is  considerable.  Nor  would  it  be 
judicious  to  expose  the  patient  to  the  hazard, 
which  might  arise  from  making  an  opening 
into  the  abdomen,  merely  for  the  sake  of 
discharging  a small  quantity  of  matter. 

Many  writers  impute  much  of  the  danger 
of  wounds  of  the  abdomen  to  the  entrance 
of  air  into  the  cavity  of  the  peritoneum, 
in  inculcating  such  opinions,  however,  they 
betray  an  inaccuracy  of  observation,  which 
a very  little  reflection  would  have  set  right. 
Too  much  stress  has  long  been  laid  on  the 
introduction  of  air  into  the  abdomen,  as 
being  a cause  of  inflammation.  The  fact 
is,  the  cavity  of  the  belly  is  always  so  com- 
pletely occupied  by  the  several  viscera,  that 
the  whole  inner  surface  of  the  peritoneum 
is  invariably  in  close  contact  with  them, 
and  therefore,  air  cannot  easily  diffuse  itself 
from  the  wound,  throughout  the  abdomen 
After  tapping,  in  dropsical  cases,  inflamma- 
tion seldom  arises,  though  here  the  air  has 
quite  as  good  an  opportunity  of  entering 
the  abdomen,  as  in  any  case  of  wound. 
The  peritoneum  in  animals  has  been  infla- 
ted, without  any  inflammation  being  exci- 
ted. In  cases  of  tympanitis,  the  peritoneum 
is  distended  with  air,  and  yet  both  this 
membrane  and  the  bowels  are  quite  unin- 
flamed. In  the  human  subject,  it  seems 
probable,  that  if  a wound  were  made  in  a 
vacuum,  the  breach  of  continuity  itself 
would  be  an  adequate  cause  of  inflamma- 
tion. It  may  also  be  remarked,  that  collec- 
tions of  matter  in  the  abdomen  are  almost 
always  completely  circumscribed,  and  sepa- 
rated from  the  general  cavity  of  the  perito- 
neum, by  the  adhesion  of  the  viscera  to  each 
other,  and  to  the  inside  of  the'peritoneum. 

1 am  of  opinion,  that  no  surgical  writer 
has  succeeded  so  well,  as  Mr.  John  Bell,  in 
exposing  the  absurd  apprehensions,  not  un  - 
commonly entertained  by  practitioners,  re- 
specting the  entrance  of  air  into  the  abdo- 
men and  oilier  cavities  of  the  body.  Ho 
inquires,  1st.  Whether  air  can  really  get  into 
the  cavity  of  the  abdomen  ? and,  2dly. 


WOUNDS.  069 

"Whether,  it  it  were  there,  it  would  produce  bowels  are  exposed  to  the  air.  ' ( Discourses 

the  dreadful  effects  ascribed  to  it  ? on  the  Nature  of  Wounds , p.  343, 344.) 

Upon  the  first  question,  his  arguments  run  In  adverting  to  the  question,  whether  ait’ 
thus: — “ Suppose  a wound  of  an  inch  in  is  so  irritating  to  the  cavities  of  the  body  as 
length  : — suppose  the  bowel  to  have  sunk,  many  have  supposed,  Mr.  John  Bell  critici- 
in  some  strange  way,  into  the  pelvis,  for  ses  with  much  spirit  and  success,  the  opi- 
example,  so  as  to  have  left  a mere  vacuum  ; nions,  published  on  this  subject  by  Mr.  A. 
what  should  happen  with  the  flexible  pa-  Monro,  in  his  account  of  the  Bursae  Muco- 
rietes  of  the  abdomen  ? Should  they  stand  sa?,  as  the  annexed  quotations  will  show, 
rigid,  while  the  air  rushed  into  the  cavity  “ That  the  vulgar  should  believe,  the  first 
to  fill  it  ? No,  surely.  But,  on  the  contrary,  superficial  impression  that  strikes  them,  of 


the  walls  of  the  abdomen  would  fall  toge- 
ther, and  the  pressure  of  the  outward  air,  far 
from  making  the  air  rush  in  by  the  outward 
wound,  would,  at  once,  lay  the  belly  flat, 
and  close  the  wound.  But,  since  the  walls 
of  the  abdomen  are  not  flaccid,  nor  the  ca- 
vity empty,  but  the  abdomen  full,  and  the 
flat  muscles,  which  cover  it,  acting  strongly, 
the  effect  must  be  much  more  particular  ; 
for,  the  moment  that  the  belly  is  wounded, 
the  action  of  the  muscles  w'ould  force  out 
part  of  the  bowels  ; the  continuance  of  that 
action  is  necessary  to  respiration  : the  re- 
spiration continues  as  regular  after  the 
wound  as  before  ; and  the  continual  pres- 
sure of  the  abdominal  muscles,  and  the 
diaphragm,  against  all  the  viscera  of  the  ab- 
domen, prevents  the  access  of  air  so  effec- 
tually, that  though  we  should  hold  such  a 
wound  open  with  our  fingers,  no  air  could 
pass  into  the  abdomen,  further  than  to  that 
piece  of  gut  which  is  first  touched  with  the 
finger,  when  we  thrust  it  into  the  abdomen. 
Nothing  is  absolutely  exposed  to  the  air,  ex- 
cept that  piece  of  intestine  which  is  without 
the  abdomen,  or  that,  which  we  see,  when 
we  expose  a small  piece  of  the  bowels,  by 
holding  aside  the  lips  of  the  wound.  The 
pressing  forward  of  that  piece,  and  the  pro- 
trusion of  a portion  of  the  gut,  proportioned 
always  to  the  size  of  the  wound  ; the  pres- 
sure from  behind  keeping  that  piece  pro- 
truded, so  that  it  is  with  difficulty  we  can 
push  it  back  with  our  finger;  this  incessant 
pressure,  in  all  directions,  is  an  absolute  se- 
curity against  the  access  of  air.  The  intes- 
tine comes  out,  not  like  water  out  of  a bottle, 
the  place  of  which  must  be  supplied  by  air 
entering  into  the  bottle,  in  proportion  as  the 
water  comes  out ; but,  the  gut  is  pushed 
down  by  the  action  of  the  muscular  walls 
of  the  abdomen,  and  that  action  follows  the 
intestine,  and  keeps  it  down,  and  prevents 
all  access  of  the  air,  whether  the  gut  con- 
tinue thus  protruding,  or  w hether  it  be  re- 
duced ; for,  if  it  be  reduced,  the  walls  of  the 
abdomen  yield,  allowing  it  to  be  thrust  back, 
but  admitting  no  air.  Those,  who  want  to 
know  the  effect  of  air,  diffused  within  the 
cavity  of  the  abdomen,  must  make  other 
experiments,  than  merely  cutting  open  pigs’ 
bellies  ; — they  must  give  us  a fair  case, 
without  this  unnecessary  wound.  We  will 
not  allow  them  to  say,  when  they  cut  open 
the  belly  of  any  creature,  with  a long  inci- 
sion, that  the  inflammation  arises  from  the 
air;  much  less  shall  we  allow  them  to  say, 
when  they  open  the  belly  with  a smaller 
incision,  that,  by  that  little  incision,  the  air 
gets  into  the  abdomen,  and  that  all  the 


air  hurting  a wound  or  sore,  is  by  no  means 
surprising ; but  it  is  not  natural  that  men, 
bred  to  philosophy,  should  allow  so  strange 
an  assertion  as  this,  without  some  kind  of 
proof.  ThM  the  air  which  we  breaihe,  and 
which  we  feel  upon  the  surface  so  bland  and 
delightful,  should  have  so  opposite  a relation 
to  the  internal  parts,  that  it  should  there  be 
a stimulus,  more  acrid  and  more  dangerous 
than  the  urine,  is-  not  to  be  believed  upon 
slight  grounds.  I do  affirm  (says  Mr.  John 
Bell)  that  it  remains  to  be  proved,  that  this 
fluid,  which  seems  so  bland  and  pleasant  to 
all  our  senses,  and  to  the  outward  surface, 
is  yet  a horrible  stimulus  when  admitted,  as 
a celebrated  author  grandly  expresses  it, 

‘ into  the  deep  recesses  of  our  body.’ 

( Monro's  Bursae  Mucosae.) 

With  how  much  reason  Mr.  John  Bell 
objects,  that  this,  doctrine  is  unfounded,  will 
be  manifest  to  every  man  of  any  discern- 
ment, or  impartiality. 

“ The  air,  for  instance,  escapes  from  the 
lungs,  in  a fractured  rib,  and  first  goes  abroad 
into  the  thorax  ; then  into  the  cellular  sub- 
stance ; then  the  emphysematous  tumour 
appears;  but  often  without  any  scarifica- 
tions, with  very  little  care  and  assistance  on 
our  part,  the  air  is  absorbed,  the  tumour 
disappears,  and,  without  inflammation  of 
the  chest  or  any  particular  danger,  the  man 
gets  well.  Here  then  is  the  air,  within  the 
cavity  of  a shut  sac,  filling  the  thorax,  and 
oppressing  the  lungs,  without  any  danger- 
ous inflammation  ensuing.  | 

u That  the  air  may  be  pushed  under  the 
cellular  substance  all  over  the  body,  without 
causing  inflammation,  is  very  plain,  from  the 
more  desperate  cases  of  emphysema,  where 
the  patients,  after  living  eight  or  ten  days, 
have  died,  not  from  inflammation,  but  from 
oppression  merely,  the  body  being  so  cram- 
med with  air,  that  even  the  eyeballs  have, 
upon  dissection,  been  found  as  tense  as 
blown  bladders.  We  have  also  many  ludi- 
crous cases  of  this  kind,  which  prove  this 
to  our  perfect  satisfaction.  Soldiers  and 
sailors  sometimes  touch  the  scrotum  with 
a lancet,  introduce  a blowpipe,  and  blow 
it  up  to  an  enormous  size,  imitating  her- 
nia?, by  which  they  hope  to  escape  from 
the  service.  The  old  story  of  a man,  who 
was  so  wicked  as  to  make  a hole  in  his  child’s 
head,  and  blow  it  up,  that  he  might  show 
the  child  in  the  streets  of  Paris  for  a mon- 
ster, is  well  authenticated  ; and  I have  lit- 
tle doubt,  that  a fellow  who  knew  how  to 
do  this,  w'ould  blow  it  up  every  morning, 
and  squeeze  it  out  when  he  put  the  child  to 
bed  at  night.  Some  villanous  butchers,  hav* 


WOUNDS. 


oru 


ing  a grudge  at  a soldier,  found  him  lying 
drunk  under  a hedge ; they  made  a little 
hole  in  his  neck,  and  blew  it  up,  till  he  was 
like  a bladder,  or,  as  Dr  Hunter  describes  the 
disease  of  emphysema,  like  a stuffed  skin." 
(P.  3S8,  389.). 

After  many  other  pertinent  observations, 
blended  with  appropriate  satire  on  the  ex- 
travagant notions  professed  by  Monro,  on 
the  bad  effects  of  the  air  in  lithotomy, 
operations  for  hernia  and  hydrocele,  the 
Caesarian  section,  Lc.  Mr.  John  Bell  most 
justly  holds  up  to  ridicule  the  propositions 
of  Dr.  Aitk to  perform  this  last  operation 
wider  the  cover  of  a warm  bath , in  order  to 
exclude  the  air.  “ This,  though  It  may  seem 
to  be  a scurvy  piece  of  wit,  was  really  pro- 
posed in  sober  serious  earnest.  But  (adds 
Mr.  John  Beil)  the  admission  of  atmospheric 
air,  as  a stimulus,  when  compared  with  the 
great  incisions  of  lithotomy,  of  hernia, of  hy- 
drocele, of  Caesarean  section,  of  the  trepan, 
is  no  more  than  the  drop  of  the  bucket  to 
the  waters  of  the  ocean.  And  it  is  just  as 
p.oor  logic  to  say,  that  after  such  desperate 
operations,  these  cavities  are  inflamed  by 
the  admission  of  air,  as  it  would  be  to  say, 
(as  Monro  did)  that  when  a man  is  run 
through  the  pericardium  with  a red-hot  po- 
ker, that  the  heart  and  pericardium  are  in- 
flamed by  the  admission  of  the  air.”  (P.  847, 
Edit.  3.) 

Enough,  I conceive,  has  been  said,  to  dis- 
pel all  the  idle  fear  and  prejudices,  which 
have  prevailed  concerning  the  bad  effects 
of  the  air  in  wounds  of  the  abdomen,  as  well 
as  several  other  cases.  When  so  justly  emi- 
nent a man  as  Dr.  Alexander  Monro,  senior, 
\vas  disturbed  by  such  apprehensions,  it  is 
not  wonderful  that  many  a poor  ordinary 
member  of  the  profession  should  have  been 
terrified  nearly  oui  of  his  wits  upon  the  sub- 
ject; and  for  quieting  this  alarm,  and  expo- 
sing its  absurdities,  I really  think  Mr.  John 
Bell  deserving  particular  praise. 

In  general,  14  all  cases  of  wounds  of  the 
abdomen,  it  is  an  excellent  rule  never  to  be 
officious  about  abscesses  which  may  take 
place,  nor  to  exhibit  a partiality  to  such  ex- 
periments as  have  been  devised  for  learning 
precisely  what  bowel  is  wounded.  It  is 
quite  time  enough  to  interfere,  when  the 
urgency  of  the  symptoms  confirm  any  sus- 
picions which  may  be  entertained.  A great 
deal  of  harm  is  frequently  done  by  hand- 
ling and  disturbing  the  wounded  parts  more 
than  is  necessary,  and  it  is  well  known  that 
wounds,  at  first  attended  with  alarming 
symptoms,  frequently  have  a favourable  ter- 
mination. Swords,  balls,  and  other  wea- 
pons, sometimes  pass  completely  through 
the  body,  without  the  patient  suffering  after- 
ward any  threatening  symptom,  or,  indeed, 
any  effects  which,  abstractedly  considered, 
would  authorize  the  inference,  that  the  vis- 
cera had  been  at  all  injured.  Severe  inflam- 
mations may  not  end  in  suppuration,  and 
when  pus  is  formed,  it  is  sometimes  absorb- 
ed again.  Nothing  then  indicates  the  ne- 
cessity for  the  discharge  of  purulent  matter 
n.  the  abdomen  , unless  the  fluctuation  and 


situation  of  the  abscess  be  very  distinct, 
and  the  quantity  and  pressure  of  the  matter 
clearly  productive  of  inconveniences.  Un- 
der these  circumstances,  the  surgeon  should 
make  a cautious  puncture  with  a lancet. 

Protrusion  of  the  Viscera. — The  omentum 
and  small  intestines  are  the  parts  most  liable 
to  protrusion  ; but,  in  large  wounds,  the 
great  intestines,  the  stomach,  and  even  the 
liver  and  spleen,  may  project  through  the 
opening.  The  general  symptoms,  indicating 
a protrusion  of  the  parts,  are  sufficiently  ob- 
vious ; but,  it  deserves  attention,  that,  in  fat 
subjects,  the  adipose  membrane  may  project 
from  the  wound,  and  put  on  somewhat  of 
the  appearance  of  omentum.  The  special 
symptoms  are  to  be  collected  from  a know- 
ledge of  the  natural  situation  of  the  parts, 
and  reflecting  what  region  of  the  abdomen  is 
wounded.  ( Callisen , Syst.  Chir.  Hodiemce , 
T.  1 ,p.  702  and  703,  edit.  1798.) 

From  penetrating  wounds  considerable 
porjjons  of  the  bowels,  or  omentum,  some- 
times protrude,  and  though  these  viscera  may 
not  have  received  injury,  yet  their  being 
displaced,  is  sometimes  productive  of  fatal 
consequences. 

The  best  mode  of  preventing  such  mis- 
chief, is  to  return  the  viscera  into  the  cavity 
of  the  abdomen  as  speedily  as  possible. 
Almost  all  authors  recommend  fomenting 
the  displaced  parts,  previously  to  the  attempt 
at  reduction  ; but  in  giving  this  advice,  they 
seem  to  forget,  that  while  time  is  lost  in  this 
preparatory  measure,  the  protruded  bowels 
suffer  much  more  harm  from  exposure,  that 
is  to  say,  from  the  very  circumstance  of 
their  being  out  of  their  natural  situation, 
than  they  can  possibly  receive  good  from 
any  application  made  to  them.  No  kind  of 
fomentation  can  be  half  so  beneficial,  as  the 
natural  warmth  and  moisture  of  the  cavity 
of  the  abdomen.  In  order  to  facilitate  the 
return  of  a protruded  piece  of  intestine,  or 
omentum,  the  abdominal  muscles  should  be 
relaxed  by  placing  the  patient  in  a suitable 
posture,  and  the  large  intestines  emptied 
with  a glyster.  In  mentioning  the  last 
measure,  it  is  not  meant,  that  the  surgeon 
should  delay  the  attempt  to  reduce  the  part, 
until  the  glyster  has  operated.  No,  this 
means  is  only  enumerated  as  one  that  may 
become  serviceable,  in  case  the  surgeon  can- 
not immediately  accomplish  the  object  in 
view. — The  mesentery  Ought  always  to  be 
reduced  before  the  intestine  ; the  intestine 
before  the  omentum  ; but,  the  last  protruded 
portion  of  each  of  these  parts  ought  to  be 
the  first  reduced. 

It  is  only  wThen  the  intestine  and  omen- 
tum are  free  from  gangrene  and  mortifica- 
tion, that  they  are  invariably  to  be  returned 
into  the  cavity  of  the  belly,  without  hesita- 
tion. Also,  when  the  protruded  parts  are 
covered  with  sand,  dust,  or  other  extraneous 
matter,  they  should  be  tenderly  washed  with 
a little  tepid  water. 

For  the  reduction  of  the  parts,  the  fore- 
fingers are  the  most  convenient,  and  it  is  a 
rule  to  keep  the  portion  first  returned,  from 
protruding  again,  by  one  finger,  until  it  has 


WOUNDS. 


i 


been  followed  by  another  portion,  introdu- 
ced by  the  other  finger.  The  second  piece 
is  to  be  kept  up,  in  the  same  way,  by  the 
finger  used  to  return  it;  and  so  on,  till  the 
displaced  parts  have  all  been  put  into  their 
natural  situation. 

In  attempting  to  reduce  a piece  of  pro- 
truded intestine,  the  patient  should  be 
placed  in  the  most  favourable  posture  : the 
head  and  chest  should  be  elevated,  and  the 
pelvis  raised  with  pillows.  Nothing  can  be 
more  absurd,  than  the  advice  to  put  the 
thorax  rather  lower  than  the  pelvis,  in  order 
that  the  weight  of  the  viscera  may  tend  to 
draw  inward  the  protruded  parts.  This  is 
another  erroneous  idea,  arising  from  the 
ridiculous  supposition,  that  a great  part  of 
the  abdomen  is  actually  an  empty  cavity. 
The  relaxation  of  the  abdominal  muscles  is 
a much  more  rational  and  useful  object. 
When  this  is  properly  attended  to,  and  the 
above  directions  observed,  and  the  wound 
is  not  exceedingly  small,  in  relation  to  the 
bulk  of  the  protruded  viscera,  the  parts 
may  generally  be  reduced.  But  in  addition 
to  what  has  been  already  stated,  it  is  neces> 
sary  to  remark,  that  the  pressure  should  be 
made  in  a straight  direction  into  the  abdo- 
men ; for  when  made  obliquely,  towards 
the  edges  of  the  wound,  the  parts  are  liable 
to  suffer  contusion,  without  being  reduced, 
and  even  to  glide  between  the  layers  of  the 
abdominal  muscles,  and  become  strangula- 
ted. When  the  wound  is  in  the  front  of  the 
abdomen,  pressure  made  in  this  unskilful 
way  may  force  the  viscera  into  the  sheath 
of  the  rectus  muscle,  and  cause  the  same 
perilous  symptoms  as  arise  from  an  incarce- 
rated hernia.  (See  Hernia.) 

When  the  reduction  seems  complete,  the 
surgeon  should  assure  himself  of  it,  by  in- 
troducing his  finger  into  the  cavity  of  (he 
abdomen  so  as  to  feel  that  the  parts  are  all 
actually  reduced,  and  sutler  no  constriction 
between  the  edges  of  the  wound  and  the 
viscera  in  the  abdomen. 

A difficulty  of  reduction  may  arise  from 
the  protruded  intestines  being  distended 
with  feces  or  air.  In  this  circumstance, 
the  contents  of  the  gut  may  frequently  be 
made  to  pass  by  degrees  into  that  portion  of 
the  intestinal  canal,  which  is  within  the 
abdomen.  In  order  to  accomplish  this  pur- 
pose, the  surgeon  must  press  the  contents 
of  the  bowel  toward  the  wound  ; and,  if  be 
succeeds  in  emptying  the  part,  he  will  com- 
monly experience  equal  success  in  his  next 
attempt  to  replace  it  in  the  abdomen. 

Sometimes,  in  cases  of  narrow  stabs, 
considerable  pieces  of  intestine  protrude, 
and  cannot  be  reduced  without  doing  im- 
prudent violence  to  the  bowel.  Under 
these  circumstances,  the  dilatation  of  the 
wound  is  indispensable.  However,  when 
the  reduction  seems  almost  a matter  of  im- 
possibility, on  account  of  the  smallness  of 
the  wound,  if  the  surgeon  be  careful  to  re- 
lax the  abdominal  muscles,  draw  a little 
more  intestine  out  of  the  wound,  and  gently 
press  the  contents  of  the  bowel  through  the 
constriction  into  the  abdomen,  he  will  fre- 


quently succeed  in  reducing  the  parts,  with- 
out using  the  knife. 

Whfen  such  operation  is  unavoidable,  the 
dilatation  should  be  made  in  a direction 
which  will  not  endanger  the  epigastric  ar- 
tery, and,  if  possible,  in  the  same  line  as 
the  muscular  fibres. 

We  are  also  advised  to  make  the  incisiou 
upward  rather  than  downward,  when  it 
can  be  done  with  equal  convenience,  be- 
cause it  is  supposed  the  first  direction  will 
be  followed  by  less  danger  of  hernia.  ( Sa- 
batier, Medecine  Opiratoire,  T.  1,  p.  220, 
Ed.  2.  Callisen , Syst.  Chir.  Hod.  T.  1,  p. 
705.)  If,  however,  the  upper  angle  of  the 
wound  correspond  to  the  direction  of  the 
suspensory  ligament  of  the  liver,  writers 
advise  making  the  dilatation  at  the  lower 
angle,  in  order  to  incur  no  risk  of  hemor- 
rhage from  the  umbilical  vein.  In  the. 
adult,  this  vessel  is  generally  obliterated, 
and  turned  into  a ligamentous  substance  ; 
though  it  would  appear  that,  in  a few  in- 
stances, it  remains  pervious  to  the  navel, 
Hildanus  saw  a young  man  die  instantly  in 
consequence  of  a stab  in  the  belly  between 
the  false  ribs  and  the  umbilicus  ; and,  on 
opening  the  body,  he  found  blood  effused 
from  a wound  of  the  umbilical  vein.  It  has 
been  feared,  also,  that  cutting  the  suspen- 
sory ligament  of  the  liver  might  give  rise  to 
such  a displacement  of  that  viscus  as  would 
interrupt  the  freedom  of  respiration,  or 
obstruct  the  circulation  of  the  blood  in  the 
vena  cava.  But  the  apprehension  is  un- 
founded ; for  Riolan  found  this  ligament 
ruptured  and  retracted  towards  the  liver  in 
a nimble  Ethiopian  female  dancer,  whose 
respiration  had  not  suffered  any  particular 
disturbance  during  her  lifetime.  ( Sabatier , 
Mid.  Opiratoire,  T.l,p.  220,  221,  Ed.  2.) 

The  incision  should  never  be  larger  than 
absolutely  requisite,  as  hernia  is  much  dis- 
posed to  occur  wherever  the  peritoneum 
has  been  divided.  The  operation  may  be 
done  with  a curved  bistoury  and  a director, 
much  in  the  same  way  as  is  done  in  cases  of 
strangulated  ruptures.  (See  Hernia.) 

After  the  battle  of  Waterloo,  many  cases 
presented  themselves  in  which  the  bowels 
and  omentum  protruded,  and  in  several  of 
these  examples  the  reduction  could  not  be 
effected  before  the  wounds  had  been  en- 
larged. So  tightly  also  were  the  parts  girt, 
that  the  operation  was  sometimes  far  from 
being  easy. 

Instead  of  enlarging  wounds  of  the  abdo- 
men, it  has  been  proposed  to  let  out  the  air 
from  the  protruded  intestines,  by  making 
small  punctures  with  a needle,  so  as  to 
lessen  their  volume  sufficiently  to  make 
them  reducible.  The  suggestion  first  origi- 
nated with  Par6,  who  declares  that  he  has 
practised  the  method  with  success.  Rousset, 
his  contemporary,  also  informs  us  that  the 
plan  was  adopted  by  another  surgeon  in  an 
instance  where  the  epigastric  region  was 
wounded,  and  a large  portion  of  the  intes- 
tines protruded  in  a strangulated  state.  Pe- 
ter Eowe,  an  English  surgeon,  likewise 
assures  us,  that  he  frequently  adopted  the 


WOUNDS 


672 


practice,  when  other  means  failed.  Garen- 
geot,  Sharp,  and  Van  Swieten,  are  all  ad- 
vocates for  Fare’s  proposal ; but  they 
recommend  the  employment  of  a round 
needle,  which  will  merely  separate  the  fibres 
of  the  intestinal  canal,  without  cutting  them, 
as  a flat,  triangular,  sharp-edged  needle 
would  unavoidably  do.  These  last  writers, 
however,  only  sanction  the  practice  when 
the  quantity  of  protruded  intestine  is  great, 
and  the  bowel  is  so  enormously  distended 
with  air,  that  it  would  be  impossible  to  re- 
duce the  part,  though  the  wound  were  en- 
larged, and  every  thing  else  put  in  practice, 
likely  to  bring  about  the  reduction.  Bui,  as 
Sabatier  remarks,  the  punctures  must  be 
entirely  useless,  if  made  with  a fine  needle, 
since  they  will  be  immediately  stopped  up 
with  the  mucous  secretion,  with  which  the 
inside  of  the  bowels  is  constantly  covered  ; 
and  if  the  punctures  are  made  with  a broad 
triangular  needle,  or  a very  large  round 
one,  as  Desault  and  Chopart  advise,  they 
must  be  highly  dangerous,  inasmuch  as  they 
are  likely  to  give  rise  to  inflammation,  and 
even  to  extravasation,  within  the  abdomen. 
(Medecine  Opiraloire,  T.  1 , p.  10.) 

That  small  punctures  in  the  bowel  would 
not  answer  the  purpose,  but  be  obstructed 
by  the  villous  or  mucous  coat,  is  a fact, 
which  has  been  for  a long  time  well  known 
to  surgeons.  Callisen,  among  "others,  has 
particularly  noticed  it:  11  Acu  puncturae 

enim  flatibus  exitum  parare  nequeunt,  siqui- 
dem  tunica  villosa  foraminula  obstruit,”  &c. 
(Sys.  Chir.  Hod . T 2,  p.  704.) 

It  was  the  circumstance  of  small  punc- 
tures being  unavailing,  that  led  Desault  and 
Chopart  to  recommend  the  use  of  a large 
round  needle  : “ pour  que  louverture  ne  soit 
point  bouchie  par  les  mucositis  dont  les  intes- 
tines sont  enduils”  But  they  were  also 
aware  of  the  danger  of  employing  such  an 
instrument,  since  they  give  us  directions 
how  to  proceed  in  order  to  prevent  extra- 
vasation and  inflammation  : On  prd  vien- 

dra  V epanchement  des  matilres  stercorales  en 
passant,  avant  de  reduire  iintestin , line  anse 
de  fil  dans  la  portion  dc  mesentere  qui  repond 
a la  piqure  pour  la  fixer  contre  les  bords  de 
la  plait  exttriture,  et  Von  combuttra  par  Its 
remedes  giniraux  Vinfiammation  que  cet  pi- 
qure peut  attirer .”  ( Traiti  des  Maladies 

Chirurg.  T.  2,  p.  135.)  Richerand  is  still 
an  advocate  for  puncturing  the  bowel,  for 
which  operation  he  boldly  recommends  a 
small  hydrocele  trocar.  ( JVosogr . Chir.  T. 
3 ,p.  336,  Ed.  4.) 

Mr.  Travers,  one  of  the  latest  and  best 
writers  upon  this  subject,  most  properly 
joins  in  the  condemnation  of  the  plan  of 
pricking  the  protruded  bowels.  Blancard 
and  others  protested  against  this  practice 
on  the  very  sufficient  ground  of  its  ineffi- 
cacy. La  Faye  very  truly  says,  it  is  a use- 
less as  well  as  dangerous  practice  ; for  the 
openings  made  by  a round  needle  cannot 
give  issue  to  the  contained  air.”  Mr.  Tra- 
vers then  cites  two  cases,  showing  that  even 
small  stabs  in  a bowel  will  not  prevent  its 
becoming  distended  w ith  air. 


“ A man  was  brought  to  St.  Thomas'? 
hospital,  on  Saturday,  the  30th  of  June  last, 
(1811)  who  had  been  stabbed  in  the  direc 
tion  of  the  epigastric  artery,  oy  the  left  side 
of  the  abdomen,  by  a case  knife.  He  died 
in  eighteen  hours,  apparently  from  the  sud- 
den and  copious  hemorrhage,  which  had 
taken  place  within  the  belly,  <\bout  half  a 
yard  of  ileon  was  protruded.  The  gut  was 
highly  discoloured,  and  so  much  distended, 
notwithstanding  it  was  pierced  in  three 
places,  that  the  wound  of  the  integuments 
required  to  be  freely  dilated  before  it  could 
be  returned.  The  apertures  were  in  fact 
obliterated  by  the  mucous  coat” 

“ It  appeared  upon  the  trial  of  Captain 
Sutherland  (Ann.  Reg.  June  1809),  for  the 
murder  of  his  cabin  boy,  that  the  intestines 
had  been  extensively  protruded  through  a 
wound  near  the  left  groin,  and  had  lain  ex- 
posed for  four  or  five  hours  ; that  the  dirk 
had  pierced  through  one  fold  of  intestine, 
and  entered  another ; that  the  wround  of 
the  intestine  was  half  an  inch  long ; that 
the  reduction  could  not  be  accomplished 
until  the  parietal  wound  was  dilated  ; and 
that  the  intestine  was  then  returned,  and 
the  integuments  sewed  up.”  (Travers  on 
Injuries  of  the  Intestines,  p.  174,  176.) 

With  respect  to  this  last  case,  however,  I 
must  observe,  that  it  does  not  satisfactorily 
prove  what  the  author  intends,  namely, 
that  the  bowel  was  distended  with  air,  though 
there  was  a wound  in  it  half  an  inch  long, 
for  the  evidence  does  not  inform  us  that  the 
difficulty  of  reduction  was  owing  to  this 
cause.  I have  seen  a very  small  portion  of 
omentum  protrude  through  a wound,  and 
baffle  all  endeavours  to  reduce  it  for  nearly 
an  hour.  The  first  case  adduced  by  Mr. 
Travers,  however,  is  more  explicit  and  in- 
teresting ; and  we  are  to  infer  from  it,  and 
the  observations  of  Haller,  Callisen,  &.c. 
that  the  punctures  made  in  an  intestine  are 
not  closed  by  mucus,  as  Sabatier  and  De- 
sault have  asserted,  but  by  the  mucous  coat 
itself. 

As  the  above  expedient  had  been  recom- 
mended by  writers  of  some  weight,  I 
thought  that  the  subject  should  not  be  passed 
over  in  silence,  and  without  a caution  to 
the  reader,  never  to  put  any  confidence  in 
the  method.  The  plan  does  not  facilitate 
the  business  of  the  operator.  There  is  not 
even  this  solitary  reason  in  favour  of  the 
practice  ; and  though  it  may  have  answered 
when  large  needles  were  used,  and  some 
patients  so  treated  may  have  recovered, 
every  person,  who  has  the  least  knowledge 
of  the  animal  economy,  will  easily  compre- 
hend how  even  the  smallest  opening,  made 
in  parts  so  irritable  and  prone  to  inflamma- 
tion as  the  bowels,  must  be  attended  with 
greater  danger  than  would  result  from  en- 
larging a wound  of  the  skin  and  muscles. 
Besides,  the  air  may  frequently  be  pressed 
out  of  the  intestine  in  a safer  way,  as  I have 
already  described. 

A wound  of  the  abdomen,  attended  with 
one  of  the  most  considerable  protrusions  ot 
the  viscera  that  1 have  ever  read  of,  is  re- 


wounds. 


horded  by  Mr.  Hague,  surgeon  at  Rippfcn  : 
“ August  30th,  1808  (says  this  gentleman) 
I went  to  Norton  Mills,  about  four  miles 
from  hence,  to  see  John  Brown,  ret.  12 
years,  who  had  received  a wound  in  the 
abdomen  by  a wool  shears.  OnHny  arrival, 
which  was  little  more  than  an  hour  after 
the  accident,  I found  the  poor  lad  in  a very 
distressing  situation  ; the  great  arch  of  the 
stomach,  and  the  whole  of  the  intestinal  ca- 
nal, (duodenum  excepted,)  contained  with- 
in the  abdomen,  having  protruded  through 
the  wound.  The  incision  was  on  the  left 
side  of  the  body,  commencing  at  about  two 
inches  below  the  scrobiculus  cordis,  and 
extending  in  a straight  line  near  four  inches 
in  length,  distant  from  the  navel  two  inches, 
and  he  was  uuite  sensible,  and  had  vomited 
so  as  to  empty  the  stomach  ; very  little 
blood  was  lost.  I immediately  proceeded 
very  carefully  to  examine  the  protruded 
viscera,  none  of  which  were  wounded,  and 
reduced  them  as  quickly  as  possible,  begin- 
ning with  the  stomach,  and  following  the 
regular  course  of  the  intestines,  in  the  latter 
portion  of  which  1 distinctly  felt  feces  of 
father  firm  consistence.  He  complained  of 
some  pain  during  the  reduction,  though  not 
much  ; and  expressed  great  relief  when  the 
parts  were  completely  returned.  I now 
desired  an  assistant  to  lay  the  palm  of  his 
hand  over  the  wound,  and  make  some 
pressure  upon  it  ; for  l found,  that,  without 
this,  the  parts  would  soon  have  protruded 
again  by  the  action  of  respiration,  which 
was  oppressed  and  laborious.  1 brought 
the  sides  of  the  wound  together  by  five  su- 
tures, beginning  from  above  downwards, 
and  passed  the  needle  on  each  side,  quite 
through  the  integuments  with  the  perito- 
neum, &Z.C.  The  wound  was  also  dressed 
with  adhesive  plaster,  and  covered  with  a 
bandage.”  (Vide  Edinburgh  Medical  and 
Surgical  Journal , Vol.  5,  p.  129,  <$/-c.) 

This  case  is  interesting ; for  notwith- 
standing so  unlimited  a protrusion  of  the 
viscera,  and  the  circumstance  of  the  parts 
being  left  unreduced  for  more  than  an  hour, 
a recovery  ensued,  under  the  judicious  em- 
ployment of  bleeding,  purging,  anodynes, 
&c. 

In  la  Caserne  de  St.  Elizabeth  at  Brussels, 
after  the  battle  of  Waterloo,  the  number  of 
protrusions  of  the  viscera,  which  fell  under 
my  notice,  were  much  more  considera- 
ble, than  what  I previously  had  any  idea  of 
ever  meeting  with.  I well  remember,  in  my 
own  part  of  the  hospital,  two  protrusions  of 
a large  portion  of  the  stomach  ; three  of  the 
bladder  ; and  ten  or  twelve  of  the  mesente- 
ry, omentum,  or  intestines. 

Whether  a suture  should  be  used,  when  the 
protruded  intestine  is  wounded,  is  a subject 
which  will  be  noticed  in  considering  wounds 
of  the  intestines. 

Some  of  the  exposed  intestine  may  have 
mortified  before  the  arrival  of  surgical  assist- 
ance. In  eases  of  wounds,  this  event  is/are  ; 
but  in  those  of  stranzulated  hernias  it  is  not 
Vos.  II  „ 85 


U73 

uncommon.  The  treatment  is  explained  in 
the  article  Hernia. 

When  the  protruded  intestine  is  in  a state 
of  inflammation,  its  immediate  reduction  isr 
beyond  all  dispute,  the  means  most  likely  to 
set  every  thing  right.  Even  when  tiie  in- 
flammation is  considerable,  a timely  reduc- 
tion of  the  displaced  part,  and  the  employ- 
ment of  antiphlogistic  means,  will  often  pre- 
vent gangrenous  mischief.  The  dull,  brown, 
dark  red  colour  of  the  intestine  may  induce 
the  practitioner  to  suppose,  either  that  the 
part  is  already  mortified,  or  must  inevitably 
become  so,  and  consequently,  he  may  delay 
returning  it  into  its  natural  situation.  But 
notwithstanding  this  suspicious  colour  of  the 
intestine,  its  firmness  will  evince,  that  it  is 
not  in  a state  of  gangrene.  The  ultimate 
recovery  of  a portion  of  intestine,  so  cir- 
cumstanced, is  always  a matter  of  uncer- 
tainty ; but  the  propriety  of  speedily  repla- 
cing the  part  in  its  natural  situation,  is  a 
thing  most  certain.  “ Partes  egressre  sanee 
(observes  Callisen)  eitissime  sunt  reponendre, 
neque  obstat  mutatio  coloris  nativi  in  rubrum 
subfuscum.”  (Sysl.  Chir.  Hod.  T.  \,p.  703, 
edit.  1798.)  In  case  the  bowel  mortify  after 
its  reduction,  all  hopes  of  the  preservation  of 
life  are  not  to  be  abandoned  ; as  I have  no 
ticed  in  the  articles  Anus,  artificial,  ami  Her- 
nia, in  which  last  part  of  the  book,  many 
things,  necessary  to  be  known,  concerning 
the  mode  of  reducing  protruded  omentum, 
will  also  be  found. 

When  a piece  of  intestine  cannot  be  re- 
duced, granulations  and  new  skin  sometimes 
grow  over  it,  and  a cure  follows,  as  the  ex- 
perience of  Callisen  confirms.  (Op.  cit.  p. 
706.) 

The  protruded  viscera  having  been  re- 
duced, the  next  object  is  to  retain  them  in 
the  abdomen,  until  the  wound  is  completely 
healed.  When  the  wound  is  small,  this  is  a 
matter  of  no  difficulty  ; for  it  is  enough  to 
put  the  patient  in  a position  which  will  re- 
lax the  fibres  of  the  wounded  muscles,  while 
the  edges  of  the  wound  are  maintained  in 
contact  with  sticking-plaster,  and  supported 
by  a compress  and  bandage.  Costiveness  is 
to  be  removed  by  the  mildest  purgatives, 
such  as  the  oleum  ricini,  or  by  laxative  clys- 
ters, which  are  still  preferable.  But  in  cases 
of  extensive  wounds,  even  when  the  treat- 
ment is  conducted  with  all  possible  judg- 
ment, it  is  occasionally  difficult,  and  even 
impossible,  to  hinder  the  protrusion  of  the 
bowels  by  common  dressings  and  a ban- 
dage. In  this  circumstance  the  edges  of 
the  wound  must  be  sewed  together.  (See 
Gastroraphe.)  In  modern  times,  however,  su- 
tures are  much  more  seldom  employed  than 
formerly,  and  in  the  above  article,  some  re- 
marks are  offered,  proving  that  the  generality 
of  wounds  of  the  abdomen  do  not  require  the 
practice. 

When  the  omentum  protrudes,  and  is 
strangulated  by  the  narrowness  of  the  open- 
ing, it  soon  contracts  adhesions  to  it,  unless 
speedily  reduced.  Should  such  connexion 
be  already  formed,  when  the  surgeon  is  first 
consulted*,  we  are  advised  to  cut  off  the  por- 


674 


WO  USD'S. 


tion  which  exceeds  the  level  of  the  integu- 
ments, and  to  leave  the  rest  in  the  wound. 
The  latter  will  block  up  the  opening, 
and  have  the  good  effect  of  preventing 
hernia.  (Richer and,  JYosogr.  Ch%r.  T.  3,  p. 
339,  edit.  4.)  When  the  protruded  omen- 
tum is  sound  and  free  from  adhesions,  it 
ought  to  be  reduced  without  delay.  But, 
when  the  protrusion  is  large,  and  there  is 
reason  to  fear,  from  the  vomiting  and  the 
pains  shooting  frdrn  the  wound  to  the  epigas- 
tric region,  that  the  stomach  is  dragged,  the 
displac  ed  part  must  be  made  free,  and  if 
sound,  reduced.  Should  it  be  in  a mortified 
state,  the  dead  part  must  be  previously  cut 
away,  and  any  vessels  which  bleed,  tied 
separately  with  a piece  of  fine  thread,  or  silk, 
both  ends  of  which  may  either  be  cut  off 
close  to  the  knot,  and  the  part  then  reduced; 
or  one  end  of  the  silk  may  be  left  out  of  the 
wround,  and  the  other  cut  away.  Practition- 
ers who  apprehend  ill  effects  from  leaving 
within  the  abdomen  so  small  a particle  of 
extraneous  matter,  as  the  little  knot  of  fine 
thread,  will  prefer  the  last  method,  and  wilh- 
dravv  the  ligature  altogether,  as  soon  as  it 
becomes  loose. 

Extravasation  in  the  Abdomen. — Wounds 
of  the  abdomen  may  be  complicated  with 
extravasations  of  blood,  chyle,  excrement, 
bile,  or  * urine.  None  of  these  complica- 
tions, however,  are  half  so  frequent,  as  an 
inexperienced  practitioner  would  apprehend. 
The  employment  of  the  phrase  cavity  of 
the  abdomen  has  paved  the  way  to  much  er- 
roneous supposition  upon  this  subject,  and 
has  induced  many  absurd  notions,  which 
even  the  sensible  observations,  long  ago  pub- 
lished by  J.  L.  Petit,  have  scarcely  yet  dis- 
pelled. 

As  a modern  writer  has  observed : “ There 
is  not  truly  any  cavity  in  the  human  body, 
but  all  the  hollow  bowels  are  filled  with 
their  contents,  all  the  cavities  filled  with 
their  hollow  bowels,  and  the  whole  is  equal- 
ly and  fairly  pressed.  Thus,  in  the  abdomen, 
all  the  viscera  are  moved  by  the  diaphragm 
and  the  abdominal  muscles  upwards  and 
downwards,  with  an  equable  coutinuai  pres- 
sure, which  has  no  interval ; and  one  would 
be  apt  to  add,  the  intestines  have  no  repose, 
being  kept  thus  in  continual  motion  ; but 
though  the  action  of  the  diaphragm,  and  the 
reaction  of  the  abdominal  muscles  are  alter- 
nate, the  pressure  is  continual;  the  motion 
which  it.  produces,  (they  produce)  is  like 
that  which  the  bowels  have,  when  we  move 
them  forwards  in  walking,  having  a motion, 
with  respect  to  space,  but  none  with  regard 
to  each  other,  or  to  the  part  of  the  belly 
which  covers  them  ; the  whole  mass  of  the 
bowels  is  alternately  pressed,  to  use  a course 
illustration,  as  if  betwixt  two  broad  boards, 
which  keep  each  turn  or  intestine  in  its  right 
place,  while  the  whole  mass  is  regularly 
moved.  When  the  bowels  are  forced  down 
by  the  diaphragm,  the  abdominal  muscles 
recede  : when  tbe  bowels  are  pushed  back 
again,  it  is  the  reaction  of  the  abdominal  mus- 
cles, lhatforces  thembackand  follows  them  ; 
there  is  never  an  instant  of  interruption  of  this 


pressure,  never  a moment,  in  which  the  bow 
els  do  not  press  against  the  peritoneum  ; nor 
is  there  the  smallest  reason  to  doubt  that  the 
same  points  in  each  are  continually  opposed 
We  see  that  the  intestines  do  not  move,  or, 
at  least,  do  not  need  to  move  in  performing 
fheir  functions;  for  in  hernia,  where  large 
turns  of  intestines  are  cutoff  by  gangrene, 
the  remaining  part  of  the  same  intestines  is 
closely  fixed  to  the  groin,  and  yet  the  bow- 
els are  easy,  and  their  functions  legular. 
We  find  the  bowels  regular,  when  they  lie 
out  of  the  belly,  in  hernia,  as  v\  hen  a certain 
turn  of  intestine  lies  in  the  scrotum  or  thigh, 
or  in  a hernia  of  the  navel  ; and  where  yet 
they  are  so  absolutely  fixed,  that  the  piece 
of  intestine  is  marked  by  the  straitness  of 
the  rings.  We  find  a person,  after  a wound 
of  the  intestine,  having  free  stools  for  many 
days ; ant)  what  is  it  that  prevents  the  feces 
from  escaping  but  merely  this  regular  and 
universal  pressure  ? We  find  a person,  on 
the  fourth  or  fifth  day,  with  feces  coming 
from  the  wound  ! a proof,  surely,  that  the 
wound  of  the  intestine  is  still  opposite  or 
nearly  opposite  to  the  external  wound.  We 
find  the  same  patient  recovering  without  one 
bad  sign  ! What  better  proof  than  this  could 
we  desire,  that  none  of  the  feces  have  exu- 
ded into  the  abdomen  ? 

“ If  in  a wound  of  the  stomach,  the  food 
could  get  easily  out  by  that  wound,  tbe  sto- 
mach would  unload  itself  that  way,  there 
would  be  no  vomiting,  the  patient  must  die; 
but  so  regular  and  continual  is  this  pressure, 
that  the  instant  a man  is  wounded  in  the 
stomach,  he  vomits,  he  continues  vomiting 
for  many  days,  while  not  one  particle  es- 
capes into  the  cavity  of  the  abdomen.  The 
outward  wound  is  commonly  opposite  to  that 
of  the  stomach,  and  by  that  passage,  some 
part  of  the  food  comes  out ; but  when  any 
accident  removes  the  inward  wound  of  the 
stomach  from  the  outward  wound,  the  ab- 
dominal muscles  press  upon  the  stomach, 
and  follow  it  so  closely,  that  if  there  be  not 
a mere  laceration  extremely  wide,  this  pres- 
sure closes  the  hole,  keeps  the  food  in,  ena- 
bles the  patient  to  vomit,  and  not  a particle, 
even  of  jellies,  or  soups,  is  ever  lost,  or  goes 
out  into  the  cavity  of  the  belly. 

i:  How  (proceeds  Mr.  J.  Bell)  without  this 
universal  and  continual  pressure,  could  the 
viscera  be  supported  ? Could  its  ligaments, 
as  we  call  them,  support  the  weight  of  the 
liver  ? Or  what  could  support  the  weight  of 
the  stomach  when  filled  ? Could  the  mesen- 
tery, or  omentum,  support  tbe  intestines  ; or 
could  its  own  ligaments,  as  we  still  name 
them,  support  the  womb  ? How,  without 
this  uniform  pressure,  could  these  viscera  fail 
to  give  way  and  burst  ? How  could  the  cir- 
culation of  the  abdomen  go  on  ? How  could 
the  liver  and  spleen,  so  turgid  as  they  ate 
with  blood,  fail  to  burst  ? Or  what  possibly 
could  support  the  loose  veins  and  arteries  of 
tbe  abdomen,  since  many  ot  them.  e g.  the 
splenic  vein,  is  (are)  two  feet  in  length,  is 
(are)  of  tbe  diameter  of  tbfe  thumb,  and  has 
(have)  no  other  than  the  common  pellucid 
and  delicate  coats  of  the  veins  ? How  could 


WOUNDS. 


675 


(be  viscera  of  Ibe  abdomen  bear  shocks  and 
falls,  if  hot  supported  by  the  universal  pres- 
sure of  surrounding  parts  ? In  short,  the  acci- 
dent of  hernia  being  forced  out  by  any  blow 
upon  the  belly,  or  by  any  sudden  strain,  ex- 
plains to  us  how  perfectly  full  the  abdomen 
is,  and  how  ill  it  is  able  to  bear  any  pressure, 
even  from  its  own  muscles,  without  some 
point  yielding,  and  some  one  of  its  bowels 
being  thrown  out.  And  the  sickness  and 
faintness,  which  immediately  follow  the 
drawing  off  of  the  waters  of  a dropsy ,«explain 
to  us,  what  are  the  consequences  of  such 
pressure  being  even  for  a moment  relaxed. 
But,  perhaps,  one  of  the  strongest  proofs  is 
this,  that  the  principle  must  be  acknowledged, 
in  order  to  explain  what  happens  daily  in 
wounds ; for  though  in  theory  ive  should  be 
inclined  to  make  this  distinction,  that  the 
hernia,  or  abscess  of  the  intestines  will  ad- 
here and  be  safe,  but  that  wounded  intes- 
tines, not  having  time  to  adhere,  will  be- 
come flaccid,  as  we  see  them  do  in  dissec- 
tions, and  so,  falling  away  from  the  external 
wound,  will  pour  out  their  feces  into  the  ab- 
domen, and  prove  fatal ; though  we  should 
settle  this,  as  a fair  and  good  distinction  in 
theory,  we  find  that  it  will  never  answer  in 
practice.  Soldiers  recover  daily  from  the 
most  desperate  wounds ; and  the  most  likely 
reasons,  that  we  can  assign  for  it,  are  the 
fulness  of  the  abdomen,  the  universal,  equa- 
ble, and  gentle  pressure  ; and  the  active  dis- 
position of  the  peritoneum,  ready  to  inflame 
with  the  slightest  touch.  The  wounded  in- 
testine is,  by  the  universal  pressure,  kept 
close  to  the  external  wound,  and  the  perito- 
neum and  the  intestine  are  equally  inclined 
to  adhere.  In  a few  hours,  that  adhesion  is 
begun,  which  is  to  save  ‘he  patient’s  life,  and 
the  lips  of  the  wrounded  intestine  are  glued 
to  the  lips  of  the  external  wound.  Thus  is 
the  side  of  the  intestine  united  to  the  inner 
surface  of  the  abdomen  ; and  though  the  gut 
casts  out  its  feces,  while  the  wound  is  open  ; 
though  it  often  casts  them  out  more  freely, 
while  the  first  inflammation  lasts;  yet  the 
feces  resume  their  regular  course,  whene- 
ver the  wound  is  disposed  to  close.”  (John 
Bell's  Discourses  on  Wounds,  p.  323,  327, 
Edit.  3.) 

The  loregoing  extract,  though  drawn  up 
in  a careless  style,  contains  such  observa- 
tions as  are  well  calculated  to  make  the 
reader  understand,  that  the  abdomen  is  in 
reality  not  a cavity,  but  a compact  mass  of 
containing  and  contained  parts ; that  the 
close  manner,  in  which  the  various  surfaces 
are  constantly  in  contact  most  powerfully 
oppose  extravasations  ; and  that,  in  fact,  it 
often  entirely  prevents  them.  The  passage 
cited  impresses  us  with  the  utility  of  that 
quick  propensity  to  the  adhesive  inflamma- 
tion, which  prevails  throughout  every  peri- 
toneal surface,  and  which  not  only  often  has 
the  effect  of  permanently  hindering  effusion  of 
the  contents  of  the  viscera,  by  agglutinating 
the  parts  together,  but  which,  even  when 
an  extravasation  has  happened,  beneficially 
confines  the  effused  blood  in  one  mass,  and 
surrounds  it  with  such  adhesions  of  the 


parts  to  each  other,  as  are  rapid  in  their 
formations,  and  effectual  for  the  purposes 
of  limiting  the  extent  qf  the  effusion,  and 
preventing  the  irritation  of  the  extravasa- 
ted  matter  from  affecting  the  rest  of  the  ab- 
domen. 

It  is  to  Petit  that  surgeons  are  indebted 
for  more  correct  modes  of  thinking  upon  the 
foregoing  subject,  and  it  is  with  great  plea- 
sure that  I here  refer  to  his  valuable  obser- 
vations. (See  Mem.  de  I'Acad.  de  Chir.) 

But  notwithstanding  the  reciprocal  pres- 
sure of  the  containing  and  contained  parts 
against  each  other,  and  the  useful  effect  of 
the  quickly  arising  adhesive  inflammation, 
in  all  penetrating  wounds  of  the  belly,  com- 
plicated with  injuries  of  the  viscera,  we  are 
not  to  suppose,  that  extravasation  never 
happens  ; but  only  that  it  is  much  less  fre- 
quent than  has  been  commonly  supposed. 
Mr.  Travers,  with  much  laudable  industry, 
has  endeavoured  to  trace  more  minutely, 
than  any  preceding  writer,  the  particular 
circumstances,  under  which  effusions  in  the 
abdomen  are  likely  or  unlikely  to  hap- 
pen.” It  being  admitted  (says  he)  tbat 
there  are  cases  in  which  effusion  does 
take  place,  it  is  easy  to  conceive  circum- 
stances which  must  considerably  influence 
this  event.  If,  for  example,  the  stomach  and 
bowels  be  in  a state  of  emptiness,  the  nausea 
which  follows  the  injury  will  maintain  that 
state.  If  the  extent  of  the  wound  be  con- 
siderable, the  matter  will  more  readily  pass 
through  the  wound,  than  along  the  canal. 
A wound  of  the  same  dimensions  in  the 
small  and  large  intestines,  will  more  readily 
evacuate  the  former  than  the  latter,  because 
it  bears  a larger  proportion  to  the  calibre. 
Incised  and  puntured  wounds  admit  of  the 
adhesion  of  the  cut  edges,  or  the  eversion  of 
the  internal  coat  of  the  gut,  so  as  to  be  in 
many  instances  actually  obliterated ; where- 
as lacerated,  or  ulcerated  openings,  do  not 
admit  of  these  salutary  processes.  Again,  in 
a transverse  section  of  the  bowel,  contrac- 
tion of  the  circular  fibre  closes  the  wound, 
whereas  in  a longitudinal  section,  the  con- 
traction of  the  fibre  enlarges  it.  Such  (says 
Mr.  Travers)  are  the  circumstances,  which 
combined,  in  a greater  or  less  degree,  in- 
crease or  diminish  the  tendency  to  effu- 
sion.” (On  Injuries  of  Intestines , §*c.  p. 
13,  14.) 

After  the  details  of  some  experiments  and 
cases,  the  preceding  author  makes,  among 
other  conclusions,  the  following  : 

1.  That  effusion  is  not  an  ordinary  conse- 
quence of  penetrating  wounds. 

2.  That  if  the  gut  be  full  and  the  wound 
extensive,  the  surrounding  pressure  is  over- 
come, by  the  natural  action  of  the  bowel 
tending  to  the  expulsion  of  its  contents. 

3.  That,  if  food  has  not  recently  been 
taken,  and  the  wound  amounts  to  a division 
of  the  gut,  or  nearly  so,  the  eversion  and 
contraction  of  the  orifice  of  the  tube  prevent 
effusion. 

4.  That  if  the  canal  be  empty  at  the  lime 
of  the  wound,  no  ^subsequent  state  of  the 
bowel  will  cause  effusion,  because  the  super- 


VJTOUA'DS. 


vening  inflammation  agglutinates  the  sur- 
rounding surfaces, and  forms  a circumscribed 
sac  ; nor  can  effusion  take  place  from  a 
bowel  at  the  moment  full,  provided  it  retains 
a certain  portion  of  its  cylinder  entire,  the 
wound  not  amounting  nearly  to  a semidivi- 
sion of  the  tube,  for  then  the  eversion  and 
contraction  are  too  partial  to  prevent  an 
extravasation. 

5.  That,  when  however  air  has  escaped 
from  the  bowel,  or  blood  has  been  extrava- 
sated  in  quantity  within  the  abdomen  at  the 
time  of  the  injury,  the  resistance,  made  to 
effusion,  will  be  less  effectual,  although  the 
parietal  pressure  is  the  same,  as  such  fluids 
will  yield  more  readily,  than  the  solids  na- 
turally in  contact.  (P.  25,  26,  100.) 

“ That,  though  extravasation  is  not  com- 
mon in  penetrating  wounds,  it  follows  more 
generally  in  cases,  where  the  bowel  is 
ruptured  by  blows,  or  falls  upon  the  belly, 
while  the  integuments  continue  upwounded. 
(P.  36.) 

7.  That  when  the  bowels  are  perforated 
by  ulceration,  there  is  more  tendency  to 
effusion,  than  in  cases  of  wounds.  (P. 
38,  fee.) 

Mr.  Travers  attempts  to  explain  the  reason 
of  the  greater  tendency  to  effusion,  in  cases 
of  intestine  burst  by  violence,  than  in  those 
of  ulceration,  “by  the  difference  in  the  na- 
ture of  the  injury,  which  the  bowel  sustains, 
when  perforated  by  a sword  or  bullet,  as  in 
the  one  case,  or  burst  or  ulcerated  in  the 
other.  A rupture  by  concussion  could  only 
take  place  under  a distended  state  of  the 
bowel,  a condition  most  favourably  to  effu- 
sion, and  from  the  texture  of  the  part,  a rup- 
ture so  produced  would  seldom  be  of  limited 
extent.  The  process  of  ulceration,  by  which 
an  aperture  is  formed,  commences  in  the  in- 
ternal coat  of  the  bowel,  which  has  always 
incurred  a more  extensive  lesion,  than  the 
peritoneal  covering.  The  puncture,  or  cut, 
is  merely  a solution  of  continuity  in  a point, 
or  line  ; the  ulcerated  wound  is  an  actual 
loss  of  substance.  The  consequence  of  this 
difference  is,  that,  while  the  former,  if  small, 
is  glued  up  by  the  effusion  from  the  cut  ves- 
sels, or,  if  large,  is  nearly  obliterated  by  the 
full  eversion  of  the  villous  coat,  the  latter  is 
a permanent  orifice  ” (P.  46.) 

How  much  Mr.  Travers  and  Mr.  John 
Bell  differ  in  opinion,  upon  these  latter 
points,  will  appear  from  th^s  following^as- 
sage  : after  adverting  to  the  adhesion,  which 
takes  place  between  the  viscera  and  the 
peritoneum,  under  a variety  of  circumstances 
attending  disease,  Mr.  John  Bell  observes  : 
“ This  it  is,  which  makes  the  chief  difference, 
in  point  of  danger,  betwixt  an  ulcerated  and 
a wounded  intestine  ; for,  in  a wound,  there 
is,  as  we  should  suppose,  no  time  for  adhe- 
sion, nothing  to  keep  the  parts  in  contact,  no 
cause,  by  which  the  adhesion  might  be  pro- 
duced. But,  in  an  ulcer,  there  is  a slow  dis- 
ease, tedious  inflammation,  adhesion  at  first, 
and  abscess,  and  bursting  afterward  j some- 
times a fistula  remains  discharging  feces,  and 
sometimes  there  is  a perfect  cure.  If  a nut- 
shell, a large  coin,  a bone,  or  any  dangerous 


thiqg  be  swallowed,  i(  stops  in  the  stomach, 
cadsing  swelling  and  dreadful  pain  ; at  last, 
a hard  firm  tumour  appears,  and  then  it  sup- 
purates, bursts,  the  bowel  opens,  the  food  is 
discharged  at  every  meal,  till  the  fistula 
gradually  lessens,  and  heals  at  last.  But 
where  the  stomach  is  cut  with  abroad  wound 
of  a sabre,  the  blood  from  the  wounded 
epiploic  vessqjs,  or  the  food  itself,  too  often 
pours  out  into  the  abdomen,  and  the  patient 
dies,'&ic.”  ( Discourses  on  Wounds,  p.  321, 
edit.  3.)  The  author  afterward  proceeds  to 
explain,  how  in  cases  of  penetrating  wounds, 
the  compact  state  of  the  containing  and  con- 
tained parts,  and  the  incessant  and  equable 
pressure,  which  the  viscera  sustain,  fre- 
quently hinder  effusion. 

Which  of  these  gentlemen  is  most  correct, 
I cannot  pretend  to  determine,  and  whether 
Mr.  Travers’s  cases  are  deviations  from  what 
is  most  comraoh,  can  only  be  decided  by  a 
comparative  examination  of  a greater  num- 
ber of  facts.  When  the  intestines  ulcerate, 
and  thus  rid  themselves  of  foreign  bodies, 
the  general  tenor  of  the  cases  on  record  un- 
doubtedly affords  us  little  reason  to  be  ap- 
prehensive of  extravasation.  Yet,  with  re- 
spect to  ulceration  of  the  intestines  from 
other  causes,  circumstances  may  be  very 
different.  And  it  is  but  justice  to  state,  That 
Mr.  Travers’s  opinions  have  received  some 
confirmation  from  an  interesting  case,  pub- 
lished by  Dr.  J.  Crampton,  of  Dublin.  It  is 
an  instance  of  rupture  of  the  stomach,  and 
fatal  effusion  of  its  contents  into  the  cavity 
of  the  abdomen.  The  patient  was  a young 
lady,  aged  29.  She  was  suddenly'fhken  ill 
with  spasm  in  her  stomach,  and  other  severe 
symptoms,  and  died  in  about  twelve  hours. 
“ On  opening  the  abdomen,  the  stomach  was 
observed  to  be  pale,  flaccid,  and  empty.  Its 
contents,  among  which  were  recognized  oat- 
meal and  castor  oil,  had  escaped  into  the 
cavity  of  the  abdomen,  through  a round 
aperture  situated  on  its  anterior  surface, 
at  the  union  of  the  cordiac  and  pyloric 
portions.  This  perforation  of  the  stomach 
was  perfectly  circular,  about  the  size  of  a 
pea,  and  appeared  to  be  the  result  of  an 
ulcer  on  the  mucous  surface,  which  had 
gradually  penetrated  the  other  coats.  This 
ulcer  was  hollow  and  circular,  nearly  the 
size  of  a shilling,  and  had  the  appearance,  as 
if  it  had  been  made  with  caustic,  with  the 
orifice  in  its  centre.”  (J.  Crampton , Med. 
Chir.  Trans.  Vol.  8,  p.  230.)  To  the  prece- 
ding, Mr.Travers  has  annexed  some  addition- 
al facts  : one  is  an  example  of  a rapidly  fatal 
effusion  of  the  intestinal  contents,  through 
an  ulcerated  opening  nbout  a finger’s 
breadth  below  the  pylorus.  The  foramen 
had  a peritoneal  margin,  and  proved  to  bo 
the  centre  of  an  irregular  superficial  ulcer  of 
the  mucous  coat.  Another  case  is  that  of  a 
similar  ulceration  of(the  small  intestines,  and 
fatal  extravasation  of  their  contents.  In 
another  example,  a circular  aperture  ot  the 
peritoneum,  large  enough  to  admit  a crow’s 
quill,  was  found  after  death  at  the  junction 
of  the  duodenum  and  stomach.  It  also  was 
the  centre  of  an  ulcer,  that  had  destroyed 


Ike  villous  and  muscular  coals  oi  the  bowel 
to  ..the  extent  of  half  an  Inch,  lor  many 
other  ingenious  observations,  I must  refer 
the  reader  to  Mr.  Travers’s  paper,  who  con- 
cludes with  remarking,  that  the  chief  diag- 
nostic symptoms  of  these  hopeless  cases  ap- 
pear to  be  : 

1.  Sudden,  most  acute,  and  unremitting 
pain,  radiating  from  the  scrobiculus  cordis, 
or  the  navel,  to  the  circumference  of  the 
trunk,  and  even  to  the  limbs.  A peculiar 
pain,  the  intensity  of  which,  like  that  of  par- 
turition, absorbs  the  whole  mind  of  the  pa- 
tient, who,  within  an  hour  from  the  enjoy- 
ment of  perfect  health,  expresses  his  serious 
•i  and  decided  conviction,  that  if  the  pain  be 
v not  speedily  alleviated,  he  must  die. 

^ Coeval  with  the  attack  of  pain,  remark  - 
f able  rigidity  and  hardness  of  the  belly,  from 
a fixed  and  spastic  contraction  of  the  abdo- 

iminal  muscles. 

3.  A natural  pulse  for  some  hours,  until 
the  symptoms  are  merged  in  those  of  acute 
peritonitis,  and  its  fatal  termination  in  the 
adhesive  stage.  (Med.  Chir.  Trans.  Vol.  8, 
p.  231,  et  seq.) 

* Blood  is  more  frequently  extrayasated  in 
the  abdomen,  than  any  other  fluid,  but,  it 
does  not  always  take  place,  Unless  the 

| wounded  vessels  be  above  a certain  rnagni- 
| tndfr.  The  compact  state  of  the  abdominal 
■'  viscera,  in  regard  to  each  other,  and  their 
f action  on  each  other,  oppose  this  effect. 

I The  action  alluded  to,  which  depends  on 
the  abdominal  muscles  and  diaphragm  i3 
rendered  very  manifest  by  what  happens  in 
consequence  of  operations  for  hernias,  at- 
tended with  alteration  of  the  intestines,  or 
omentum  If  these  viscera  burst,  or  suppu- 
rate, after  being  reduced,  the  matter  which 
escapes  from  them,  or  the  pus  which  they 
secrete,  is  not  lost  in  the  abdomen  -,  but  is 
propelled  towards  the  wound  in  the  skin, 
and  there  makes  its  exit  The  intestinal  mat- 
ter effused  from  a mortified  bowel,  has  been 
known  to  remain  lodged  the  whole  inter- 
val, between  one  time  ot  dressing  the  wound 
and  another,  in  consequence  of  the  surgeon 
stopping  up  the  external  wound  with  a large 
tent.  When  the  above-mentioned  action  or 
pressure  of  the  muscles,  is  not  sufficient  to 
keep  the  blood  from  making  its  escape  from 
the  vessels,  still  it  may  hinder  it  from  be- 
coming diffused  among  the  convolutions  of 
the  viscera,  and  thus  theSextravasation  is 
confined  in  one  mass.  The  blood,  effused 
and  accumulated  in  this  way,  is  commonly 
lodged  at  the  inferior  and  anterior  part  of 
the  abdomen,  above  the  lateral  part  of  the 
pubes,  and  by  the  side  of  one  of  the  recti 
' muscles.  The  weight  of  the  blood  may 
l propel  it  into  this  situation,  or  perhaps,  there 
may  be  less  resistance  in  this  direction,  than 
! in  others.  In  opening  the  bodies  of  persons, 
x«ho  have  died  with  such  extravasations, 
things  may  put  on  a different  aspect,  and 
j the  blood  seem  to  be  promiscuously  extra- 
1 vasated  over  every  part  of  the  abdomen. 
But,  when  such  bodies  are  examined  with 
care,  it  will  be  found,  that  the  blood  does 
i not  insinuate  itself  among  the  viscera,  till 


the  moment  when  the  abdomen  is  opened, 
and  the  masy  previously  lies  in  a kind  ot’ 
pouch.  This  pouch  is  frequently  circum- 
scribed, and  bounded  by  thick  membranes, 
especially  when  the  extravasation  has  been 
of  some  standing.  (Sabatier  Medecine  Opt' 
ratoire , T.  l,p.  28 — 30.) 

Every  practical  surgeon  should  remember 
well  that  all  the  abdominal  viscera  closely 
touch  either  each  other,  or  the  inner  surface 
of  the  peritoneum.  This  is  one  grand  reason, 
why  extravasations  are  seldom  extensively 
diffused  ; but,  commonly  lie  in  one  mass,  as 
Petit,  Sabatier,  and  all  the  best  moderns  have 
noticed.  The  pressure  of  the  elastic  bowels, 
diaphragm,  and  abdominal  muscles,  not  only 
frequently  presents  an  obstacle  to  the  diffu-  • 
sion  of  extravasaied  matter,  but  often  serves 
to  propel  it  towards  the  mouth  of  the  wound. 
The  records  of  surgery  furnish  numerous 
instances,  in  which  persons  have  been  stab- 
bed through  the  body,  without  fatal  conse- 
quences, and  sometimes  without  the  symp- 
toms being  even  severe.  In  Mr.  Travers’s 
publication  many(cases, exemplifying  this  ob- 
servation, are  quoted  from  a Variety  of 
sources:  Fab.  Ilildan.  Obs.  Chirurg.  Cent, 
5.  Obs.  74.  CEuvres  de  Pare,  liv.  10.  Chap. 
35.  Wiseman’s  Surgery,  p.  371.  La  Motte’s 
Traite  Complet  de  Chirurgie,  &c.  &.c.  In 
such  cases,  the  bowels  have  been  supposed 
to  have  eluded  the  point  of  the  weapon,  and, 
perhaps, in  a few  instances,  this  may  actually 
have  been  the  fact ; but,  in  the  generality  of 
such  examples,  the  bowels  must  have  been 
punctured,  and  the  extravasation  of  intes- 
tinal matter  prevented  by  the  pressure  of  the 
viscera  against  each  other. 

The  pouch,  or  cyst,  in  which  the  extrava- 
sated  blood,  or  matter,  lies,  as  mentioned  by- 
Sabatier,  is  formed  by  the  same  process, 
which  circumscribes  the  maiter  of  abscesses. 
(See  Suppuration.)  It  is,  in  short,  the  adhe- 
sive inflammation.  All  the  surfaces  in  con* 
tact  with  each  other,' and  surrounding  the 
extravasation,  and  traffk  of  the  wound,  ge- 
nerally become  so  intimately  connected  to- 
gether by  the  adhesive  inflammation,  that 
the  place,  in  which  the  extravasation  is 
lodged,  is  a cavity  entirely  destitute  of  ail 
communication  with  the  cavity  of  the  peri- 
toneum. The  track  of  the  wound  leads  to 
the  seat  of  the  effused  fldld,  but  has  no 
distinct  opening  into  the  general  cavity  of 
the  abdomen.  The  rapidity,  vith  which  the 
above  adhesions  frequently  form,  is  almost 
incredible. 

It  should  be  known,  however,  that  extra- 
vasations are  occasionally  diffused  in  various 
degrees  among  the  viscera,  owing  to  the 
patient  being  subjected  to  a great  deal  of 
motion,  or  affected  with  violent  spasmodic 
contractions  of  the  intestines.  Urine  and 
bile  are  also  generally  dispersed  to  a great 
extent.  As  for  blood,  its  disposition  to 
coagulate  must  often  tend  both  to  stop  fur- 
ther hemorrhage,  and  confine  the  extravasa- 
tion in  one  mass. 

Symptoms  and  Treatment  of  Extravasations 
in  the  Abdomen.  1.  Blood - — Wounds  of  the 
,spleen,  and  of  very  large  veins  and  arteries 


WOUNDS- 


4 S 


in  the  abdomen,  almost  always  soon  prove 
fatal  from  internal  hemorrhage.  The  blood 
generally  makes  its  way  downwards,  and 
accumulates  at  the  inferior  part  of  the  ab- 
domen, unless  the  presence  of  adhesions 
happen  to  oppose  the  descent  of  the  fluid 
to  the  most  depending  situation.  The  bidly 
swells,  and  a fluctuation  is  perceptible.  The 
patient  grows  pale,  loses  his  strength,  is 
affected  with  syncope,  and  his  pulse  be- 
comes weak,  and  scarcely  distinguishable. 
In  short,  the  symptoms  usually  attendant  on 
profuse  hemorrhage  are  observable.  As 
the  viscera  and  vessels  in  the  abdomen  are 
compressed  on  all  sides  by  the  surrounding 
parts,  the  blood  cannot  be  effused  without 
* overcoming  a certain  degree  of  resistauce  ; 
and  unless  a vessel  of  the  first  magnitude, 
like  the  aforta,  the  vena  cafa,  or  one  of 
their  principal  branches,  has  been  wounded, 
the  blood  escapes  from  the  vessel  slowly, 
and  several  days  elapse,  before  any  consi- 
derable quantity  accumulates. 

In  these  cases,  the  symptoms,  which  per- 
haps bad  disappeared  under  the  employ- 
ment of  bleeding  and  anodyne  medicines, 
now  recur.  A soft  fluctuating  tumour  may 
be  felt  at  the  lower  part  of  the  abdomen  ; 
sometimes  on  the  right  side  ; sometimes  on 
the  left ; but  occasionally  on  both  sides. 
The  pressure  made  by  the  effused  blood,  on 
the  urinary  bladder,  excites  distressing  incli- 
nations to  make  water  ; while  the  pressure, 
which  the  sigmoid  flexure  of  the  colon 
suffers,  is  the  cause  of  obstinate  constipa- 
tion. In  the  mean  time,  as  the  quantity  of 
extravasated  blood  increases,  the.  perito- 
neum inflames.  The  pulse  grows  weaker  ; 
debility  ensues  ; -the  countenance  becomes 
moistened  with  cold  perspirations ; and 
according  to  some  w riters,  unless  the  sur- 
geon practise  an  incision  for  the  discharge 
of  the  fluid,  the  patient  falls  a victim  to  the 
accident 

In  the  year  1733,  Vacher  adopted  this 
treatment  with  success.  Petit  afterward 
tried  the  same  plan,  though  it  did  not  an- 
swer, (as  is  alleged)  in  consequence  of  the 
inflammation  having  advanced  too  far  before 
the  operation  w'as  performed.  Long  before 
the  time  of  Vacher  and  Petit,  a successful 
instance  of  similar  practice  was  recorded  by 
Cabrole,  in  a work  which  this  author  pub- 
lished, under  the  title  of  A\y*(Znrov  ctvetro/ui- 
xsv,  id  est,  Anatbmes  elenchus  accuratissi- 
mus,  omnes  humani  corporis  partes  ea  qui 
solent  secari  methodo,  delineans.  Accessere 
osteologia,  observationesque  Medicis  ac 
Chirurgicis  perutiles.  Geneva*  1604.  The 
method  pursued  by  Vacher,  was  therefore 
not  so  new  as  Petit  imagined. 

Indeed,  w^hen  the  symptoms  leave  no 
doubt,  of  there  being  a large  quantity  of 
blood  extravasated  in  the  abdomen  ; when 
the  patient’s  complaints  are  of  a very  serious 
nature,  and  are  evidently  ow  ing  to  the  irri- 
tation and  pressure  of  the  blood  on  the 
surrounding  viscera  ; and  when  a local 
swelling  denotes  the  seat  of  the  extravasa- 
tion-, there  cannot  he  two  opinions  about,  the 


propriety  of  making  an  incision  for  its  eva= 
cuation. 

Surgeons  should  recollect,  however,  that 
if  no  opening  be  made,  a small  extravasation 
of  blood  may  not  produce  any  considerable 
irritation.  On  the  contrary,  when  the  cyst 
including  the  blood  is  opened,  the  air  then 
has  access,  and  that  part  of  the  fluid  which 
cannot  be  discharged,  putrifies  and  becomes 
so  irritating,  as  to  be  a true  cause  of  inflam- 
mation. The  bad  symptoms  are  also  some- 
times chiefly  owing  to  the  injury  done  to 
parts  within  the  abdomen,  and  still  more 
commonly  to  inflammation  within  that  ca- 
vity, arising  rather  from  the  wound  than 
from  the  presence  of  effused  blood.  On  the 
whole,  I am  disposed  to  join  a late  waiter 
in  the  belief,  that  the  practice  of  discharging 
extravasated  blood  from  the  abdomen  can 
rarely  be  adviseable — (See  Htnneris  Mil, 
Surgery , P.  412,  erf.  2.) 

2.  Chyle  and  Feces. — These  are  not  so 
easily  extravasated  in  the  abdomen  as  blood, 
because  they  do  not  require  so  much  resist- 
auce, on  the  outside  of  the  stomach  and 
intestines,  to  make  them  continue  their  na- 
tural route  through  the  alimentary  canal,  as 
blood  requires  to  keep  it  in  the  vessels. 
However,  when  the  wound  is  large,  aud 
the  bowel  distended  at  the  moment  of  the 
injury,  or  when,  as  Mr.  Travers  has  explain- 
ed, air  is  extravasated,  or  blood  effused  in 
the  abdomen,  which  fluids  are  incapable  of 
making  effectual  resistance  to  the  escape  of 
the  intestinal  matter,  the  latter  may  be  ef- 
fused. (See  an  Inquiry  into  the  Process  of 
JYature  in  repairing  Injuries  of  the  Intestines , 
fyc.p.  26.)  Nothing  is  a better  proof  of  the 
difficulty,  with  which  chyle  and  feces  are 
extravasated,  than  the  operation  of  an 
emetic,  when  the  stomach  is  wounded  and 
full  of  aliment.  In  this  instance,  if  the  re- 
sistance to  the  extravasation  of  the  contents 
of  the  stomach  were  not  considerable,  they 
would  be  effused  in  the  abdomen,  instead  of 
being  vomited  up.  A peculiarity  in  wounds 
of  the  stomach  and  intestines  is,  that  the 
opening,  which  allows  their  contents  to 
escape,  may  also  allow  them  to  return  into 
the  wounded  viscus. 

Extravasation  of  intestinal  matter  in  the 
abdomen  is  attended  with  severe  febrile 
symptoms;  considerable  pain  and  swelling 
of  the  belly  ; convulsive  startings  ; and  hic- 
cough and  vomiting,  with  which  the  patients 
are  generally  attacked  the  day  after  the  re- 
ceipt of  the  wound.  ( Sabatier , Mtd.  Optra- 
toirc , T.  1 ,p.  34.) 

In  these  cases,  only  general  means  can 
be  employed  ; venesection,  leeches,  fomen- 
tations, low  diet,  perfect  rest,  anodynes,  he. 
All  solid  food  must  be  strictly  prohibited. 
If  pressure  can  be  borne  without  inconve- 
nience, as  is  sometimes  the  case  in  the  early 
stage,  the  close  state  of  the  viscera  may  bo 
increased  by  the  application  of  a bandage 
round  the  body. 

If  the  symptoms  arc  not  speedily  assua- 
ged, the  inflammation  spreadsover  the  whole 
cavity  of  thc;)bdomcn,  gangrenous  Mischief 


WOUNDS. 


: akes  place,  and  the  patients  die  in  the  course 
of  a lew  days. 

3.  Bile — Bile,  on  account  of  its  great 
fluidity,  is  more  apt  to  be  widely  extravasa- 
ted  in  the  abdomen,  than  either  blood,  or  the 
( contents  of  the  stomach  aud  intestines. 
However,  on  account  of  the  small  size  of 
the  gad  bladder,  and  its  deep  guarded  situa- 
tion, between  the  concave  surface  of  the 
i liver,  and  upper  part  of  the  transverse  arch 
of  the  colon,  wounds  of  it  are  uncommon. 

Sabatier  informs  us,  that  he  has  only  been 
able  to  find  one  example  on  record.  This 
case  was  communicated  to  the  Royal  Socie- 
ty of  London,  by  Dr.  Stewart  (No.  414, 

| pag.  341.  Abridgm.  Vol.  7,  pag.  571 — 572,) 
A wound  penetrated  the  cavity  of  the  abdo- 
men, and  entered  the  fundus  of  the  gall 
p bladder,  without  doing  any  material  injury 
[ to  the  adjacent  parts.  The  abdomen  was 
I immediately  distended,  as  if  the  patient  had 
| been  afflicted  with  an  ascites,  or  tympanitis  ; 

? nor  did  the  swelling  either  increase  or  di- 
minish, till  the  patient’s  death,  which  hap- 
| pened  in  a week. 

i Though  there  was  a great  deal  of  tension, 
I there  was  no  rumbling  noise  in  the  abdomen. 

! No  stools,  and  very  little  urine  were  dis- 
I charged,  notwithstanding  purgatives  and 
I clysters  and  a good  deal  of  liquid  nourish- 
f ment,  were  given.  Anodynes  failed  to 
i;1  procure  one  instant  of  sound  sleep,  and  tile 
patient  was  incessantly  in  a most  restless 
state.  There  was  no  appearance  of  fever, 

' and  the  pulse  was  always  natural  till  the  last 
| day  of  the  patient’s  life,  when  it  became 
1 intermittent.  After  death,  the  intestines 
® were  found  much  distended,  the  gall  bladder 
v quite  empty,  and  a large  quautity  of  bile 
5 extravasated. 

Sabatier  had  an  opportunity  of  noticing 
the  symptoms  of  an  extravasation  of  bile, 
in  consequence  of  a wound  of  the  gall  blad- 
der. The  patient’s  abdomen  swelled  very 
quickly  ; his  respiration  became  difficult, 
and  he  soon  afterward  complained  of  tension 
and  pain  in  the  right  hypochondrium.  His 
pulse  was  small,  frequent,  and  contracted  ; 
his  extremities  were  cold,  and  his  counte- 
nance very  pale.  The  bleedings  which 
were  practised  the  first  day,  gave  him  a little 
relief ; but  the  tension  of  the  abdomen, 
and  the  difficulty  of  breathing,  still  continu- 
ed. A third  bleeding  threw  the  patient  into 
the  lowest  state  of  weakness,  and  he  vomit- 
ed up  a greenish  matter.  On  the  third  day, 

; the  lower  part  of  the  belly  was  observed  to 
be  more  prominent,  and  there  was  no  doubt 
of  an  extravasation.  Sabatier  introduced  a 
trocar,  and  gave  vent  to  a green  blackish 
' fluid,  which  had  no  smell,  and  was  pure  bile 
! that  had  escaped  from  the  wound  of  the 
gall  bladder.  After  the  operation,  the  pa- 
tient grew  weaker  and  weaker,  and  died  in 
I a few  hours.  On  opening  the  body,  a large 
quantity  of  yellow  bile  was  found  between 
the  peritoneum  and  intestines ; but  it  had 
not  insinuated  itself  among  the  convolutions 
1 of  the  viscera.  A thick  gluten  connected 
the  bowels  together,  and  they  were  prodi- 
ji  giously  distended.  The  gall  bladder  was 


shrivelled,  and  almost  empty.  Towards  its 
fundus,  there  was  a wound,  about  a line  and 
a half  long,  corresponding  to  a similar 
wound  in  the  peritoneum.  The  wound 
which  had  occurred  at  the  middle  and  lower 
part  of  the  right  hypochondrium,  between 
the  third  and  fourth  false  ribs,  had  glided 
from  behind  forward,  and  from  above 
downward,  between  the  cartilages  of  the 
ribs,  until  it  reached  the  fundus  of  the  gall 
bladder. 

Sabatier  takes  notice,  that  the  symptoms 
of  the  two  cases,  which  have  just  now  been 
related,  were  very  similar.  Both  the  patients  1 
were  affected  with  an  exceedingly  tense 
swelling  of  the  belly,  unattended  with  pain, 
or  borborygmus,  and  they  were  both  obsti- 
nately constipated.  Their  pulse  was  ex- 
tremely weak  the  latter  days  of  their  indis- 
position, and  they  were  afflicted  with  hic- 
cough, nausea,  and  vomiting. 

Sabatier  seems  to  think  one  thing  certain, 
viz.  that  wounds  of  the  gall  bladder  attended 
with  effusion  of  bile,  are  absolutely  mortal, 
and  that  no  operation  can  be  of  any  avail. 

( Mddecine  Operatoire,  T.  1 ,p.  34 — 37.) 

A contrary  inference,  however,  may  be 
drawn  from  a case,  detailed  by  Parois^g,  in. 
which  a bullet  had  lodged  in  the  gall  bladder 
two  years.  (Opuscules  de  Chir.  p.  255.)  The 
recovery  published  by  Mr.  Fryer,  of  Stam- 
ford, tends  also  to  prove,  that  every  effusion 
of  bile  is  not  unavoidably  fatal.  A boy, 
about  thirteen  years  old,  received  a violent 
blow  from  one  of  the  shafts  of  a cart,  on 
the  region  of  the  liver.  The  injury  was 
succeeded  by  pain,  frequent  vomiting  of 
bilious  matter,  great  sinking,  coldness  of  the 
extremities,  and  a weak,  small,  fluttering 
pulse.  The  belly  was  fomented,  and  pur- 
ging clysters  thrown  up.  On  the  third  day, 
symptoms  of  inflammation  began,  attended 
with  considerable  pain  about  the  liver,  great 
tension  and  soreness  of  the  abdomen,  and 
frequent  vomiting.  The  pulse  was  quick, 
small,  and  weak  ; the  skin  hot  and  dry;  the 
tongue  mucii  furred  ; the  urine  high-colour- 
ed ; and  there  was  some  difficulty  of  breath- 
ing ; and  great  thirst.  Eigh^  ounces  of 
blood  were  taken  away,  the  fomentations 
continued,  and  a few  grains  of  calomel  were 
directed  to  be  given  every  four  hours  until 
the  bowels  were  properly  opened.  After- 
ward, the  effervescing  mixture,  with  ten 
drops  of  laudanum,  was  exhibited  every 
four  hours. 

On  the  following  day,  the  patient  had 
some  motions,  and  was  much  better;  but, 
as  his  sickness  continued,  he  was  ordered  a 
grain  of  opium  every  four  hours.  About  a 
week  afterward,  he  complained  of  a great 
increase  of  pain,  which  was  Bomewhat  re- 
lieved by  a blister.  He  was  now  completely 
jaundiced,  and  his  stools  were  white,  but 
the  tension,  pain,  and  sickness  were  abated. 

Two  days  afterward,  a fluctuation  was 
perceived  in  the  abdomen,  which,  in  another 
week,  became  considerably  distended  with 
fluid.  The  patient  did  not  now  complain  of 
much  pain  ; but  appeared  to  be  sinking  fast ; 
a puncture  was  made  in  the  swelling,  and 


woL\m- 


ti&Q 

thirteen  pints  of  what  appeared  to  be  pure 
bile  were  evacuated.  The  bowels  then  soon 
became  regular,  and  the  appetite  good.  In 
twelve  days,  the  operation  was  repeated, 
and  fifteen  pints  of  the  same  bilious  fluid 
were  drawn  oft'.  Nine  days  afterward,  an- 
other punctune  was  made,  and  thirteen  pints 
more  let  out ; and  six  were  discharged  in  an- 
other fortnight.  From  this  period  the  boy 
went  on  well,  and  perfectly  recovered  un- 
der the  use  of  light  tonic  medicines.  (See 
Med.  Chir.  Trans.  Vol.  4,  p.  330.) 

A previous  accidental  adhesion  of  the 
galWuadder  to  the  peritoneum  might  also 
prevent  the  extravasation  of  bile,  and  its 
tiangerous  effects.  ( Callisen , Syst.  Chir. 

Homtrnoe.  T.  1.^.718.) 

According  to  Dr.  Hennen,  a deep  wound 
of  the  liver  is  as  fatal  as  if  the  heart  itself 
was  engaged.  The  slighter  injuries  are  re- 
coverable. He  states,  that  the  usual  symp- 
toms of  a wound  of  the  liver  are  yellowness 
of  the  skin  and  urine  ; derangement  of  the 
alimentary  canal,  and  great  and  distressing 
itching  of  the  skin.  The  discharge  from 
the  wound  is  generally  yellow  and  glutin- 
ous . though  sometimes  either  serous,  or 
like^,  unraixed  bile.  (On  Militai'y  Surgery, 
Ed72^p.  429.)  For  some  other  interesting 
observations  on  wounds  of  the  liver,  I have 
great  pleasure  in  referring  to  the  latter  work. 
(See  akfo  Wedekind  de  Vulnere  Hcpatis  C'ura- 
io,  Jence,  1735 ; and  Thomson's  Report  of 
Obs . made  in  the  Military  Hospitals  in  Bel- 
gium, 8ro.  1816.) 

4.  Urine. — Urine  being  of  a very  fluid 
nature,  may,  like  the  bile,  be  extensively 
diffused  in  the  abdomen,  when  the  bladder 
is  wounded  at  any  part,  connected  with  the 
peritoneum.  If,  in  this  kind  of  case,  the 
urine  be  not  drawn  off  with  a catheter,  so 
as  to  prevent  its  extravasation,  the  patient 
soon  perishes.  Many  instances  are  recorded 
of  the  bladder  being  injured  even  by  gun- 
shot wounds,  which  were  not  mortal. 

Wounds  of  the  bladder  are  attended  with 
a discharge  of  bloody  urine  and  difficulty 
of  making  water.  They  are  always  dan- 
gerous cases,  both  on  account  of  the  risk 
of  the  effusion  of  so  irritating  a fluid  in  the 
abdomen,  and  of  the  chance  of  extravasa- 
tion in  the  cellular  membrane.  Under 
proper  treatment,  however,  they  often  ad- 
mit of  cure.  (See  Gunshot  Wounds.)  If 
possible,  the  elfused  fluid  should  be  dischar- 
ged by  a depending  posture,  or  suitable 
punctures,  or  incisions,  and  the  recurrence 
of  extravasation  prevented  by  the  introduc- 
tion of  a catheter,  which  is  to  be  left  in  the 
urethra.  The  patient  must  also  be  allowed 
little  drink.  As  for  the  tension  and  pain  of 
the  belly,  the  common  attendants  of  a 
wounded  bladder,  they  may  be  greatly  re- 
lieved by  the  use  of  the  warm  bath,  ( Calli - 
sen,  T.  1,  p.  719.)  bleeding,  low  diet,  and 
other  antiphlogistic  means  not  being  omit- 
ted. 

Wounds  of  the  Stomach. — As  Dr.  Hennen 
has  observed,  these  cases  are  extremely 
dangerous,  though  not  always  mortal. 
91  Baron  Percy  calculates,  that  of  twenty 


cases,  four  or  live  onTy  have  escaped ; this.* 
however,  is  a most  favourable  average.' * 
Two  cures  of  wounds  of  the  stomach  are 
reported  by  Dr.  Thomson.  (Obs.  made  in 
the  Military  Hospitals  in  Belgium,  fyc.)  With 
respect  to  the  chances  of  recovery,  Dr. 
Hennen  justly  remarks,  that,  in  the  histories 
of  the  Bohemian,  Prussian  (D.  Beckher  de 
Cultriroro  Prussiaco,  12wo.  Lugd.  1638,)  and 
English  u Cultri-sores,”  in  some  of  whom 
the  knives  have  been  cut  out,  and  in  others, 
discharged  spontaneously  through  the  coats 
of  the  stomach  and  parietes  of  the  abdomen, 
are  very  encouraging.  Hevin  has  collected^ 
many  instances  of  recovery  both  from  in- 
cised and  gunshot  wounds  of  the  stomach. 
(Mem.  de  VAcad.  de  Chir.  T.  1.)  But,  ac- 
cording to  Dr.  Hennen,  Ploucquet,  in  the 
articles  “ Ventriculus”  and  “ Pantophagi,” 
has  brought  together  the  largest  number  of 
cases.  Dr.  Hennen,  also  refers  to  Loie * 
thorpe's  Abridgment  of  the  Phil.  Trans.  Vol. 
6,  p.  192,  for  instances,  in  which  the  sto- 
mach of  a horse  was  wounded  and  sewed 
up,  and  the  same  practice  extended  to  the 
human  subject,  with  success.  It  appears  | 
also  from  the  “ Annales  de  Literature,”  &c. 
T.  2,  by  Kluyskens,  from  Sehlichting’s 
“ Iraumatologia,”  and  the  “ Bulletin  de  la 
Faculty,"  fyc.  Tom.  5 ,p.  386,  that  wounds  of 
the  human  stomach  have  been  stitched  with 
success  in  various  cases  of  recent  date. 
(See  Hennen' s Military  Surgery,  Ed.  2,  p. 
438  ) As  the  latter  author  observes,  wounds 
of  the  stomach  not  unfrequently  become 
fistulous  and  remain  open.  In  a case,  re- 
corded by  Richerand.  the  fistula  continued 
open  nine  years  ; and  in  another  instance, 
related  by  Ettmuller,  ten  years.  (De  Vul- 
nere Ventriculi  Programme,  l dp.  1730.)  And 
Wencker  has  detailed  a case,  in  which  the 
opening  continued  twenty-seven  years. 
(See  Halteri  Dissert.  Chir.  Vol.  5,  art.  19. V 
For  farther  information,  connected  witn 
this  subject,  the  reader  may  also  consult, 
Jungen,  de  Lethalitate  Vulnerum  Ventriculi, 
Helmsl.  1751  ; and  Ludov.  Horn,  de  Ventri- 
culi Ruptura,  8 vo  Berol.  1817.  Also  Med, 
Chir.  Journ.  Vol.  5,  p.  72. 

Wounds  of  the  Intestines. — The  vomiting 
of  blood,  or  discharge  of  it  by  stool  ; the 
escape  of  fetid  air,  or  of  intestinal  matter, 
from  the  mouth  of  the  wound  ; an  empty 
collapsed  state  of  a portion  of  bowel,  pro- 
truded at  the  opening  in  the  skin,  are  the 
common  symptoms  attending  a wound  of 
this  kind.  When  the  wound  is  situated  in 
the  prolruded  portion,  it  is  obvious  to  the 
surgeon’s  eye  ; but  when  it  affects  apart  of 
the  intestinal  canal  within  the  abdomen,  the 
nature  of  the  case  can  be  known  only  by  a 
consideration  of  other  symptoms.  In  addi- 
tion to  such  as  I have  already  described, 
there  are  some  others,  whicli  ordinarily 
accompany  wounds  of  the  bow’els  ; as,  for 
instance,  oppression  about  the  proecordia, 
acute  or  griping  pain  in  the  belly,  cold 
sweats,  syncope,  &.c.  But,  unless  the 
wounded  intestine  protrude,  there  is  no 
ractical  good  in  knowing  whether  the 
owel  is  Injured  or  not,  since,  if  it  be  in.  the 


WOUNDS 


’abdomen,  the  treatment  ought  not  to  be 
materially  different  from  that  of  a simple 
penetrating  wound  of  the  belly,  unattended 
with  a wound  of  any  of  the  viscera.  Large 
wounds  of  the  small  intestines,  particularly 
of  the  duodenum  and  jejunum,  are  attended 
with  acute  fever,  anxiety,  paleness  of  the 
countenance,  syncope,  cold  perspirations,  a 
small,  intermitting,  tremulous  pulse,  and 
they  frequently  prove  fatal.  Injuries  of  the 
small  intestines  are  also  more  otten,  than 
those  of  the  large  ones,  followed  by  extra- 
vasation. A total  division  of  the  upper  part 
of  the  intestinal  canal,  towards  the  pylorus, 
will  deprive  the  body  of  the  nourishment 
requisite  for  its  support.  If  the  chyle 
escape  from  the  wound,  the  patient  will  die 
of  a slow  marasmus  ; and  if  it  become  ex- 
travasated,  it  will  be  likely  to  excite  such 
irritation  as  will  prove  fatal.  The  escape  of 
excrement,  or  of  fetid  air  from  the  wound, 
indicates  an  injury  of  one  of  the  large  in- 
testines. In  these  cases,  the  symptoms  are 
generally  milder,  and  the  passage  of  the 
intestinal  contents  outward  through  the 
wound  more  easy,  on  account  of  the  bowel 
being  less  moveable.  For  the  same  reason, 
the  wounded  intestine  more  readily  con- 
tracts an  adhesion  to  the  adjacent  parts. 
(Callisen,  Sysl.  Chirurgice  Hoditrnte,  T.  1,  p. 
717.) 

A wounded  intestine  is  said  to  present 
some  particular  appearances,  to  which  the 
generality  of  writers  have  paid  no  attention  : 
u If  a gut  be  punctured,  the  elasticity  of  the 
peritoneum,  and  the  contraction  of  the 
muscular  fibres,  open  the  wound,  and  the 
villous,  or  mucous  coat,  forms  a sort  of  her- 
nial protrusion,  and  obliterates  the  aperture. 
If  an  incised  wound  be  made,  the  edges  are 
drawn  asunder,  and  reverted  so  that  the 
mucous  coat  is  elevated  in  the  form  of  & 
fleshy  lip.  If  the  section  be  transverse,  the 
lip  is  broad  and  bulbous,  and  acquires  tume- 
faction and  redness  from  the  contraction  of 
the  circular  fibres  behind  it,  which  produces, 
icelatively  to  the  everted  portion,  the  ap- 
pearance of  a cervix.  If  the  incision  be 
according  to  the  length  of  the  cylinder,  the 
lip  is  narrow,  and  the  contraction  of  the  ad- 
jacent longitudinal  fibres,  resisting  that  of 
the  circular  fibres,  gives  the  orifice  an  oval 
form.  This  eversion  and  contraction  are 
produced  by  that  series  of  motions,  which 
constitutes  the  peristaltic  action  of  the  in- 
testines.” ( Travers  on  Injuries  of  the  Intes- 
tines, p.  85.) 

According  to  this  gentleman,  some  of 
these  appearances  were  described  by  Haller, 
in  Element.  Physiol,  lib.  24,  sect.  2 ; and 
Opera  Minora , T.  1,  sect.  15. 

Having  witnessed  the  facility,  with  which 
considerable  injuries  of  the  intestinal  tube 
were  repaired,  Mr.  Travers  was  desirous  of 
ascertaining  more  fully  the  powers  of  na- 
ture in  the  process  of  spontaneous  repara- 
tion, and  of  determining,  under  how  great 
a degree  of  injury  it  would  commence,  as 
well  as  the  mode  of  its  accomplishment. 
For  these  purposes,  he  divided  the  small 
intestine  of  several  dogs  as  far  as  the  mesen- 
Voji.  II.  86 


lory.  All  these  animals  died,  in  corise 
quence  of  the  intestinal  matter  being  extra 
vasated,  if  they  had  been  lately  fed,  or  if 
they  had  been  fasting  in  consequence  of  in- 
flammation, attended  with  a separation  of 
the  ends  of  the  divided  bowel,  eversion  of 
the  mucous  coat,  and  obliteration  of  the 
cavity,  partly  by  this  eversion,  and  partly 
by  a plug  of  coagulated  chyle. 

In  one  particular  instance,  in  which  Mr. 
Travers  made  a division  of  the  bowel,  half 
through  its  diameter,  a sort  of  pouch  was 
formed  round  the  injured  intestine.  “A 
pouch,  resembling  somewhat  the  diverti- 
culum in  these  animals,  was  formed  opposite 
to  the  external  wound,  on  the  side  of  the  pa- 
rietes,  by  the  lining  peritoneum,  on  the  other 
side,  by  the  mesentery  of  the  injured  intes- 
tine, that  iqtestineitself,and  an  adjacentfold, 
which  had  contracted  with  it  a close  adhe- 
sion. The  pouch,  thus  formed  and  insula- 
ted, included  the  opposed  sections  of  the 
gut,  and  had  received  its  contents,  he.  The 
tube,  at  the  orifices,  was  narrowed  by  the 
half  eversion,  but  ottered  no  impediment  to 
the  passage  of  fluids.”  (P.  96.)  Whether, 
under  these  circumstances,  the  functions  of 
the  alimentary  canal  could  have  been  con- 
tinued, Mr.  Travers  professes  himself  inca- 
pable of  deciding.  Among  the  inferences, 
which  this  gentleman  has  drawn  from  the 
experiments,  detailed  in  bis  publication,  the 
tendency  of  the  two  portions  of  a divided 
bowel  to  recede  from  each  other,  instead 
coalescing  to  repair  the  injury,  merits  no- 
tice, inasmuch  as  it  tends  to  show,  that  the 
only  means  of  spontaneous  reparation  con- 
sist in  the  formation  of  an  adventitious 
canal,  by  the  encircling  bowels  and  their 
appendages.  The  everted  mucous  coat, 
which  is  the  part  opposed  to  the  surround- 
ing peritoneum,  is  also  indisposed  to  the  ad- 
hesive inflammation. 

When,  however,  the  wound  of  the  intes- 
tine is  smaller,  the  obstacles  to  reparation 
are  not  absolutely  insurmountable.  Here, 
retraction  is  prevented,  and  the  processes  of 
eversion  and  contraction  modified  by  the 
limited  extent  of  the  injury.  If,  therefore, 
the  adhesive  inflammation  unite  the  con- 
tiguous surfaces,  effusion  will  be  prevented, 
and  the  animal  escape  immediate  destruc- 
tion. But,  union  can  only  take  place 
through  the  medium  of  the  surrounding 
parts. 

According  to  Mr.  Travers,  it  is  the  re- 
traction, immediately  following  the  wound, 
that  is  a chief  obstacle  to  the  reparation  of 
the  injury  ; for,  if  the  division  be  performed 
in  such  a way  as  to  prevent  retraction,  the 
canal  will  be  restored  ia  so  short  a time,  as 
but  slightly  to  interrupt  the  digestive  func- 
tion. In  confirmation  of  this  statement,  a 
ligature  was  tightly  applied  round  the  duo- 
denum of  a dog,  which  became  ill,  but  en- 
tirely recovered,  and  was  killed.  “ A liga- 
ture, fastened  around  the  intestine,  divides 
the  interior  coats  of  the  gut,  in  this  effect 
resembling  the  operation  of  a ligature  upon 
an  arfery.  The  peritoneal  tunic  alone 
maintains  its  integrity.  The  inflammation, 


WOUNDS 


which  the  ligature  induces  on  either  side  of 
it,  is  terminated  by  the  deposition  of  a coat 
of  lymph,  which  is  exterior  to  the  ligature, 
and  quickly  becomes  organized.  When  the 
ligature,  thus  enclosed,  is  liberated  by  the 
ulcerative  process,  it  falls  of  necessity  into 
the  canal,  and  passes  oft'  with  its  contents.” 
(P.  103,  104.) 

It  appears  also  from  Mr.  Travers’s  experi- 
ments and  observations,  that  longitudinal 
wounds  of  the  bowels  are  more  easily  repair- 
ed, than  such  as  are  transverse.  In  a dog,  a 
longitudinal  wound,  of  the  extent  of  an  inch 
and  a half,  was  repaired  by  the  adhesive 
inflammation.  Here  the  process  of  eversion 
is  very  limited  ; the  aperture  bears  a smaller 
proportion  to  the  cylinder  of  the  bowel ; 
and  the  entire  longitudinal  fibres  resist  the 
action  of  the  circular,  which  ane  divided, 
and  can  now  only  slightly  lessen  the  area 
of  the  canal.  (P.  108.) 

We  come  now  to  the  consideration  of  the 
treatment  of  wounds  of  the  intestines;  a 
subject,  in  which  much  difference  of  opinion 
has  prevailed  ; principally,  however,  con- 
cerning the  circumstances  in  which  sutures 
are  necessary, . and  the  most  advantageous 
way  of  applying  them. 

When  the  wounded  bowel  lies  within  the 
cavity  of  the  abdomen,  no  surgeon  of  the 
present  day  would  have  the  rashness  to 
think  of  attempting  to  expose  the  injured 
intestine,  for  the  purpose  of  sewing  up  the 
breach  of  continuity  in  it.  In  fact,  the  sur- 
geon seldom  knows  at  first  what  has  hap- 
pened ; and  when  the  nature  of  the  case  is 
afterward  manifested,  by  the  discharge  of 
blood  per  anum,  an  extravasation  of  intes- 
tinal matter,  Sic.  it  would  be  impossible  to 
get  at  the  injured  part  of  the  bowel,  not 
only  because  its  exact  situation  is  unknown, 
but  more  particularly  on  account  of  the  ad- 
hesions,  which  are  always  formed  with  sur- 
prising rapidity.  But,  even  if  the  surgeon 
knew  to  a certainty,  in  the  first  instance, 
that  one  of  the  bowels  was  wounded,  and 
the  precise  situation  of  the  injury,  no  suture 
could  be  applied,  without  considerably  en- 
larging the  external  wound,  drawing  (he 
wounded  intestine  out  of  the  cavity  of  the 
abdomen,  and  handling  and  disturbing  all 
the  adjacent  viscera.  Nothing  would  be 
mure  likely,  than  such  proceedings,  to  ren- 
der the  accident,  which  may  originally  be 
curable,  unavoidably  fatal.  1 entirely  agree 
upon  this  point  with  Mr.  John  Bell,  who 
says,  “ When  there  is  a wounded  intestine, 
which  we  are  warned  of  only  by  the  pass- 
ing out  of  the  feces,  we  must  not  pretend 
to  search  for  it,  nor  put  in  our  finger,  nor 
expect  to  sew  it  to  the  wound  ; but  we  may 
trust  that  the  universal  pressure,  which 
prevents  great  effusion  of  blood,  and  col- 
lects the  blood  into  one  place,  that  very 
pressure,  which  always  causes  the  wounded 
bowel  and  no  other  to  protrude,  will  make 
the  two  wounds,  the  outward  wound  and 
the  inward  wound  of  the  intestine,  opposite 
each  other,  point  to  point ; and  if  all  be 
kept  there  qyiet,  though  but  for  one  day,  so 
lively  is  the  tendency  to  inflame,  that  the 


adhesion  will  be  begun,  which  is  to  save  the 
patient’s  life.”  (Discourses  on  Wounds  v 
361,  Edit.  3.) 

When  the  extravasation,  and  other  symp- 
toms, a few  days  after  the  accident,  show 
the  nature  of  the  case,  a suture  can  be  of 
no  use  whatever,  as  the  adhesive  inflamma- 
tion has  already  fixed  the  part  in  its  situ- 
ation, and  the  space  in  which  the  extrava- 
sation lies  is  completely  separated  from  the 
general  cavity  of  the  abdomen  by  the  sur- 
rounding adhesions. 

When  the  bowel  does  .not  protrude,  and 
the  opening  in  it  is  situated  closely  behind 
the  wound  in  the  peritoneum,  a suture  is 
riot  requisite ; for  the  contents  of  the  gut 
not  passing  onward,  will  be  discharged 
from  the  outer  wound,  and  not  be  diffused 
among  the  viscera,  if  care  be  taken  to  keep 
the  external  wound  open.  There  is  no  dan- 
ger of  the  wounded  bowel  changing  its 
situation,  and  becoming  distant  from  the 
wound  in  the  peritoneum,  for  the  situation 
which  it  now  occupies  is  its  natural  one. 
Nothing  but  violent  motion  or  exertions 
could  cause  so  unfavourable  an  occurrence., 
and  these  should  always  be  avoided.  The 
adhesions,  which  take  place  in  the  course 
of  a day  or  two,  at  length  render  it  impos- 
sible for  the  bowel  to  shift  its  situation. 

Things,  however,  are  far  different  when 
the  wounded  part  of  the  bowel  happens  to 
protrude.  Here  we  have  the  authority  of 
all  writers  in  sanction  of  the  employment  of 
a suture.  No  enlargement  of  the  outer 
wound  is  requisite  to  enable  the  practitioner 
to  adopt  such  practice  ; there  is  no  disturb- 
ance of  the  adjacent  parts;  there  is  no 
doubt  concerning  the  actual  existence  of  the 
injury  . no  difficulty  in  immediately  finding 
out  its  situation. 

But,  though  authors  are  so  generally 
agreed  about  the  propriety  of  using  a suture 
in  the  case  of  a wounded  and  protruded 
bowel,  they  dift’er  exceedingly  both  as  to 
the  right  object  of  the  method,  and  the 
most  advantageous  mode  of  sewing  the  in- 
jured part  ot  the  intestine.  Some  have 
little  apprehension  of  extravasation,  advise 
only  one  stitch  to  be  made,  and  use  the  li- 
gature chiefly  with  a view  of  confining  the 
injured  bowel  neat*  the  external  wound,  so 
that  in  the  event  of  an  extravasation  the 
eft'used  matter  may  find  its  way  outward. 
Other  writers  wish  to  remove  the  possibi- 
lity of  extravasation,  by  applying  numerous 
stitches,  and  attach  little  importance  to  the 
plan  of  using  the  ligature  principally  for  the 
purpose  of  keeping  the  intestine  near  the 
superficial  wound. 

When  the  wound  of  a bowel  is  so  small 
that  it  is  closed  by  the  protrusion  of  the 
villous  coat,  the  application  of  a suture 
must  evidently  be  altogether  needless  ; and 
since  the  ligature  would  not  fail  to  cause 
irritation,  as  an  extraneous  substance,  the 
employment  of  it  ought  unquestionably  to 
be  dispensed  with. 

Supposing,  however,  the  breach  in  the 
intestine  to  be  small,  yef  sufficient  to  let  the 
feces  escape,  what  method  ought  to  be 


VYOI/NDS. 


adopted  V The  following  practice  seems 
rational.  As  Sir  Astley  Cooper  was  ope- 
rating on  a strangulnted  hernia,  at  Guy’s 
hospital,  an  aperture  giving  issue  to  the  in- 
testinal contents  was  discovered  in  a portion 
of  the  sound  bowel,  just  when  the  part,  was 
about  to  be  reduced.  The  operator,  inclu- 
ding the  aperture  in  his  forceps,  caused. a tine 
silk  ligature  to  be  carried  beneath  the  point 
of  the  instrument,  firmly  tied  upon  the  gut, 
and  the  ends  cutoff  close  to  the  intestine. 
The  part  was  then  replaced,  and  the  patient 
did  well.  Mr.  Travers,  who  has  related  this 
fact,  approves  of  the  plan  of  cutting  away 
the  extremities  of  the  ligature,  instead  of 
leaving  them  hanging  out  of  the  external 
wound.  It  appears,  that,  when  the  first 
practice  is  followed,  the  remnant  always 
makes  its  way  into  the  intestine,  and  is 
discharged  with  the  stools  without  any  in- 
convenience. But  when  the  long  ends  are 
drawn  through  the  outer  wound,  and  left  in 
it,  they  materially  retard  the  process  of  heal- 
ing. (On  Injuries  of  the  Intestines,  fyc.  p. 
1 12,  113.) 

Let  us  now  inquire  what  ought  to  be  the 
conduct  of  a surgeon,  should  he  be  called 
to  a patient,  whose  bowel  is  divided  through 
Its  whole  cylinder,  and  protruded  out  of  the 
external  wound. 

Various  have  been  the  schemes  and  pro- 
posals for  the  treatment  of  this  sort  of  acci- 
dent; and  since  experience  has  furnished 
few  practitioners  with  an  opportunity  of 
seeing  such  a case  in  the  human  subject,  a 
variety  of  experiments  have  been  made  on 
animals,  in  order  to  determine  what  treat- 
ment would  be  the  most  successful.  Ram- 
dohr,  indeed,  is  stated  by  Moebius  to  have 
had  occasion  to  try  on  the  human  subject  a 
plan,  of  which  a vast  deal  has  been  said  and 
written.  He  cut  off  a large  part  of  a mor- 
tified intestine,  and  joined  the  two  sound 
ends  together,  by  inserting  the  upper  within 
the  lower  one,  and  fixing  them  in  this  posi- 
tion with  a suture,  the  ligature  being  also 
employed  to  keep  them  at  the  same  time 
near  the  external  wound.  The  patient  re- 
covered, and  the  feces  continued  to  pass 
entirely  by  the  rectum  in  the  natural  way. 
(See  Halleri  Disput.  Anat.  Vol.  6,  Obs.  Med. 
Miscdlan.  18.) 

About  a year  after  the  operation,  the 
patient  died,  when  the  anatomical  prepara- 
tion of  the  parts  was  sent  to  Ramdohr  by 
Heister.  They  were  preserved  in  spirits  of 
wine,  and  exhibited,  according  to  the  latter 
author,  an  union  of  the  two  ends  of  the 
bowel  together,  and  their  consolidation  ivilh 
a part  of  the  abdomen.  Now  it  has  been 
questioned  by  a late  writer,  whether  the 
union  here  spoken  of  ever  really  happened. 
When  the  upper  end  of  the  bowel  is  intro- 
duced into  the  lower,  the  external  surface 
of  the  former  is  put  in  contact  with  the 
inner  one  of  the  latter;  a serous  membrane 
is  placed  in  contact  with  a mucous  one. 
These  heterogeneous  structures,  he  alleges, 
are  not  disposed  to  unite.  The  mucous 
membrane,  when  inflamed,  more  readily 
secretes  h kind  of  mucus,  which  would  be 


an  invincible  obstacle  to  adhesion.  He 
thinks  it  therefore  more  than  probable,  that,, 
in  the  case  related  by  Heister,  the  invagi- 
nation was  maintained  by  the  union  of  the 
intestine  with  the  corresponding  part  of  the 
abdominal  parietes.  Several  experiments 
on  living  animals  have  convinced  him  that 
this  happens,  ana  that  the  mucous  mem- 
brane will  not  unite  with  the  external  peri- 
toneal coat.  This  impossibility  of  produ- 
cing an  immediate  union  between  the  mu- 
cous and  serous  membranes  may  of  course 
be  urged  as  an  objection  to  Ramdohr’s 
practice.  (Richer and,  Nosographie  Chir.  T. 
3,  p.  344,  345,  Edit.  4.)  Another  equally 
strong  objection  is,  that  the  upper  end  of 
the  bowel  cannot  be  put  into  the  lower 
one,  unless  it  be  separated  from  a part  of 
the  mesentery.  Here  the  division  of  the 
mesenteric  arteries  may  cause  a dangerous 
bleeding.  In  vain  did  Boyer  tie  seven  or 
eight  of  these  vessels  : his  patient  died  with 
an  extravasation  in  the  abdomen.  ( Riche- 
rand ’,  T 3,  p.  343,  Edit.  4.) 

Moebius  attempted  to  repeat  Ramdohr’s 
operation  upon  a dog;  but  he  could  not 
succeed  in  insinuating  the  upper  part  of  tho 
divided  bowel  into  the  lower  one,  on  ac- 
count of  the  contraction  of  the  two  ends  of 
the  intestinal  tube,  and  the  smallness  of  the 
canal.  Moebius,  therefore,  was  obliged  to 
be  content  with  merely  bringing  the  ends  of 
the  bowel  together  with  a suture  : the  ani- 
mal soon  afterward  died  of  an  extravasa- 
tion of  the  feces. 

Dr.  Smith,  of  Philadelphia,  also  tried  to 
repeat  Ramdohr’s  method,  but  could  not 
succeed.  He  divided  the  intestine  of  a dog 
transversely,  and  having  inserted  a piece  of 
candle  into  that  portion  of  the  bowel,  which 
was  supposed  to  be  uppermost,  he  endea- 
voured to  introduce  the  superior  within  the 
inferior;  but  the  ends  became  so  inverted, 
that  it  was  found  utterly  impossible  to  suc- 
ceed. The  scheme  was  therefore  given  up, 
and  only  one  stitch  made,  the  ligature 
being  then  attached  to  the  external  Wound, 
in  the  manner  advised  by  Mr.  John  Bell. 
The  dog  died,  and  on  examination  there 
was  found  a considerable  quantity  of  feces 
and  water  in  the  abdominal  cavity. 

Two  more  trials  were  made  of  Mr.  John 
Beil’s  plan,  by  Dr.  Smith,  on  the  intestines 
of  dogs.  In  both  instances  the  animals 
died,  the  intestines  being  much  inflamed, 
and  feces  effused  in  the  abdomen.  (See 
Dr.  Smith's  Thesis.) 

Mr.  Travers  likewise  tried  the  same  ex- 
periment. <{  1 divided  the  small  intestine  of 
a dog,  whTch  had  been  for  some  hours  fast- 
ing, and  carried  a fine  stitch  through  the 
everted  edges,  at  the  point  opposite  to  their 
connexion  with  the  mesentery.  The  gut 
was  then  allowed  to  slip  back,  and  the 
wound  was  closed.  The  animal  survived 
only  a few  hours.  Examination.  The  pe  - 
ritoneum appeared  highly  inflamed.  Adhe- 
sions were  formed  among  the  neighbouring 
folds,  and  lymph  was  deposited  in  masses 
upon  the  sides  of  the  wounded  gut.  This 
presented  two  large  circular  orifices.  Among 


684 


WOUNDS. 


the  viscera  were  found  a quantity  of  bilious 
fluid,  and  some  extraneous  substances,  and 
a worm  was  depending  from  one  of  the 
apertures.  By  the  artificial  connexion  of 
the  edges  in  a single  point  of  their  circum- 
ference, and  their  natural  connexion  at  the 
mesentery,  they  could  recede  only  in  the 
intervals,  and  here  they  had  receded  to  the 
utmost.”  In  another  experiment,  Mr.  Tra- 
vers increased  the  number  of  points  of 
contact,  by  placing  three  single  stitches 
upon  a divided  intestine,  cutting  away  the 
threads,  and  returning  the  gut.  The  animal 
died  on  the  second  day.  Examination. 
Similar  marks  of  inflammation  presented 
themselves.  The  omentum  was  partially 
wrapped  about  the  wound  ; but  one  of  the 
spaces  between  the  sutures  was  uncovered, 
and  from  this  the  intestinal  fluids  had  esca- 
ped. On  cautiously  raising  the  adhering 
omentum,  the  remaining  stitches  came  into 
view.  Here  again  the  retraction  was  con- 
siderable, and  the  intervening  elliptical 
aperture  proportionally  large.  On  the  side, 
next  to  the  peritoneum,  however,  the  edges 
were  in  contact  and  adhered,  so  as  to  unite 
the  sections  at  an  angle. 

From  such  experiments,  the  conclusion 
drawn  by  Mr.  Travers  is,  that  apposition  at 
a point  or  points,  is,  as  respects  effusion, 
more  disadvantageous  than  no  apposition  at 
all  ; for  it  admits  of  retraction  and  prevents 
contraction,  so  that  each  stitch  becomes  the 
extremity  of  an  aperture,  the  area  of  which 
is  determined  by  the  distance  of  the  stitches. 
(P.  116,  119.)  This  gentleman  therefore 
maintains,  that  the  absolute  contact  of  the 
everted  surfaces  of  a divided  intestine,  in 
their  entire  circumference,  is  requisite  to  secure 
the  animal  from  the  danger  of  abdominal 
effusion.  (P.  121.)  The  species  of  suture 
employed  (says  Mr.  Travers)  is  of  second- 
ary importance,  if  it  secures  this  contact. 
(P.  134.)  And  among  other  observations, 
I find  “ wounds  amounting  to  a direct  divi- 
sion of  the  canal  are  irreparable,  and  there- 
fore invariably  fatal.”  (P.  133.) 

These  inferences  do  not  appear  to  me 
satisfactorily  established.  We  are  told,  that 
apposition  at  a point  or  points  is,  as  respects 
effusion,  more  disadvantageous  than  no  ap- 
position at  all,  and  that  the  absolute  con- 
tact of  the  divided  surfaces,  in  their  entire 
circumference,  is  requisite  to  secure  the 
animal  from  the  danger  of  abdominal  effu- 
sion. The  foundation  of  these  unqualified 
conclusions  is  five  experiments  made  on 
dogs,  in  four  of  which  experiments  the  di- 
vided bowel  was  brought  together  with  one 
stitch,  on  Mr.  John  Bell’s  plan,  while  in 
another  three  stitches  were  made  ; and  yet, 
in  all  these  instances,  the  animals  died  with 
the  contents  of  the  bowels  effused.  So  far 
the  inferences  seem  established.  Unfortu- 
nately for  their  stability,  however,  Mr. 
Travers  immediately  afterward  proceeds  to 
relate  other  experiments,  instituted  by  Sir 
Astley  Cooper,  Dr.  Thomson,  and  Dr. 
Smith,  which,  though  Mr.  Travers  seems 
unaware  of  the  fact,  tend  Piost  completelv 


to  overturn  the  conclusions,  which  he  had 
been  previously  making. 

“ Sir  A.  Cooper  repeated  the  experiments 
of  Duverger,  who  had  succeeded  in  uniting 
by  suture,  the  divided  intestine  of  a dog,  in- 
cluding in  it  a portion  of  the  trachea  of  a calf. 
In  place  of  the  uninterrupted  suture,  three 
distinct  stitches  were  inserted.  On  the  six- 
teenth day  the  animal  was  killed,  and  the 
union  was  complete.”  (P.  123.) 

Here  are  two  facts,  proving  diat  a wound- 
ed intestine  may  be  united,  though  the  suture 
was  not  such  as  to  maintain  the  divided  sur- 
faces in  contact,  in  the  whole  of  their  cir- 
cumference. 

Sir  Astley  Cooper  then  made  the  experi- 
ment, without  including  the  foreign  sub- 
stance. The  animal  recovered,  being  a 
third  fact,  tending  to  prove,  that  the  absolute 
contact  of  every  point  of  the  ends  of  the 
divided  bowel  is  not  essential  to  the  cure. 
(See  A.  Cooper  on  Inguinal  and  Congenital 
Hernia,  Chap.  2.) 

After  dividing  the  small  intestine  of  a dog. 
Dr.  John  Thomson,  of  Edinburgh,  applied 
five  interrupted  stitches,  at  equal  intervals, 
the  ends  of  the  ligatures  were  cut  off,  and 
the  external  wound  was  closed  with  a su- 
ture. This  animal  did  not  die  of  the  opera- 
tion, and  when  he  was  afterward  killed,  it 
appeared  that  the  threads  had  made  their 
way  into  the  interior  of  the  intestinal  canal. 
Dr.  Thomson  repeated  this  experiment,  and 
did  not  kill  the  animal  till  six  weeks  after- 
ward, when  the  same  tendency  of  ligatures 
to  pass  into  the  bowels,  and  be  thus  dischar- 
ged, was  exemplified. 

These  two  last  cases  make  five,  in  proof 
that  the  absolute  contact  of  every  part  of 
the  ends  of  a divided  bowel  is  not  essentia? 
to  prevent  effusion,  or  the  cen§equences  of 
the  wound  from  proving  fatal ; and  several 
other  experiments  were  made  by  Dr.  Smith, 
of  Philadelphia,  who  employed  four  stitches 
with  similar  success. 

As  far  then  as  the  majority  of  such  facts 
ought  to  have  weight,  we  are  bound  to  re- 
ceive the  conclusions  of  Mr.  Travers  as  in- 
correct, and  unestablished.  I am  only  sur- 
prised, that  Mr.  Travers  himself,  who  has 
cited  the  particulars  of  all  these  last  experi- 
ments, did  not  perceive,  that  they  struck  di- 
rectly at  his  own  inferences.  They  are  not 
only  irresistible  arguments  against  Mr.  Tra- 
vers’s conclusion,  that  the  union  of  a divided 
bowel  requires  the  contact  of  the  cut  extre- 
mities in  their  entire  circumference;  but 
they  are  a plain  denial  of  another  position 
advanced  by  this  author,  viz.  that  wounds 
amounting  to  a direct  division  of  the  canal, 
are  irreparable,  and,  therefore,  invariably 
fatal. 

With  respect  to  the  species  of  suture  be- 
ing of  secondary  importance,  provided  it 
secure  the  complete  contact  of  every  part 
of  the  everted  ends  of  the  divided  bowel,  I 
regret,  that  Mr.  Travers  has  omitted  to  insti- 
tute experiments,  in  order  to  show  that  any 
such  suture  can  be  practised,  and  if  he  has 
the  ingenuity  to  apply  it,  whether  the  result 
would  be  for  or  against  the  conclusions 


WOUNDS, 


which  he  has  formed.  The  lact  of  the  su- 
tures always  making  I heir  way  into  the  cavi- 
ty of  the  bowel,  and  being  thus  got  rid  of, 
appears  to  me  highly  interesting,  since  it 
shows  the  safety  of  cutting  away  the  ends 
instead  of  leaving  them  hanging  out  of  the 
external  wound,  so  as  to  creale  the  usual  ir- 
ritation and  inconveniences  of  extraneous 
substances.  It  seems  that  Mr. Benjamin  Bell 
first  recommended  cutting  the  ends  of  the  li- 
gatures away,  and  reducing  the  bowel  in  this 
state  into  the  abdomen,  as,  he  says,  a con- 
siderable part  of  the  remainder  of  the  liga- 
ture will  fall  into  the  cavity  of  the  gut.  ( Sys- 
tem of  Surgery,  Vol.  2,  p.  128,  edit.  7.)  We 
have  seen  that  the  experiments  of  Dr.  Thom- 
son confirm  the  observation,  and  those  insti- 
tuted by  Mr.  Travers,  tend  to  the  same  con- 
clusion. 

According  to  the  latter  writer,  the  follow- 
ing is  the  process,  by  which  a divided  intes- 
tine is  healed,  when  sutures  are  employed. 
“ It  commences  with  the  agglutination  of 
the  contiguous  mucous  surfaces,  probably  by 
the  exudation  of  a fluid,  similar  to  that  which 
glues  together  the  sides  of  a recent  flesh 
wound,  when  supported  in  contact.  The 
adhesive  inflammation  supervenes,  and  hinds 
down  the  everted  edges  of  the  peritoneal 
coat,  from  the  whole  circumference  of  which 
a layer  of  coagulable  lymph  is  effused,  so  as 
to  envelope  the  wounded  bowel.  The  ac- 
tion of  the  longitudinal  fibres,  being  oppo- 
sed to  the  artificial  connexion,  the  sections 
mutually  recede,  as  the  sutures  loosen  by 
the  process  of  ulcerative  absorption.  During 
this  time,  the  lymph  deposited  becomes  or- 
ganized, by  which  further  retraction  is  pre- 
vented, and  the  original  cylinder,  with  the 
threads  attached  to  it,  is  encompassed  by  the 
new  tunic. 

“ The  gut  ulcerates  at  the  points  of  the 
ligatures,  and  these  fall  into  its  canal.  The 
fissures  left  by  the  ligatures,  are  gradually 
healed  up;  but  the  opposed  villous  surfaces, 
so  far  as  my  observation  goes,  neither  ad- 
here, nor  become  consolidated  by  granula- 
tion, so  that  the  interstice,  making  the  divi- 
sion internally, is  probably  never  obliterated.” 
(Travers  on  Injuries  of  the  Intestines , fyc.  p. 
12S.) 

Notwithstanding  I have  carefully  read  all 
the  arguments  adduced  by  Mr.  Travers  in 
favour  of  stitching  a divided  bowel  at  as 
many  points  as  possible,  I still  remain  un- 
convinced of  the  advantage  of  such  practice, 
for  reasons  already  suggested.  If  a case 
were  to  present  itself  to  me,  in  which  a 
bowel,  partly  cut  through,  protruded,  l 
should  apply  only  a single  suture,  made  with 
a small  sewing-needle,  and  a piece  of  fine 
silk.  If  the  bowel  were  completely  cut 
across,  I should  have  no  objection  to  attach 
its  ends  together  by  means  of  two  or  three 
stitches  of  the  same  kind.  I coincide  with 
Mr.  Travers,  respecting  the  advantage  of 
cutting  off  the  ends  of  the  ligature,  instead 
of  leaving  them  in  the  wound,  as  I believe 
he  is  right,  in  regard  to  the  little  chance  there 
is  of  the  injured  intestine  receding  far  from 
the  wound,  and  if  the  ends  of  the  ligature 


&& 

are  then  of  no  use  in  keeping  the  bowel  in 
this  position,  they  must  be  objectionable,  as 
extraneous  substances. 

As  confirming  some  of  the  foregoing  ob- 
servations, I would  refer  to  the  valuable  wri- 
tings of  Scarpa,  and  those  of  Dr.  Hennen. 
The  parts  of  the  former,  to  which  I allude, 
being  contained  in  the  last  edition  of  the 
First  Lines  of  Surgery,  need  not  here  be  re- 
peated. u The  older  practitioners,  (says  Dr. 
Hennen,)  were  very  much  averse  from  leav- 
ing any  thing  to  nature  in  cases  of  abdomi- 
nal injuries,  although  their  universal  em- 
ployment of  sutures  ought  to  have  convinced 
them,  bow  much  she  could  bear  with  impu- 
nity; for  there  can  be  very  little  doubt,  that 
their  uniform  performance  of  the  operation 
of  gastroraphe  was  at  least  superfluous,  if  not 
positively  hurtful.  In  the  course  of  a very 
extensive,  practice,  two  cases  only  have  come 
under  my  notice,  where  if  was  required  to  a 
wounded  intestine,  though  frequently  it  may 
be  needed  for  injuries  to  the  parietes.”  (On 
Military  Surg.  ed  2,  p 411.) 

When  the  protruded  intestine  is  mortified, 
which  must  be  a very  rare  occurrence  in 
cases  of  wounds,  the  treatment  should  be  the 
same  as  (hat  of  a mortified  enterocele.  (See 
Hernia.) 

As  Dr.  Hennen  observes,  in  the  treatment 
of  wounds  of  the  abdomen,  the  violence  of 
sypmtom  • is  to  be  combated  more  by  gene- 
ra! means,  than  by  any  of  the  mechanical 
aids  of  surgery.  The  search  for  extraneous 
bodies,  unless  superficially  situated,  or  they 
can  be  felt  with  a probe,  is  entirely  out  of 
the  question.  “ Enlargement,  or  contrac- 
tion of  the  wound,  as  the  case  may  require, 
for  returning  protruded  intestine,  securing 
the  intestine  itself,  and  promoting  the  ad- 
hesion of  the  parts,  is  all  that  the  surgeon 
must  do  in  the  way  of  operation ; and 
even  in  this,  the  less  he  interferes  the 
better.”  (On  Military  Surgery,  ed.  2 p 
401.) 

The  principal  indicat  ion  is  to  prevent  n 
dangerous  degree  of  inflammation.  Hence 
bleeding  and  the  antiphlogistic  treatment 
are  highly  indispensable.  Let  not  the  sur 
geon  be  deterred  from  such  practice  by  the 
apparent  debility  of  the  patient,  hi^  smalt 
concentrated  pulse,  and  the  coldness  of  bis 
extremities,  symptoms  common  in  acute  in- 
flammation of  the  bowels,  and,  in  fact,  them- 
selves, indicating  the  propriety  of  repeated 
venesection.  Wounds  of  the  small  intes- 
tines are  attended  with  more  dangerous 
symptoms  than  those  of  the  large  ones.  AH 
flatulent,  stimulating,  and  solid  food,  is  to 
be  prohibited.  The  bowels  are  to  be  daily- 
emptied  with  glysters,  by  which  means,  no 
matter  will  be  suffered  to  accumulate  in  the 
intestinal  canal,  so  as  to  creale  irritation  and 
distention. 

When  excrementitious  matter  is  discharged 
from  the  outer  wound,  it  is  highly  necessarv 
to  clean  and  dress  the  part  very  frequentl)* 
Gentle  pressure  should  also  be  made  with 
the  fingers,  at  the  circumference  of  (ha 
vvouud,  at  each  time  of  applying  the  dress- 
ings, for  the  purpose  of  promoting  the  es* 


WOUNDS. 


&80 


cape  of  any  exlravasated  matter.  For  (be 
same  reason,  the  patient  should  always  lie, 
if  convenient,  in  a posture  that  will  render 
the  external  opening  depending. 

After  a day  or  two,  the  surgeon  need  not 
be  afraid  of  letting  the  outward  wound  heal 
up;  for  the  adhesive  inflammation,  all  around 
the  course  of  the  wound,  will  now  prevent 
any  extravasated  matter  from  becoming  dif- 
fused among  the  viscera.  If  the  case  should 
ond  well,  the  intestine  generally  undergoes 
a diminution  in  its  diameter  at  the  place 
where  the  wound  was  situated.  When  this 
contraction  is  considerable,  the  patient  oc- 
casionally experiences  colic  pains  at  the  part, 
especially  after  eating  such  food  as  tends  to 
produce  flatulence.  As  these  pains  usually 
go  entirely  off  after  a certain  time,  and  no 
inconvenience  whatsoever  remains,  the  in- 
testine may  possibly  regain  its  wonted  capa- 
city again.  A more  considerable  constric- 
tion of  the  above  sort  has  been  known  to 
occasion  a fatal  miserere.  Even  the  intes- 
tine itself  has  been  known  to  burst  in  this 
situation,  after  its  contents  had  accumulated 
behind  the  contracted  part.  Patients  who 
have  recovered  from  wounds  in  the  intes- 
tines, should  ever  afterward  be  particularly 
careful  not  to  swallow  any  hard  substances, 
or  indigestible  flatulent  food.  On  this  sub- 
ject the  writings  of  Scarpa  are  particularly 
interesting. 

In  some  instances,  intestinal  matter  con- 
tinues to  be  discharged  from  the  outer 
wound,  either  in  part,  or  entirely,  so  that 
either  a fistula,  or  an  artificial  anus,  is  the 
consequence.  A fistula  is  more  apt  to  fol- 
low, when  an  intestine  has  been  injured  by 
a ball,  has  been  quite  cut  through,  or  has 
mortified.  But  numerous  cases  prove,  that 
this  is  not  invariably  the  consequence,  and 
that  a perfect  cure  has  frequency  followed 
each  of  these  occurrences.  (See  Amis,  Arti- 
ficial.) 

When  an  intestine  is  completely  cut 
through,  and  the  lower  portion  of  the  canal 
lies  inaccessibly  concealed  in  the  abdomen, 
writers  insist  upon  the  necessity  of  promoting 
the  formation  of  an  artificial  anus.  In  this 
particular  case,  they  recommend  fixing  the 
extremity  of  the  intestine  with  a fine  suture, 
to  the  edges  of  the  outer  wound.  In  order 
to  distinguish  the  upper  end  of  the  intestine 
from  the  lower,  the  proposal  is  sometimes 
made  to  give  the  patient  a little  milk,  and  to 
observe  whether  the  fluid,  after  a time,  issues 
from  the  mouth  of  the  protruded  gut.  In 
the  mean  while  fomentations  are  employed. 
If  the  upper  end  of  ihe  intestine  be  in  the 
abdomen,  these  speculative  authors  even 
deem  it  justifiable,  when  the  accident  is 
quite  recent,  to  dilate  the  outer  wound, 
search  for  the  hidden  continuation  of  the 
bowel,  and  then  sew  the  two  ends  together. 

Practical  surgeons,  I believe,  are  right  in 
attaching  little  value  to  such  directions. 
“ Indeed,  (says  a modern  writer,)  the  surgi- 
cal world  have  long  since  dismissed  their 
feurs  about  the  intestine  falling  inwards,  and 
about  the  difficulties  of  distinguishing  be- 
i ween  the  right  and  the  wrong  end  of  it 


The  apprehensions  of  abdominal  effusion? 
are  now  all  pretty  well  subdued.  The  occur 
rence  is  extremely  rare,  and  when  it  does 
happen,  we  leave  the  poor  wretch  to  die  in 
peace,  without  searching  after  effused  fluids, 
the  nature  of  which  cannot  be  known,  or  if 
known,  the  information  canno‘  in  the  most 
remote  degree  lead  to  recovery.  I have 
never  witnessed  a case  where  any  possible 
good  effects  could  follow  the  paracentesis; 
for  peritonitis,  in  its  most  exquisite  form, 
has  always  preceded  the  symptoms  which 
would  lead  to  the  performance  of  that  ope- 
ration.” ( Hennen  on  Military  Surgery,  Ed, 

2,  MU  ) 

In  some  instances,  musket-balls  pass  into 
the  abdomen,  lodge  there  a considerable 
time,  and  are  tiien  voided  through  the  in- 
testinal canal ; while,  in  other  examples, 
they  become  encysted,  and  continue  lodg- 
ed (he  rest  of  the  patient’s  life,  without 
producing  much,  or,  indeed,  any  inconve- 
nience. 

Contusions  and  other  Injuries  of  the  Ab- 
domen.— A violent  contusion  of  the  abdo- 
men may  injure  the  contained  viscera,  with- 
out the  occurrence  of  any  external  wound. 
It  was  in  this  way,  that  the  liver  or  gall- 
bladder was  ruptured  in  the  boy  mentioned 
by  Mr.  Fryer,  (Med.  Chir.  Trans.  Vol.  4 ;) 
and  that  the  vena  cava  was  lacerated  in 
the  case  which  fell  under  the  observation  of 
Richerand,  where  a cart-wheel  passed  over 
child’s  belly.  (Koso^raphie  Chir.  T.  3,  p. 
353.)  In  other  instances,  the  mischief  is 
done  to  the  intestines ; and  still  more  fre- 
quently, the  viscera,  as  well  as  the  parietes 
of  the  abdomen,  have  only  suffered  a more 
or  less  forcible  contusion.  The  effects  of 
such  violence,  are  inflammation  of  the  in- 
jured bowels,  and  their  adhesion  to  the  in- 
side of  the  peritoneum.  Thus  the  stomach 
and  intestines,  the  liver,  and  the  gall-blad- 
der, wThen  inflamed  from  a blow  upon  the 
front  of  the  belly,  contract  adhesions  to  Ihe 
corresponding  portion  of  the  parietes,  which 
has  been  also  bruised,  and  is  itself  inflamed. 
When  such  inflammations  suppurate,  (and, 
according  to  Richerand,  it  is  their  most  usu- 
al course,)  on  opening  the  abscess,  the  pus  is 
found  blended  with  the  matter,  which  the 
viscera  contain  or  secrete.  Thus  the  alimen- 
tary matter,  and  even  intestinal  worms  have 
been  discharged  with  the  pus  on  opening 
certain  abscesses,  which  communicated  with 
the  cavity  of  the  stomach  or  bowels  ; and 
bile  has  been  found  blended  with  the  mat- 
ter of  abscesses  in  the  right  hypochondri- 
um. 

When  in  consequence  of  a blow  upon  the 
anterior  part  of  the  belly,  the  patient  expe- 
riences in  the  situation  of  the  injury  a deeply- 
seated  pain  ; wdien  a tumour  forms,  and  the 
symptoms  indicate  violence  done  to  some  of 
the  adjacent  viscera  ; the  inflammation  is  to 
be  opposed  by  every  possible  antiphlogistic 
means.  But  when,  notwithstanding  such 
treatment,  the  swelling  increases  and  suppu- 
rates, the  abscess  is  not  to  be  opened  until  it 
is  perfectly  mature.  The  inflammatory  symp- 
toms, which  preceded  its  formation,  indicate 


WOUJN’DH. 


63 


vhat  there  is  an  adhesion  between  the  in- 
jured organ  and  the  parietes  of  the  abdomen. 
Without  this  adhesion,  opening  the  abscess 
would  be  attended  with  more  risk,  because 
the  pus,  or  other  matter,  might  become  ex- 
travnsated  in  the  cavity  of  the  peritoneum. 
For  the  same  reason,  in  the  examples  of  tu- 
mours, caused  by  bile  in  the  gall  bladder,  J. 
L.  Petit  recommends  deferring  the  opera- 
tion of  opening  them,  until  the  inflammatory 
symptoms  evince,  that  an  adhesion  has  taken 
place  between  the  fundus  of  the  gall  bladder, 
and  the  corresponding  point  of  the  parietes 
of  the  abdomen. 

An  adhesion  of  the  abdominal  viscera  to 
the  inner  surface  of  the  peritoneum  may  be 
induced  by  other  causes,  besides  the  action 
of  contusing  bodies.  A knife,  a fork,  a 
shoemaker's  awl,  a needle,  and  other  extra- 
neous substances  incapableof  passing  through- 
out the  alimentary  canal,  have  been  known 
to  irritate  the  stomach,  or  bowel,  and  to 
bring  on  adhesion  of  them  to  the  parietes  of 
the  abdomen,  where  a tumour  has  formed, 
which,  on  being  opened,  has  discharged  the 
foreign  body.  The  records  of  surgery 
abound  in  facts  of  this  kind.  A fistula  suc- 
ceeds the  opening  of  the  abscess  ; the  ali- 
mentary matter  escapes ; and  if  the  aper- 
ture admit  not  of  beiug  healed  by  methodi- 
cal compression,  the  intestinal  canal  between 
the  fistula  and  the  anus  contracts  ; most  of 
the  contents  of  the  bowels  pass  out  at  the 
preternatural  opening,  and  the  patient  falls 
into  a state  of  marasmus,  the  more  quickly 
fatal,  the  nearer  the  injury  of  the  intestinal 
canal  is  to  the  stomach. 

A long-continued  pressure  on  the  epigas- 
tric region  may  cause  an  adhesion  of  the 
stomach  to  the  peritoneum,  and  suppuration 
taking  place  at  the  part,  a fistula,  communi- 
cating with  the  cavity  of  that  organ,  may  be 
formed,  and  allow  the  victuals  to  escape  ex- 
ternally. (See  Richer  and,  Physiologic,  T.  1. 
Chymijication  : A osographie  Chirurg.  T.  3 ,p. 
353 — 356,  Ed.  4.) 

I shall  conclude,  with  repeating,  that  in 
the  generality  of  injuries  of  the  abdomen 
from  external  violence,  whether  wounds  or 
contusions,  the  principal  danger  depends 
upon  inflammation  of  the  peritoneum.  In 
the  treatment,  therefore,  the  most  necessary 
thing  is  to  prevent  and  oppose  this  perilous 
affection.  Copious  and  repeated  venesec- 
tion, the  application  of  leeches,  mild  ape- 
rient clysters,  a low  fluid  diet,  perfect  rest, 
fomentations, and  the  warm  bath,  are  among 
the  most  effectual  antiphlogistic  remedies, 
which,  in  such  cases,  are  entitled  to  praise 
and  confidence. 

For  information  on  wounds  of  the  abdo 
men,  see  Flajani,  Osservazioni,  fyc.  T.  3.  A. 
Malaval  Qucestio,  fyc.  an  tenuium  inlesti- 
norum  vuluus  letkale  ? Paris,  1734.  fVcncker , 
Virginis  per  viginti  septem  annos  ventriculum 
perforatum  habentis,  Hisloria  et  Sedio,  Ar- 
gent. 1743.  Haller,  Disp.  Chir  6 — 19. 
Callisen's  Systema  Chirurgice  Hodiernee,  T. I, 
p.  697,  fyc.  Edit.  1798,  Hafnice.  Richerand, 
Nosogr.  Chir.  T.  3,  p.  327,  fyc.  Edit.  4. 
Med  Chir.  Trans.  Vof.  4,p.  330.  J.  Cromp- 


ton's Case  of  Rupture  of  the  Stomach  and 
Escape  of  its  Contents,  fyc.  with  Obs.  by  B. 
Travers , in  Med.  and  Chir.  Trans.  Vol.  8,  p. 
228,  fyc.  Richter,  Anfangsgriinde  der  IV un - 
darzneykunst,  B.  5,  Kap.  1.  Discourses  on 
tht  Nature  and  Cure  of  Wounds,  by  John 
Bell , Edit.  3.  L.  Nahnoni , De  Simiiium par- 
tium  humanum  corpus  consiituteniium  rege- 
nera tiont,  Mediolani.  1782.  Encyclopidie 
Methodique,  Partie  Chir.  Art.  Abdomen  et 
Intestins.  Dr.  Smith’s  Inaugural  Thesis. 
B.  Travers,  an  Inquiry  into  the  Process  of 
Nature.  in  repairing  Injuries  of  the  Intes- 
tines, 8 vo.  1812.  J.  Hunter  on  Gunshot  Wounds. 
Sir  A.  Cooper’s  work  on  Inguinal  and  Conge- 
nital Hernia,  Chap.  2,  fol.  1804.  Sabatier, 
Midecine  Op&ratoire,  T.  1.  Petit,  Essai  sv.r 
Its  Epanchemens,  fy  Suite  de  V Essai  sur  les 
Epanchemens,  in  M6m.  de  I’Acad.  de  Chir. 

For  information  on  wounds  in  general,  sec 
Coes.  Magatus,  De  Rara  Medicalione  Vul- 
nerum,  seu  de  Vulneribus  raro  tractandis , fol. 
Ven.  1616.  A.  Read,  his  Works,  containing , 
1.  Lectures  on  Tumours  and  Ulcers.  2.  A 
Treatise  of  the  first  Part  of  Chirurgery,  which 
teacheth  the  reunilion  of  the  parts  of  the  Body 
disjointed,  arid  the  methodical  doctrine  of 
Wounds,  fyc.  2d  Edit.  8vo.  Loud.  1650.  Wer- 
ner, De  Vulneribus  absolute  et  per  accident  le- 
thalibus,  Regiom.  1650.  J.  Bohn,  De  rtnun- 
ciatione  Vulnerum  ; seu  Vulnemm  Lethalium 
Examen , 12mo.  Lips.  1689.  P.  Ammannus , 
Praxis  Vulnerum  lethalium,  fyc.  12 mo.  Fran - 
cof.  1690.  ./.  Colbatch,  New  Light  of  Sur- 
gery, showing  a more  safe  and  speedy  way  of 
curing  Wounds,  thati  has  hitherto  been  prac- 
tised, 12 mo.  Lond.  1695.  Ph.  Com.  Fabri ♦ 
civs,  Programma  quo  causae  injr^quentice  vul- 
nerum lethalium,  pree  minus  lethiferi  sexfab- 
rica  corporis  human!  anatomica , el  situpartium 
praecipue  eruuntur,  Ilelmstad.  1753.  John 
Hunter,  a Treatise  on  the  Blood,  Inf  animation, 
fyc.  John  Bell’s  Principles  of  Surgery,  and 
his  Discourses  on  Wounds.  W.  Balfour,  Ob- 
servations on  Adhesion , with  two  Cases,  de- 
monstrative of  the  Powers  of  Nature  to  re- 
unite parts , which  have  been  totally  separated 
from  the  animal  System,  8 vo.  Edinb.  1814. 
Larrey , M6moires  de  Chirurgie  Militaire, 
Memoir es  et  i rix  de  V Academic  Royale  de. 
Chirurgie.  Sabatier,  Mcdecine  Oplraloire. 
Assalini,  Manuale  di  Chirurgia ; Milano , 
1812.  Richerand,  Nosogr.  Chir.  Ed.  4.  Boyer , 
Trait 6 des  Maladies  Chir.  T.  1.  Delpech , 
Precis  des  Maladies  Reputtes  Chirurgicales , 
T.  1.  Sclimucker , Wahrnehmungen  und  Chi- 
rurgische  Schriften.  Lombard,  Instruction  Som 
maire  sur  VArl  des  Pansemens,  8ro.  Stras- 
bourg. 1797.  Also,  Clinique  Chirurgicale 
relative  aux  plaies,  8vo.  Strusb.  an.  6.  Guth- 
rie. oi.  Gunshot  Wounds.  2d  Edit.  Jones,  on 
Hemorrhage.  Schreger,  Chirurgische  l er- 
siiche,  B 2.  p.  260,  fyc.  8 vo.  Nurnberg.  1818. 
Thomson's  Lectures  on  Inflammation,  8 vo. 
1813;  and  his  Report  and  Obs.  made  in  the 
Military  Hospitals  in  Belgium,  Sro.  1816.  J. 
Hennen’s  Military  Surgery,  Ed.  2,  8ro.  Ed  in. 
1820;  and  the  various  Works  cited  in  the 
course  of  this  article,  and  at  the  conclusion  of 
that  on  Gunshot  Wounds.  For  information 
on  poisoned  wounds,  consult  F.  Re&,  Osser* 


BOUNDS 


■tibS 


vasioni  inlorno  alle  Vipere.  Firenze,  1664. 
M.  Charas,  Nouvelles  Experiences  sur  la 
Vipere , 4 to.  Paris,  1669.  Also,  a Reply  to 
Redi's  Letter,  concerning  Vipers.  12 mo.  Lond. 
1673.  Stanford  Wolf erstan.  Inquiry  into  the 
Causes  of  Diseases  in  General , fyc.  Also,  of 
the  Venom  of  Vipers,  12 mo.  Lond.  1692.  A. 
Moureau  de  Jonn6s  Monographic  dn  Trigono- 
ciphale.  des  Antilles  ou  Grand  Vipere  Fer-de 
Lance  de  la  Martinique,  Par  8 vo.  1816.  A. 
Vater.  et  F Gensler,  de  Antidolo  JYovo  ad- 
verms  viper  arum  morsum,  prcesentissimo  in 
Anglia  hand  ita  pridem  delecto ; Witlemb. 
1736.  ( Haller , Disp.  ad  Morb.  6,  693.)  J.  E. 
Bertin  et  J.  F.  C.  Morand,  Thesis  in  here 
verba , ergo  Specijicum  Viperce  Morsus  antido- 
tum  Alkali  Volatile,  in  Haller's  Disp.  ad 
Morb.  6,611,  Paris.  1 749.  Catesby's  Hist, 
of  Carolina.  Mead  on  Poisons.  Fontana , on 
the  Venom  of  the  Viper.  Acrel  de  Morsura 
Serpentum,  4 to.  Upsal.  1762.  Russell , on 
Indian  Serpents  Ireland,  in  Med.  Chir. 
Trans.  Vol.2.  Sir  E.  Home,  in  Phil.  Trans. 
1810. 

WRY-NECK.  ( Caput  Obslipum ; Torti- 
collis.) An  involuntary  and  fixed  inclina- 
tion of  the  head  towards  one  of  the 
shoulders  ; a disorder  not  spoken  of  by  the 
ancients.  It  should  not  be  confounded 
with  a mere  rheumatic  tension  and  stiffness 
of  the  neck,  nor  with  the  faulty  position  of 
the  head,  arising  from  deformity  of  the  cer- 
vical vertebrae. 

Tulpius,  a learned  physician  at  Amster- 
dam, about  the  middle  of  the  seventeenth 
century,  has  recorded  the  cure  of  a boy, 
twelve  years  old,  who,  from  his  earliest 
infancy,  had  had  his  head  drawn  down  to- 
wards the  left  shoulder,  by  a contraction  of 
the  scalenus  muscle.  Fomentations  were 
applied  in  vain.  The  head  could  not  be 
brought  into  the  right  posture,  even  with 
the  aid  of  steel  collars  A consultation  was 
therefore  held,  in  which  it  was  decided  to 
put  the  boy  under  the  care  of  Minnius,  a 
surgeon  who  had  performed  several  opera- 
tions with  success  in  similar  cases.  A large 
eschar  was  first  made  with  caustic  ; and  tiie 
muscle,  which  drew  the  htad  to  one  side, 
was  then  divided  with  a knife.  Tulpius, 
who  has  left  a very  confused  account  of  the 
operation,  observes  that  it  was  performed 
with  great  slowness  and  circumspection, 
for  fear  of  wounding  the  carotid  artery  and 
jugular  vein.  However,  he  offers  one  good 
piece  of  advice,  which  is,  not  to  make  any 
preliminary  application  of  caustic,  as  it 
only  causes  useless  pain,  and  cannot  be  of 
any  service.  He  also  recommends  the  ope- 
ration not  to  be  done  by  little  and  little,  at 
repeated  times  ; and  says,  that  the  surgeon 
should  make  a complete  division  of  the 
muscle  at  once,  with  the  necessary  degree 
of  caution. 

Job  k Meckren  also  treats  of  the  opera- 
tion for  the  cure  of  a wry-neck.  He  states, 
that  he  had  seen  it  performed  on  a boy, 
fourteen  years  old.  The  tendon  of  the 
sterno-cleido-mastoideus  muscle  was  skill- 
fully divided  with  one  stroke  of  a sharp  pair 


of  scissors,  by  a surgeon  named  Flurianu 
and  as  soon  as  the  incision  was  made,  the 
head  resumed  its  right  position.  ( Obs . Med. 
Chir.  C.  33.)  Mr.  S.  Sharp  believed,  that 
the  wry-neck  mostly  arose  from  a contrac- 
tion  of  the  sterno-cleido-mastoideus  muscle, 
which  he  proposed  the  division  of,  when- 
ever the  disorder  seemed  to  proceed  from 
this  kind  of  cause.  However,  he  made  an 
exception  of  cases,  in  which  the  disorder 
had  existed  a considerable  time,  or  from  in- 
fancy. He  remarks,  that,  if  the  cervical 
vertebrae  have  grown  in  a distorted  direc- 
tion, the  position  of  the  head  cannot  be 
rectified.  With  these  restrictions,  the  fol- 
lowing is  the  operation,  which  he  recom- 
mends : A transverse  incision  is  to  be 

made  through  the  skin  and  fat,  of  a size 
somewhat  more  extensive  than  the  breadth 
of  the  muscle,  and  about  one  third  of  its 
length  from  the  clavicle.  A probed  razor 
is  then  to  be  passed  underneath  the  muscle, 
and  to  be  drawn  out,  so  as  to  make  the  re- 
quisite division  of  the  part.  After  the  inci- 
sion has  been  made,  Mr.  Sharp  recommends 
the  wound  to  be  filled  with  dry  lint,  and  to 
be  always  dressed  in  a way  best  calculated 
to  keep  the  extremities  of  the  muscle  from 
growing  together  again.  For  this  purpose, 
he  directs  the  cut  ends  to  be  separated  from 
each  other  as  much  as  possible,  with  the 
assistance  of  a bandage  to  support  the  head, 
duringthe  w'hole  time  of  the  cure,  which,  he 
says,  will  generally  be  about  a month  (On 
the  Operations  of  Surgery,  Chap  35.) 

According  to  Mr  Sharp’s  account,  this 
operation  ought  to  be  common.  However, 
if  attention  be  paid  to  the  nature  and 
causes  of  the  disease,  and  to  the  differ- 
ences resulting  from  whether  the  disorder 
be  recent,  or  of  long  standing  ; constant, 
or  periodical ; idiophatic,  or  sympathetic  ; 
dependent  on  spasm,  or  merely  on  paraly- 
sis of  the  antagonist  muscles;  and,  lastly, 
if  it  be  recollected,  that  the  affection  may 
be  produced  by  other  muscles,  besides  the 
sterno-cleido  mastoideus  ; it  will  appear, 
that  cases,  in  which  the  foregoing  opera- 
tion can  be  judiciously  undertaken,  are 
not  frequent. 

With  regard  to  the  manner  in  which  Mr, 
Sharp  operated,  Mr.  B.  Bell  conceived, 
that  it  was  attended  with  hazard  of  wound- 
ing the  large  blood  vessels.  But,  though  it 
seems  to  me  better  to  use  a probe-pointed 
bistoury  and  a director,  than  the  kind  of 
razor  which  Mr.  Sharp  employed,  I do  not 
coincide  with  Mr.  B Bell  in  thinking, 
that  the  latter  surgeon’s  plan  was  at  all 
objectionable  on  the  score  of  danger,  in  re- 
spect to  wounding  the  vessels.  Some 
practitioners  may  even  think  Mr.  B.  Bell’s 
method  most  likely  to  injure  the  large  ves- 
sels; for  be  advises  the  operator  to  cut  the 
muscle  from  without  gradually  inward,  as 
deeply  as  necessary. 

Perhaps,  the  most  prudent  method  of 
operating,  is  to  divide  the  clavicular  portion 
of  the  contracted  muscle,  near  the  clavicle, 
and  even  to  cut  out  a sufficient  piece,  to  re 
move  all  chance,  of  the  twe  ends  uniting 


WRY-NECK. 


689 


again,  This  step  would  weaken  the  muscle 
considerably,  and  perhaps,  might  answer 
every  purpose.  It  could  easily  be  accom- 
plished, by  means  of  a director,  and  curved 
bistoury,  after  making  the  requisite  division 
of  the  skin  with  a common  scalpel.  Were 
this  proceeding  to  produce  only  partial 
amendment,  the  sternal  port  ion  of  the  mus- 
cle might  afterward  be  divided.  A director 
should  be  passed  under  it,  and  the  division 
made  with  a probe-pointed  curved  knife. 

Any  cause,  destroying  the  equilibrium  be- 
tween the  two  sterno-cleido-mastoidei  mus- 
cles, will  produce  a wry-neck.  Thus,  when 
one  of  them  is  affected  with  spasm,  and  acts 
more  forcibly  than  Uie  other,  it  draws  the 
head  towards  the  shoulder  of  its  own  side  ; 
but,  when  one  sterno-cleido-mastoideus  is 
paralytic,  while  the  other  retains  only  its 
natural  power,  the  balance  of  action  is 
equally  destroyed,  and  the  sound  muscle  in- 
clines the  head  toward  the  nearest  shoulder. 
Jn  paralytic  cases,  electricity,  (Phil.  Trans. 
Vol.  68,  p.  97  ; Gilby.  in  London  Med.  Journ. 
Vol.  4,  1790.)  blisters,  stimulating  liniments, 
the  shower  bath,  seh-bathing,  issues,  setons, 
the  application  of  moxa,  and  attention  to  the 
health  in  general,  are  the  means  affording 
the  best  chances  of  relief. 

Although  the  wry-neck  may  occasionally 
depend  on  the  state  of  the  sterno-cleido- 
mastoidei  muscles,  the  case  is  far  from  being 
frequent  The  deformity  is  much  oftener 
owing  to  some  affection  of  the  integuments. 
Louis  often  successfully  divided  contractions 
of  the  skin,  which  had  kept  the  head  drawn 
to  one  side  for  many  years,  and  had  been 
occasioned  by  burns.  Some  of  these  con- 
tractions, he  says,  might  easily  have  been 
mistaken  fora  part  of  the  sterno-cleido-mas- 
toideus itself. 

Mr.  Gooch  relates  a case  of  wry-neck, 
which  was  caused  by  a contraction  of  the 
platysma  myoides  muscle.  The  patient  was 
a young  gentleman,  fourteen  years  of  age, 
who  had  always  enjoyed  very  good  health 
in  every  other  respect.  For  several  months, 
his  head  had  been  strongly  drawn  to  one 
side  by  a constant  contraction  of  the  platys- 
ma myoides  muscle,  which  was  exceedingly 
rigid,  especially  about  its  insertion  at  the 
basis  of  the  jaw,  and  from  the  angle  of  the 
os  maxillare  inferius  to  the  chin,  the  skin 
presented  an  appearance  like  that  of  the 
cicatrix  of  a burn.  The  same  side  of  the 
face,  quite  from  the  point  of  the  chin,  Was 
much  shrunk,  and  distorted  by  the  contrac- 
tion of  the  muscle,  and  the  corner  of  the 
mouth,  in  particular,  was  so  drawn  to  one 
side  and  downward,  when  the  patient  turn- 
ed his  head,  that  a vast  deal  of  deformity 
was  the  consequence.  From  the  inferior 
part  of  the  eyebrow,  at  the  internal  angle  of 
the  eye,  to  near  the  top  of  the  head,  there 
was  a kind  of  furrow  upon  the  skin,  about 
half  an  inch  broad,  with  a shining,  polished 
appearance,  like  the  cicatrix  of  a wound, 
and  destitute  of  hair,  which  had  fallen  off. 
From  the  corner  of  the  eye  downwards, 
there  was  the  same  kind  of  appearance  in  a 
less  degree.  The  patient  wag  subject  to  re- 
Vol.  IF  ' 87 


peated  attacks  of  spasms,  whicn  began  at 
the  insertion  of  the  muscle,  and  terminated 
at  the  eye,  attended  with  a great  deal  of 
pain.  The  ear,  and  also  the  temporal  and 
frontal  muscles,  were  sometimes  affected  in 
a similar  manner.  The  parts,  in  the  course 
of  the  insertion  of  the  muscle  into  the  jaw- 
.bone,  were  considerably  thickened,  without 
being  in  the  least  inflamed  externally,  and 
when  touched,  but  not  stretched,  they  were 
little  painful.  The  subjacent  muscles  did 
not  seem  at  all  affected. 

It  appears  from  the  account  given  by  Mr. 
Gooch,  that  in  the  treatment  of  this  affec- 
tion, every  known  means  had  been  tried, 
by  the  advice  of  the  most  eminent  practi- 
tioners ; but  without  effect.  Mr.  Gooch  de* 
termined  to  try  what  benefit  would  be  pro- 
duced by  the  division  of  the  muscle.  He 
first  divided  the  integuments  a little  below 
the  jaw,  and  thus  exposed  the  whole  brea.  th 
of  the  platysma  myoides  muscle,  the  fibres 
of  which  seemed  to  be  in  a state  of  violent 
extension,  especially  when  the  patient’s 
head  was  inclined  towards  the  opposite  side 
Mr.  Gooch  then  divided  the  muscle  com- 
pletely across  by  a very  careful  dissection, 
until  the  fascia?  of  the  subjacent  muscles 
were  exposed.  The  patient  was  then  di- 
rected to  turn  his  head  towards  the  opposite 
side,  and  Mr.  Gooch  had  the  satisfaction  of 
observing  that  the  palient  could  perform 
this  motion,  without  the  face  and  corner  of 
the  mouth  being  affected,  as  they  used  pre- 
viously to  be.  The  wound  was  treated  in 
the  ordinary  way,  and  no  particular  symp- 
toms arose.  As  soon  as  the  inflammation 
had  subsided,  the  patient  was  directed  fre- 
quently to  move  his  head  about  in  order  to 
prevent  any  kind  of  stiffness  which  mi  tit 
ensue  from  the  contraction  of  the  muscular 
fibres,  and  the  inelasticity  of  the  cicatrix. 

The  patient  was  perfectly  relieved  by  the 
foregoing  operation,  and  had  no  return  of 
the  painful  spasms,  to  which  he  had  been 
previously  subject.  The  side  of  his  face, 
however,  never  recovered  its  proper  degree 
of  plumpness.  ( Chir . Works  of  B.  Gooch , 
Vol.  2 ,p.  81.) 

Whenever  an  attempt  is  made  to  cure  a 
wry-neck,  by  dividing  any  of  the  muscles, 
or  merely  the  integuments,  it  becomes  ne- 
cessary to  take  some  measures  for  keeping 
the  head  in  a proper  position,  during  the 
treatment  of  the  wound,  lest,  in  conse- 
quence of  the  head  inclining  in  the  direc- 
tion in  which  it  was  before  the  operation, 
the  divided  parts  grow  together  again,  and 
bring  the  patient  into  the  same  condition, 
in  which  he  was  before  any  thing  had 
been  done.  With  a view  of  preventing  this 
unpleasant  circumstance,  Mr.  Sharp  recom- 
mends filling  the  wound  with  lint,  and  ma- 
king it  suppurate.  Mr.  B.  Bell,  on  the  other 
hand,  advises  the  employment  of  a proper 
machine  for  keeping  the  head  in  a due  po- 
sition. Some  writers  think  the  use  of  a 
bandage  quite  sufficient  for  the  purpose. 
When  the  sterno-cleido-mastoideus  is  af- 
fected, perhaps  the  excision  of  a small  por 
tion  of  if  would  be  prudent 


ZINC. 


690 


Boyer  met  with  a case  of  paralysis  of  the 
extensor  muscles  of  the  head,  attended  with 
a constant  approximation  of  the  chin  to  the 
sternum.  The  disease  resisted  every  plan 
of  treatment,  and  an  apparatus  for  support- 
ing the  head  was  the  only  thing  found  of  any 
use.  (See  Trait#  des  Mai  Chir.  T.  7 ,p.  61, 
8 vo.  Paris , 1821.)  Sharp's  Treatise  on  the 
Operations  of  Surgery,  chap.  35.  Blasius, 
Ohs.  Med.  Rar.  p.  2,  No  1.  Cure  effected  hy 
operation.  Mauchart,  De  Capile  Obstipo, 


Tub . 1737.  Chirurgical  Worlds  of  B.  Goochs 
Vol.  2,  p.  81.  B.  Bell's  System  of  Surgery 
Roonhuysen , Heylcuren,  p.  1,  No.  22  and  33 
successful  operation.  Encyclopedic  M6tho- 
dique , Partie  Chirurgicale  T.  2,  Art.  Torti- 
collis. Joh.  Christ.  G.ottfr.  Jorg.  itber  die 
Verrkriimmungen  des  MenschlicHen  Harpers , 
und  eme  rationelle  und  sichere  Heilart  der- 
selbcn  ; Leipzig,  1810.  Baron  Boyer,  Trait 6 
des  Mai.  Chir  T.  7,  p.  48,  fyc.,  8 vo.  Paris, 
1821. 


z. 


ZINC.  The  preparations  of  this  metal 
are  of  considerable  use  in  surgery. 
With  respect  to  the  sulphate  of  zinc , it  may 
be  said  to  be  generally  the  best  emetic,  in 
cases  where  it  is  desirable  to  empty  the  sto- 
mach without  the  least  delay,  as  in  cases  of 
poison,  for  which  purpose,  the  common  dose 
is  3j.  “ As  an  external  application,  this 

salt  dissolved  in  rose-water,  in  the  propor- 
tion of  gr.  iss  to  %j.  of  rose-water,  forms  an 
excellent  collyrium  in  the  latter  stage  of 
ophthalmia,  after  the  inflammatory  action 
has  subsided  ; it  is  a good  injection  in  a si- 
milar stage  of  gonorrhoea  ; and  a lotion  in 


some  kinds  of  superficial  inflammations.  Oi 
double  strength,  this  solution  is  the  best  ap- 
plication that  can  be  used  in  scrofulous  tu- 
mours, after  they  have  suppurated,  and  the 
abscess  been  discharged.”  (A.  T.  Thomson , 
London  Dispensatory,  Ed.  2,  p.  559.)  The 
unguentum  zinci , composed  of  an  ounce 
of  the  oxide  of  zinc,  and  six  ounces  of  pre- 
pared lard,  is  an  useful  astringent,  mildly 
stimulant  application  ; and  is  frequently  em- 
ployed in  various  cases  of  cutaneous  dis- 
eases, ringworm,  sore  nipples,  and  chronic 
inflammation  of  the  conjunctiva  of  the 
eyelids 


APPENDIX. 


HYDROPHOBrA.  Our  author,  after 
a most  laborious  research  into  the  annals 
of  surgery,  in  orderto  ascertain  the  patho- 
logy of  this  disease,  and  without  being 
able  to  decide  upon  any  of  the  at  present 
promulgated  opinions,  is  constrained,  be- 
ing in  doubt,  at  length  to  ask,  “ Does  the 
infectious  principle  of  ixibies  reside  in  the 
salivary  secretion , or  in  the  mucus  of  the 
trachea  and  bronchia  and  immediately 
adds,  “ The  common  belief  is . that,  in  hy- 
drophobia, the  salivary  glands  arc  consi- 
derably affected By  this  b shon  n,  that, 
notwithstanding  the  mystery  in  which 
the  pathology  of  this  disease  is  invol- 
ved, the  mind  of  the  inquirer  has  been  led 
to  the  site  of  the  salivary  organs,  to 
search  for  a cause  which  he  deleares 
himself  satisfied  existed  in  no  other  situa- 
tion. 

It  is  for  me  now  to  record  a com- 
munication from  a most  respectable 
physician  at  St.  Petersburg,  Dr.  Maro- 
chetti,  handed  me  by  the  Honourable  S. 
L.  Mitchill,  M.  D.,  in  the  hope  that  the 
medical  community  of  this  country  will 
exert  itself,  as  frequently  as  oppor- 
tunity may  offer,  either  to  substantiate 
the  doctrine  of  the  salivary  glands  being 
the  particular  and  primary  localit  y of  hy- 
drophobia ; or  disprove  the  assertion, 
by  an  evidence  which  shall  direct  the 
mind  to  another  source. 

• St.  Petersburgh,  17th  (29th)  Nov.  1821. 

Sir — I did  myself  the  honour  of  en- 
closing you,  about  a month  since,  a ma- 
nuscript copy  of  a report  read  October, 
1820,  to  the  Medico-Physical  Society  of 
Moscow,  by  Dr.  Michel  Marochetti,  upon 
hydrophobic  virus,  and  the  means  of  dis- 
covering its  presence  and  destroying  its 
activity  in  an  infected  subject.  Appre- 
hending that  my  letter  may  have  mis- 
carried, I trouble  you  with  the  duplicate, 
accompanied  by  the  same  memoir  in  a 
printed  form,  which  it  has  received  since 
my  first  letter. 

The  art  of  inoculating  for  small-pox, 
and  thereby  mitigating  the  violence  of 
the  disease,  having  been  first  known  and 
practised  in  the  East,  encourages  a hope 
that  the  discovery  from  the  same  quar- 
ter, of  a mode  of  curing  the  incipient 
symptoms  of  hydrophobia,  by  a process 
in  some  degree  analogous,  may  be  the 


means  of  rescuing  numbers  of  victims 
from  encountering  death  in  one  of  its 
most  horrid  forms. 

Desiring  to  give  a wide  circulation  to 
the  paper  of  Dr.  Marochetti,  in  order 
that  our  country  may  have  the  early  be- 
nefit of  his  discovery,  I have  thought  I 
could  not  address  myself  better  than  to 
the  President  of  the  Medical  Society  of 
New-York,  who  will  not  fail  to  give  his 
recommendation  so  far  as  it  may  be  me- 
•rited. 

S have  the  honour  to  be,  Sir,  respect 
fully*,  your  obedient  servant, 

HENRY  M1DDEL  ON. 
Hon.  S.  L.  Mitchill. 

Observations  on  Hydrophobia : contain- 
ing certain  indications  for  ascertaining 
the  existence  of  the  hydrophobic  poison 
in  an  individual , and  the  means  of  pre- 
venting its  developement  by  destroying 
Us  germ.  In  a memorial  read  before  the 
Medico- Physical  Society  of  Moscoiv,  on 
the  4 ih  of  October,  1820;  by  Michel 
Marochetti,  Attending  Physician  at  the 
Gallitzin  Hospital , and  member  of  the 
said  Society.  Printed  in  St.  Peters- 
burgh, at  the  Press  of  Public  Instruc- 
tion, 1821. 

Among  the  fatal  accidents  to  which 
man  is  exposed,  the  hydrophobia,  a ter- 
rible consequence  of  the  bite  of  rabid 
animals,  is  a disease  whose  cruelty  is  ag- 
gravated by  the  insufficiency  of  all  the 
means  hitherto  employed  to  save  its  vic- 
tims, and  by  the  acknowledgment  of  all 
practical  men,  that  there  is  no  specific 
against  the  hydrophobic  virus,  after  ab- 
sorption has  taken  place,  and  the  symp- 
toms have  appeared.  I shall  not  under- 
take a refutation  of  this  truth.  I shall 
only  say,  that,  with  a knowledge  of  the 
cause,  it  is  possible,  by  means  of  help  duly- 
afforded,  to  prevent  the  mischief,  and 
consequently  to  save  from  certain  death, 
those  persons  who,  before  the  discovery 
which  I have  the  honour  to  announce, 
had  no  chance  of  safety. 

Hitherto,  the  professors  of  the  healing 
art  have  been  ignorant  of  the  true  seat  of 
the  disease.  A crowd  of  remedies  have 
been  administered  ; some  because  they 
had  doubtlessly  been  employed  with  suc- 
cess in' cases  where  there  was  no  hydro- 
hobia,  and  others  for  the  purposes  of 
enevolenee  and  prevention.  But  a very 


APPENDIX 


important  point  in  medicine,  and  one 
that  has  been  sought  in  vain,  is.the  cause 
of  this  malady.  Its  effects  are,  unfortu- 
nately, but  too  well  known.  I shall  there- 
fore, on  this  occasion,  endeavour  to  state, 
1st,  the  knowledge  1 have  derived  from 
observation ; 2d,  the  origin  of  the  dis- 
covery ; and  3d,  the  different  patholo- 
logical  occurrences  I have  been  able  to 
collect,  with  my  own  remarks  upon  them. 

Having  spent  almost  eight  years  of  my 
life  in  the  southern  governments  of  Rus- 
sia, where  there  is  a great  number  of 
dogs,  some  of  them  often  run  mad,  and 
produce  frequent  accidents.  Repeatedly 
I have  endured  the  distress  of  beholding 
the  deaths  of  these  victims.  1 necessa- 
rily made  inquiries  concerning  hydro- 
phobia, and  tried  all  the  known  methods 
of  treating  it.  Confined  to  a village  in 
the  midst  of  the  wretched  creatures, 
some  of  whom  had  been  bitten  by  mad 
dogs,  and  others  by  mad  wolves,  nobody 
possessed  better  opportunities  than  my- 
self to  follow  and  to  watch  the  course 
and  progress  of  this  horrible  disorder. 

I now  state  the  conclusions  I have 
drawn  from  the  most  scri/pulous  atten- 
tion to  hydrophobia. 

In  the.  first  place,  I am  convinced  by 
experience,  that  if  several  persons  are 
bitten  in  succession  by  a rabid  animal, 
the  first  bitten  exhibits  in  the  develope- 
rnent  of  the  disease,  more  serious  and 
violent  symptoms  than  the  second,  this 
more  than  the  third,  and  so  on  ; the  poi- 
son acting  always  in  an  inverse  ratio  to 
the  numbers,  in  such  a manner  that  the 
eighteenth  or  twentieth  person  may  be 
considered  out  of  danger.  Such  a case 
sometimes  happens. 

Secondly,  the  hydrophobic  virus  does 
not  constantly  reside  in  tile  mouth  of  the 
mad  animal. — It  gathers  there  only  at 
the  end  of  a certain  time.  The  bite,  in 
this  interval,  is  not  to  be  considered  as 
venomous.  Here  is  another  case  in  which 
the  rabies  is  not  communicated. 

Thirdly,  the  hydrophobic  virus  does 
not  lose,  like  the  pestilential  miasma, , any 
of  its  intensity  in  being  communicated 
from  one  body  to  another — but  it  acts 
with  more  or  iess  violence  in  proportion 
to  its  quantity.  Unfortunately,  the  effect 
is  not  the  less  fatal,  by  reason  of  its 
quicker  or  slower  operation. 

Fourthly,  it  is  evident  that  this  virus 
does  not  continue  in  the  wounds ; but  is 
conveyed  in  its  full  force  to  a part  of  the 
body  presently  to  be  described.  In  this 
part,  it  instantly  acts  as  a most  powerful 
astringent,  and,  by  accumulation,  inflames 
and  shuts  the  passages,  by  which  nature 
endeavours  to  expel  it  from  the  animal 
economy. 

Fifthly,  there  is  one,  and  only  one  way, 
to  prevent  the  developement  of  hydro- 
phobia in  a person  who  is  threatened  with 


it.  I declare  boldly,  and  experience  will 
bear  me  out  in  the  assertion,  that  this  is 
to  evacuate  the  hydrophobic  virus  when 
itappears.  Where  does  this  reside  ? and 
how  can  it  be  evacuated  ? 

Sixthly,  the  sub-lingual  glands  are  two 
in  number,  one  on  each  side,  under  the 
tongue,  between  the  genio-glossi  muscles, 
the  lower  jaw,  and  the  inner  membrane 
of  the  mouth,  which  immediately  covers 
them.  From  these  glands  proceed  two 
or  three  secretory  ducts,  which  open  in- 
to the  ducts  of  the  sub  maxillary  glands, 
and  those  latter  open  one  on  the  one  side, 
and  the*  other  on  the  other  side  of  the 
frajnum  of  the  tongue — it  is  precisely  to 
the  extremities  of  these  ducts,  that  the 
hydrophobic  virus  is  conveyed  after  a 
bite  indicted  by  a rabid  animal,  and  there 
it  is  temporarily  detained,  forming,  at  the 
two  spots  just  described,  one  or  two  small 
tumours  of  unequal  size.  By  touching, 
which  may  be  done  with  a probe,  it  is 
found  that  there  is  contained  a fluctua- 
ting humour,  which  is,  as  absorption 
proves,  the  hydrophobic  poison  itself. 
It  is  there  that  nature  delivers  to  us  her 
enemy,  it  is  from  this  hold  that  the  sur- 
geon ought  to  expel  him. 

Seventhly,  the  time  cannot  be  exactly 
defined  at  which  these  small  tumours 
will  show  themselves.  If  the  virus  is  not 
evacuated  in  twenty- four  hours  it  disap- 
pears by  re-absorption . Then  no  trace 
is  left  of  its  pre-existence.  There  takes 
place  a double  metastasis  towards  the 
brain.  The  most  frightful  symptoms  of 
hydrophobia  commence,  and  the  patient 
sinks  under  one  of  its  paroxysms. — On 
opening  the  body,  nothing  remarkable  is 
observed ; pathological  anatomy,  after 
all  its  explorations,  has  not  discovered 
any  indication  capable  of  fixing  the  atten- 
tion of  physicians,  and  of  rendering  an 
explanation  of  the  causes,  because  they 
did  not  understand  the  re-absorption  of 
this  virus. 

Eighthly,  the  first  thing  to  be  observed 
when  a person  believes  he  has  been  bit- 
ten by  a mad  animal,  is  the  lower  side  of 
the  tongue,  which  ought  to  be  examined 
for  six  weeks,  once,  or  even  twice  a dajr, 
for  more  perfect  precaution.  If  at  the 
end  of  this  term  there  is  no  appearance 
of  the  small  swellings  already  described, 
we  may  rest  assured  that  the  individual 
is  not  to  be  infected  with  hydrophobic 
virus,  During  these  examinations,  if  the 
tumours  appear,  they  must  be  instantly 
cauterized , or,  what  is  better,  opened  with 
a small,  sharp  lancet.  This  operation  is 
performed  by  raising  the  tongue  with  one 
hand,  covered  with  a suitable  cloth,  to- 
wards the  palate,  and  somewhat  side 
ways,  to  the  end  that  the  small  button® 
or  tumours  may  be  easily  touched.  For 
greater  convenience  the  tongue  ought  to 
be  supported  by  an  assistant:  so  that 


APPENDIX. 


093 


There  uiay  be  made  as  many  longitudinal  eyewitness.  Leave  was  obtained  from 
incisions  as  there  are  lumps.  From  these  the  master  of  the  village;  and  my  per  - 
latter  there  will  proceed  some  drops  of  mission  w as  additionally  granted,  that 
a sanious  lymph,  somewhat  greenish , the  peasant  should  take  charge  of  the 
which,  the  patient  operated  upon,  will  patients.  I however  imposed  two  condi  • 
spit  out.  As  soon  as  the  operation  is  tions;  the  first  of  which  was,  that  I 
over,  the  patient  must  wash  his  mouth  should  be  present  at  every  thing  he  did  ; 
with  a strong  decoction  of  the  tops  and  and  the  second, that  to  be  sure  that  the  dog 
flowers  of  the  Genista  lateo-iindoria , that  had  bitten  them  was  really  mad.  and 
(Dya’s  Broom.)  It  is  almost  superfluous  hydrophobic,  I should  practise  upon  one 
to  observe,  that  this  decoction  must  be  of  the  patients  in  my  own  way.  I se- 
prepared  in  advance,  for  it  must  be  regu-  lected  from  among  them  a girl,  six  years 
larly  taken  during  the  six  weeks  that  the  old,  whom  1 subjected  to  medical  treat- 
patient  is  under  examination,  as  a com-  ment.  The  others  began  to  take  the  de- 
mon drink.  The  dose  is  a pound  and  a coction  of  the  genista  lateodindoria , 
half  per  day,  in  decoction  ; or  four  which  the  peasant  prepared  in  my  pre- 
drachms  a day  in  pow  der,  in  doses  of  one  sence. 

drachm  each.  The  prescriber,  however,  As  I passed  the  greater  part  of  my 
will  always  take  into  consideration  the  time  near  these  unfortunate  persons,  1 
age  and  constitution  of  the  patient.  administered  my  own  remedies  for  the 

Ninthly,  1 observe  that  the  operation  girl  I had  taken  for  my  own  patient.  I 
which  consists,  in  opening  the  small  tu-  had  engaged  a surgeon,  with  orders  not 
mours,  has  the  great  advantage  of  being  to  let  the  peasant  do  any  thing  in  ray 
so  simple,  and  so  easy  to  execute,  that  absence.  This  plain  man  began  by  exa- 
not  only  professional  men,  but  every  in-  mining  the  tongue  of  each  individual,, 
dividual  who  has  seen  it  performed  two  one  after  the  other,  on  its  low?er  part,  or 
or  three  times,  can  perform  it  himself,  under  side,  every  morning  and  evening. 
This  is  very  important  for  the  small  As  the  tumours  appeared,  he  showed 
towns  and  villages,  where,  as  yet,  there  them  to  me;  and  he  opened  them,  and 
are  no  settled  and  established  surgeons,  cauterized  them  with  a sort  of  large 
I offer  myself,  on  the  occurrence  of  the  needle,  heated  red  hot  in  the  candle,, 
first  accident  of  this  kind,  to  perform  the  After  the  operation,  he  caused  them  to 
operation  in  the  presence  of  any  person  rinse  their  mouths  with  the  same  decoc- 
whom  the  government  may  be  pleased  tion  which  has  been  mentioned  for  inter- 
to  appoint.  nal  use. 

I inhabited  the  Ukraine,  during  1813,  The  girl  of  six  years  old,  whose  trpat- 
in  the  capacity  of  physician  to  his  excel-  ment  bad  been  continued  w ith  the  great- 
lency  the  count  Morzezensky.  In  one.  est  care,  and  conformably  to  the  rules  of 
of  his  villages,  called  Kijawka,  during  an  established,  practice,  became  the  victim 
evening  of  the  autumn,  at  the  hour  when  of  the  experiment  ! for,  on  the  morning 
the  peasants  return  home  from  their  la-  of  the  seventh  day  after  the  bite,  she  was 
bour,  a huge  hydrophobic  dog  of  a neigh-  suddenly  seized  with  symptoms  of  hy- 
houring  village,  bit  fifteen  persons  of  dif-  drophobia,  and  at  the  end  of  eight  hours 
ferent  ages  and  sexes.  As  1 lived  at  the  expired  in  my  presence,  during  a parox- 
distance  of  five  versts,  1 received  no  intel-  ysm  of  the  most  frightful  symptoms. 
Iigence  until  the  next  morning  Proceed-  Of  the  fourteen  remaining  persons, 
ing  then  with  all  possible  speed  to  the  twelve  underwent  the  opt  ration  of  open- 
place,  1 procured  for  these  unfortunate  ing  their  tumours,  and  w ere  saved.  The 
persons  a house,  spacious  enough  to  con-  two  others,  w ho  had  been  bitten  last,  had 
tain  them  all,  and  I placed  near  them  at-  no  tumours.  These  fourteen  persons, 
teridants  to  .nurse  and  attend  them.  after  hav  ing  for  six  weeks  made  use  of 

While  these  arrangements  were  ma-  the  decoction  of  Genista , were  dischar- 
king, a deputation  of  old  men  waited  up-  ged  Vured. 

on  me,  praying  that  the  bitten  persons  Having  remained  there  more  than 
might  be  treated  by  a Peasant  of  the  three  years  after  this  occurrence,  1 saw, 
neighbourhood,  w ho  had  for  a number  of  a number  of  times,  all  the  individ  jals, 
years  made  a business  of  attending  such  and  can  attest  that  their  recovery  was 
cases,  and  with  constant  success.  They  complete. 

all  assured  me  they  would  bear  w itness  l state  more  facts.  Being  in  Podolia 
in  favour  of  this  man,  who.  according  to  during  1818,  1 resided  in  a small  tows 
their  declaration,  had  already  served  called  Meskowka,  within  the  district  of 
several  hundred  persons  in  that  govern-  Olgapal.  In  the  month  of  February, 
ment.'  twenty  six  persons, partly  Christians  and 

I had  previously  heard  of  this  man.  I partly  Jews,  of  different  ages  and  sexes, 
was  desirous  of  satisfying  myself  as  to  were  bitten  by  a hydrophobic  dog.  This 
the  efficacy  of  a means  so  very  important  dog  made  incursions  into  the  town,  and 
to  humanity,  and  of  which  I had  wished  having  bitten  all  the  persons  he  met,  had 
to  have  an  opportunity  to  become  an  disappeared.  The  inhabitants,  however. 


(.94 


APPENDIX. 


rallied  ; and  in  their  search  for  him,  in 
the  place  of  his  usual  retreat,  found  him 
dead  near  a heap  of  wheat. 

Though  I took  great  pains  to  ascertain 
the  successive  order  of  the  bites,  I was 
unable  to  determine  the  exact  series  in 
these  twenty-  x individuals. 

So  con.  durable  a number  of  the  bitten 
and  calamitous  beings  could  not  be  ac- 
commodated in  any  house  that  could  he 
procured.  I was  therefore  obliged  to 
separate  them  into  three  divisions  ; and 
send  each  division  to  a distinct  house. 
I attached  to  the  first  division,  nine  men; 
to  the  second,  eleven  women  ; and  to  the 
third,  six  children.  Iri  each  of  the 
houses  I stationed  a Hebrew  surgeon,  to 
prepare  the  decoction  of  the  Genista 
lateo -tinctoria,  to  administer  it  to  them 
regularly,  and  to  report  to  me  every 
thing  that  happened. 

The  result  was,  that,  in  the  first  divi- 
sion, five  persons  had  swellings  under 
the  tongue ; in  the  second,  all  had  them  ; 
and  in  the  third,  only  three  of  the  child- 
ren. 

Among  these  individuals,  they  who 
had  the  deepest  and  most  numerous 
wounds,  experienced  the  tumours  on  the 
third  day.  The  rest  on  the  fifth,  seventh, 
and  ninth  days.  In  one  woman,  these 
sub  lingual  swellings  did  not  manifest 
themselves  until  the  twenty- first  day  after 
the  bite.  This  woman  had  received  a 
slight  bite  in  the  right  leg. 

The  seven  persons  who  had  no  tu- 
mours nevertheless  drank  the  decoction 
for  six  weeks,  and  were  then  set  at  liberty 
with  the.  res#t,  excepting  those  whose 
wounds  were* not  healed.  They  remain- 
ed in  charge  until  their  entire  restoration 
to  health.  I have  employed,  as  an  excel- 
lent detergent,  the  residue  of  the  decoc- 
tion of  the  herb  Genista,  as  an  applica- 
tion to  the  wounds,  in  the  form  of  a poul- 
tice. 

It  is  not  uhfrequently  necessary,  to 
give  a gentle  purgative,  once  a week,  or 
at  least  a simple  clyster  prepared  from 
a decoction  of  the  marsh-mallows  of  the 
shops,  in  which  a small  quantity  of 
Aslrakan  salt  is  dissolved.  By  either  of 
these  means,  costiveness  is  prevented. 

There  is  a matter  which  merits  the 
greatest  attention  This  is  t he  succession 
of  forerunning  symptoms,  observable 
during  the  formation  of  the  small  pus- 
tules, whose  discovery  is  the  offspring  of 
a most  lucky  observation.  Towards  that 
stage,  the  pupil  of  the  eye  is  dilated  and 
fixed ; the  look  is  sad ; uneasiness  is 
complained  of;  and  there  is  a small  pain 
in  the  head.  These  are  the  only  symp- 
toms I have  been  able  to  detect.  The 
simple  and  easy  method  of  treating  per- 
sons threatened  with  hydrophobia,  is 
that  which  has  been  practised  upon  about 
forty  individuals  with  complete  success. 


The  little  girl,  who  fell  a sacrifice  to  my 
experiment,  affords  a piece  of  evidence 
quite  as  strong.  Henceforward  a regi- 
on can  be  adopted,  of  which  I will  war 
rant  the  salutary  result. 

Byway  of  conclusion,  I remark,  that 
at  different  times  and  places,  1 have 
treated  six  persons  in  the  same  manner ; 
among  others,  a peasant  who  had  been 
bitten  by  a mad  wolf,  as  he  was  going 
from  one  village  to  another.  His  cries 
brought  other  men,  who  assisted  iri  killing 
the  ferocious  beast,  who  had  been  already 
marked  as  hydrophobic.  The  only  dif- 
ference between  this  and  the  radical  cure, 
was,  that  this  man,  among  other  wounds, 
had  been  bitten  on  the  forepart  of  the 
ankle;  and  that  the  tendons  and  liga- 
ments were  so  lacerated,  that  all  the  sur- 
gical means  which  were  applied,  could 
not  prevent  a great  deformity  of  the  foot. 
He  was  confined  to  hi§  bed  for  two 
months. 

After  the  disclosures  I have  made  con- 
cerning the  hydrophobic  virus,  1 consider 
the  disease  as  a local  evil , of  which  it  is 
possible  to  prevent  the  consequences,  by 
a seasonable  removal  of  the  morbific 
matter.  For  after  the  reabsorption  has 
been  made,  there  are  no  means  of  arrest- 
ing its  terrific  effects.  I think  it  may  be 
thence  concluded,  that  the  known  symp- 
toms of  hydrophobia,  such  as  constriction 
of  the  breast,  violent  pain  in  the  head, 
dilatation  of  the  pupil,  occasional  palsy  of 
the  tongue,  convulsions,  dread  of  liquids, 
all  nervous  symptoms,  are  produced  by 
the  reabsorption  of  the  hydrophobic  poi- 
son. The  nerves  from  the  fifth  pair, 
those  which  go  to  the  tongue,  the  inter- 
costal and  corvical  nerves,  furnish  direct 
evidence  of  the  manner  in  which  the  \ irus 
exerts  its  deleterious  action  through  the 
medium  of  the  nerves  leading  from  the 
sublingual  and  submaxillary  glands. 
Without  taking  into  consideration  the 
complicated  distribution  of  these  nerves, 
their  connexions  and  sympathies,  1 en- 
tertain the  hope,  that  Physiology  will, 
one  day,  give  us  more  satisfactory  details 
on  this  subject.  It  only  remains  for  me, 
gentlemen,  to  state  my  sole  and  particu- 
lar desire  for  the  publication  of  a me- 
moir, useful  to  humanity,  and  the  chief 
object  of  my  researches  and  of  my  exer- 
tions. 

Accept,  respectable  president,  and 
members,  who  have  had  the  goodness  to 
receive  me  as  a colleague  and  fellow- 
labourer,  the  observations  which  I offer 
you,  in  the  most  philanthropic  spirit ; add 
thereto  your  own  intelligence,  and  aid  me 
with  your  practical  experience.  I shall 
be  overjoyed  if  I should  be  happy  enough 
to  limit  the  disasters  caused  by  hydro- 
phobia. 

( Signed)  M A HOC H ETTf 


APPENDIX. 


Since  the  receipt  of  the  foregoing,  the  teeth  in  it.  Tn  the  evening  f gave  him 
Doctor  has  had  forwarded  to  him  a some  more  milk  and  water,  and  mutton 
communication,  which,  when  read,  will  be  broth,  which  he  took  freely  and  went  to 


found  in  affinity  with  the  preceding 

Remarks  on  Hydrophobia , more  particu- 
larly as  it  occurs  in  Dogs  ; in  « letter 
from  a gentleman  of  observation  and 
exverience  in  New- Jersey*  dated  March 
15,  1822. 

Sir— 1 lately  read  with  much  plea- 
sure, in  the  New-York  Spectator  oi  the 
1st  instant,  Mr.  Middleton’s  letter  to  you 
accompanying  Dr.  Marochetti’s  very 
interesting  report  on  the  symptoms  and 
cures  of  hydrophobia. 

As  I consider  it  the  duty  of  every 
member  of  the  human  race,  to  commu- 
nicate any  thing  that  may  in  any  way 
tend  to  elucidate  or  corroborate  tiiis 
wonderful  discovery,  (the  greatest  th;*t 
has  yet  been  made  in  medical  science,!  1 
beg  leave  to  submit  to  your  considera- 
tion two  cases,  which  within  these 
eighteen  months  have  fallen  within  my 
personal  knowledge  and  information,  and 
may  be  depended  on. 

On  the  morning  of  the  eighteenth  of 
December,  1820,  while  living  in  Canada, 
a favourite  dog,  belonging  to  me,  of  the 
Setter  breed,  showed  what  1 imagined 
to  be  symptoms  of  madness,  on  which  1 
immediately  directed  my  servant  to  tie 
him  up  in  an  out-house,  and  to  give  him 
some  salt  and  water,  as  he  appeared 
from  scratching  his  neck  and  throat  until 
it  absolutely  bled , to  have  something 
sticking  in  it ; this  made  him  in  a short 
time  throw  up  a quantity  of  yellow 
frothy  matter,  and  seemed  to  relieve  him 
very  much,  so  that  at  12  o’clock  he  ap- 
peared free  from  every  species  of  com- 
plaint. Soon  after,  the  servant  gave  him 
some  water,  which  he  lapped  freely,  and 
immediately  threw  up  a large  quantity  of 
the  same  yellow  frothy  matter,  some  of 
it  in  large  lumps.  From  these  symp- 
toms, l was  induced  to  think  .that  he  had 
swallowed  some  poisonous  substance,  on 
which  account  I gave  him  some  milk 
and  water  and  fat  mutton  broth,  which 
lie  took  freely,  and  appeared  as  if  sensi- 
ble of  the  attention  paid  him,  and  as 
usual  wagged  his  tail,  and  readily  obeyed 
every  order  I gave  him. 

Next  day  his  appearance  was  more 
unfavourable  : his  eyes  appeared  glazed 
and  heavy,  his  tail  drooped,  his  stomach 
and  bowels  were  contracted,  his  back 
raised  in  a circular  form,  and  his  neck 
raw  from  continual  scratching.  At  this 
time  ! had  him  and  the  barrow  in  which 
he  lay  removed  to  a warmer  place,  which 
I did  witiiout  any  difficulty,  as  he  knew 
and  obeyed  me  as  usual;  yet, soon. after, 
when  I held  out  my  stick  towards  him, 
he  laid  hold,  and  left  the  marks  of  his 


rest. 

Ahout  midnight  1 was  awakened  by 
his  incessant  and  apparently  painful 
barking,  which  he  continued  without  in- 
termission until  daylight,  when  he  exhi- 
bited what  appeared  to  me  such  un- 
doubted signs  of  violent  madness,  that  f 
was  under  the  painful  necessity  of  shoot- 
ing him.  My  servant  then  told  me,  that 
the  day  I desired  him  to  be  tied  up,  he 
made  a snap  at  his  thigh,  and  gave  it  a 
pinch,  but  having  on  thick  pantaloons,, 
and  drawers,  he  did  not  break  the  skin, 
and  no  bad  consequences  have  ensued 
from  it. 

When  staying  last  August  with  my 
friend,  Mr.  Grant,  at  Montreal,  I happen-  . 

< d to  mention  all  these  circumstances  to 
him,  when  he,  pointing  to  a favourite 
dog,  lying  at  his  feet,  told  me,  that  about 
two  years  ago  he  was  in  so  similar  a 
situation,  that  he  left  orders  with  his 
servant  to  shoot  him, and  as  he  could  not 
do  it  himself,  or  be  in  the  way  when  it 
was  done,  he  went  into  the  country  for 
some  h'*urs.  On  his  return  home,  the 
first  question  he  asked  was,  ‘l  have  you 
disposed  of  the  dog  ?”  to  which,  to  his 
great  surprise , the  servant  answered, 

“ No,  sir,  l could  not  find  in  my  heart 
to  kill  the  poor  dumb  brute,  and  as  he 
seemed  by  his  violent  scratching  to  have 
something  in  his  throat,  or  mouth,  that 
caused  his  illness,  I got  a friend  to  assist 
me,  who  held  him  down  while  I opened 
his  mouth  for  the  purpose  of  examining 
it,  and  his  throat,  when  under  his  tongue ,, 

I observed  a large  Blob  or  Tumour , which 
I opened  with  a penknife,  and  out  of  it 
came  a great  deal  of  nasty  matter,  which 
the  dog  threw  out  of  his  mouth,  imme- 
diately leaped  up,  frisked  about  the  room 
as  if  sensible  of  the  cure  that  had  been 
effected  on  him,  and  he  is  now  as  well  as 
ever  he  was.”  Mr.  Grant  could  hardly 
believe  the  story  ; but  the  entrance  of 
the  dog  into  the  room,  in  his  usual  man- 
ner, to  his  great  joy,  confirmed  the  truth 
of  it. 

On  Mr.  G’s  relating  these  circum- 
stances to  me,  I mentioned  to  him,  that; 
I thought  the  matter  of  so  great  conse  • 
quence,  that  he  ought  to  draw  up  a state  - 
ment, and  communicate  it  to  some  medi  - 
cal friend,  as  it  might,  perhaps,  be  the 
means  of  finding  out  a cure  for  the  dis- 
temper in  dogs,  which  I then  thought  it 
was,  though  was  convinced,  from  Dr. 
M.’s  report,  that  it  was  the  real  hydro- 
phobia. 

As  I soon  after  left,  that  country,  1 do 
not  know  whether  or  not  Mr.  G.  follow- 
ed my  advice  ; but  in  case  he  has  not,  I 
now  give  you  all  the  circumstances  of 
both  cases,  well  convinced  that  they  can- 


& 


APPENfo/X 


€96 


not  be  placed  in  better  hands;  leaving 
you  at  liberty  to  make  such  use  as  you 
may  think  proper  of  this  information. 

As  Dr.  M.  mentions  having  the  hands 
properly  covered  when  examining  the 
mouths  of  patients,  I would  beg  leave  to 
suggest  your  publishing  what  material 
you  deem  a proper  and  necessary  cover- 
ing for  the  hand  ; with  which,  and  a lan- 
cet, at  least  one  person  in  each  village,  or 
large  family,  ought,  in  case  of  accidents , 
to  be  provided,  as  there  are  many  parts 
of  this  extensive  country,  where  medical 
aid  cannot  be  procured,  or  the  patient 
unable  to  pay  the  expense  of  the  long 
attendance  necessary.  And  I would  also 
beg  leave  to  suggest  the  propriety  of 
having  this  report  of  Dr.  M.’s  promulga- 
ted throughout  the  country  in  general, 
through  the  medium  of  newspapers  or 
cheap  pamphlets,  with  the  addition  of 
such  remarks  as  you  may  think  proper 
or  necessary  to  make  to  it. 

When  1 was  a boy,  at  school  in  the 
North  of  England,  1 learnt  to  worm  dogs, 
which,  it  was  said , did  not  prevent  their 
going  mad  ; but  in  case  they  were  infect- 
ed, occasioned  a relaxation  or  paralysis 
in  the  lower  jaw,  which  disabled  them 
from  biting  any  thing,  and  under  that 
idea,  t afterward  wormed  a number  of 
dogs,  but  cannot,  at  this  distant  period, 
say  what  were  the  consequences  or 
effects  of  it ; but  as  the  custom  was  ge- 
neral, there  must  have  been  something 
in  it,  and  perhaps  might  have  proceeded 
from  the  idea  that  the  tongue  was  some- 
how afflicted.  That  the  saliva  of  a mad 
dog  will  not  communicate  the  disease, 
unless  carried  into  the  circulation  through 
a wound  in  the  skin,  I am  perfectly  con- 
vinced, as  a lady,  a friend  of  mine,  had 
her  face  licked  all  over  by  a favourite 
gray  hound,  which  had  been  tied  up  on 
account  of  being  supposed  to  be  infected, 
but  got  loose,  and  immediately  after  be- 
ing again  tied  up,  got  loose  a second 
time,  and  ran  off,  and,  before  he  was 
killed,  bit  a number  of  dogs  and  cattle, 
all  of  which  went  mad,  yet  the  lady 
never  felt  any  bad  consequences  from  it. 

With  real  esteem,  I have  the  honour 
to  be, 

Sir,  your  most  obedient, 

Humble  Servant, 

W.  ARMSTRONG. 
S.  L.  Mitchill,  M.  D. 

March  26,  1822. 

LITHOTOMY.  What  I have  to  say 
at  present  upon  this  article,  is  founded 
upon  two  lately-discovered  anatomical 
facts,  which,  in  my  opinion,  will  become 
of  the  first  consideration  in  regulating  the 
operation  of  lithotomy.  The  first  of 
them  has  reference  to  the  particular  ex- 
tent, thickness,  and  connexion  of  the 
triangular  ligament  of  the  urethra  : and 


the  second  to  the  pelvic  partition,  or  that 
extension  of  the  fascia  iliaca,  which 
passes  over  the  brim  of  the  pelvis  to  be- 
come attached  to  the  side  of  the  urinary 
bladder,  and  called  ileo-vescial-fascia. 

“ The  triangular  ligament  of  the  urethra 
is  stretched  across  the  arch,  between  the 
rami  of  the  pubes  at  the  anterior  edges  of 
these  bones.  It  is  connected  above,  to 
the  middle  of  the  lower  edge  of  the  pubic 
ligament,  by  which  a space  is  left  on  each 
side,  for  the  passage  of  the  internal  pu- 
pendal  arteries  to  the  penis. 

This  ligament  is  about  an  inch  and  a 
half  in  depth,  having  its  lower  edge  semi- 
lunated,  and  formed  into  two  arches,  both 
sprung  from  a central  projecting  portion 
of  the  ligament,  which  will  be  afterward 
mentioned  as  the  centre  of  union  of  the 
muscles  of  the  perineum.  These  arches 
are  concave  facing  the  coccyx,  and  go 
towards  the  tuberosities  of  the  ischia,  by 
processes  firmly  attached  to  the  inner 
edge  of  the  bone,  and  that  terminate  by 
being  incorporated  with  the  anterior  sa~ 
cro-sciatic  ligaments. 

This  branch  of  the  triangular  ligament, 
moreover,  assists  the  sacro-sciatic  on  each 
side,  in  sending  up,  within  the  pelvis,  the 
aponeurosis  to  the  obturator  in-ternus 
muscle. 

The  central  projecting  point,  at  the 
lower  edge  of  the  triangular  ligament,  is 
kept  in  its  place,  in  giving  form  to  these 
arches,  by  the  action  of  the  sphincter 
ani,  and  transversales  perinei  muscles. 

At  about  the  middle  of  the  triangular 
ligament  is  a hole,  for  the  urethra,  in  its 
passage  from  the  bulb. 

The  triangular  ligament  is  composed 
of  two  very  distinct  lamina;,  which  are 
naturally  separated  at  some  distance  from 
each  other,  in  consequence  of  having 
between  them,  the  glandulse  antepros- 
tatae,  or  Cowper’s  glands.” — Surg.  Anal. 

By  this  description,  I wish  it  to  be  un- 
derstood, that  the  triangular  ligament  of 
the  urethra  is  closing  the  outlet  of  the 
pelvis  for  a great  extent  under  the  arch 
of  the  pubis  ; and  that,  at  its  upper  part, 
it  is  full  half  an  inch  thick,  getting  gra- 
dually thinner  towards  its  arched  edge, 
at  its  under  part. 

Now,  in  almost  every  book  which  con- 
tains directions  for  the  operation  of 
lithotomy,  we  are  told  to  “ cut  through 
the  common  integuments  by  the  side  of 
the  rapha  of  the  perineum,  against  the 
groove  of  the  staff,  which  is  to  be 
the  fir^t  incision ; thpn  to  divide  the 
transversales  perinei  muscles,  which  is 
the  second  incision;  and  after  this,  to 
feel  for  the  groove  of  the  staff,  in  the 
membranous  part  of  the  urethra,  to  cut 
upon  it,  and  to  introduce  the  beak  of 
the  instrument,  that  is  to  divide  the 
prostate  gland.  Hence  we  find  surgeons 
getting  into  the  bulb  of  the  urethra  in- 


APPENDIX 


stead  oft  Up  membranous  part ; from  their 
attention  not  having  been  directed  to  the 
presence  of  the  thick  triangular  ligament. 
After  this,  by  carrying  the  beak  of  their 
instrument  on,  they  cut  the  bladder  and 
prostate,  and  prepare  to  introduce  the 
forceps  for  the  extraction  of  the  stone, 
without  having  made  sufficient  room  for 
its  exit.  The  bare  hint  at  this  circum- 
stance. will  sufficiently  account  for  the 
pulling  and  twisting  we  every  da)’  see  and 
hear  tell  of,  during  the  effort  to  extract 
even  very  small  stones  by  the  lateral  ope- 
ration. [ have  seen  a patient,  under  such 
circumstances,  sent  from  the  operating 
table  of  a large  hospital,  who  died,  soon 
after  two  hours  had  been  spent  in  vain 
efforts  to  extract  not  a very  large  stone, 
from  the  urinary  bladder. 

The  French  surgeons,  from  having 
often  met  with  these  difficulties,  choose 
at  length  to  dignify  the  accident  by  a 
particular  epithet  ; not  however  for  the 
purpose  of  guarding  against  it,  hut  that 
the  world  might  know  they  had  in- 
vented a new  operation  for  lithotomy, 
which  they  called  1’operation  par  deux 
temps  : that  is,  wherein’ the  patient, 
found  exhausted  by  the  laborious  efforts 
to  extract  the  stone  by  the  forceps,  at 
the  time  of  the  operation,  was  put  to 
bed,  in  order  to  recruit  for  another  trial 
the  following  day.  1?  operation  par  deux 
temps ! 

The  Pelvic  Partition.  I believe  nine 
out  of  ten  of  the  cases  of  death  after 
lithotomy,  are  to  be  attributed  to  perito- 
neal inflammation,  caused  by  extrava- 
sated  urine  retained  in  some  quantity 
against  the  under  surface  of  the  perito- 
neum, as  it  passes  from  the  bladder  to 
the  rectum  and  side  of  the  pelvis. 

1 have  taken  some  pains,  in  the  first 
part  of  a System  of  Surgical  Anatomy, 
published  this  year,  to  describe  the  par- 
ticular connexions  of  the  iliac  fascia  with 
the  side  of  the  urinary  bladder,  and  to 
show  that  a complete  septum  is  formed 
by  this  membrane  at  each  side,  which 
is  impenetrable  by  any  aqueous  fluid  ; 
and  by  its  peculiar  attachments,  a pit 
exists  at  the  side  of  the  back  part  of  the 
bladder,  which  is  bounded  below  by  this 
fascia,  and  above  and  behind  by  the  peri- 
toneum, as  it  goes  from  the  bladder  to 
the  side  of  the  pelvis.  That  this  pit  is 
likely  to  be  filled  with  urine,  during  the 
incision  into  the  bladder  in  the  operation 
for  stone  : and  that,  when  urine  is  here 
placed,  it  has  no  possible  way  of  escape 
but  by  absorption.  When  urine  is  in  this 
situation,  therefore,  it  is  in  constant  con- 
tact with  a considerable  extent  of  sur- 
face of  peritoneum;  and  that,  under  such 
circumstances,  it  is  equal  to  produce  ery- 
sipelatous inflammation  of  the  mem- 
brane, no  one  will  deny. 

.1  think  it  can  be  demonstrated  by  fair 
Voi,  If  '08 


induction,  that,  from  the  time  of  Celsus 
to  the  present  day,  the  different  opera- 
tions of  lithotomy  were  successful  in  pro- 
portion as  this  pelvic  partition  remained 
uncut.  The  fatality  attending  Mr.  Chc- 
selden’s  first  operation,  is  to  he  ascribed 
to  the  urinal  infiltration,  consequent  upon 
the  manner  in  which  he  divided  the  blad- 
der. He  cut  upwards,  and  necessarily 
wounded  this  partition.  We  are  permit- 
ted to  draw  this  inference,  especially  as 
Mr.  Cheselden  has  not  accounted  for 
such  events  in  any  other  way.  The 
high  operation  has  been  laid  aside  from 
being  so  often  unsuccessful ; and,  in  all 
the  descriptions  given  of  that  perform- 
ance, we  are  left  in  the  dark  as  to  the 
cause ; being  only  presented  with  ac- 
counts of  its  comparative  ill  success.  The 
operation  by  the  apparatus  major,  I have 
no  doubt,  was  instituted  in  its  day  from 
a consciousness  that  something  was  cut 
in  other  operations,  that  ought  not  to 
be  cut.  Hence  the  method  by  dilatation 
was  thought  more  adviseable. 

[Surg.  Anat.  Pari  /.] 
The  result  of  my  observations  upon  the 
structure  of  the  parts  within  the  pelvis, 
in  reference  to  the  division  of  the  bladder 
and  prostate  in  the  operation  of  lithotomy, 
is  this ; that  there  is  a line  for  this  inci- 
sion, which,  when  observed,  the  prostate 
gland  can  be  completely  divided,  and  the 
neck  of  the  bladder  beyond  it,  for  the  ex- 
tent of  two  inches,  with  all  safety  to  the 
patient,  and  without  opening  the  pelvic 
partition,  or  wounding  the  peritoneum  or 
vesicula  seminalis ; which  line  w ill  he 
obtained  by  observing  the  following  rule. 
The  patient  is  to  be  placed  on  the  table  in 
the  usual  manner,  tied  hands  and  feet, 
and  in  that  exact  position  in  which  he  is 
ordinarily  placed  for  the  operation.  Then 
let  the  knife,  having  entered  the  groove  of 
the  staff',  be  carried  into  the  bladder,  and 
the  bladder  and  prostate  divided,  while  the 
instrument  is  held  in  a line  with  the  ho- 
rizontal table  on  which  the  patient  lies, 
that  will  give  an  angle  of  forty-five  de- 
grees. 

NEEDLE,  surgeons’.  Every  prac- 
titioner must  have  felt,  even  at  the  ends 
of  his  fingers,  the  inconvenience  and  diffi 
culty  attending  the  introduction  through 
the  skin  of  Ihe  common  curved  needle. 
The  young  student  is  almost  sure  to  prick 
his  fingers,  in  his  first  attempts  at  sew’ing 
up  the  dead  body;  although  a large 
needle  is  then  generally  made  use  of. 
And  in  the  living  subject,  when  bringing 
arts  together  by  suture,  as  in  case  of 
arelip,  it  is  not  always  easy  to  intro- 
duce the  common  needle  in  the  course 
we  wish  it,  or  do  it  at  all,  in  any  thing  like 
a graceful  manner.  The  needle  is  small, 
rolls  between  the  fingers,  and  has  its 
point  coming  out  sometimes  at  a dart 
at  which  we  feast  expect  if. 


APPEND 1&. 


'SJfr 


Dr.  Miller,  of  Franklin,  Massachu- 
setts, has  contrived  a delicate  instrument, 
which  I think  in  every  instance  will  be 
more  efficient  than  the  ordinary  needle. 

It  is  a curved  needle,  with  an  eye  about 
the  eighth  of  an  inch  from  its  point,  fixed 
into  a straight  handle,  by  which  full 
power  is  had  over  the  instrument.  It  is 
first  introduced  through  both  lips  of  in- 
tegument, and  then  armed  with  silken 
ligature,  when  the  thread  takes  the  place 
of  the  needle  as  the  latter  is  withdrawn. 

OSTEO  SARCOMA  The  following 
is  an  account  of  three  cases  in  which  ex- 
tensive portions  of  the  lower  jaw  were 
taken  away  for  the  removal  of  this  dis- 
ease ; after  previously  tying  the  carotid 
artery,  in  each  individual,  by  Professor 
Valentine  Mott.  Two  of  these  cases  were 
of  successful  issue,  but  the  third  was  lost; 
from  circumstances,  however,  which 
could  not  be  fairly  referred  to  the  opera- 
tion. 

On  the  12th  Nov.  1821,  being  asked  by 
Dr.  Mott  to  see  a patient  of  his  with  a 
curious  disease  on  the  right  side  of  the 
lower  jaw,  1 was  shown  an  interesting 
young  woman,  by  name  Catharine 
Bucklew,  of  about  17  years  of  age,  of 
healthy  appearance,  good  constitution, 
and  who  gave  of  herself  the  following 
account. 

She  stated  that  at  about  two  years  pre- 
vious, a swelling  commenced  behind  the 
last  molar  tooth,  attended  with  acute 
pain  about  the  angle  of  the  jaw,  that  con- 
tinued for  three  weeks ; at  which  time  the 
inflammation  left  her,  without  any  evi- 
dent resolution.  During  this  attack  there 
was  no  inflammation  of  the  integument, 
nor  could  any  pus  be  discovered,  either 
on  the  cheek  or  about  the  bone  within 
the  mouth.  That  some  domestic  appli- 
cations were  made  use  of  to  the  cheek, 
hut  the  swelling  remained,  assuming  the 
appearance  of  smooth  and  hard  bone. 
That,  at  about  twelve  months  after  its 
commencement,  she  applied  to  a physi- 
cian in  New- Jersey,  (it  being  her  resi- 
dence,) who  advised  blisters  to  the  cheek, 
with  the  topical  application  of  caustic  to 
the  tumour,  together  with  a general  anti- 
phlogistic constitutional  treatment:  and 
that  this  was  persisted  in  for  two  months 
without  any  benefit. 

Soon  after  this  she  came  to  the  city, 
and  put  herself  under  the  care  of  Dr. 
Mott,  in  the  New-York  Hospital,  when 
the  tumour  had  extended  from  the  root 
f the  coronoid  process  to  the  second 
bieuspis  tooth,  being  elevated  nearly  an 
inch  above  the  level  of  the  teeth,  and 
spreading  considerably  wider  than  the 
alveolar  processes.  Its  appearance  was 
smooth,  and  to  the  touch  somewhat  elas- 
tic, though  firm.  Dr.  Mott  made  an  in- 
cision on  each  side  the  alveolar  margin, 


with  a scalpel,  by  which  he  was  enabled 
pretty  readily  to  remove  the  tumour  to  a 
level  with  the  jaw  bone.  The  tumour, 
upon  examination  after  removal,  was 
found  to  contain  many  cartilaginous  and 
osseous  spiculae ; and  in  its  substance 
one  of  the  molar  teeth  was  imbedded, 
in  a perfectly  sound  state.  About  three 
months  after  this  a small  sprout,  which 
had  grown  rapidly,  was  taken  off ; she 
upon  this  removed  to  the  country,  where 
she  remained  in  a very  comfortable  state 
for  several  months. 

At  the  time  I saw  her,  she  further 
stated,  that  the  first  molar  tooth  came 
away  early  in  the  disease ; that  the  se- 
cond soon  followed;  after  which,  three 
or  four  of  the  other  teeth  at  that  side  of 
the  jaw  ; and  that  previously  to  this  dis  - 
ease, she  had  never  a decayed  tooth : 
and  further,  that  no  fluctuation  was  to  be 
felt  at  any  time  in  the  tumour  ; had 
no  constitutional  symptoms  as  the  ef- 
fects of  this  disease,  nor  any  inordinate 
headach  on  that  side.  The  lymphatic 
glands  of  the  neck  were,  however,  swol- 
len during  the  continuance  of  the  inflam- 
mation, in  the  early  period  of  the  disease, 
but  disappeared  when  the  pain  subsided. 

When  1 saw  her,  at  the  date  mention- 
ed, the  tumour  had  the  same  firm  and 
slightly  elastic  feel,  which  was  said  to 
characterize  it  in  its  early  stage,  and  in- 
volved all  the  right  side  of  the  inferior 
maxillary  bone.  Projecting  outwards,  it 
formed  a great  convexity  of  the  cheek  ; 
upwards  it  was  divided  into  two  por- 
tions by  a furrow  made  by  the  pressure 
of  the  teeth  of  the  upper  jaw  ; this  was 
attended  with  a constant  abrasion  of  sur- 
face and  discharge,  which,  though  offen- 
sive, did  not  appear  to  be  acrid  or  irrita- 
ting : downwards,  it  was  nearly  in  con- 
tact with  the  thyroid  cartilage ; and  in- 
wards, it  extended  beyond  the  middle 
line  of  the  mouth,  pushing  the  tongue 
and  uvula  much  to  the  left  side. 

The  tumour,  at  the  back  part  of  the 
mouth,  had  encroached  so  much  upon 
the  passage  leading  to  the  fauces,  and 
the  pressure  of  the  lower  part  on  the 
pharynx  was  so  considerable,  that  deglu- 
tition became  difficult ; and  from  the 
great  inconvenience  attending  mastica- 
tion, she  had  been  compelled  for  some 
time  to  subsist  upon  liquid  aliment.  Her 
speech  was  much  interfered  with,  in  con- 
sequence of  the  displacement  of  the 
tongue  ; but  she  had  no  pain  in  any  part 
of  the  tumour. 

Under  all  these  circumstances,  she  was 
very  desirous  to  be  made  acquainted  if 
an  operation  could  not  be  performed, 
which  might  extend  to  her  some  chance 
of  life;  observing,  that  if  she  continued 
in  the  present  state  much  longer,  she 
would  soon  be  unable  to  swallow  anr 


APPENDIX. 


tiling,  judging  from  the  vapid  growth  that 
the  tumour  had  shown  for  the  few  weeks 
previous  ; and  fully  aware  of  the  danger- 
ous nature  of  the  novel  operation  her  ease 
would  reouire,  she  expressed  herself 
determin*  a to  submit  to  it,  and  hazard 
the  consequences.  The  uncertain  result 
of  the  operation  was  fully  explained  to 
her  by  Dr.  Mott,  and  moreover  that  she 
might  die  under  its  performance ; but 
that  it  was  believed  both  practicable  and 
proper. 

After  preparing  the  sj'stem  for  about  a 
Week,  with  a light  diet  and  a few  doses 
of  neutral  salts,  the  operation  was  com- 
menced on  the  morning  of  the  17th.  As 
it  was  thought  prudent  to  begin  by  pla- 
cing a ligature  on  the  common  carotid, 
this  vessel  was  sought  for  at  the  middle 
of  the  neck,  and  one  ligature  placed 
around  it.  Very  little  blood  was  lost, 
and  only  one  subcutaneous  branch  at  the 
lower  end  of  the  wound  required  tying. 
Although  she  submitted  to  this  part  of 
the  operation  with  firmness,  yet  imme- 
diately afterward  she  became  pale  and 
almost  pulseless,  with  the  presentiment 
that  she  should  die  if  the  operation  of 
extracting  the  tumour  was  persisted  in. 
In  this  her  state  of  mental  perturbation, 
it  was  resolved  not  to  proceed  ; she  was 
therefore  put  to  bed. 

After  she  recovered  a little,  she  was 
apprized  that  what  had  been  done,  was 
only  preparatory  to  the  most  important 
part  of  the  operation  ; and  that  that 
would  prove  of  little  or  no  benefit  to  her 
if  it  was  not  further  proceeded  in.  She 
was  then  urged  to  give  the  thing  full  con- 
sideration, and,  if  possible,  to  make  up 
her  mind  to  submit  to  the  performance 
of  the  remaining  part,  which  on  no  ac- 
count should  be  deferred  longer  than  the 
following  day. 

13 tk,  7 A.  M. — Found  her  this  morn- 
ing much  composed,  having  slept  well, 
and  free  from  fever.  Upon  putting  the 
question,  would  she  submit  to  the  rest  of 
the  operation  ? she  answered,  with  much 
decision,  that  she  was  determined  to  un- 
dergo it.  She  was,  therefore,  being 
cheerful  and  resolute,  at  ten  o’clock  pla- 
ced again  upon  the  table,  when  Dr.  Mott 
proceeded  with  the  operation  in  the  fol- 
lowing manner. 

Feeling  for  the  condyloid  process,  the 
incision  was  begun  upon  it  opposite  the 
lobe  of  the  ear,  and  carried  downwards 
opposite  the  ear,  over  the  angle  of  the 
'aw,  in  a semicircular  direction  along  the 
ower  part  of  the  tumour  as  it  rested  upon 
the  thyroid  cartilage,  ending  at  about 
half  an  inch  beyond  the  angle  of  the 
mouth,  upon  the  chin.  After  this  the  se- 
cond incisor  tooth  of  the  right  side  was  ex- 
tracted, which  was  from  a sound  part  of 
the  bone ; and  upon  further  separating 
the  soft  parts  from  tire  side  of  the  jaw 


near  tire  chin,  a narrow  saw,  similar  to  a 
key-hole  saw,  was  introduced  into  the 
mouth  from  the  wound,  by  which  was 
divided  the  jaw-bone  in  a perpendicular 
direction,  commencing  where  the  incisor 
tooth  had  been  extracted.  The  lower 
part  of  the  tumour  was  then  laid  bare  by 
cutting  through  the  mylo-hyoid  muscle  ; 
when  the  flap  of  the  cheek  was  carefully 
separated  and  turned  up  over  the  eye. 
This  exposed  fully  to  view  the  whole  ex- 
tent of  the  tumour,  as  it  rose  towards  the 
os  make.  Now,  after  the  integuments 
were  cautiously  dissected  from  the  paro- 
tid gland,  the  masseter  muscle  was  detach- 
ed at  its  insertion,  until  the  edge  of  this 
gland ; then  separating  a few  more  fibres 
of  the  muscle  under  the  gland,  the  paro- 
tid was  readily  raised  without  injury. 
The  maxilla  was  next  laid  bare  for  some 
way  above  its  angle,  where  it  was  seen 
sound  and  in  a healthy  state.  To  facili- 
tate the  sawing  of  the  bone  in  this  second 
situation,  it  was  necessary  to  make  a fur- 
ther incision  through  integument  for 
about  an  inch  close  to  the  lobe  of  the  ear, 
and  over  against  the  mastoid  muscle. 
Then  with  a fine  saw  made  for  the  pur- 
pose, smaller  and  more  convex  than 
Hey’s,  the  bone  was  divided  obliquely 
downward  and  backward,  at  a part  about 
midway  between  the  angle  and  condy- 
loid process.  This  part  of  the  sawing 
was  necessarily  performed  with  much 
caution,  to  avoid  wounding  the  great  ves- 
sels, and  the  inferior  maxillary  nerve. 
After  the  bone  was  sawed  through,  the 
action  of  the  temporal  muscle  separated 
the  coronoid  from  the  eondyloid  process, 
and  drew  it  up  under  the  zygomatic  arch. 

An  elevator  was  now  introduced,  where 
the  bone  was  divided  at  the  chin,  by 
which  the  whole  diseased  mass  was  rais- 
ed ; and,  with  a scalpel  passed  into  the 
mouth,  the  tumour  was  separated  from 
the  side  of  the  tongue,  as  far  back  as  the 
posterior  fauces.  The  tumour  could 
now  be  turned  against  the  side  of  the 
neck,  to  assist  its  separation,  from  the 
parts  below  the  base  of  the  jaw,  and 
from  the  pharynx.  The  pterygoid  mus- 
cles were  next  detached,  and  the  third 
branch  of  the  fifth  pair  of  nerves  divided 
a little  above  the  foramen  at  which  it 
enters  the  hone,  observing  much  caution 
to  secure  the  safety  of  the  trunk  of  the 
internal  carotid,  and  deep-seated  jugular 
both  of  which  were  exposed. 

At  the  several  periods  of  this  operation, 
the  curved  spatulas  of  Colles  were  found 
of  infinite  service,  as  in  elevating  the  pa- 
rotid gland,  keeping  the  tongue  steady, 
&tc. 

Very  little  blood  was  lost  in  this  ope- 
ration ; three  arteries  only,  of  any  size, 
required  a ligature  : viz.  the  facial,  lingua), 
and  a little  branch  behind  and  under- 
neath the  angle  of  the  jaw. 


APPEJNDIX. 


luo 

After  waiting  for  a little  time  to  ob- 
serve if  any  hemorrhage  should  ensue 
upon  the  reaction  of  the  system  : the 
dap  of  the  cheek  was  brought  down  and 
closely  approximated  to  the  divided  inte- 
guments below  by  three  interrupted 
sutures;  after  which, adhesive  straps,  lint, 
compress,  and  a double-headed  roller, 
being  applied,  the  patient  was  made,  as 
comfortable  as  possible,  and  directed  to 
be  continued  upon  the  table  for  a few 
hours  to  recruit. 

At  eight  o’clock  in  the  evening  she  had 
been  removed  to  her  bed,  and  signified 
that  she  was  comfortable.  Some  reaction 
of  the  circulation  had  taken  place ; but 
there  had  been  no  hemorrhage.  The 
pain  from  the  operation  she  said  was  less 
than  she  had  expected.  For  the  first  time 
since  the  operation  she  sipped  three  tea- 
spoonsful  of  cold  water,  and  gave  evi- 
dence by  a nod  that  she  could  swallow. 
One  hundred  drops  of  tinct.  opii  was  di- 
rected to  be  given  if  any  twitching,  more 
pain,  or  restlessness,  should  come  on. 
She  was  recommended  to  make  no  effort 
to  speak. 

19 ih,  7 A.  M. — She  w’as  found  quite 
free  of  fever  and  irritation,  and  in  every 
respect  comfortable  : she  swallowed  cold 
water  by  the  tea-spoonful  with  but  little 
inconvenience : she  slept  several  hours 
during  the,  night. 

12  at  noon. — She  was  found  comforta- 
ble ; skin  moist;  pulse  less  frequent,  and 
soft : an  enema  was  directed  to  be  admi- 
nistered of  soft  soap  and  water;  she  had 
a little  more  difficulty  in  swallowing,  but 
none  in  breathing. 

9 P.  M. — She  was  as  well  as  in  the 
morning  ; the  enema  had  operated  three 
times,  and  relieved  her ; pulse  frequent, 
but  not  tense  : she  had  taken  about  two 
ounces  of  cold  water  by  the  spoon  since 
daylight. 

20/A,  7 A.  M. — She  had  had  a very 
comfortable  night ; instead  of  nodding, 
she  answered  yes  and  no  to  the  several 
questions,  in  an  audible  whisper. 

9 P.  M. — She  was  much  as  in  the 
morning. 

21s/,  9 A.  M. — Was  as  comfortable  as 
yesterday  morning. 

9 P.  M. — There  was  no  material  alter- 
ation. 

22 d,  9 A.  M. — An  enema  was  directed 
to  be  administered  as  before.  She  was 
allowed  to  take,  in  addition  to  her  cold 
water  and  teas,  some  thin  chicken  soup  ; 
and  was,  in  every  respect,  doing  well. 

9 P.  M.— Tumefaction  of  the  lips  and 
cheek  very  trifling,  not  enough  to  effect 
the  least  change  in  the  lids  of  the  right 
eye. 

— Was  in  every  respect  comforta- 
ble. 

24 tk,  1 1 A.  M. — Has  made  no  com- 


plaint. The  wounds  were  dressed,  and 
union  by  adhesion  had  taken  place  in 
their  whole  extent,  excepting  about  the 
ligatures  and  sutures.  Suppuration  hav- 
ing come  on  about  two  of  the  sutures, 
were  removed.  Pulse  about  120. — 
The  adhesive  straps  were  renewed,  with 
lint  interposed  between  them  and  the 
double-headed  roller. 

25 th. — Was  every  way  comfortable. 
Pulse  120. 

26/A. — She  said  she  had  no  complaint 
to  make.  Pulse  80.  She  was  directed 
to  take  a small  dose  of  sulphate  of  mag- 
nesia. 

27/A. — Spoke  audibly,  and  said  she  was 
very  well.  Pulse  about  84 

28 Ih. — Was  as  well  as  before  ; the 
wounds  were  dressed  ; the  two  sutures 
at  the  upper  part,  near  the  ear,  were 
removed  ; wounds  appeared  heated,  at 
every  part  except  where  the  ligatures  re 
main  upon  the  arteries.  Pulse  80. 

.2 9th. — Felt  very  well  ; spoke  dis- 
tinctly ; took  freely  of  soup  and  other 
thin  food.  Pulse  100. 

Dec.  8 d. — Ligature  from  the  carotid 
came  away  with  the  other  three  ligatures 
from  the  upper  wound.  A small  collec- 
tion of  matter  was  evacuated  from  under 
the  integuments  in  the  lower  wound, 
which  had  been  produced  by  the  irrita- 
tion of  the  ligature. 

4 th. — Spoke  and  swallowed  very  well ; 
wounds  almost  healed.  Hits  used  for 
some  days  a wash  of  spirits  and  water  to 
the  mouth,  with  a view  to  correct  some 
feetor  of  the  saliva,  and  cleanse  the 
mouth. 

6 th. — She  was  found  dressed,  and  sit- 
ting in  an  adjoining  room,  reading  by 
the  fire.  She*  looked  and  said  she  felt 
very  w ell.  The  bandages  being  all  left 
oft',  the  only  deformity  apparent  was  a 
little  more  tumefaction  of  the  right 
cheek  than  the  left ; wounds  almost  well : 
moved  very  readily  the  sound  half  of 
the  under  jaw.  She  was  permitted  to 
chew’  some  animal  food. 

10/A. — Wounds  all  healed;  made  no 
complaint. 

March , 1822. — There  was  scarcely  any 
perceptible  deformity:  the  right  cheek 
appeared,  upon  close  examination,  to  be 
a little  more  depressed  than  the  left;  and 
some  osseous  deposit  had  commenced  at 
the  two  situations  at  w hich  the  bone  had 
bee n d i vi d ed . H er  hea  1 1 h , i n e v t* ry  respec t , 
was  perfectly  good,  and  she  enjoyed  the 
free  use  of  the  left  side  of  the  lower  jaw. 

Maky  Roe,  a married  woman,  aged 
22  years,  came  to  New- York  from  Long- 
Island,  on  the  25th  of  March,  1822,  to 
consult  Dr.  Mott  concerning  a tumefac- 
tion of  the  left  side  of  her  lower  jaw-bone. 

She  stated,  that  about  one  year  from 
date  there  appeared  an  enlargement  of 
the  bone,  at  a point  from  which  one  of 


APPENDIX.  m 


the  molar  teeth  some  time  before  had 
been  extracted.  That  it  continued  to  in- 
crease gradually  ; but  being  at  that  time 
pregnant  with  her  second  child,  and 
feeling  little  pain  in  the  swelling,  she 
took  no  particular  notice  of  it.  Since  her 
delivery,  however,  which  took  place 
about  six  months  before  she  came  to  the 
city,  it  has  increased  much  more  rapidly, 
but  the  pain  remained  as  at  first,  and  has 
been  only  felt  occasionally  to  shoot 
through  the  part. 

This  disease  was  much  less  extensive 
than  that  in  the  preceding  case,  but  it 
reached  from  the  base  of  the  coronoid 
process  to  the  first  bicuspis  tooth,  ex- 
tending on  each  side  of  the  bone  to  near 
the  base,  and  as  far  back  as  the  angle,  at 
which  part  the  base  was  comprehended 
in  the  disease.  Several  of  the  teeth  had 
been  thrust  out  by  the  growth  of  the  tu- 
mour, and  those  which  remained  were 
very  much  displaced.  The  tumour  had 
the  same  appearance  and  elastic  feel  of 
that  in  the  former  case. 

On  the  SOth  March,  at  12  o’clock,  Dr. 
Mott,  assisted  by  Drs.  Post,  Burro  we-,  and 
myself,  tied  the  ieft carotid  artery  through 
an  opening  of  about  two  inches  in  length 
opposite  the  thyroid  cartilage  ; and  so  lit- 
tle was  the  constitutional  effect  of  this, 
that  it  was  determined  to  proceed  with 
the  rest  of  the  operation  immediately. 

An  incision  through  the  integuments 
was  now  made,  as  in  the  former  case,  be- 
ginning over  the  condyloid  process  above 
the  meatus  auditorius,  and  carried  in  a 
semicircular  direction  below  the  base  of 
the  jaw,  to  terminate  upon  the  chin  a lit- 
tle under  the  lip.  The  flap  of  the  cheek 
being  dissected  up,  the  first  bicuspis 
tooth  was  extracted  to  prepare  the  way 
for  the  saw ; which  instrument  was 
then  applied,  and  the  bone  divided  in  a 
perpendicular  direction  front  that  situa- 
tion. The  masseter  muscle  was  separa- 
ted from  the  angle  of  the  jaw,  and  the 
parotid  gland  carefully  elevated  anteri- 
orly, in  order  to  exhibit  the  hone  a little 
above  the  angle,  that  room  might  be  made 
for  the  saw.  The  bone  was  now  cut 
through  midway  between  the  processes 
and  angle,  in  aline  parallel  with  the  zygo- 
matic arch. 

The  bone  was  now  raised  at  the  chin 
by  the  finger  and  thumb,  then  detached 
from  the  parts  within  the  mouth  by  a 
scalpel,  until  the  diseased  mass  was  com- 
pletely removed. 

During  the  elevation  of  the  flap,  and 
removal  of  the  bone,  the  hemorrhage  was 
profuse.  At  least  a dozen  ligatures  were 
applied  to  bleeding  arteries  ; some  of  the 
vessels  bleeding  equally  free  from  both 
their  extremities. 

The  patient  bore  the  operation  with 
undaunted  firmness,  the  flaps  of  integu- 
ment were  brought  together  by  several 


interrupted  sutures,  accompanied  by  ad- 
hesive straps  and  proper  bandaging. 

The  operation  occupied  one  hour  and 
fifty  minutes. 

7 o’clock,  P.  M.— Pulse  30  ; nodded 
that  she  was  comfortable  ; had  slept  lb 
minutes,  and  was  refreshed,  but  was  sick 
at  stomach,  and  had  made  an  effort  to 
vomit  ; ordered  not  to  attempt  to  speak. 

10  P.  M. — Had  coughed  some,  which 
was  followed  by  a discharge  of  fresh 
blood  from  ttie  mouth,  as  well  as  from 
the  wound,  so  as  to  come  through  the 
bandage,  and  run  upon  the  neck.  Pulse 
88  : had  taken  a little  cold  water  by  tea- 
spoonsful 

31  st,  to  X.  M» — Had  a good  night,  but 
coughed  hard  several  times,  yet  no  more 
bleeding  ; felt  much  refreshed  from  deep ; 
pulse  y2;  skin  natural;  took  10  drops 
tinct.  opii  to  allay  cough,  but  nausea  be- 
ing the  effect,  was  not  repeated : to  have 
cold  barley  water  instead  of  common  wa- 
ter, by  the  tea-spoonful. 

April  ls£. — Passed  an  uncomfortable 
night,  owing  to  cough  ; pulse  02  ; was 
ordered  enema  communis , which  was  re- 
peated in  the  afternoon  with  good  effect. 
Five  P.  M.  pulse  120  to  135;  articulates 
a little,  though  indistinctly  ; was  ordered 
a cough  mixture. 

2 d — More  comfortable  ; pulse  88  ; all 
symptoms  favourable.  No  tumefaction 
about  the  eyelids  ; cough  less. 

3d.— Felt  refreshed ; countenance  good  ; 
no  tumefaction  of  the  face  ; articulated 
distinctly  ; pulse  88  ; complained  of  hun- 
ger. 8 P.  M.  pulse  80;  cough  was  trou- 
blesome forepart  of  the  day.  mixt.  ex- 
pect. cont. 

4th. — Said  with  a distinct  and  audible 
voice  that  she  was  better  than  at  any 
other  time  since  the.  operation  ; felt  no 
pain  in  the  wound;  coughed  less;  but 
from  the  state  of  the  bandages,  the  wound 
was  cleaned  and  dressed.  The  parts 
were  found  to  look  well;  pulse  92;  felt 
hungry  ; was  ordered  some  thin  broth. 

5th. — Had  a comfortable  night;  took 
some  chicken  tea  with  much  relish ; pulse 
104;  no  appearance  of  tumefaction.  Had 
an  enema  this  morning  which  operated 
well ; cough  much  relieved. 

6th. — Dressed ; removed  from  the  up- 
per wound  the  sutures,  and  all  the  liga- 
tures except  one ; parts  looked  well. 
The  lower  wound  looked  well ; but  there 
was  little  union  there  by  adhesion,  proba- 
bly ow'ing  to  cough  ; pulsq  80. 

7th. — Has  been  sitting  up  in  bed  a lit- 
tle ; pulse  32 ; was  ordered  sulphate  of 
soda  in  divided  doses. 

8th. — Improving  daily;  wounds  doing 
well  ; the  last  ligature  from  the  upper 
wound  was  removed  ; pulse  120.  The 
increase  of  pulse  probably  owing  to  the 
operation  of  salts,  which  had  just  then 
taken  place. 


APPENDIX. 


\<Zth. — 'W  hile  the  wound  was  dressing; 
this  day  the  ligature  from  the  carotid 
came  away ; patient  doing  well ; pulse 
104. 

1 Oth. — The  fcetorand  disagreeable  taste 
in  the  mouth  very  much  gone,  from  the 
daily  use  of  a w dak  spirit  and  water  lo- 
tion. She  w'ns  permitted  to  nurse  her 
babe  a little  to-day,  for  the  first  time 
since  the  operation. 

16th. — YVounds  almost  closed. 

17 th. — She  felt  satisfied  that  the  wound 
within  the  mouth  was  completely  healed. 

2,0th. — Had  been  down  stairs. 

23d. — Was  permitted  to  chew  some 
animal  food  on  the  right  side  of  the 
mouth. 

28 th,  Mid-day.—  Suppuration  was  ob- 
served in  the  course  of  the  cicatrix  of  the 
upper  wound.  Upon  opening  the  part 
with  a lancet,  the  noose  of  one  of  the  li- 
gatures came  away  which  had  been  left 
in  the  wound,  the  thread  having  been 
taken  off  before  close  to  the  knot.* 

May  6. — Left  the  city  this  day,  com- 
pletely recovered,  for  her  residence  on 
Long- Island. 

The  last  case,  though  not  by  any 
means  the  least,  1 have  now  to  commu- 
nicate. 

Prince,  a coloured  lad,  aged  18  years, 
was  sent  to  Dr.  Mott,  from  Middletown 
Point,  Now-Jersey,  having  an  osteo-sar- 
comatous  tumour,  embracing  the  lower 
jaw-bone  from  the  articulation  of  the 
right  side,  as  far  round  as  the  alveolar 
socket,  supporting  the  first  molar  tooth 
on  the  left,  presenting  in  size  an  appear- 
ance equal  to  that  of  his  head. 

In  giving  his  history,  he  stated  that,  at 
the  age  of  twelve,  an  enlargement  of  the 
bone  showed  itself  at  the  right  side,  op- 
posite the  situation  of  the  second  molar 
tooth,  which  was  at  first  considered  a 
gum-bile,  but,  gradually  increasing,  dis- 
Jodged,  one  after  another,  the  teeth  in  its 
neighbourhood. 

When  it  had  arrived  to  the  size  of  a 
walnut,  a lancet  was  put  into  it,  but  no 
pus  or  fluid  issued  In  1818,  (then  as 
large  as  a goose’s  egg)  it  was  again  open- 
ed, and  a small  quantity  of  blood  and 
matter  wras  discharged.  Lately,  two  or 
three  small  openings  had  taken  place 
within  the  mouth,  attended  with  a dis- 
charge of  pus  and  ichor,  at  which  places 
also  were  denuded  several  bony  spiculse, 
clearly  characterizing  the  disease.  Ex- 
ternally, and  near  the  most  depending 
part,  an  ulceration  of  the  skin  had  shown 
itself,  from  which  the  tumour  afforded 
a daily  discharge  of  an  ounce  or  two  of 
matter ; and  this  had  been  kept  up  for 
the  several  last  weeks.  By  this  opening, 
a probe  could  be  passed  tor  some  dis- 

* The  reader  may  apply  this  fact  to  what  has  been 
said  in  ihe  Appendix  of  s'ol  1 upon  leaving  ligatures 
under  the  shin  for  absorption,  after  amputation. 


tance  into  the  substance  of  the  enlarge- 
ment. 

From  the  great  emanation  which  was 

firesent  in  this  lad’s  case,  there  could  be 
ittle  hope  entertained  from  the  formida- 
ble operation  which  would  be  required  to 
relieve  him  from  such  a mass  of  disease. 
Still,  as  he  was  about  to  perish,  and  being 
on  his  own  part  very  desirous  to  take 
what  little  chance  the  means  might  pro- 
mise, it  was  thought  right  to  operate. 

Having  assisted  Dr.  Mott  in  this  opera- 
tion also,  1 had  opportunity  to  observe 
the  different  steps  of  the  performance. 

May  15 th,  1822. — At  noon  this  day  the 
doctor  commenced  by  tying  the  right  ca- 
rotid artery,  a little  above  the  clavicle. 
This  the  patient  bore  well,  being  little 
exhausted  ; and  after  resting  and  refresh- 
ing himself  with  a little  wine,  he  express- 
ed his  wish  that  the  operation  might  be 
continued. 

An  incison  was  now?  begun  opposite  the 
jugum  temporale , carried  in  a semicircu- 
lar course  over  the  most  prominent  part 
of  the  swelling,  and  terminated  opposite 
the  first  molar  tooth  of  the  left  side. 
Another  cut  of  the  same  form,  but  of  less 
extent,  below  this,  left  insulated  a large 
piece  of  integument,  in  which  was  situated 
the  ulceration.  The  flaps  being  then  dis- 
sected from  the  tumour,  the  second 
bicuspis  tooth  of  the  left  side  was  extract- 
ed, and  the  bone  sawed  through  at  this 
sound  part,  by  the  same  instrument  which 
had  been  devised  for  the  other  cases. 
Now  raising  with  an  elevator,  and  then 
by  the  thumb  and  finger,  the  bone,  where 
sawn  through,  the  diseased  mass  was 
cautiously  di-sected  from  the  tongue, 
palate,  and  pharynx,  until  the  joint  upon 
the  right  side  was  exposed.  The  capsu- 
lar ligament  was  then  cut  into,  at  the  in- 
ner side  of  the  joint  ; after  which,  the 
bone  was  easily  removed  from  its  articu- 
lation. In  the  course  of  this  operation, 
very  little  blood  was  lost,  it  being  neces- 
sary only  to  apply  four  ligatures. 

The  patient  was  much  exhausted,  as 
the  operation,  from  the  great  extent  «ff 
the  disease,  necessarily  occupied  a con- 
siderable time ; and  this  was  also  favoured 
by  his  previous  state  of  debility. 

After  he  recruited  a little,  the  flaps  of 
the  parts  were  brought  together  by  seve- 
ral interrupted  sutures,  and  upon  apply- 
ing adhesive  straps  with  the  double-head- 
ed roller,  he  was  sent  to  bed. 

This  tumour  weighed  twenty  ounces. 
3 P.  M. — Has  continued  to  recover 
gradually  from  the  shock  of  the  opera- 
tion. 

5 o’clock.— Had  a sleep  of  half  an 
hour;  awakened  relieved;  pulse  regu- 
lar and  distinct. 

8 o'clock.— Pulse  140,  rind  regular; 
skin  cool  and  moist ; .signified  by  a nod 


APPENDIX 


703* 


that  he  was  more  comfortable  than  he 
expected  to  be  ; had  spoken  pretty  dis- 
tinctly for  several  things,  contrary  to  par- 
ticular orders  ; swallowed  some  water 
from  the  spout  of  a teapot,  but  taken  with 
much  difficulty. 

16/Ji,  10  A.  M.— Has  slept  quietly  for 
the  most  of  the  night,  and  only  took  a 
little  cold  water  once;  skin  of  natural 
temperature;  pulse  120,  and  stronger 
than  last  evening  ; nodded  that  he  felt 
comfortable;  was  ordered  a little  cold 
water  occasionally,  but  to  take  it  as  sel- 
dom as  possible. 

10  P.  M. — Pulse  124,  and  fuller;  skin 
pleasantly  warm;  articulated  that  he 
felt  refreshed  from  sleep  ; swallows  well, 
the  fluid  being  conveyed  into  the  poste- 
rior fauces  by  means  of  an  elastic  tube 
and  bottle.  Contrary  to  orders,  rose  from 
his  bed  to  have  an  evacuation  from  his 
bowels,  and  pass  urine  ; all  which  he  ac- 
complished without  difficulty. 

\7th,  10  A.  M. — Had  a good  night. 
Pulse  120  ; skin  natural ; swallows  with 
more  difficulty  ; and  some  of  the  liquid 
passes  through  the  wound.  Bandage 
was  removed,  and  all  the  dressings  ad- 
justed anew  ; slight  cough. 

9 P.  M. — Said  he  was  as  comfortable 
as  in  the  morning.  Pulse  124.  Has  slept 
considerably  during  the  day7,  and  ex- 
pressed himself  as  much  strengthened  by 
it. 

18 th,  10  A.  M. — Passed  a good  night ; 
is  quite  as  well  as  yesterday  ; swallowed 
better;  pulse  130. 

10  P.  M. — Was  not  so  well  as  in  the 
morning.  Pulse  from  13:)  to  140. 
Coughed  more  frequently,  with  hurried 
respiration  ; was  restless,  and  felt  faint 
at  times ; in  the  course  of  the  afternoon , 
during  a very  heavy  lightning-storm , he 
suddenly  fainted,  and  appeared  threaten- 
ed with  immediate  dissolution  : but  after 
a short  interval,  revived  by  the  use  of 
volatiles  and  fanning  ; said  he  felt  consi- 
derable pain  in  his  left  side,  which  pre- 
vented him  from  taking  a full  inspiration  ; 
he  described  every  breath  as  painful  to 
him,  which  was  also  evinced  by  the  dis- 
tress of  his  countenance;  w;is  ordered  a 
blister  immediately  to  his  side. 

VHh,  10  A M — Relieved  by  the  blis- 
ter; slept  considerably  during  the  night; 
had  fainted  once  during  the  night.  Dress- 
ed the  wound  ; more  than  two-thirds  of 
it  had  united  by  adhesion.  Breathing 
better.  Pulse  from  132  to  140.  Cough 
less  troublesome  ; swallowed  some  cho 
colate. 

In  the  course  of  this  day,  however,  his 
breathing  became  more  troublesome, 
with  great  anxiety  and  restlessness ; and 
4 o’clock  in  the  afternoon,  after  two 
or  three  faint  turns,  he  expired. 

Anxious  to  be  satisfied  of  the  cause  of 
his  sudden  death?  1 examined  the  body. 


1 found  the  wounds,  the  result  of  the 
operation,  healthy,  and  united  by  adhe- 
sion throughout  the  most  of  their  course. 

Upon  raising  the  sternum,  I found  in 
the  anterior  mediastinum  a massy  depo- 
sit of  coagulahle  lymph,  seemingly  of 
recent  exudation  ; this  was  of  a yellowish 
hue,  having  the  exact  appearance  of  pus, 
but  wanting  fluidity.  In  the  cavity 
of  the  pericardium  was  contained  a pint 
of  yeliow  serum  ; and  each  lung  exhibited 
marks  of  high  inflammation  ; the  surface 
of  both  lungs  w as  of  a florid,  arid  in  some 
places  a deep  purple  hue.  There  was, 
however,  in  no  place  any  adhesion  be- 
tween the  lung  and  the  side  of  the  chest. 

The  conclusion  I have,  drawn  from  this 
examination,  coupled  w ith  my  acquaint- 
ance with  the  more  particular  circum- 
stances of  this  man’s  case  is,  that  his 
death  was  to  be  attributed  to  inflamma- 
tion of  both  lungs,  caused  hy  lightning. 

As  I am  informed  these  cases  are  yet 
to  appear  before  the  public  in  a more  de- 
tailed state,  I shall  content  myself  with 
this  one  remark  : — 1 believe  an  important 
practical  fact  has  been  confirmed  by  these 
operations ; namely,  that  the  tying  of  the 
common  carotid  previously  to  any  other 
part  of  the  operation  in  these  individual 
cases,  did  prevent  hemorrhages  during 
the  performance,  which  would  have  so 
interrupted  the  surgeon  that  he  might 
have  been  unable  to  proceed.  But  more- 
over, that  tying  these  arteries  low  dowrn  in  , 
the  neck  before  the  other  part  of  the  ope- 
ration, and  not  their  branches,  as  they 
might  have  been  from  time  to  time  cut 
in  the  course  of  the  operation,  did  prevent 
an  excess  of  inflammation  during  the 
cure;  which,  as  can  be  imagined,  might 
have  extended  to  the  brain  and  its  mem- 
branes, and  been  the  cause  of  death. 
At  all  events,  might  have  protracted  the 
cure,  by  effecting  a long-continued  puru  - 
lent discharge,  w ith  emaciation,  and  much 
loss  of  strength  to  the  patients. 

Aboutthree  weeks  after  Prince’s  death, 
an  old  gentleman  came  from  Westches- 
ter, with  a similar  disease  of  the  right 
side  of  the  jaw,  of  considerable  extent ; 
but  as  he  w as  of  an  irritable  constitution, 
bad  habit,  and  upwards  of  sixty  years  of 
age,  he  was  advised  to  go  home,  and  not 
think  of  an  operation. 

I have  been  (yesterday,  December  11,) 
shown  another  case  b}  Dr.  Mott, in  a fine- 
looking  boy  of  about  nine  years  of  age, 
from  the  neighbourhood  of  Corlaer’s 
Hook,  on  whom  it  is  purposed  to  operate 
in  the  course  of  the  week.  The  disease 
is  of  three  years’  growth,  and  extends 
from  the  angle  at  the  left  side  of  the  jaw 
to  the  chin. 

it  is  probable,  that  had  it  not  been  for 
the  successful  issue  ot  Catharine  Buck- 
lew’s  case,  vve  should  never  have  heard 
of  the  remaining  four ; proving  that  osteo- 


APPENDIX 


%M 


sarcoma  in  that  situation,  is  not  a novel 
disease  ; nor  so  rare  as  may  have  been 
hitherto  supposed. 

PESSARY.  I have  lately  had  pre- 
sented me,  by  Dr.  Barker  of  this  city,  a 
newly-constructed  pessary  for  prolapsus 
uteri;  for  which  he  has  just  now  ob- 
tained a patent. 

That  there  was  room  for  improvement 
in  these  instruments,  no  practitioner,  to 
whose  lot  it  has  fallen  to  direct  ihe  ap- 
plication of  those  hitherto  in  use,  can 
deny;  and  it  will  be  admitted,  that  the 
common  boxwood  pessary,  to  say  the 
least  against  it,  is  calculated  to  excite  and 
keep  up  a debilitating  discharge  from  the 
vagina. 

Dr.  Barker  s instrument  is  a pyriform 
gum-elastic  bag:  h ving  connected  with 
its  neck  a valvular  m*  < lamsm  of  ivory, 
for  retaining  such  r-  as  might  be  intro- 
duced to  fill  it,  alter  it  had  been  passed 
up  the  vagina.  The  pressure  induced 
by  such  an  instrument  must  be  one  as 
will  most  effectually  answer  the  com- 
manding indication ; and  can  never  be 
unpleasant  or  injurious  to  the  patient. 

There  is  attached  to  it  a contrivance, 
by  which  the  patient  herself  can  fill  it 
with  air,  and  by  which  also  she  may 
empty  it  when  it  may  be  her  wish  to 
have  it  withdrawn.  That  this  part  of  it, 
however,  may  not  be  improved  upon,  1 
am  not  so  well  convinced  ; but,  as  re- 
gards the.  instrument  itself,  it  is  undoubt- 
edly the  best,  under  the  name  of  pessary, 
that  has  yei  been  submitted  to  the  pub- 
lic ; proved  by  the  assurances  of  the  nu- 
merous patients  wrho  have  already  put  it 
to  test. 

PROSTATE  GLAND.  Whatlhave 
to  say  upon  this  article,  is,  that  1 have 
never  seen  any  thing  like  a third  lobe,  as 
described  by  Sir  Everard  Home  to  this 
gland  in  its  healthy  state:  yet  1 have 
seen  something  like  it  behind  the  veru- 
montanum,  while  the  prostate  was  gene- 
rally enlarged,  although  not  tumefied  in 
any  other  particular  situation.  And  I will 
venture  this  explanation  for  the  occur- 
rence. 

The  prostate  gland  is  surrounded  by  a 
tunic,  derived  from  the  posterior  surface 
of  the  triangular  ligament,  and  which, 
after  strengthening  the  urethra  at  the 
membranous  part,  passes  on  to  this  gland, 
affording  a covering  equally  dense  with 
the  tunica  albuginea  of  the  testis.  But 
the  prostate  is  not  lined  with  any  thing 
like  this  where  it  is  pierced  by  the  ure- 
thra : yet  the  verumontanum  gives 

firmness  to  the  anterior  part  of  that 
roove.  As  (he  effect  of  a general  in- 
animation of  this  gland,  its  whole  sub- 
stance will  at  first  become  gradually  en- 
larged, and  then,  if  the  disease  continues, 
a special  tumefaction  or  elevation  will 
show  itself,  projecting  towards  the  cavity 


of  the  bladder  behind  the  verurnontanua^ 
or  in  other  words,  at  that  part  of  the 
prostate  tvhich  is  tvanting  support  from 
the  dense  tunic  just  spoken  of.  And 
when  inflammation  exists  in  that  part  of 
the  gland  exclusively,  this  peculiar  eleva- 
tion,or  third  lobe , may  show  itself  without 
any  general  enlargement  of  the  prostate 
gland, 

TIC  DOULOUREUX.  Upon  the 
operation  lor  this  disease  I have  had  fre- 
quent conversations  with  my  friend  Pro- 
fessor Mott,  who,  as  far  as  1 can  learn, 
has  had  more  to  do  with  it  than  any  me- 
dical man  in  the  country.  He  informed 
me  that  he  had  operated  for  neuralgia 
about  fifty  different  times,  with  varied 
success  ; and  has  among  other  facts  ob- 
served, that  in  cases  wherein  he  had 
operated  more  than  once,  the  interval  of 
relief  became  less,  in  proportion  as  the 
operation  had  been  often  performed. 

The  inaugural  dissertation  of  the  late 
J.  W.  B.  Murray,  M D.,  which  contains 
a summary  of  Dr.  Mott’s  experience  up 
to  1816,  the  time  of  its  publication,  hav- 
ing fallen  into  my  hands,  1 shall  copy  as 
much  of  it,  as  has  reference  to  the  opera- 
tion for  tic  douloureux. 

“The  most  strenuous  advocate  for  the 
operation,  in  this  country,  is  Professor 
Mott.  His  success  has  been  so  unequi- 
vocal, and  his  opportunities  of  witnessing 
the  disease  so  comparatively  numerous, 
that  his  unqualified  opinion  in  all  cases  of 
Neuralgia,  is  ‘divide  the  nerve  f then,  if 
necessary,  employ  the  other  remedies  to 
destroy  or  diminish  the  susceptibility  to 
return,  which  will  be  accomplished  most 
certainly  by  hemlock  and  other  narco- 
tics. Dr.  Mott  has  operated  on  five  pa- 
tients. He  has  divided  different  nerves 
on  Dr.  Jones’s  face  eleven  times,  but  the 
disease  seems  so  rooted  in  the  old  gen- 
tleman’s constitution,  as  to  require  fre- 
quent repetition  of  the  operation.  He 
has  become  so  accustomed  to  it,  that 
whenever  the  inveterate  tormentor  deve- 
lopes  itself,  he  sends  for  his  surgeon  with- 
out delay,  knowing  that  from  his  hands 
he  shall  receive  relief.  Mr.  George  G. 
Graham,  practitioner  in  Orange  County, 
while  a student  of  medicine,  divided  the 
infra  orbitar  nerve  with  success;  and  Dr 
Post,  associated  with  Dr.  Mott,  operated 
lately  on  a gentleman,  whose  left  cheek 
was  diseased,  and  he  instantly  arrested 
the  spasms. 

The  d<  gree  of  certainty  promised  by 
the  operation,  as  resulting  from  the  phy- 
siology of  nervous  reunion,  becomes  an 
interesting  question.  Dr.  Haighton’s 
masterly  and  conclusive  experiments  on 
the  reunion  of  divided  nerves,  have  com- 
pletely established  that  point:  and  it  is  a 
settled  dogma  in  physiology,  that  by  the 
growth  of  Iresh  matter,  or  by  the  ap- 
proximation of  the  divided  ends,  the 


APPENDIX 


functions  of  a nerve  are  restored.  Mr. 
Abernethy,  however,  arguing  from  the 
renewed  sensibility  and  mobility  of  the 
ring  finger,  on  which  he  operated,  thought 
that  the  anastomosing  branches  had  be- 
come enlarged,  and,  officiating  in  lieu  of 
the  original  trunk,  rendered  a complete 
cure  impracticable.  Had  that  learned 
surgeon  removed  a portion  of  the  trunk 
of  the  ulnar  nerve,  and  then  been  baf- 
fled in  his  anticipated  cure,  his  apprehen- 
sion would  be  well  founded.  There  is 
some  difference  between  the  effects  of  a 
divided  trunk  and  of  its  branches.  Ner- 
vous influence  can  readily  be  reeommu- 
nicated  by  the  preservation  of  the  for- 
mer, should  the  latter  be  effectually  ope- 
rated upon.  Moreover,  as  the  nerve  of 
the  opposite  side  of  the  finger  was  deri- 
ved from  the  radial  nerve,  the  difficulty 
of  solving  the  mystery  is  diminished. 

In  opposition  to  the  utility  of  operating, 
the  uncertainty  of  immediate  relief  from 
a division  of  the  nerve  has  been  particu- 
larly urged.  For,  say  they,  the  reunion 
5s  so  speedy  and  so  certain,  that  nature 
will  commence  her  countervailing  pro- 
cess before  the  desired  object  is  com- 
pletely attained;  thus  tantalizing  the  pa- 
tient still  more,  and  adding  unnecessa- 
rily to  his  sufferings.  The  author  of  a 
thesis*  supported  before  the  Faculty  of 
Medicine  of  Paris,  expresses  his  doubts 
of  the  success  of  the  operation  ; he  pre- 
tends that  it  was  repeated  five  times  on 
one  patient,  and  asserts  that  he  finally 
owed  his  cure  to  the  warm  baths  of  Plom- 
bieres. 

In  the  same  dissertation  are  the  histo- 
ries of  two  other  patients,  on  whom  a 
Parisian  surgeon  practised  without  suc- 
cess the  division,  and  afterward  the  cau- 
tery on  the  supra  and  infra-orbitar  nerves, 
the  malar  branches  of  the  portio  dura, 
and  the  mental  nerve. f The  preceding 
remarks  on  the  success  of  the  operation 
are  a full  reply  to  such  objections. 

Wherever  a considerable  portion  of  the 
nerve  can  be  abstracted,  a greater  dura- 
tion will  assuredly  be  given  to  the  cure. 
This  cannot  be  attempted  on  many  of 
the  nerves  of  the  face ; because  the  ra- 
mification is  so  immediate  and  extensive, 
as  to  preclude  a successful  endeavour  to 
remove  much  of  the  frontal,  infra-orbital, 
or  mental  nerves.  The  branches  of  the 
pes  anserinus  are  intimately  connected 
with  the  parotid  gland  and  duct ; also  by 
some  very  beautiful  and  extraordinary 
anastomoses  with  the  other  facial  nerves, 
so  that  a similar  hinderance  occurs  here. 
The  only  nerve  about  the  head  which 
affords  the  slightest  chance  for  effectual 
and  final  division  is  the  portio  dura,  in 

* Utrura  in  pcrtinacibus  capitis  et  faciei  doloribus 
aliquld  prodesse  possit,  sectio  ramorum  nervi  quinti 
paris  ? proponebat  Veillart,  1763,  conclusio  negative. 
t Richerand  Nosorraotue  Obirumcale,  T.  II.  P-  201* 
Vol.  II.  ' ' *0 


iOo 

its  passage  between  file  stylo-mastoid 
hole,  and  the  angle  of  the  lower  jaw. 
When  the  disease  is  in  any  other  part  of 
the  system,  if  half  an  inch  of  the  princi- 
pal trunk  supplying  the  affected  spot 
could  be  removed,  there  would  be  little 
dread  of  its  return.  A repetition  of  in- 
cisions through  a nerve,  by  insulating  se- 
veral portions,  would  be  another  means 
of  protracting  a renewal  of  the  disease ; 
and  in  the  sub-orbitar  nerve,  this  has 
been  done  by  Dr.  Mott,  when  operating 
on  Dr.  Jones.J  This  improvement,  I be- 
lieve, is  attributable  to  Dr.  Mott,  and  its 
application  must  be  productive  of  dec!-* 
ded  and  happy  consequences. 

It  is  a curious  circumstance  connected 
with  the  operation,  that  although  the 
nerve  shall  be  completely  divided,  from 
some  cause,  the  chain  of  morbid  actions 
will  not  be  interrupted  for  several,  per  - 
haps twelve  or  fourteen,  days.  This  has 
induced  some  to  pronounce  hastily,  that 
the  operation  has  failed.  Any  attempt 
satisfactorily  to  explain  this  occurrence, 

1 think  would  be  fruitless. 

Operation  on  the  infra-orbitar  nerve.— 
The  participation  of  this  nerve  in  neural- 
gia, may  be  detected  by  the  course  of 
the  pain  up  the  side  of  the  nose,  some  - 
times following  an  arched  direction  be- 
tween the  eyebrow  and  upper  lid,  or  in 
either  the  brow  or  lid,  and  extending 
along  the  zygomatick  arch : or  it  may  be 
confined  to  the  muscles  passing  between 
the  os  mala?  and  the  angle  of  the  mouth, 
involving  the  buccinator  and  masseter. 
Pressure  may  be  applied  to  the  infra-oi- 
hitar  foramen,  during  which  the  pain  will 
be  arrested,  provided  the  disease  depends 
on  that  nerve.  A tremulous  motion  of 
the  upper  lip  on  one  side,  most  commonly 
attends  this  variety  of  neuralgia. 

To  Dr.  Haighton  we,  are  indebted  for 
an  excellent  view  of  this  nerve,  and  a. 
delineation  of  the  point  for  division. 

“ He  measured  the  space  between  the 
inferior  edge  of  the  orbit  and  the  superior 
edge  of  the  foramen  in  thirty  skulls,  and 
found  the  distance  in  sixteen  skulls  1-4 
of  an  inch,  which  he  considers  the  me- 
dium distance  from  the  upper  part  of  the 
foramen  ; and  if  we  allow  1-3  of  an  incii 
for  the  breadth  of  the  foramen,  and  1-ff 
below  its  inferior  part,  half  an  inch  from 
the  lower  edge  of  the  orbit  will  be  a pro- 
per place  for  performing  the  operation. 
Having  endeavoured  to  establish  a rule 
for  determining  its  distance  from  the 
orbit,  it  may  be  proper  to  ascertain  its 
situation  with  respect  to  a line  drawn 
from  the  inferior  part  of  the  internal  an- 
gular process  of  the  os  frontis , obliquely' 
across  the  orbit,  to  the  centre  of  the  os 
males.  The  measurement  of  this  line  i« 
tnirty  skulls,  did  not  vary  more  than  1-a 

X Medical  Repos  fOry.  (».  series  } Vol.  TT.  Nrfc  " 


7 U.o 


APPENDIX* 


of  an  inch,  anil  it  was  found  that  a line 
drawn  downward  perpendicular  to  this 
oblique  line,  at  the  distance  of  7-3  of  an 
inch  from  the  internal  angle  of  the  eye, 
passed  across  the  orifice  of  the  sub-orbi- 
tar  foramen.’’ 

This  point  being  settled,  Dr.  Haighton’s 
direction,  for  operating,  is  “ to  make  an 
incision  of  3-4  of  an  inch  in  length,  car- 
ried obliquely  downwards,  (on  account 
of  the  oblique  course  which  many  of 
these  nerves  take,  in  their  passage  from 
the  foramen  to  the  ala  nasi,)  the  centre 
of  which  must  correspond  with  the  fora- 
men, only  1-4  of  an  inch  below  it.  The 
incision  must  be  made  down  to  the  bone, 
otherwise  we  cannot  be  certain  of  divi- 
ding the  nerves,  as  they  are  situated  very 
deep.” 

The  deformity  produced  by  a large 
cicatrix,  in  this  method  of  operating,  ex- 
poses it  to  objection.  Professors  Post 
and  Mott  have  employed  the  following 
mode  with  the  happiest  success, and  per- 
fect facility. 

The  only  instrument  required  is  a 
sharp-pointed  bistoury,  or  phymosis 
knife,  either  in  a stiff  handle,  or  well 
secured. 

Having  ascertained  the  situation  of  the 
infra-orhitary  foramen,  by  Dr.  Haighton’s 
rule,  and  also  by  the  depression  which 
can  be  distinguished  in  most  subjects,  let 
the  nose  be  held  aside  by  the  assistant 
who  secures  the  patient’s  head.  Intro- 
duce the  bistoury  about  midway  between 
the  nose  and  the  nasal,  margin  of  the 
foramen  ; carry  it  down  to  the  bone,  and 
pass  the  point  close  to  the  hone,  in  order 
to  get  it  under  the  nerve.  The  point 
must  then  he  elevated  a little,  though  it 
must  not  pass  through  the  skin  from  be- 
neath ; by  a littie  rubbing  motion  with 
one  finger  upon  the  point  of  the  knife,  at 
the  same  time  cutting  gently  with  the 
knife,  the  nerve  will  he  divided. 

As  a considerable  branch  of  the  inter- 
nal maxillary  artery  accompanies  the  in- 
fra-orbital nerve,  its  division  will  be  shown 
by  a copious  arterial  hemorrhage  ; and  a 
peculiar  acute  pain  accompanies  the  sec- 
tion of  the  nerve,  in  addition  to  the  dif- 
ference, perceptible  to  the  operator,  be- 
tween cutting  a nerve, .and  any  other  soft 
solid.  The  upper  lip  must  now  he  exa- 
mined by  touch.  If  the  patient  acknow- 
ledge a destruction  of  sensibility,  the  sur- 
geon may  withdraw  his  bistoury  ; other- 
wise, the  cutting  must  be  repeated,  until 
from  numbness,  he  is  satisfied  that  the 
nerve  is  divided.  By  asking  the  question 
previously  to  withdrawing  the  knife,  the 
patient  has  no  reason  to  conceive  that 
any  disappointment  attended  the  first  at- 
tempt, and  the  repetition  of  incisions  he 
may  suppose  to  belong  regularly  to  the 
operation. 

Being  certain  that  the  nerve  is  tho- 


roughly divided  at  the  first  point  of  sec- 
tion, make  two  or  three  incisions  through 
it  lower  down  ; and  thus  endeavour,  as 
Dr.  Jones  expresses  it,  to  “insulate  a 
portion  of  it,  (included  as  it  were  in  a pa- 
renthesis,) with  respect  to  the  common 
sensorium.”  Since  the  in  fra- or  bitary 
nerve  as  it  leaves  the  foramen  expands 
immediately  like  a fan,  and  distributes  its 
branches  to  the  surrounding  parts,  the 
incisions  last  mentioned  may  be  exten- 
sive, retaining  the  knife  still  underneath 
the  skin.  The  knife  is  then  to  be  with- 
drawn through  the  first  opening,  and  the 
lips  of  this  diminutive  external  wound 
can  be  drawn  together,  and  secured  by 
adhesive  plaster. 

The  only  obstacle  to  a free  section  to 
wards  the  nose,  is  the  facial  vein,  Which, 
beginning  at  the  inner  angle  of  the  eye, 
holds  a diagonal  course  towards  the  angle 
of  the  jaw.  A wound  of  this,  however, 
will  not  be  attended  with  any  serious  con- 
sequences: it  will  only  add  to  the  ecchy- 
mosis  already  arising  from  the  artery, 
and  can  be  compressed  by  a slight  force 
applied  to  the  spot.  The  suffusion  of 
blood  will  be  removed  by  absorption  in  a 
few  days,  and  its  removal  may  be  aided 
by  any  moderately  stimulating  lotion. 

The  great  advantage  of  this  method 
over  Dr.  Haighton’s,  will  be  apparent 
from  the  impossibility  of  any  large  cica 
trix  being  the  consequence. 

Operation  on  the  Frontal  nerve. — This 
final  distribution  of  a highly  useful  and 
important  branch  of  the  trigemini,  after 
it  has  entered  the  orbit  through  the  fora 
men  lacerum,  appears  to  cling  to  the  roof 
of  the  orbit,  passing  between  the  bone  and 
the  periosteum,*  of  course  above  the  le 
vator  muscle  of  the  upper  eyelid.  It 
leaves  the  oi  bit  through  the  supra-orbitav 
foramen,  w hich  in  many  skulls  is  only  a 
notch,  closed  below  by  a ligament.  The 
situation  of  this  hole  or  notch  may  be 
ascertained,  w ith  tolerable  precision,  by 
finding  the  sub-orbitar  foramen  ; as  it  is 
about  1-4  of  an  inch  within  a perpendi- 
cular line  drawn  from  the  latter,  and  con- 
tinued up  the  forehead. 

Pass  a bistoury  or  knife  about  S-4  of 
an  inch  within  the  orbit,  immediately 
beneath  the  superciliary  ridge  of  the  os 
frontis,  and  divide  the  her\e  outwardly. 
A numbness  must  be  felt  on  the  forehead 
and  eyebrow,  and  down  the  nose,  before 
the  knife  is  withdrawn.  The  connexion 
between  the  nerve  and  the  bone  is  suffi- 
cient to  impress  the  necessity  of  keeping 
the  point  of  t he  bistoury  as  close  as  pos- 
sible to  the  bone,  and  the  dense  perioste- 
um affords  additional  resistance  w hile  di 
viding  the  nerve.  The  ophthalmic  artery 
will  bleed  profusely  for  a few  minutes. 

Meckel.  Traclatua  AnaUnnico-pliysiologicu?  dr 
quin  to  pare  nervorum  cerebri-  See.  j'nkK. 


appendix 


and  when  its  flow  outwardly  is  repress- 
ed, it  will  produce  so  much  ecchymosis 
as  to  blacken  the  eye  to  a considerable 
extent. 

Operation  on  the  Menial  nei've. — The 
foramen  through  which  emerges  the  in- 
ferior-maxillary branch  of  the  fifth  pair, 
is  situated  generally  about  midway  be- 
tween the  alveolar  processes  of  the  jaw 
and  its  base,  in  a line  between  the  cuspi- 
dal us  and  anterior  bicuspid  teeth.  The 
nerve  rnay  be  divided  by  turning  down 
the  lip,  and  introducing  the  bistoury 
about  the  first  bicuspid  tooth,  with  the 
back  towards  the  angle  of  the  jaw.  K«  ep 
the  knife  close  to  the  bone,  and  by  fol- 
lowing the  excavation  of  the  jaw,  the 
nerve  will  he  divided  by  a cutting  mo- 
tion rather  from  the  hone. 

In  the  aged  edentulous  subject,  from 
the  absorption  of  the  alveolar  processes, 
no  reference  can  he  made  to  the  teeth, 
in  finding  the  mental  foramen.  It  is 
situated  generally  in  the  same  line  with 
the  supra  orbitary  hole,  and  consequently 
can  easily  be  discovered. 

Operation  on  the  Portio  Dura. — A 
mere  description  of  the  complicated  and 
extensive  distribution  of  this  nerve,  will 
be  sufficient  to  justify  a doubt  of  any 
operation  being  so  devoid  of  danger,  or 
troublesome  consequences,  as  to  author- 
ize its  performance. 

When  neuralgic  sensations  are  traced 
from  just  above  the  angle  of  the  jaw,  in 
transverse  lines  across  the  face,  upwards 
through  the  temples,  downwards  along 
the  base  to  the  symphysis  of  the  chin 
backwards  behind  the  ear  ; exciting  es- 
pecially a profuse  discharge  of  saliva," 
and  frequently,  from  their  severity,  ab- 
sorbing all  perception  of  distinct  linear 
direction,  but  communicating  the  idea  of 
the  whole  cheek  being  in  a paroxysm  of 
neuralgia,  a surgeon  may  pronounce  the 
portio  dura  tu  he  the  affected  nerve. 

A brief  display  of  the  organs  contained 
in  the  side  of  the  face,  seems  necessary 
for  the  purpose  of  conveying  a distinct 
view  of  the  embarrassment  and  difficulty 
attending  any  projected  operation  on  the 
portio  dura. 

The  parotid  gland,  whose  agency  in 
furnishing  saliva  is  superior  to  any  other 
destined  for  that  use,  occupies  the  w hole 
space  from  the  mastoid  process  of  the 
temporal  bone,  penetrating  to  the  ‘‘very 
root  of  the  external  auditory  sinus,  almost 
to  the  internal  carotid  artery  and  jugular 
vein  ;”f  it  is  sunk  behind  the  lower  jaw, 
and  adheres  to  the  pterygoideus  internus 
muscle,  while  it  reaches  forwardly,  by 

* I have  not  noticed  this  in  any  description  of  Neu- 
ralgia 5 but  a moment’s  reflection,  I think,  will  show, 
that  a diseased  nerve  passing  through  the  parotid 
gland,  imbedded  in  its  substance,  must  affect  the  flow 
of  saliva  from  that  gland. 

t Surgical  Anatomy  of  the  ITead  and  Nock,  by  Mr. 
Mian  Tlurns  of  Glasgow. 


means  of  the  socia  parolidis,  nearly  to  the 
anterior  edge  of  the  masseter  muscle,  and 
upwards  to  the  zygoma.  The  ducts  from 
its  numerous  lobuli  unite,  and  are  conti- 
nued in  one  trunk  to  the  buccinator  mus- 
cle, which  it  perforates  nearly  opposite 
the  second  or  third  dens  molaris.  “ Its 
course  will  generally  he  defined,  by  a line- 
extended  from  the  junction  of  the  lobe  of 
the  ear  and  figured  portion,  to  midway 
between  the  root  of  the  nose,  and  the 
angle  of  the  mouth.” 

The  arteria  transversalis  faciei  “is 
generally  placed  midway  between  the 
parotid  duct  and  the  zygoma.  At  this 
part  it  lies  between  the  socia  parolidis 
and  the  masseur  muscle.” 

“The  portio  dura,  when  passingdrom 
the  foramen  stylo-mastoideum,  lies  be 
hind  the  parotid  gland  ; but  it  immedi- 
ately dips  into  its  substance.  It  conti- 
nues a single  and  undivided  trunk,  for 
about  half  an  inch  of  its  course.  This 
part  of  the  nerve  runs  in  a slanting  di- 
rection, downward  and  forward,  imbed- 
ded in  the  gland.  Where  the  portio 
dura  is  escaping  from  the  skull,  it  is  deep- 
seated,  and  nearly  in  contact  with  tne 
arteria  posterior  auris,  and  where  that 
artery  and  the  occipital  arise  by  a com- 
mon trunk,  the  latter  vessel  is  quite  in 
the  vicinity  of  the  portio  dura.  By  the 
styloid  process,”  (which  is  the  bar- 
rier between  the  external  and  internal 
carotids,)  “the  nerve  is  separated  from 
the  internal  carotid  artery,  and  jugular 
vein.  About  midway  between  the 
ascending  plate  of  the  jaw-hone  and  the 
mastoid  process,  the  portio  dura  is  nearly 
opposite  to  the  posterior  facial  vein,  and 
the  external  carotid  artery. 

“ It  is  at  this  point,  at  a place  where 
the  nerve  is  still  deeply  covered  by  the 
glandular  substance,  that  it  divides  into 
its  branches,  which  separately  perforate 
the  gland,  to  reach  the  cheek,  and  other 
parts  on  which  they  are  to  be  distributed. 
The  largest  of  these  branches  inclines 
upward  and  forward,  and  while  still  im- 
bedded in  the  gland,  it  subdivides  into  a 
numerous  set  of  twigs,  which  cover  as 
with  a net- work,  the  zygoma  and  the  ar- 
teria transversalis  faciei.  The  largest  of 
these  twigs  runs  nearly  midway  between 
the  zygoma  and  the  parotid  duct.  The 
other  divisions  of  this  nerve  ramify  over 
the  face,  and  about  the  throat. 

‘‘  The  trunk  of  the  nerve  can  be  reach  - 
ed, with  safety,  only  by  an  incision  be- 
ginning at  the  very  root  of  the  mastoid 
process,  and  continued  downward  and 
forward,  along  the  anterior  margin  of  the 
sterno-mastoid  muscle.  The  dissection 
no  doubt  will  require  to  be  deep;  but  in 
performing  it  the  surgeon  will  not  expe- 
rience much  difficulty  The  lobe  of  the 
ear  will  require  to  be  pulled  upward,  and 
held  forward,  while  prosecuting  this  dis- 


APPEiNDIK- 


':ob 


section,  In  performing  the  dissection, 
'he  nei*vu3  superficialis  colli  will  necessa- 
rily be  divided,  where  entering  the  lower 
angle  of  the  parotid.  Tlfe  glandular 
substance  itself  will  be  injured,  and  the 
arteria  posterior  auris  w ill  be  cut  across.”* 

In  this  manner,  Mr.  Burns  has  been  in 
the  habit  of  removing  half  an  inch  of  the 
nerve  on  the  dead  subject ; and  Professor 
Mott,  since  the  inestimable  Surgical 
Anatomy  of  the  Head  and  Neck  made  its 
appearance,  has  exhibited  to  his  class  of 
surgery  the  mode  of  performing  the  ope- 
ration. It  has  never  been  attempted  in 
this  complete  and  radical  manner  on  the 
living  subject ; although  many  incisions 
have  been  made  in  the  cheek,  for  the 
purpose  of  dividing  the  branches  of  the 
pes  anserinus:  The  outline  that  has  been 
given  of  the  anatomy  of  the  face,  exhibits 
the  difficulty  attending  that  procedure, 
and  the  infallible  consequence  must  be 
troublesome,  perhaps  perpetual,  salivary 
fistulas. 

Should  it  be  necessary,  however,  to 
divide  any  of  the  facial  branches  of  the 
portio  dura,  it  has  been  suggested  by 
Dr.  Mott,  that  it  might  by  effected  by  in- 
troducing a bistoury,  as  in  the  other  ope- 
rations, and  making  the  incisions  in  vari- 
ous directions  beneath  the  skin.  The 
prospect  of  an  unpleasant  result  will  be 
thus  considerably  diminished,  and  the 
fistula  would  probably  admit  of  a more 
rapid  cure. 

A few  observations  on  the  propriety  of 
employing  caustic  applications,  will  close 
the  subject.  If  the  object,  be  to  destroy 
every  prospect  of  a recurrence  of  neural- 
gia, and  if  the  patient  will  consent  to  an 
experiment,  which,  if  successful,  must 
effectually  annihilate  the  nerve,  the  pre- 
cedents afforded  by  the  French  surgeons 
will  authorize  the  attempt.  It  has  been 
objected,  that  the  proximity  of  some  of 
• he  nerves  to  the  bone  must  necessarily 
involve  exfoliation.  This  consequence 
depends,  very  probably,  on  the  manage- 
ment of  the  caustic,  which  should  not  be 
left  so  long  in  contact  with  the  bone  as 
to  endanger  its  continuity. 

After  the  nerve  has  been  divided  by 
the  operation,  it  may  answer  a good  pur- 
pose to  interpose  caustic  between  the 
extremities  of  the  nerve,  and  thus  com- 
bine both  expedients.  The  tediousness 
of  reaching  the  nerve  from  the  surface  by 
caustic,  besides  the  torture  it  would  in- 
dict, possibly  producing  tetanus,  seem  to 
interdict  any  proceeding  different  from 
that  proposed  Dr.  Jones  declined  the 
use  of  caustic,  from  dread  of  tetanus,  nor 
was  his  fear  without  foundation.  VVe 
should,  however,  repose  some  confidence 
in  the  practice  of  the  French,  and  admit 
this  method  of  destroying  a nerve  to  an 


equal  rank  with  the  knife,  in  those  eases 
where  its  employment  is  feasible,  and 
unattended  with  danger  to  the  bone. 

Following  this  is  a letter  by  the  Pro- 
fessor to  Dr.  Murray,  from  which  some 
additional  information  can  be  collected. 

Esteemed  Pupil , — Since  a doubt  has 
been  expressed  by  some,  as  to  the  even- 
tual result  of  the  operation  of  dividing 
the  nerve  in  Neuralgia,  allow  me  to  avail 
myself  of  this  opportunity,  to  state  the 
success  which  has  attended  it  in  my 
practice. 

In  a confirmed  case  of  neuralgia,  in  a 
lady  about  60  years  old,  in  1810,  i divi- 
ded the  infra  orbital  nerve  on  the,  right 
side;  the  relief  was  instantaneous.  Be- 
fore the  knife  wras  withdrawn,  she  ex- 
claimed, “ I am  relieved,  I can  nov/ 
speak,  blow  my  nose,  and  swallow,’ 
which  had  been  almost  impossible  for 
some  days,  owing  to  the  unspeakable 
agorijr  of  the  disease.  There  were  slight 
neuralgic  symptoms  for  about  ten  days, 
then  she  became  perfectly  free  from  the 
slightest  trace  of  it,  and  has  never  since 
had  a return  severe  enough  to  induce  her 
to  resort  to  the  operation,  the  pain  of 
which  she  by  no  means  dreads : for  all 
attest  that  a single  paroxysm  far  sur- 
passes the  smart  from  the  incision.  For 
about  four  months  she  was  entirely  free 
from  the  disease. 

A gentleman,  aged  about  fifty,  having 
had  neuralgia  for  four  years,  applied  to 
me,  in  the  beginning  of  the  year'1811, 
for  surgical  relief.  Palliative  means 
having  failed,  and  the  disease  increasing 
in  violence,  I recommended  the  opera- 
tion as  the  best  and  only  remaining  re- 
source. 1 divided  the  infra-orbital  nerve 
of  his  right  cheek.  The  paroxysms  con  - 
tinued for  a day  or  two  as  frequent  and 
violent  as  before  the  operation  : but  in  a 
week  it  entirely  left  him.  In  about  four 
months,  the  pain  began  to  return,  and 
increased  in  violence  from  time  to  time, 
but  did  not  equal  its  former  severity 
till  about  six  months  since,  when  it  be- 
came more  severe  than  ever.  About 
three  months  ago  I repeated  the  opera- 
tion on  the  same  nerve;  the  pain  went 
off  gradually  in  about  a week,  and  he 
says  the  last  operation  is  by  far  the  most 
successful. 

In  1811,  I divided  the  right  infra-orbi- 
tary  nerve  for  a lady,  who  had  been 
labouring  under  severe  neuralgia  for  two 
or  three  years.  She  experienced  no 
immediate  relief  ; on  the  contrary,  the 
paroxysms  appeared  to  be  increased  in 
frequency,  and  aggravated  in  violence, 
for  several  days:  they  then  began  to  de- 
cline, and  had  entirely  left,  hei  about  the 
twelfth  day.  I believe  the  disease  has 
never  returned . 


* Surgical  Atfatonv’  of  tine  H®nrt  amt  Norti- 


APPENDIX. 


309 


On  that  highly  respectable  physician, 
and  victim  to  neuralgia,  Dr.  Jones,  of  this 
city,  I have  operated  about  eleven  times, 
and  in  every  instance  with  the  most  per- 
fect success. 

After  having  been  afflicted  with  this 
horrible  disease  for  seven  or  eight  years, 
apd  having  exhausted  all  the  resources  of 
the  Materia  Medica  to  no  purpose,  the 
doctor  at  last  yielded  to  my  frequent  and 
earnest  importunities,  and  allowed  me  to 
divide  the  right  infra-orbital  nerve,  at  the 
advanced  age  of  sixty-seven  years.  His 
pains  were  increased  for  several  days, 
but  about  the  twelfth  they  abated  gradu- 
ally, and  in  a few  days  completely  left 
him.  He  continued  for  four  or  five  months 
free  from  pain  ; but  after  exposure  to 
cold,  he  felt  now'  and  then  alarming 
touches  of  the  disease,  which  at  length 
became  very  violent.  Every  subsequent 
operation  on  the  infra-orbital  and  mental 
nerves,  has  been  followed  with  complete 
relief ; but  the  intervals  have  been  mostly 
shorter  than  the  first;  they  do  not,  how- 
ever, gradually  shorten  ; several  of  the 
last  operations  have  varied  very  little  in 
the  interval  of  ease,  it  being  of  from  three 
to  four  months  duration. 

The  violence  of  the  paroxysms  has  se- 
veral times  been  augmented  for  a day  or 
two  after  the  operation,  and  as  the  addi- 
tional irritation  of  the  division  of  the 
nerves  subsides,  the  pain  gradually  dimi- 
nishes. The  disease  always  leaves  him 
in  from  seven  to  twelve  days  after  the 
operation.  From  the  last  division,  how- 
ever, of  the  infra-orbitary,  about  three 
weeks  since,  he  received  immediate  ease, 
having  scarcely  a single  pain  afterward. 

Last  winter,  I divided  the  right  infra- 
orbital nerve  for  Major  B , aged  about 

fifty,  who  had  been  labouring  under  a 
regularly  increasing  neuralgia  for  about 
four  years.  The  operation  increased  his 
disease  in  every  respect  for  several  days  ; 
it  then  abated,  and  gradually  went  com- 
pletely off  in  about  the  usual  period  of 
twelve  days.  Four  months  and  more 
have  now’  elapsed,  and  the  disease  has 
not  returned. 

About  three  weeks  since,  I attended, 
in  conjunction  with  Dr.  Post,  a Colonel 

K , aged  about  sixty,  who  for  five 

years  had  been  afflicted  with  severe  neu- 
ralgia of  the  left  infra-orbital  nerve.  Dr. 
P.  divided  this  nerve,  and  it  was  fol- 
lowed with  immediate  relief.  He  expe- 
rienced little  or  no  pain  afterward. 

Hoping  that  all  the  miserable  victims 
of  neuralgia  may  be  encouraged  to  resort 
to  a surgical  operation,  either  in  the  form 
of  a simple  or  double  division  ; by  a sin- 
gle external  incision,  or,  where  practica- 
ble, the  removal  of  a portion  of  the  nerves, 

1 am,  with  sentiments  of  high  regard 
and  esteem, 

VALENTINE  MOTT, 

fj  mo.  (May)  1st  1816. 


TOURNIQUET.  Notwithstanding 
all  the  encomium  justly  paid  to  the  screw 
tourniquet  of  M.  Petit,  that  instrument 
seems  superseded  by  one  of  American 
invention.  I could  never  bring  myself  to 
believe,  that  a sufficient  pressure  could 
be  obtained  against  the  artery  by  the  pad 
of  that  instrument,  while  applied  as  di- 
rected in  the  text  ; viz.  the  tourniquet 
itself  being  upon  the  extremity  in  an  op- 
posite direction,  w ithout  pioducing  much 
more  general  constriction  of  the  limb 
than  was  to  he  desired.  On  this  account, 

1 have  been  in  the  habit  of  dispensing 
with  the  ordinar)  pad,  and  substituting 
a small  and  firm  single  headed  roller 
undpr  the  base  of  the  instrument,  and 
placing  the  whole  over  the  artery.  Whe- 
ther it  was  merely  ideal  or  not,  1 will  not 
pretend  to  answer  ; hut  certainly  patients 
were  much  better  satisfied  by  this  method 
of  applying  the  instrument. 

The  tourniquet  invented  by  Dr.  Moore, 
of  Massachusetts,  appears  to  answ  er  in  a 
most  excellent  manner  this  design.  It  is 
made  of  brass,  and  intended  to  be  ap- 
plied over  the  artery.  It  has  a pad  of 
metal,  of  an  oval  convex  form,  that  can 
be  projected  from  the  under  part  of  the 
instrument  by  the  operation  of  a male 
and  female  screw,  which 's  morticed  in  a 
frame,  also  of  brass,  for  the  purpose  of 
its  support,  and  forgiving  it  a proper  di- 
rection. There  may  be  a linen  compress 
between  this  pad  and  the  limb,  or  the 
brass  pad  may  be  covered  by  a piece  of 
shamois  leather,  gathered  around  it  for 
the  time,  after  the  manner  that  tailors 
cover  buttons.  The  strap  of  this  instru- 
ment is  intended  to  buckle  on  the  outside 
of  the  limb  ; and  to  prevent  the  skin  from 
any  unpleasant  sensation,  there  is  a piece 
of  leather  placed  under  the  buckle  analo  - 
gous to  that  for  the  under  part  of  Petit’s 
screw  tourniquet. 

TRUSS.  I am  at  a loss  to  divine  w;hy 
Mr.  Cooper  has  altogether  omitted  the 
mention  of  the  truss  of  Messrs.  Salmon,- 
< >ddy , & Co.  of  London,  w hich  does  ap 
pear  to  me  as  infinitely  sup*  rior  to  any 
now  in  use,  or  likely  to  be  contrived. 

There  are  tt\o  very  formidable  objec- 
tions that  I think  must  obtain  against  all 
the  trusses,  with  that  exception,  and  they 
are  the  follow  ing  : V hen  the  pad  is  firm- 
ly connected  with  the  steel  strap,  it  is 
clear,  that  in  the  different  positions  of  the 
body,  and  constantly  during  progressive 
motion,  pressure  is  made  alternately  by 
the  one  edge  of  the  pad. then  by  the  cen- 
tre, or  the  other  odge  ; and  in  proportion 
as  the  truss  has  been  at  first  well  applied, 
that  is,  with  the  more  convex  part  of 
the  pad  against  the  ring,  so  the  same 
centre  of  the  pad  n ay  be  the  cause  of 
strangulation  of  a portion  of  intestine  or 
omentum,  that  should  have  been  pei  mil- 
ted to  peep  through  the  opening  in  the 
abdominal  pnrietes.at  a time  when  prer 


APPENDIX. 


•<io 


sure  was  made  by  the  edge  of  the  truss. 
In  this  way  I would  explain  the  evils  at- 
tributed to  trusses.  The  truss  I speak 
of  provides  against  this  accident,  by  ha- 
ving a hall  and  socket  joint  between  the 
pad  and  steel  strap,  by  which  contrivance 
no  other  part  of  the  pad  can  at  any  time 
make  pressure  but  the  very  centre  ; and 
which,  if  in  the  first  instance  properly  ap- 
plied to  the  ring,  must  continue  to  make 
a fair  and  an  equable  pressure. 

The  other  objection  applicable  to 
trusses  in  general,  is  derived  from  the  cir- 
cumstance of  the  strap  which  passes  by 
the.  pelvis  being  in  close  contact  with  the 
body  at  that  part ; so  that  in  progressive 
motion,  when  the  muscles  at  the  upper 
part  of  the  thigh  and  outer  part  of  the 
pelvis  contract,  the  parts  become  for  a 
time  swollen,  so  that  the  pad  is  neces- 
sarily drawn  from  immediately  over  the 
ring.  The  consequence  of  this  is,  a pro- 
trusion of  the  hernia  ; against  which  the 
ball  and  socket  joint,  I have  just  alluded 
to,  will  not  protect. 

The  truss,  however,  I would  recom- 
mend, has  a provision  by  which  this 
occurrence  cannot  take  place.  The  strap 
is  not  in  contact  with  the  pelvis,  but  takes 
a free  course  by  its  side,  and  can,  for 
convenience  sake,  be  laid  against  the  soft 
abdominal  muscles  above  the  spine  of  the 
ilium  ; while  from  having  a free  motion 
with  the  pads  by  virtue  of  the  ball  and 


socket  joint,  it  preserves  at  the  same  time 
a sufficient  and  most  uniform  pressure. 

VARICOSE  VEINS.  From  what  1 
have  seen  in  this  country,  the  practice  of 
Mr.  Brodie  seems  to  have  been  impro- 
ved upon,  by  one  more  in  conformity 
with  that  of  the  ancients. 

I have  reference  to  the  excision  of 
about  an  inch  of  the  trunk  of  the  princi- 
pal superficial  vein,  which  receives  the 
blood  from  those  in  the  varicose  state. 
Last  year,  I witnessed  this  operation  at 
the  Philadelphia  Hospital,  on  a man  with 
extensive  varices  of  the  superficial  veins 
below  the  knee.  The  vein  in  the  ham, 
or  the  branch  ir>  that  situation  which  was 
to  become  the  saphena,  was  cut  upon 
with  a scalpel,  and  about  an  inch  of  its 
length  extracted.  The  integuments  were 
brought  together  by  adhesive  plaster, 
and  in  about  three  weeks  all  the  varices 
disappeared. 

I have  been  in  the  habit  of  puncturing 
these  veins  with  a lancet,  in  several  situa- 
tions at  the  same  time  ; and  after  they 
had  bled  freely,  of  dressing  the  limb  with 
a compress  and  bandage,  very  systemati- 
cally applied,  moistening  the  whole  three 
or  four  times  within  the  first  twenty-four 
hours  with  the  rectified  spirits  of  w ine. 
By  this  treatment,  the  disease  was  very 
generally  removed,  provided  it  was  not 
dependent  upon  constitutional  circum- 
stances. 


T'5V»  OP  THR  SBCONfc  VOT.UMK, 


life  LIBRARY  OF  THE 
JUL 1 u 1933 

WajVWiSJtV  fif  IWMMM3. 


b 


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